Guideline sources The following summarized guidelines for the evaluation and management of chronic bacterial prostatitis (CBP) are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the Prostatitis Expert Reference Group (PERG 2015), and the Canadian Urological Association (CUA 2011). 1 2 3 4 4 4 4 Definition CBP is caused by a chronic bacterial infection of the prostate gland characterized by recurrent UTIs caused by the same bacterial strain, pelvic pain, and LUTS. 4 Epidemiology CBP is caused by a chronic bacterial infection commonly involving E. coli and enterococci. 4 Disease course Clinical manifestations include pain, which may be poorly localized (pelvis, genitalia, lower back, or hypogastrium), and LUTS (weak stream, straining, hesitancy, urgency, frequency, dysuria). 4 https://web.pathway.md/diseases/recwWMErCS0aCBMeD 1/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway Prognosis and risk of recurrence CBP is not associated with increased mortality. 4 Guidelines 1. Classification and risk stratification Staging: Classify patients as being: in the early stages of the disease, if they have experienced persistent, recurrent symptoms for < 6 months and are antibiotic-na ve in the later stages of the disease, if they have experienced persistent, recurrent symptoms for > 6 months and are refractory to initial pharmacotherapy. B Severity assessment: As per PERG 2015 guidelines, consider using the NIH-CPSI, IPSS, and UPOINT scales to assess initial symptom severity, evaluate phenotypic differences, and monitor response to therapeutic intervention. C As per CUA 2011 guidelines, use the NIH-CPSI questionnaire to assess the severity of prostatitis symptoms and as an outcome measure to evaluate the course of symptoms over time and with treatment. B 2. Diagnostic investigations Physical examination: perform a physical examination (including the abdomen, external genitalia, perineum, prostate, and pelvic floor) in patients with suspected CBP or chronic prostatitis/chronic pelvic pain syndrome. B Microbiologic testing: As per EAU 2022 guidelines, obtain accurate microbiological evaluation for atypical pathogens, such as Chlamydia trachomatis or Mycoplasmata, in patients with CBP. B Show 2 more As per CUA 2011 guidelines: Obtain microbiological localization cultures of the lower urinary tract (4- and 2-glass pre- and post-massage test) in patients with suspected CBP or chronic prostatitis/chronic pelvic pain syndrome. B Do not obtain culture or microscopic evaluation of the semen for the diagnosis of CBP or chronic prostatitis/chronic pelvic pain syndrome. D Prostate-specific antigen: do not measure serum PSA levels for the diagnosis of chronic prostatitis/chronic pelvic pain syndrome or directing therapy. D Transrectal ultrasound: https://web.pathway.md/diseases/recwWMErCS0aCBMeD 2/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway As per EAU 2022 guidelines, obtain transrectal ultrasound in selected cases to rule out the presence of prostatic abscess. B As per CUA 2011 guidelines, do not obtain routine transrectal prostatic ultrasound D unless specific indication exists. D Cystoscopy: consider obtaining cystoscopy in selected patients with chronic prostatitis/chronic pelvic pain syndrome with obstructive voiding symptoms (refractory to medical therapy), hematuria, or other suspected lower urinary tract pathology. C Pelvic imaging: do not obtain CT and/or MRI in patients with chronic prostatitis/chronic pelvic pain syndrome. D Urodynamic testing: consider obtaining urodynamic evaluation (such as flow rates, post-void residual, pressure flow studies) to confirm obstruction and/or bladder problems. C Psychosocial assessment: As per PERG 2015 guidelines: Screen patients for psychosocial symptoms (such as anxiety and stress) using either the psychosocial yellow flag system and/or PHQ-9 and/or GAD-7 scales. Consider referring patients to a psychosocial specialist (psychiatrist, specialist psychologist, or cognitive behavioral therapist) if a clinically relevant level of psychosocial symptoms is observed. B Assess psychosocial symptoms in both the early and late stages of CBP or chronic prostatitis/chronic pelvic pain syndrome. Screen for psychological factors contributing to the patient's condition in case of significant suspicion. B As per CUA 2011 guidelines, obtain psychological assessment as psychosocial parameters (such as depression, maladaptive coping mechanisms) and poor social support impact symptoms and results of therapy. B 3. Medical management General principles: ensure a multidisciplinary team care including urologists, pain specialists, nurse specialists, physiotherapist, general physicians, cognitive behavioral/psychological therapists and sexual health specialists. B Show 2 more Antibiotic therapy: As per EAU 2022 guidelines, initiate a fluoroquinolone (such as ciprofloxacin, levofloxacin) as first-line therapy in patients with CBP. A Show 2 more As per PERG 2015 guidelines, consider initiating antimicrobial therapy as an initial treatment option to improve total urinary, pain, and quality of life scores in patients with CBP or chronic prostatitis/chronic pelvic pain syndrome. B Show 4 more https://web.pathway.md/diseases/recwWMErCS0aCBMeD 3/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway As per CUA 2011 guidelines, initiate fluoroquinolones for 4-6 weeks as first-line therapy in patients with CBP. B Show 2 more Analgesic therapy: As per PERG 2015 guidelines, offer NSAIDs only for short-term treatment of pain, with regular reassessment by a general practitionner, in patients with early-stage disease with symptoms suspected to be due to an inflammatory process or experiencing an inflammatory flare. B Show 4 more As per CUA 2011 guidelines: Consider offering anti-inflammatory therapy as an adjunct in a multimodal treatment strategy in patients with chronic prostatitis/chronic pelvic pain syndrome. C Consider offering pregabalin in patients with chronic prostatitis/chronic pelvic pain syndrome with neuropathic type pain. Alpha-blockers: As per PERG 2015 guidelines, consider initiating alpha-blockers as an initial treatment option to improve total, urinary, pain, and quality of life scores in patients with CBP or chronic prostatitis/chronic pelvic pain syndrome. B Show 2 more As per CUA 2011 guidelines: Consider adding alpha-blockers to antimicrobials to reduce recurrence rate in patients with CBP and in patients with obstructive voiding symptoms. C Do not use alpha-blockers as first-line monotherapy in patients with chronic prostatitis/chronic pelvic pain syndrome. D . Consider including alpha-blockers in the multimodal therapeutic plan, and continue for > 6 weeks, in patients with voiding symptoms. D 5-alpha reductase inhibitors: As per PERG 2015 guidelines, insufficient evidence to support the use of 5-ARIs as monotherapy in patients with chronic prostatitis/chronic pelvic pain syndrome, unless coexisting benign prostatic hyperplasia is present. I As per CUA 2011 guidelines, consider offering 5-alpha-reductase inhibitors in older patients with LUTS and/or as part of a multimodal treatment strategy in patients with chronic prostatitis/chronic pelvic pain syndrome. C Pentosan polysulfate: consider offering pentosan polysulfate in patients with chronic prostatitis/chronic pelvic pain syndrome with associated perceived bladder pain and irritative voiding symptoms. 4. Nonpharmacologic interventions Cognitive behavioral therapy: consider offering CBT in conjunction with other treatments to improve pain and quality of life in later-stages of CBP or chronic prostatitis/chronic pelvic pain syndrome. C https://web.pathway.md/diseases/recwWMErCS0aCBMeD 4/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway Physiotherapy: Obtain the following evaluation to confirm a physical causative route, and exclude non-physical causes, for symptoms before referring patients to specialist physiotherapy: screening for STIs culture/microscopy of voided bladder urine urethral smear NAAT relevant pelvic physical examination. B Show 3 more Alternative medicine: As per PERG 2015 guidelines, consider offering phytotherapy (such as pollen extracts, bioflavonoids and/or Serenoa repens) as a treatment option in treatment-refractory patients with CBP or chronic prostatitis/chronic pelvic pain syndrome. C As per CUA 2011 guidelines, consider offering phytotherapies, specifically quercetin and the pollen extract, cernilton, as first-line option C and in combination multimodal therapy in patients with chronic prostatitis/chronic pelvic pain syndrome. C 5. Surgical interventions Drainage of prostatic abscess: perform incision and drainage of the prostatic abscess, preferably via transurethral route. B Prostatectomy: insufficient evidence to recommend surgical techniques (such as radical prostatectomy or TURP) or high-intensity focused ultrasound for the treatment of CBP or chronic prostatitis/chronic pelvic pain syndrome, except in the context of a clinical trial setting. I 6. Specific circumstances Patients with asymptomatic prostatitis: Do not screen or evaluate for asymptomatic prostatitis. D Do not treat patients with asymptomatic prostatitis. D Consider initiating antimicrobial therapy in selected patients with asymptomatic prostatitis with elevated ptostate-specific antigen, infertility, and in patients scheduled to undergo prostate biopsy. D 7. Patient education General counseling: discuss differential diagnoses (including urological cancers) and other concerns (such as infertility) at first presentation to establish a full patient history and help inform future investigations. B Show 2 more https://web.pathway.md/diseases/recwWMErCS0aCBMeD 5/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway 8. Follow-up and surveillance Management of refractory disease: As per PERG 2015 guidelines, switch to an alternative treatment method or refer to specialist care if a bacterial cause is excluded and no symptom improvement is observed after antibiotic therapy. B Show 2 more As per CUA 2011 guidelines, consider offering the following options in patients with refractory CBP with confirmed uropathogen localized to the prostate: intermittent antimicrobial treatment of acute symptomatic episodes B low-dose antimicrobial suppression B radical TURP or open prostatectomy if all other options have failed. C Clinical findings Symptoms Past medical history Dysuria Acute bacterial prostatitis Fever Benign prostatic hyperplasia Foul-smelling urine Epididymitis Hematuria Inserted urinary catheter Low back pain Orchitis Painful bowel movements Sexually transmitted diseases Painful ejaculation UTI Pelvic pain Urethral stricture Penile pain Lab findings Scrotal pain Suprapubic pain serum PSA Urinary frequency Rectal exam Enlarged prostate Prostatic nodularity Prostatic tenderness Microbiological findings urine culture References 1. G. Bonkat, R. Bartoletti, F. Bruy re et al. EAU Guidelines on Urological Infections. EAU. 2022. Open https://web.pathway.md/diseases/recwWMErCS0aCBMeD 6/7 6/29/23, 3:52 AM Chronic bacterial prostatitis Pathway 2. Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015 Oct;116 4 509 25. Open 3. J Curtis Nickel. Prostatitis. Can Urol Assoc J. 2011 Oct;5 5 306 15. Open 4. James D Holt, W Allan Garrett, Tyler K McCurry et al. Common Questions About Chronic Prostatitis. Am Fam Physician. 2016 Feb 15;93 4 290 6. Open 5. Zhuo Tony Su, Jonathan Mark Zenilman, Karen Sandell Sfanos et al. Management of Chronic Bacterial Prostatitis. Curr Urol Rep. 2020 Jun 3;21 7 29. Open 6. Jerneja Vide nik Zorman, Mojca Mati i , Samo Jeverica et al. Diagnosis and treatment of bacterial prostatitis. Acta Dermatovenerol Alp Pannonica Adriat. 2015;24 2 25 9. Open https://web.pathway.md/diseases/recwWMErCS0aCBMeD 7/7