REVIEWS Prostatitis and Urinary Tract Infection in Men: What’s New; What’s True? Benjamin A. Lipsky, MD Urinary tract and prostatic infections are common in men, and most are treated by primary providers. Acute bacterial prostati- tis is caused by uropathogens, presents with a tender prostate gland, and responds promptly to antibiotic therapy. Chronic bacterial prostatitis is a subacute infection, may present with a variety of pelvic pain and voiding symptoms, and is character- ized by recurrent urinary tract infections. Effective treatment may be difficult and requires prolonged antibiotic therapy. Nonbacterial prostatitis and chronic pelvic pain syndrome are more common than bacterial prostatitis, and their etiologies are largely unknown. Treatment for both nonbacterial disorders is primarily symptomatic. An underlying anatomic or functional condition usually complicates urinary tract infections in men, but uncomplicated infections occur, often related to sexual ac- tivity. Gram-negative bacilli cause most urinary tract and pros- tate infections. Therapy for prostatic infections requires an agent that penetrates prostatic tissue and secretions, such as trimethoprim-sulfamethoxazole or, preferably, a fluoroquino- lone. Duration of antibiotic therapy is typically 1 to 2 weeks for cystitis, 4 weeks for acute bacterial prostatitis, and 6 to 12 weeks for chronic bacterial prostatitis. Long-term suppressive antibi- otic therapy and nonspecific measures aimed at palliation may be useful in selected patients with recurrent bacteriuria or per- sistent symptoms of chronic bacterial prostatitis. Am J Med. 1999;106:327–334. 1999 by Excerpta Medica, Inc. B y the time men reach their eighth decade, at least one third will have had an episode of bacteriuria (1) and one quarter will have been diagnosed with prostatitis (2). The majority of patients are seen by pri- mary care physicians (2,3). PROSTATITIS About half of all men will have symptoms consistent with prostatitis at some time, and about 25% of visits to phy- sicians for male genitourinary complaints are attributed to one of the prostatitis syndromes (1,4). These are the most common urologic problems in men younger than 50 years of age and the third most common in older men (4,5). Chronic prostatitis impairs quality of life to a mag- nitude similar to that of coronary artery disease or Crohn’s disease (6). Classification of Prostatitis Prostatitis encompasses a heterogeneous group of infec- tious and noninfectious disorders, most of which are not sufficiently evaluated to determine their cause (7,8). The diagnostic classification system for prostatitis syndromes has been updated recently (Table 1) (9). Bacterial prostatitis is characterized by symptoms of urinary tract infection, positive cultures of urine or pros- tatic secretions, and inflammatory cells in prostatic secre- tions. Acute bacterial prostatitis causes intense symptoms, as well as constitutional findings. Chronic bacterial pros- tatitis has a more insidious onset and less pronounced prostatic inflammation; patients have irritative or ob- structive genitourinary symptoms and relapsing or per- sistent urinary tract infections. Nonbacterial prostatitis or chronic pelvic pain syndrome occurs in men with no history of urinary tract infection and negative bacterial cultures of urine and prostatic fluid. The inflammatory type presents with genitourinary or rectal pain or voiding symptoms; the prostatic fluid contains inflammatory cells. Men with the noninflam- matory type, whose prostatic fluid has no leukocytes, have similar symptoms but pelvic pain is usually the pre- dominant complaint. Asymptomatic inflammatory pros- tatitis is a new category that accounts for men with pros- tatic inflammation detected during evaluation of another disorder. Of men referred for symptoms consistent with prostatitis, only 5% to 10% have acute bacterial prostati- tis or chronic bacterial prostatitis. Most of the remainder have nonbacterial prostatitis or chronic pelvic pain syn- drome (10 –12). This classification may help guide therapy and follow- up, but it is often unreliable in practice. Men referred for symptoms of chronic prostatitis are more likely than From the University of Washington School of Medicine, and Veterans Affairs Puget Sound Health Care System, Seattle, Washington. Requests for reprints should be addressed to Benjamin A. Lipsky, MD, Antibiotic Research Clinic (111M), Veterans Affairs Puget Sound Health Care Clinic, 1660 South Columbian Way, Seattle, Washington 98108. Manuscript submitted March 3, 1998 and accepted in revised form October 20, 1998. 1999 by Excerpta Medica, Inc. 0002-9343/99/$–see front matter 327 All rights reserved. PII S0002-9343(99)00017-0