Rosen & Barkin's 5-Minute Emergency Medicine Consult (576 page)

FOLLOW-UP

• Postprocedural sedation
  
• Inability to walk
  
• No responsible adult to accompany patient home
  
• Reason for undergoing conscious sedation still present
  
• Postprocedure complication
  

• Patient is awake, alert, and at baseline
  
• Procedure was of sufficiently low risk that additional monitoring for complications is unnecessary
  
• Stable hemodynamically
  
• Ambulatory 30 min before discharge
  
• Able to urinate
  
• Able to retain oral fluids
  
• Pain controlled
  
• Under observation of a responsible person and have transportation from the hospital
  

• All airway adjuncts should be readily available in case of respiratory compromise.
  
• All reversal agents should be readily available in case of inadvertent overdose of medications.
  
• Patients must have continuous cardiorespiratory monitoring during and after procedural sedation.
  

BASICS

• Acute (bacterial) prostatitis:
  
  • Acute febrile illness
    
  • Systemic symptoms may appear days before localizing urinary symptoms appear.
    
  • Patients may appear toxic and usually have a concurrent cystitis.
    
• Prostatic abscess:
  
  • Once common after acute prostatitis, now rare except in immunocompromised patients
    
  • Fever, rectal pain, and leukocytosis despite treatment
    
  • Fluctuant mass on rectal exam
    
• Chronic bacterial prostatitis:
  
  • ∼10% of cases of prostatitis
    
  • Most common cause of recurrent UTI in men
    
  • WBC and bacteria may be present in expressed prostatic secretions (EPS).
    
• Chronic nonbacterial prostatitis (also called prostatosis):
  
  • Same symptoms as chronic bacterial prostatitis but unable to culture organisms from urine or EPS
    
• Chronic pelvic pain syndrome (CPPS):
  
  • Symptoms referable to the prostate
    
  • No inflammatory cells are found
    
  • No bacteria cultured from the urine or EPS
    

• Usually a single-organism bacterial infection of the prostate
  
• Acute prostatitis:
  
  • Age <35 yr:
    
    • Neisseria gonorrhoeae
      and
      Chlamydia trachomatis
      are usual etiologies.
      
  • Age ≥35 yr:
    
    • Enterobacteriaceae or
      Escherichia coli
      (usual),
      Klebsiella
      ,
      Pseudomonas
      ,
      Enterococcus
      , and
      Proteus
      also seen
      
  • Rarely may be caused by
    Salmonella
    ,
    Clostridia
    , tuberculosis, or fungi.
    
  • Cryptococcus neoformans
    in AIDS patients
    
• Chronic bacterial prostatitis:
  
  • Enterobacteriaceae (80%),
    Enterococcus
    (15%), and
    Pseudomonas aeruginosa
    
• Chronic nonbacterial prostatitis:
  
  • Possible role for
    Chlamydia, Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma hominis
    

DIAGNOSIS

• Irritative voiding symptoms:
  
  • Frequency, urgency, dysuria
    
• Low back pain
  
• Perineal, suprapubic, or testicular pain
  
• Bladder outlet obstruction and urinary retention
  
• Ejaculatory symptoms such as hematospermia
  
• Acute prostatitis:
  
  • Fever, chills
    
  • Malaise
    
  • Arthralgias or myalgias
    
• Primary symptom in chronic prostatitis is relapsing dysuria.
  

• Acute prostatitis:
  
  • Exquisitely prostate tenderness
    
  • Warm, swollen
    
  • Firm or boggy prostate
    
  • Acutely inflamed prostate should not be massaged because that may precipitate hematogenous spread of organisms.
    
• In chronic prostatitis, the exam is usually normal.
  

• Urinalysis (with microscopy) and culture
  
• Acute prostatitis:
  
  • CBC, electrolytes, and blood cultures may be helpful in the acutely ill patient.
    
  • If <35 yr old or suspected sexual transmission, test for syphilis:
    
    • Venereal Disease Research Lab or rapid plasma reagin
      
• Chronic prostatitis/CPPS:
  
  • Prostatic massage between voiding may be used to capture EPS for Gram stain and culture if organism or white cells not present in the urine.
    

• Not indicated in acute prostatitis
  
• If prostatic abscess suspected, transrectal US or pelvic CT with IV and rectal contrast will confirm diagnosis.
  

Not applicable in ED

• Benign prostatic hyperplasia
  
• Cystitis
  
• Epididymitis
  
• Orchitis
  
• Perirectal/perianal abscess
  
• Proctitis
  
• Prostatic carcinoma
  
• Prostatic infarction
  
• Pyelonephritis
  
• Seminal vesiculitis
  
• Urethritis
  
• Urolithiasis
  
• Vesicular calculi
  
• Other causes of lower back pain (strain, disc disease, sacroiliac joint disease, etc.)
  

TREATMENT

Initial resuscitative measures as indicated

• Prostatic abscess requires urgent urologic consultation and transrectal US-guided aspiration.
  
• Antibiotic therapy should be initiated in ED (see Medications).
  
• Urinary tract instrumentation should be avoided:
  
  • If patient has painful urinary retention in acute prostatitis, suprapubic needle aspiration or suprapubic catheter placement should be performed.
    
• Many patients will benefit from IV fluid.
  
• Pain control with NSAIDs and narcotic analgesics as needed
  
• Stool softeners
  
• Bed rest
  
• Irritative voiding symptoms may persist for months after antibiotic therapy and may be treated with NSAIDs.
  

• Analgesia:
  
  • Narcotic, analgesic combinations such as hydroxycodone/acetaminophen: 1–2 tabs PO q4h
    
  • NSAIDs such as ibuprofen: 800 mg PO TID
    
• Parenteral antibiotic therapy for acute prostatitis:
  
  • Levofloxacin: 750 mg IV daily
    
  • Ampicillin/sulbactam: 3 g IV q6h
    
  • Cefotaxime: 2 g IV q8h
    
  • Ceftriaxone: 2 g IV daily
    
  • Ciprofloxacin: 400 mg IV BID
    
  • Ofloxacin: 200 mg IV BID
    
  • Piperacillin/tazobactam: 3.375 g IV q6h or 4.5 g IV q8h
    
  • Ticarcillin/clavulanate: 3.1 g IV q6h
    
• Antibiotics for outpatient treatment of acute (≤35 yr old) prostatitis, suspected etiology
  N. gonorrhoeae
  or
  C. trachomatis
  :
  
  • Ceftriaxone: 250 mg IM, then doxycycline: 100 mg PO BID × 10–14 days
    
  • Levofloxacin: 500 mg PO every day for 10–14 days
    
  • Ofloxacin: 400 mg PO × 1, then 300 mg PO BID × 10–14 days
    
• Antibiotics for outpatient treatment of acute (>35 yr old) prostatitis, suspected etiology Enterobacteriaceae (coliforms); some authorities recommend 3–4 wk of therapy:
  
  • Ciprofloxacin: 500 mg PO BID × 14 days
    
  • Levofloxacin: 500 mg PO every day for 14 days
    
  • Ofloxacin: 200 mg PO BID × 14 days
    
  • Trimethoprim/sulfamethoxazole: 1 double-strength (DS) tab or 2 regular-strength tabs PO BID × 28 days
    
• Outpatient therapy for chronic bacterial prostatitis (Enterobacteriaceae,
  Enterococcus,
  or
  P. aeruginosa
  ):
  
  • Ciprofloxacin: 500 mg PO BID for 4 wk
    
  • Levofloxacin: 500 mg PO every day for 4 wk
    
  • Ofloxacin: 300 mg PO BID for 6 wk
    
  • Trimethoprim/sulfamethoxazole DS: 1 tab PO BID for 1–3 mo
    
• CPPS:
  
  • Tamsulosin: 0.4 mg PO every day
    
  • Doxazosin: 1 mg PO (immediate release) every day
    
  • Peripheral β-adrenergic blocking agents have been used with some success; consult a urologist.
    
  • Prazosin: 1 mg PO BID/TID
    
  • Terazosin: 1 mg PO qhs