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Sepsis with shock can occur with acute pyelonephritis In diabetics, emphysematous pyelonephritis resulting from gas-producing organisms may be life-threatening if not
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adequately treated Healthy adults usually recover complete renal function, yet if coexistent renal disease is present, scarring or chronic pyelonephritis may result Inadequate therapy could result in abscess formation
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Severe infections or complicating factors require hospital admission Urine and blood cultures are obtained to identify the causative agent and to determine antimicrobial sensitivity Intravenous ampicillin and an aminoglycoside are initiated prior to obtaining sensitivity results (Table 23 1) In the outpatient setting, quinolones or nitrofurantoin may be initiated (Table 23 1) Antibiotics are adjusted according to sensitivities Fevers may persist for up to 72 hours; failure to respond warrants radiographic imaging (ultrasound) to exclude complicating factors that may require intervention Catheter drainage may be necessary in the face of urinary retention and nephrostomy drainage if there is ureteral obstruction In inpatients, intravenous antibiotics are maintained for 24 hours after the fever resolves, and oral antibiotics are then given to complete a 14-day course of therapy Follow-up urine cultures are mandatory following the completion of treatment
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which may lead to urinary retention High fevers and a warm and often exquisitely tender prostate are detected on examination Care should be taken in performing a gentle rectal examination, as vigorous manipulations may result in septicemia Prostatic massage is contraindicated
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Complete blood count shows leukocytosis and a left shift Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria Urine cultures will demonstrate the offending pathogen
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Differential Diagnosis
Acute pyelonephritis or acute epididymitis should be distinguishable by the location of pain as well as by physical examination Acute diverticulitis is occasionally confused with acute prostatitis; however, the history and urinalysis should permit clear distinction Urinary retention from benign or malignant prostatic enlargement is distinguishable by initial or follow-up rectal examination
Treatment
Hospitalization may be required, and parenteral antibiotics (ampicillin and aminoglycoside) should be initiated until organism sensitivities are available (Table 23 1) After the patient is afebrile for 24 48 hours, oral antibiotics (eg, quinolones) are used to complete 4 6 weeks of therapy If urinary retention develops, urethral catheterization or instrumentation is contraindicated, and a percutaneous suprapubic tube is required Follow-up urine culture and examination of prostatic secretions should be performed after the completion of therapy to ensure eradication
Prognosis
With prompt diagnosis and appropriate treatment, acute pyelonephritis carries a good prognosis Complicating factors, underlying renal disease, and increasing patient age may lead to a less favorable outcome
Meng MV et al Infections of the upper urinary tract In: Urologic Emergencies, Humana Press, 2005
ACUTE BACTERIAL PROSTATITIS
Prognosis
ESSENTIALS OF DIAGNOSIS
Fever Irritative voiding symptoms Perineal or suprapubic pain; exquisite tenderness common on rectal examination Positive urine culture
With effective treatment, chronic bacterial prostatitis is rare
Hua VN et al Acute and chronic prostatitis Med Clin North Am 2004 Mar;88(2):483 94 [PMID: 15049589]
CHRONIC BACTERIAL PROSTATITIS
ESSENTIALS OF DIAGNOSIS
Irritative voiding symptoms Perineal or suprapubic discomfort, often dull and poorly localized Positive expressed prostatic secretions and culture
General Considerations
Acute bacterial prostatitis is usually caused by gram-negative rods, especially E coli and Pseudomonas species and less commonly by gram-positive organisms (eg, enterococci) The most likely routes of infection include ascent up the urethra and reflux of infected urine into the prostatic ducts Lymphatic and hematogenous routes are probably rare
General Considerations
Although chronic bacterial prostatitis may evolve from acute bacterial prostatitis, many men have no history of acute infection Gram-negative rods are the most common etiologic agents, but only one gram-positive organism (Enterococcus) is associated with chronic infection Routes of infection are the same as discussed for acute infection
Clinical Findings
A Symptoms and Signs
Perineal, sacral, or suprapubic pain, fever, and irritative voiding complaints are common Varying degrees of obstructive symptoms may occur as the acutely inflamed prostate swells,
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