46.1 Acute Prostatitis, Epididymitis & Orchitis

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

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3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

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4 Chapter 4: Lifestyle Counseling & Behavior Change

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5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

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6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

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10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

46.1 Acute Prostatitis, Epididymitis & Orchitis

Key Takeaways Explain This Topic AI

Acute Bacterial Prostatitis (ABP) is an acute urologic infection predominantly caused by Gram-negative enteric bacilli (Escherichia coli in >80% of cases, followed by Klebsiella, Proteus, and Enterobacter), presenting with abrupt high fever, chills, perineal or sacral pain, dysuria, and acute voiding dysfunction.

Vigorous or repeated prostatic massage is STRICTLY CONTRAINDICATED in suspected acute bacterial prostatitis due to the imminent risk of inducing bacteremia, severe septic shock, and ascending epididymo-orchitis.

Empiric outpatient oral antibiotic therapy for ABP requires high lipid solubility and prostatic tissue penetration: oral Fluoroquinolones (Ciprofloxacin 500 mg BID or Levofloxacin 500 mg daily) or Trimethoprim-Sulfamethoxazole (TMP-SMX 1 DS tablet BID) for a MANDATORY FULL DURATION OF 4 TO 6 WEEKS to prevent relapsing chronic bacterial prostatitis or prostatic abscess.

Acute epididymitis etiology is strictly age-stratified: sexually active males <35 years are primarily infected with sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae) requiring Ceftriaxone 500 mg IM single dose plus Doxycycline 100 mg PO BID for 10 days; males >=35 years or post-instrumentation are infected with enteric coliforms requiring Levofloxacin 500 mg PO daily for 10 to 14 days; men who practice insertive anal sex require Ceftriaxone plus a Fluoroquinolone.

Prehn sign (relief of scrotal pain with elevation of the affected hemiscrotum) suggests epididymitis but is completely unreliable and CANNOT be used to exclude testicular torsion; persistent fevers or clinical toxicity after 48 to 72 hours of appropriate antimicrobial therapy indicates a prostatic abscess requiring urgent transrectal ultrasound (TRUS) or pelvic CT and urologic drainage.

Last updated: September 2026

Epidemiology & Pathophysiology of Acute Bacterial Prostatitis (ABP)

Acute bacterial prostatitis (National Institutes of Health [NIH] Category I) is a severe, acute infectious illness of the prostate gland that accounts for approximately 5% to 10% of all prostatitis presentations in primary care. Unlike non-bacterial chronic pelvic pain syndromes (NIH Category III), ABP represents an active, life-threatening parenchymal infection demanding rapid diagnostic recognition and prolonged bactericidal therapy.

NIH Classification of Prostatitis Syndromes

To avoid diagnostic confusion, the NIH categorizes prostatitis into four distinct entities:

Category I: Acute Bacterial Prostatitis (ABP) — Acute systemic bacterial infection of the prostate gland.

Category II: Chronic Bacterial Prostatitis (CBP) — Recurrent urinary tract infections caused by the same bacterial pathogen persisting within the prostatic parenchyma or calculi.

Category III: Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP/CPPS) — Perineal or pelvic pain for >=3 months without identifiable bacterial infection (Subtype IIIa: Inflammatory [leukocytes in semen/EPS]; Subtype IIIb: Non-inflammatory).

Category IV: Asymptomatic Inflammatory Prostatitis — Incidental finding of inflammatory cells in prostatic secretions or histology in the absence of genitourinary symptoms.

Microbiologic Etiology

The microbiologic spectrum of acute bacterial prostatitis mirrors that of complicated ascending urinary tract infections:

Gram-Negative Enteric Coliforms (>90% of cases) :

Escherichia coli : The predominant causative pathogen, accounting for 80% to 85% of all community-acquired cases.

Klebsiella pneumoniae : 3% to 5%.

Proteus mirabilis : 3% to 5% (frequently associated with alkaline urine and struvite calculi).

Enterobacter aerogenes / cloacae and Serratia marcescens : 2% to 3%.

Healthcare-Associated & Resistant Pathogens :

Pseudomonas aeruginosa : Seen particularly after transurethral instrumentation, indwelling urethral catheterization, or recent transrectal prostate biopsy.

Enterococcus faecalis (Gram-positive) and Staphylococcus aureus (including MRSA, often via hematogenous dissemination from distant infectious foci or injection drug use).

Sexually transmitted pathogens ( Neisseria gonorrhoeae , Chlamydia trachomatis ) are rare causes of isolated acute prostatitis, though they frequently cause concurrent urethritis and epididymo-orchitis in men younger than 35 years.

Pathogenesis & The Route of Infection

The predominant mechanism of infection is retrograde ascent of infected urine from the posterior urethra into the prostatic branched tubuloalveolar ducts , often facilitated by high intraurethral voiding pressures against an unrelaxed external sphincter (urinary reflux). Bacteria adhere to the prostatic ductal epithelium, colonize the glandular acini, and induce intense microvascular congestion, intraprostatic edema, polymorphonuclear infiltration, and microabscess formation. The resultant dramatic swelling of the prostate gland compresses the prostatic urethra, leading to secondary bladder outlet obstruction and acute urinary retention.

Clinical Presentation & Physical Examination

Patients with acute bacterial prostatitis characteristically present with an explosive, rapidly progressive clinical constellation of systemic toxicity combined with severe lower urinary tract irritation and voiding obstruction.

Cardinal Symptoms

Systemic Toxicity : Abrupt high fevers (temperature often >38.5°C [101.3°F]), shaking chills, diaphoresis, generalized arthralgias, myalgias, nausea, and profound malaise.

Irritative Lower Urinary Tract Symptoms (LUTS) : Severe dysuria, marked urinary frequency, urgency, and nocturia, secondary to trigonal and posterior urethral inflammation.

Obstructive Voiding Symptoms : Hesitancy, straining, weak or split urinary stream, terminal dribbling, sensation of incomplete emptying, and frank acute urinary retention resulting from mechanical compression of the urethra by the swollen, edematous prostate.

Pain Distribution : Deep-seated, throbbing ache localized to the perineum, sacrococcygeal spine, suprapubic area, or low back. Pain is characteristically exacerbated by sitting, defecation (due to fecal compression against the posterior prostate), or ejaculation.

Digital Rectal Examination (DRE) & The Cardinal Safety Warning

Caution

CRITICAL CLINICAL PEARL: PROSTATIC MASSAGE IS STRICTLY CONTRAINDICATED Vigorous, forceful, or repeated digital manipulation or massage of the prostate is STRICTLY CONTRAINDICATED in suspected acute bacterial prostatitis.

Applying mechanical compression to an acutely infected, hyperemic prostate forces massive inocula of bacteria into the friable prostatic venous plexus and pudendal circulation, directly precipitating bacteremia, septic shock, and hematogenous seeding . Furthermore, manual compression risks retrograde dissemination through the vas deferens, causing acute secondary epididymo-orchitis or capsular rupture. DRE must be performed with extreme gentleness purely to establish the diagnosis.

Gentle DRE Technique & Findings :

Perform an exceptionally gentle, single-finger digital examination.

The acutely infected prostate is palpated as exquisitely tender, hot/warm to the touch, swollen, tense, and boggy (soft and spongy) .

The normal median sulcus is frequently effaced by bilateral lobar swelling.

If focal fluctuation or severe asymmetric asymmetry is noted, a prostatic abscess must be strongly suspected.

Diagnostic Evaluation & Laboratory Workup DIAGNOSTIC TRIAGE FOR ACUTE PROSTATITIS

• Diagnostic Test Expected Finding Clinical Pitfall / Pearl
• ═════════════════════════════════════════════════════════════════════════════════════════════
• Midstream Urinalysis Pyuria (>10 WBC/HPF), leukocyte Essential first step; bacteriuria

esterase (+), nitrites (+), hematuria confirms infected urinary tract.

Urine Culture & Growth of >=10^5 CFU/mL coliform Mandatory in ALL suspected cases;

Susceptibility (typically E. coli) guides targeted de-escalation.

Serum PSA Markedly elevated (often >20 ng/mL) DO NOT ORDER in acute phase;

due to architectural disruption remains elevated for 4-6 weeks.

Blood Cultures (x2 sets) Positive in 20-30% of febrile cases; Mandatory if febrile, toxic, or

identifies bacteremia admitted to inpatient service.

Bedside Bladder US Elevated post-void residual volume Identifies acute urinary retention;

(often >300-500 mL) guides cautious decompression.

• ═════════════════════════════════════════════════════════════════════════════════════════════
• Laboratory Workup

Clean-Catch Midstream Urinalysis : Typically reveals marked pyuria, positive leukocyte esterase, positive nitrites, and variable microscopic hematuria. Unlike chronic prostatitis (which requires the Meares-Stamey 4-glass localization test or 2-glass pre/post-massage test), a simple midstream specimen in ABP is heavily colonized and diagnostic.

Urine Culture and Susceptibility : An absolute standard of care in every suspected case of ABP. Culture identifies the organism and provides minimum inhibitory concentrations (MICs) to confirm susceptibility to fluoroquinolones and TMP-SMX.

Blood Cultures : Two sets of peripheral blood cultures must be drawn in all patients with systemic fevers, hemodynamic instability, or those requiring hospitalization.

Serum Prostate-Specific Antigen (PSA) :

Acute inflammatory disruption of the prostatic epithelial-stromal barrier allows leakage of massive amounts of PSA into the systemic circulation, often elevating serum PSA to >20 to 50 ng/mL.

Clinical Warning : Serum PSA should never be measured during an acute episode of prostatitis to screen for prostate cancer. Testing during active infection generates false-positive alarms, causes profound patient distress, and leads to inappropriate biopsies. If an incidental PSA was drawn, it should be repeated no earlier than 4 to 6 weeks after complete resolution of the infection.

Emergency Management of Acute Urinary Retention in ABP

Prostatic swelling frequently precipitates acute urinary retention. Urethral catheterization must be approached with extreme caution:

Transurethral catheterization through a severely inflamed, friable prostatic urethra can cause severe mucosal trauma, intolerable pain, and hematogenous bacteremia.

If bladder decompression is required, a gentle attempt with a small-caliber (12 to 14 French) soft silicone Foley catheter may be performed by an experienced clinician.

If any resistance is encountered or the patient experiences agonizing pain, do not force the catheter. Immediate percutaneous suprapubic cystostomy (placed by urology under ultrasound guidance) is the preferred, safe method to drain the bladder while completely bypassing the infected prostate.

Antimicrobial Pharmacotherapy & Tissue Penetration

Treating bacterial prostatitis presents a unique pharmacokinetic challenge because the prostate is protected by a physiological blood-prostate barrier similar in function to the blood-brain barrier.

Pharmacokinetics of Prostatic Penetration

During acute inflammation, increased vascular permeability temporarily permits hydrophilic drugs (such as beta-lactams and aminoglycosides) to enter the prostatic interstitium. However, within 48 to 72 hours of antimicrobial initiation, local inflammation subsides, the prostatic capillary endothelium reconstitutes its tight junctions, and the blood-prostate barrier is re-established. To achieve therapeutic bactericidal concentrations within the prostatic acini and lipid-rich stroma, an antimicrobial must possess:

• High lipid solubility (allowing passive diffusion across epithelial membranes);
• Low plasma protein binding (maximizing free drug fraction);

A favorable ionization constant (pKa) that facilitates "ion trapping" within the acidic environment of prostatic fluid (prostatic fluid pH ~6.5 to 7.0 vs serum pH 7.40).

Only two oral antibiotic classes reliably satisfy these rigorous criteria: Fluoroquinolones and Trimethoprim-Sulfamethoxazole (TMP-SMX) . ANTIMICROBIAL REGIMENS FOR ACUTE BACTERIAL PROSTATITIS

• Clinical Setting Preferred Regimen Dosage & Route Mandatory Duration
• ═════════════════════════════════════════════════════════════════════════════════════════════════
• Outpatient Ciprofloxacin 500 mg PO BID 4 to 6 WEEKS
• (Mild-to-moderate, OR Levofloxacin 500 mg PO daily (MANDATORY FULL
• hemodynamically OR Trimethoprim-Sulfamethoxazole 1 DS tablet PO BID COURSE)
• stable, tolerating (TMP-SMX 160/800 mg) (if susceptible)
• oral fluids)

• Inpatient Ampicillin PLUS Gentamicin 2 g IV q6h + Step-down to oral
• (High fevers, OR Ceftriaxone 5 mg/kg IV q24h; quinolone once
• hemodynamic OR Levofloxacin 1-2 g IV daily; afebrile for 48 hr;
• instability, sepsis, OR Ciprofloxacin 750 mg IV daily; complete 4 to 6
• urinary retention) OR Piperacillin-Tazobactam 400 mg IV q12h; WEEKS total
• (if hospital-acquired/Pseudomonas) 3.375 g IV q6h therapy
• ═════════════════════════════════════════════════════════════════════════════════════════════════

Why a Mandatory 4 to 6 Weeks of Therapy?

Important

THE 4-TO-6-WEEK ANTIMICROBIAL MANDATE Primary care clinicians must prescribe a FULL COURSE OF 4 TO 6 WEEKS of targeted antimicrobial therapy for acute bacterial prostatitis, even if the patient becomes completely asymptomatic and afebrile within 48 to 72 hours.

Short antibiotic courses (e.g., 7 to 14 days, as used for uncomplicated pyelonephritis or cystitis) result in an unacceptably high rate of treatment failure (>50%). Inadequate duration allows viable bacteria to hide within obstructed prostatic canaliculi and calcified corpora amylacea, creating chronic bacterial prostatitis (Category II) or a frank prostatic abscess , which requires surgical intervention and months of suppressive therapy.

Prostatic Abscess: Diagnosis & Urologic Intervention

A prostatic abscess is a localized collection of purulent fluid within the prostate parenchyma. It arises as a direct complication of untreated or inadequately treated acute bacterial prostatitis.

Clinical Suspicion & Red Flags

A prostatic abscess should be strongly suspected in any patient with ABP who exhibits:

Persistent fever, chills, or leukocytosis after 48 to 72 hours of appropriate, culture-directed intravenous or oral antimicrobial therapy;

• Worsening pelvic, perineal, or rectal pain despite therapeutic compliance;
• Recurrent or progressive urinary retention ;

A fluctuant, tender mass or asymmetrical softening palpated during a repeat, exceptionally gentle digital rectal examination.

High-Risk Patient Populations

Prostatic abscess is disproportionately encountered in men with:

• Poorly controlled diabetes mellitus (impaired neutrophil chemotaxis and microvascular perfusion);
• Chronic immunosuppression (HIV/AIDS, solid organ transplantation, chronic corticosteroid therapy);
• Chronic indwelling urethral Foley catheters or intermittent clean catheterization;

Recent transrectal ultrasound-guided prostate needle biopsy.

Diagnostic Imaging & Surgical Management

Diagnostic Modality of Choice :

Transrectal Ultrasound (TRUS) : Highly accurate for defining the exact location, volume, and internal septations of the abscess, visible as single or multiple hypoechoic, thick-walled fluid cavities. TRUS is contraindicated if the patient has extreme rectal pain or anal strictures.

Contrast-Enhanced Pelvic CT or Pelvic MRI : Indicated when TRUS is contraindicated or if periprostatic, levator ani, or ischiorectal fossa extension is suspected.

Intervention :

Abscesses <1 cm in diameter without systemic sepsis may occasionally resolve with prolonged intravenous antibiotics alone.

Abscesses >=1 to 2 cm , or those accompanied by severe sepsis, mandate active drainage:

Transurethral Unroofing / Resection : Transurethral resection of the prostate (TURP) roof covering the cavity allows immediate, wide-open drainage into the prostatic urethra.

Transrectal or Transperineal Needle Aspiration : Performed under real-time TRUS or CT guidance; fluid is aspirated completely and sent for Gram stain, culture, and sensitivities.

Acute Epididymitis & Orchitis

Acute epididymitis is an inflammation of the epididymis characterized by scrotal pain, erythema, and progressive swelling lasting fewer than 6 weeks. In up to 60% of cases, the inflammatory process spreads to the adjacent testicle, producing acute epididymo-orchitis .

Pathophysiological Mechanism

The primary pathophysiologic mechanism is retrograde intraurethral ascent of microorganisms from the bladder neck, prostate, or urethra along the ejaculatory duct and vas deferens into the coiled tubules of the epididymis. Straining against a closed bladder neck, heavy lifting with a full bladder, or vigorous physical exertion can generate transient high retrograde pressures that drive infected urine through the vas deferens into the tail (globus minor) of the epididymis. AGE-STRATIFIED MANAGEMENT OF ACUTE EPIDIDYMITIS

• Patient Category Primary Microbial Etiologies First-Line Guideline Antimicrobial Regimen
• ═════════════════════════════════════════════════════════════════════════════════════════════════════
• Sexually Active Men Chlamydia trachomatis Ceftriaxone 500 mg IM in a single dose*
• Aged < 35 Years Neisseria gonorrhoeae PLUS Doxycycline 100 mg PO BID x 10 days
• (Sexually Transmitted)

• Men Aged >= 35 Years Enteric Coliforms Levofloxacin 500 mg PO once daily x 10-14 days
• OR Post-Catheterization (Escherichia coli, OR Ciprofloxacin 500 mg PO BID x 10-14 days
• OR Post-Instrumentation Klebsiella, Pseudomonas)

• Men Practicing Dual Etiology: Ceftriaxone 500 mg IM single dose*
• Insertive Anal Sex Enteric Coliforms (E. coli) PLUS Levofloxacin 500 mg PO daily x 10 days
• (Any Age) PLUS C. trachomatis / N. gon (covers coliforms + STIs)
• ═════════════════════════════════════════════════════════════════════════════════════════════════════

*Note: For patients weighing >= 150 kg (330 lbs), Ceftriaxone dose should be increased to 1,000 mg (1 g) IM.

Clinical Presentation & Physical Examination

Onset & Evolution : Unlike testicular torsion (which begins abruptly in seconds to minutes), epididymitis develops gradually over 24 to 72 hours .

Symptoms : Unilateral scrotal ache that radiates up the spermatic cord into the ipsilateral flank or groin, progressive scrotal enlargement, dysuria, urethral discharge (in sexually transmitted cases), and fever (present in 25% to 35% of cases).

Physical Examination :

Early: Marked induration, tenderness, and swelling isolated strictly to the posterior aspect of the testis along the epididymis (starting at the tail).

Late: Inflammation envelops the entire testicle (epididymo-orchitis) with an inflammatory reactive hydrocele, making physical distinction between the testis and epididymis impossible.

The Cremasteric Reflex : Intact and brisk in epididymitis. Lightly stroking the superior-medial thigh produces elevation of the ipsilateral testis (>0.5 cm). An intact cremasteric reflex strongly argues against testicular torsion.

Prehn Sign : Passive manual elevation of the painful hemiscrotum over the pubic symphysis relieves pain (positive Prehn sign) due to temporary reduction in venous and gravitational tension on the epididymal pedicle.

Warning

CLINICAL ALERT: PREHN SIGN CANNOT EXCLUDE TESTICULAR TORSION Although a positive Prehn sign is historically taught as suggestive of epididymitis, prospective surgical studies demonstrate that Prehn sign has low specificity and can be falsely positive in patients with partial or intermittent testicular torsion .

Clinicians must NEVER rely upon Prehn sign alone to rule out testicular torsion. In any post-pubertal adolescent or young adult presenting with acute scrotal pain, urgent Color Doppler Scrotal Ultrasound is mandatory unless the clinical picture is unequivocally typical of an STI in an older patient with normal anatomy and a clear timeline.

Diagnostic Workup for Epididymitis

Urine Testing : Midstream urinalysis and urine culture (identifies enteric coliforms in men >=35).

Urethral Swab or First-Catch Urine Nucleic Acid Amplification Testing (NAAT) : Mandatory in sexually active men <35 or those with risk factors; tests for Neisseria gonorrhoeae , Chlamydia trachomatis , and Mycoplasma genitalium (patient must not have voided within 1 to 2 hours prior to collection).

Color Doppler Scrotal Ultrasound : The definitive imaging study. Confirms acute epididymitis by demonstrating an enlarged, hyperemic epididymis with markedly increased blood flow (hypervascularity) on color and power Doppler, preserved or increased testicular perfusion, and frequently an associated reactive hydrocele with thickened scrotal wall.

Supportive Management

In addition to targeted antimicrobial therapy:

Strict bed rest for 48 to 72 hours during the peak acute phase;

Scrotal elevation and immobilization : Use of an athletic supporter (jockstrap) or a rolled towel placed beneath the scrotum while recumbent dramatically decreases venous tension;

Cold ice packs applied to the scrotum for 20 minutes at a time (never apply ice directly to skin);

Scheduled oral non-steroidal anti-inflammatory drugs (NSAIDs; e.g., Naproxen 500 mg PO BID) for pain relief and soft tissue anti-inflammatory action;

Sexual partner notification: Partners from the preceding 60 days must be referred for evaluation and empiric treatment, and the patient must abstain from sexual contact until both partners complete therapy and symptoms resolve.

Isolated Viral Orchitis: Mumps & Systemic Pathogens

Isolated orchitis (testicular inflammation without primary epididymal involvement) is overwhelmingly viral in origin, with Mumps (paramyxovirus) serving as the classic prototypical pathogen.

Mumps Orchitis

Epidemiology : Occurs in 20% to 30% of post-pubertal adolescent and adult males afflicted with mumps parotitis. It is extremely rare in prepubertal boys (<10 years old).

Clinical Presentation :

Develops acutely 4 to 7 days after the onset of bilateral or unilateral painful parotitis (swelling and erythema anterior to the ear and over the angle of the mandible).

Abrupt high fevers (up to 40°C [104°F]), shaking chills, severe headache, nausea, and excruciating unilateral (70-80%) or bilateral (20-30%) testicular pain and massive scrotal enlargement.

Physical examination reveals a shiny, erythematous, tense hemiscrotum with a profoundly enlarged, exquisitely tender testis; the epididymis is typically spared or only mildly reactive.

Complications & The Fertility Threat :

Testicular Atrophy : Seen in 30% to 50% of affected testes within 1 to 6 months post-infection, secondary to pressure-induced necrosis caused by tunica albuginea inelasticity during severe parenchymal edema.

Impairment of Spermatogenesis : Abnormal sperm count, decreased motility, and elevated abnormal forms occur in up to 30% of cases. However, permanent complete sterility is uncommon , occurring in <1% to 2% of bilateral cases, because Leydig cell function and some seminiferous tubules are usually preserved.

Management & Prevention :

No specific antiviral therapy exists; management is strictly supportive (strict bed rest, scrotal suspension, ice compresses, NSAIDs, or narcotics for severe intractable pain).

Prevention : High two-dose coverage with the Measles-Mumps-Rubella (MMR) live-attenuated vaccine (first dose at age 12-15 months, second dose at age 4-6 years).

Loading diagram... Clinical Triage and Antimicrobial Selection for Acute Prostatitis and Epididymitis