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uro.prostatitis.v1PRODUCTION
uro.prostatitis.v1

Prostatitis spectrum (NIH I/II/IIIa/IIIb/IV) — acute bacterial + chronic + CP/CPPS

urologyacutechronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult man with acute fever + perineal pain (acute bacterial) OR chronic pelvic pain ≥3 mo + LUTS (chronic / CP/CPPS) → prostatitis differential. Pivots: BPH without infection → uro.bph.v1; epididymitis → out of scope; prostate cancer → urology referral (Krieger 1999)

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Patient inputs (23)

Acute and chronic can occur at any adult age; TRUS-bx context typically 50+; CP/CPPS typically 20–50

TRUS-bx within prior 1–7 d → empiric broad-spectrum (FQ-resistant E. coli common) (Liss AUA 2014)

Recurrent UTI same organism → chronic bacterial prostatitis NIH II differential (EAU 2013)

Recent FQ exposure → FQ-resistant Enterobacteriaceae risk; alternative empiric needed (Liss AUA 2014)

Immunocompromise → broaden empirics + admit + ID consult low threshold (EAU 2013)

Diabetic → emphysematous prostatitis / abscess risk; broader empirics if non-resolving (EAU 2013)

Engine scope is adult men only (anatomic prostate)

DRE — boggy + tender + warm prostate confirms acute; DO NOT vigorously massage in acute (bacteremia risk) (EAU 2013)

Leuk-esterase + nitrite + WBC; sterile pyuria possible if recent abx (EAU 2013)

Always obtain in acute and chronic before abx; drives narrowing (EAU 2013)

Leukocytosis confirms inflammation; thrombocytopenia → sepsis severity (SCC 2026)

AKI screen + dose adjustment for renal-excreted abx (KDIGO AKI 2026)

Mandatory if febrile / septic appearance (SCC 2026)

Fever drives acute vs chronic differentiation; fever curve drives PO step-down timing (EAU 2013)

Hypotension + fever → urosepsis ICU pathway (SCC 2026)

Tachycardia component of qSOFA / sepsis screen (SCC 2026)

Anticoagulant + FQ caution; warfarin + TMP-SMX INR rise; methotrexate + sulfa toxicity; tricyclic + cardiac caution in elderly (FDA)

TRUS or CT for abscess concern (non-responder at 48–72 h, fluctuant mass on DRE) (EAU 2013)

Localizing culture for chronic bacterial (NIH II) — VB1 / VB2 / EPS / VB3; differentiates from CP/CPPS IIIa (Krieger 1999)

CP/CPPS often presents with ejaculatory pain / dysfunction → UPOINT phenotyping (AUA 2019)

CP/CPPS UPOINT P (psychosocial) domain — CBT + SSRI / SNRI targeted; common comorbidity (AUA 2019)

CRP + procalcitonin for bacterial vs viral differentiation; serial trend in chronic (panel.inflammation)

AVOID PSA screening during acute (transiently elevated); defer 6–8 wk post-acute for return-to-baseline (EAU 2013)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsepsis_prostatic_abscess
    Septic appearance + fluctuant DRE mass OR imaging confirms abscess — STAT drainage + broad-spectrum + ICU (EAU 2013; SCC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_bacterial_prostatitis
    NIH I — acute bacterial prostatitis: fever + perineal / pelvic pain + dysuria + tender enlarged prostate on DRE (Krieger 1999 PMID 10422990)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereTRUS-bx-induced_acute_prostatitis
    Acute febrile illness within 1–7 d of TRUS-bx — often FQ-resistant E. coli; empiric ertapenem / pip-tazo pending culture (Liss AUA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronic_bacterial_prostatitis
    NIH II — chronic bacterial prostatitis: recurrent UTI same organism + Meares-Stamey confirms prostatic localization (EAU 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecnpcfs_chronic_nonbacterial
    NIH IIIa (inflammatory) + IIIb (non-inflammatory) — chronic pelvic pain syndrome (CP/CPPS) ≥3 mo; UPOINT-directed multimodal (AUA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildasymptomatic_inflammatory
    NIH IV — incidental WBC on EPS / VB3 / semen analysis without symptoms (Krieger 1999)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildprostatic_calcification
    Incidental prostatic calcification on imaging — common finding; not treated unless symptomatic obstruction (EAU 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Prostatitis — NIH I/II/IIIa/IIIb/IV stratified regimen: acute IV→PO ceftriaxone+FQ × 4–6 wk; chronic FQ × 4–6 wk; CP/CPPS UPOINT multimodal; sepsis broad-spectrum + drainage; TRUS-bx FQ-resistant empirics
axis: prostatitis_NIH_stratifiedstep 1 - NIH I — acute bacterial prostatitis: IV ceftriaxone + FQ × 4–6 wk total
Selected step "NIH I — acute bacterial prostatitis: IV ceftriaxone + FQ × 4–6 wk total" — Acute bacterial prostatitis: fever + perineal pain + dysuria + tender enlarged prostate on DRE
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    1–2 g IV q24h • IV • q24h × 24–72 h until afebrile + PO tolerance
    triggers: acute_bacterial_prostatitis_NIH_I, no_pseudomonas_or_ESBL_risk
    EAU 2013 + Schaeffer 2006 — empiric IV pending culture; broad gram-negative coverage; PO step-down per culture (PMID 17050893)
    rxcui 2193
  • ciprofloxacin
    first line
    fluoroquinolone
    500 mg PO BID (or 400 mg IV q12h if NPO) • PO/IV • BID × 4–6 wk total
    triggers: acute_bacterial_prostatitis_culture_susceptible, PO_step_down, no_FQ_contraindication
    FQ achieves excellent prostate tissue penetration; first-line PO step-down after IV ceftriaxone; 4–6 wk total to prevent chronic evolution (EAU 2013)
    rxcui 2551
  • levofloxacin
    first line
    fluoroquinolone
    750 mg PO daily (or IV) • PO/IV • once daily × 4–6 wk total
    triggers: acute_bacterial_prostatitis_culture_susceptible, compliance_preference_qd
    FQ alternative with QD dosing; same prostate penetration profile
    rxcui 82122
  • trimethoprim-sulfamethoxazole
    second line
    sulfa_antibiotic
    160/800 mg (DS) PO BID • PO • BID × 4–6 wk total
    triggers: FQ_contraindicated, culture_susceptible_TMP_SMX
    EAU 2013 alternative — good prostate penetration; only if susceptible per culture
    rxcui 10831

outpatient playbook — drug actions (4)

  1. 1. ceftriaxone (acute IM single dose) + FQ PO start
    Ceftriaxone 1 g IM × 1 + cipro 500 mg PO BID × 4–6 wk OR levo 750 mg PO daily × 4–6 wk • IM + PO • q24h IM × 1 then PO × 4–6 wk
    trigger: NIH I outpatient — mild-moderate without sepsis
    EAU 2013 — IM ceftriaxone covers empiric while PO FQ achieves prostate penetration; 4–6 wk total prevents chronic evolution
  2. 2. ciprofloxacin / levofloxacin (chronic bacterial)
    Cipro 500 mg PO BID OR levo 750 mg PO daily × 4–6 wk • PO • BID or QD × 4–6 wk
    trigger: NIH II — chronic bacterial culture-directed
    EAU 2013 + Schaeffer 2006 — FQ first-line for chronic bacterial; biofilm penetration
  3. 3. TMP-SMX (FQ alternative)
    160/800 mg (DS) PO BID × 4–6 wk acute or 6 wk chronic • PO • BID
    trigger: FQ contraindicated or resistant
    EAU 2013 second-line for both acute and chronic
  4. 4. CP/CPPS UPOINT multimodal — α-blocker + tricyclic + PT + CBT
    Tamsulosin 0.4 mg + amitriptyline 10–25 mg qhs + pelvic floor PT + CBT referral • PO + non-drug • daily + ongoing PT
    trigger: CP/CPPS NIH IIIa or IIIb with UPOINT phenotyping positive in U/N/T/P domains
    AUA 2019 + Aoun 2017 — UPOINT-directed multimodal superior to monotherapy

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + perineal / pelvic / suprapubic pain + dysuria + tender enlarged prostate on DRE — acute bacterial prostatitis NIH I (Krieger 1999 PMID 10422990); Chronic pelvic / perineal pain ≥3 mo + LUTS ± ejaculatory pain — CP/CPPS NIH III (Schaeffer NEJM 2006); Recurrent UTI in adult man with same organism — chronic bacterial prostatitis NIH II (EAU 2013).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Prostatitis spectrum (NIH I/II/IIIa/IIIb/IV) — acute bacterial + chronic + CP/CPPS** (uro.prostatitis.v1).
Phenotype framing: NIH I (acute bacterial) vs NIH II (chronic bacterial) vs NIH IIIa (CP/CPPS inflammatory) vs NIH IIIb (CP/CPPS non-inflammatory) vs NIH IV (asymptomatic) vs epididymitis vs orchitis vs perirectal abscess vs prostate cancer vs ureterolithiasis vs UTI without prostatitis vs IC/BPS (Krieger 1999)
Scope: Adult man with acute fever + perineal pain (acute bacterial) OR chronic pelvic pain ≥3 mo + LUTS (chronic / CP/CPPS) → prostatitis differential. Pivots: BPH without infection → uro.bph.v1; epididymitis → out of scope; prostate cancer → urology referral (Krieger 1999)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Prostatitis — NIH I/II/IIIa/IIIb/IV stratified regimen: acute IV→PO ceftriaxone+FQ × 4–6 wk; chronic FQ × 4–6 wk; CP/CPPS UPOINT multimodal; sepsis broad-spectrum + drainage; TRUS-bx FQ-resistant empirics** — step "NIH I — acute bacterial prostatitis: IV ceftriaxone + FQ × 4–6 wk total".
1. ceftriaxone 1–2 g IV q24h IV q24h × 24–72 h until afebrile + PO tolerance (cephalosporin_3rd_gen, first line) — EAU 2013 + Schaeffer 2006 — empiric IV pending culture; broad gram-negative coverage; PO step-down per culture (PMID 17050893)
2. ciprofloxacin 500 mg PO BID (or 400 mg IV q12h if NPO) PO/IV BID × 4–6 wk total (fluoroquinolone, first line) — FQ achieves excellent prostate tissue penetration; first-line PO step-down after IV ceftriaxone; 4–6 wk total to prevent chronic evolution (EAU 2013)
3. levofloxacin 750 mg PO daily (or IV) PO/IV once daily × 4–6 wk total (fluoroquinolone, first line) — FQ alternative with QD dosing; same prostate penetration profile
4. trimethoprim-sulfamethoxazole 160/800 mg (DS) PO BID PO BID × 4–6 wk total (sulfa_antibiotic, second line) — EAU 2013 alternative — good prostate penetration; only if susceptible per culture

Setting playbook (outpatient) — Acute mild: ceftriaxone 1 g IM single + FQ PO × 4–6 wk; chronic bacterial: FQ × 4–6 wk per culture; CP/CPPS: UPOINT-directed multimodal + multidisciplinary team (EAU 2013; AUA 2019)
5. ceftriaxone (acute IM single dose) + FQ PO start Ceftriaxone 1 g IM × 1 + cipro 500 mg PO BID × 4–6 wk OR levo 750 mg PO daily × 4–6 wk IM + PO q24h IM × 1 then PO × 4–6 wk — NIH I outpatient — mild-moderate without sepsis (EAU 2013 — IM ceftriaxone covers empiric while PO FQ achieves prostate penetration; 4–6 wk total prevents chronic evolution)
6. ciprofloxacin / levofloxacin (chronic bacterial) Cipro 500 mg PO BID OR levo 750 mg PO daily × 4–6 wk PO BID or QD × 4–6 wk — NIH II — chronic bacterial culture-directed (EAU 2013 + Schaeffer 2006 — FQ first-line for chronic bacterial; biofilm penetration)
7. TMP-SMX (FQ alternative) 160/800 mg (DS) PO BID × 4–6 wk acute or 6 wk chronic PO BID — FQ contraindicated or resistant (EAU 2013 second-line for both acute and chronic)
8. CP/CPPS UPOINT multimodal — α-blocker + tricyclic + PT + CBT Tamsulosin 0.4 mg + amitriptyline 10–25 mg qhs + pelvic floor PT + CBT referral PO + non-drug daily + ongoing PT — CP/CPPS NIH IIIa or IIIb with UPOINT phenotyping positive in U/N/T/P domains (AUA 2019 + Aoun 2017 — UPOINT-directed multimodal superior to monotherapy)

Non-pharmacologic actions:
- Patient education — NIH category + treatment expectations + sepsis return precautions
- Multidisciplinary team for CP/CPPS — urology + PT + pain + mental health (AUA 2019)
- Avoid PSA screening during or within 6–8 wk of acute (EAU 2013)
- Counselling on FQ side effects + tendinopathy + dysglycemia (FDA 2016)
- Follow-up 6–12 wk for response assessment + UPOINT re-score

AVOID / contraindication checks:
- AVOID_vigorous_prostatic_massage_in_acute_bacteremia_risk (EAU 2013)
- Nitrofurantoin_CONTRAINDICATED_in_prostatitis_no_prostate_penetration (EAU 2013)
- Fluoroquinolones_FDA_black_box_tendinopathy_aortic_CNS_dysglycemia (FDA 2016 PMID 27121095)
- Fluoroquinolones_steroid_combination_tendinopathy_amplified (FDA)
- Fluoroquinolones_avoid_throughout_pregnancy_cartilage (FDA) — relevant for pregnancy partners + sexual transmission (rare)
- Fluoroquinolones_avoid_if_recent_exposure_FQ_resistant_E_coli_risk (Liss AUA 2014)
- TMP_SMX_interaction_with_warfarin_INR_rise (FDA)
- TMP_SMX_interaction_with_methotrexate_toxicity (FDA)
- PSA_AVOID_during_acute_prostatitis_transiently_elevated (EAU 2013)
- Tricyclic_cardiac_arrhythmia_in_elderly_and_QTc_prolongation (AGS_Beers)
- Tricyclic_anticholinergic_burden_in_elderly_dementia_risk (AGS_Beers)
- Gabapentin_dose_adjust_renal_impairment (FDA)
- NSAID_GI_renal_caution_short_course_only_in_CPPS (AUA 2019)
- Carbapenem_CNS_lowered_seizure_threshold_renal_dose_adjust (FDA)
- Prostatic_abscess_drainage_mandatory_source_control (EAU 2013)
- TRUS_bx_augmented_prophylaxis_prevents_post_biopsy_bacterial_prostatitis (Liss AUA 2014)
- Asymptomatic_NIH_IV_DO_NOT_TREAT_unless_fertility_workup (EAU 2013)

Monitoring

Regimen monitoring:
- fever curve in acute q4 to q8h drives PO step down (EAU 2013)
- IV to PO step down when afebrile 24h and PO tolerance (EAU 2013)
- total course 4 to 6wk for acute and chronic bacterial to prevent chronic evolution (EAU 2013)
- PSA at 6 to 8wk post acute for return to baseline (EAU 2013)
- urine culture at 4 to 6wk post treatment for chronic bacterial (EAU 2013)
- UPOINT score quarterly in CP CPPS to track multimodal response (AUA 2019)
- NIH CPSI score at baseline then quarterly in CP CPPS (AUA 2019)
- tricyclic ECG in elderly at baseline and dose changes (AGS Beers)
- gabapentin renal function adjust per eGFR (FDA)
- CRP PCT trend serial in sepsis or treatment failure (SCC 2026)
- blood cultures q24 48h until negative if initial positive (SCC 2026)

Setting (outpatient) monitoring:
- Symptom resolution at 6–12 wk (EAU 2013)
- Repeat urine culture at 4–6 wk post-treatment in chronic NIH II
- UPOINT score quarterly in CP/CPPS (AUA 2019)
- PSA at 6–8 wk post-acute (EAU 2013)

Follow-up plan: Outpatient urology if non-responder or chronic recurrent; CP/CPPS multimodal team (urology + PT + pain + mental health); counsel return precautions in TRUS-bx context (EAU 2013; AUA 2019)
- Close-out criterion: follow-up scheduled

Monitoring phase: Acute: fever curve drives IV-to-PO step-down (afebrile × 24 h + PO tolerance); PSA at 6–8 wk post-acute. Chronic: re-culture at 4–6 wk after treatment; UPOINT score quarterly in CP/CPPS (EAU 2013)

Disposition

Current setting: outpatient — Acute mild: ceftriaxone 1 g IM single + FQ PO × 4–6 wk; chronic bacterial: FQ × 4–6 wk per culture; CP/CPPS: UPOINT-directed multimodal + multidisciplinary team (EAU 2013; AUA 2019)

Disposition criteria:
- Outpatient if stable + responding (EAU 2013)
- ED admit if sepsis / abscess / poor PO / TRUS-bx-induced severe

Escalation triggers (move to higher acuity):
- Fever / sepsis / poor PO tolerance → ED (EAU 2013)
- Non-responder at 48–72 h → admit + imaging for abscess (EAU 2013)
- Refractory CP/CPPS on multimodal at 6–12 mo → pain specialist + tertiary urology center (AUA 2019)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Septic appearance + fluctuant DRE mass OR imaging confirms abscess — STAT drainage + broad-spectrum + ICU (EAU 2013; SCC 2026)
- [SEVERE] NIH I — acute bacterial prostatitis: fever + perineal / pelvic pain + dysuria + tender enlarged prostate on DRE (Krieger 1999 PMID 10422990)
- [SEVERE] Acute febrile illness within 1–7 d of TRUS-bx — often FQ-resistant E. coli; empiric ertapenem / pip-tazo pending culture (Liss AUA 2014)

Citations

- Krieger NIH classification 1999 (I/II/IIIa/IIIb/IV) + Schaeffer NEJM 2006 chronic prostatitis review + EAU prostatitis 2013 + Aoun CP/CPPS multimodal 2017 + AUA chronic pelvic pain 2019 (UPOINT) + Liss TRUS-bx augmented prophylaxis AUA 2014 + FDA FQ Black Box 2016 + SCC 2026 sepsis bundle (urosepsis pathway) [PMID:10422990](https://pubmed.ncbi.nlm.nih.gov/10422990/)
- Cited evidence (PMID 17050893) [PMID:17050893](https://pubmed.ncbi.nlm.nih.gov/17050893/)
- Cited evidence (PMID 19118880) [PMID:19118880](https://pubmed.ncbi.nlm.nih.gov/19118880/)
- Cited evidence (PMID 18164597) [PMID:18164597](https://pubmed.ncbi.nlm.nih.gov/18164597/)
- Cited evidence (PMID 26970449) [PMID:26970449](https://pubmed.ncbi.nlm.nih.gov/26970449/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Krieger NIH classification 1999 (I/II/IIIa/IIIb/IV) + Schaeffer NEJM 2006 chronic prostatitis review + EAU prostatitis 2013 + Aoun CP/CPPS multimodal 2017 + AUA chronic pelvic pain 2019 (UPOINT) + Liss TRUS-bx augmented prophylaxis AUA 2014 + FDA FQ Black Box 2016 + SCC 2026 sepsis bundle (urosepsis pathway) — PMID:10422990
  • Cited evidence (PMID 17050893) — PMID:17050893
  • Cited evidence (PMID 19118880) — PMID:19118880
  • Cited evidence (PMID 18164597) — PMID:18164597
  • Cited evidence (PMID 26970449) — PMID:26970449