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Prostatitis and chronic pelvic pain syndrome in men
Under the NIH classification there are four types: I — acute bacterial prostatitis (a febrile patient with a tender prostate, antibiotic treatment without massage), II — chronic bacterial (recurrent infections with the same organism), III — chronic pelvic pain syndrome (CP/CPPS) without infection, and IV — asymptomatic inflammation.
Why it matters in the exam
The exam shows a man with fever, rigors, perineal pain, dysuria and difficulty voiding, and on rectal examination a swollen tender prostate; or a man with fever two days after a transrectal prostate biopsy. In acute prostatitis a urine culture and blood cultures are taken and prostatic massage must not be done. Antibiotics are started — a fluoroquinolone or an intravenous beta-lactam (for example ceftriaxone or piperacillin-tazobactam) with or without an aminoglycoside — and completed for 2 to 4 weeks. In retention a suprapubic catheter or a thin urethral catheter is inserted. When fever does not settle — transrectal ultrasound or CT to look for a prostatic abscess, which is drained.
Infection after transrectal biopsy is often caused by fluoroquinolone-resistant, ESBL-producing bacteria, so in a septic patient after biopsy a carbapenem or amikacin is started. A transperineal biopsy approach greatly lowers the infection rate. Chronic bacterial prostatitis presents as recurrent infections with the same organism; diagnosis is by urine tests before and after massage (the two-glass or Meares-Stamey four-glass test), and treatment is a fluoroquinolone for at least 4 weeks.
Chronic pelvic pain syndrome is pain in the pelvis, perineum or genitalia lasting at least 3 of the last 6 months, without proven infection. It is common, harms quality of life, and does not respond to repeated courses of antibiotics. The approach is tailored to symptoms (by domains: urinary, psychosocial, organ-specific, infection, neurological, muscle tenderness): an alpha-blocker when there are voiding symptoms and relatively recent disease, pelvic floor physiotherapy, pain management and psychological support. The NIH-CPSI questionnaire is used for assessment and follow-up.
Key points
- Four NIH types.
- Acute — antibiotics 2 to 4 weeks, no massage.
- After biopsy — think of ESBL.
- Chronic bacterial — at least 4 weeks.
- CP/CPPS — symptom-based treatment.
Summary table
| NIH type | Picture | Diagnosis | Treatment |
|---|---|---|---|
| I — acute bacterial | Fever, tender prostate, retention | Urine and blood cultures, no massage | Antibiotics 2 to 4 weeks; drain an abscess |
| II — chronic bacterial | Recurrent infections with the same organism | Urine before and after massage | Fluoroquinolone for at least 4 weeks |
| III — CP/CPPS | Pelvic pain 3 of 6 months, no infection | Exclude infection, NIH-CPSI | By symptoms: alpha-blocker, physiotherapy |
| IV — asymptomatic | Incidental finding | Biopsy or semen | No treatment |
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Sources
- EAU Guidelines on Urological Infections, 2025 edition — Bacterial prostatitis
- EAU Guidelines on Chronic Pelvic Pain, 2025 edition — Chronic prostatitis / chronic pelvic pain syndrome
- NIH Chronic Prostatitis Collaborative Research Network classification, 1999 — Categories I to IV
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.