Chronic prostatitis and chronic pelvic pain syndrome

Acute bacterial prostatitis is a sudden bacterial infection of the prostate presenting with local urinary symptoms plus fever, chills, and a tender boggy prostate on exam. Diagnosis is clinical, confirmed by urinalysis and culture, and treatment is empiric antibiotics chosen by patient age and risk, continued for 2-4 weeks.

Chronic bacterial prostatitis is a persistent bacterial infection of the prostate lasting more than 3 months that presents with recurrent lower urinary tract infections caused by the same organism, confirmed by a positive expressed-prostatic-secretion or post-massage urine culture, and treated with a 6 to 8 week course of a culture-directed, prostate-penetrating oral antibiotic.

Benign prostatic hyperplasia is age-related epithelial and stromal growth of the prostate transition zone causing bladder outlet obstruction and lower urinary tract symptoms in older men. Diagnosis rests on history, the AUA/IPSS symptom score, and a symmetrically enlarged, smooth prostate on digital rectal exam; management is staged from observation to alpha-1-blockers, 5-alpha-reductase inhibitors, and surgery.

Prostate cancer is the most commonly diagnosed cancer in men, usually found through an elevated PSA in an asymptomatic patient, with risk stratified by PSA, Grade Group (Gleason score), and TNM stage. Localized low-risk disease is often managed with active surveillance, while higher-risk and metastatic disease require radiation, surgery, or androgen deprivation therapy escalated through castrate-sensitive and castrate-resistant phases.

Epididymitis is inflammation of the epididymis, most often infectious, causing unilateral scrotal pain and swelling of gradual onset that must be distinguished urgently from testicular torsion. Diagnosis is clinical, supported by a positive Prehn sign and preserved cremasteric reflex, and treatment is empiric ceftriaxone plus doxycycline for age under 35 or STI risk, or levofloxacin alone for age over 35 with enteric-organism risk.

Orchitis is inflammation of the testis, most commonly viral (mumps) with isolated testicular involvement or bacterial as a contiguous extension of epididymitis (epididymo-orchitis), presenting as testicular pain and swelling that must be distinguished from the surgical emergency of testicular torsion. Diagnosis is clinical, guided by exposure history and preserved cremasteric reflex, with mumps orchitis managed supportively and bacterial epididymo-orchitis treated with the same age- and risk-stratified antibiotics used for epididymitis.

Testicular torsion is twisting of the spermatic cord causing testicular ischemia, presenting with acute severe unilateral scrotal pain, a swollen high-riding testis in a horizontal lie, and an absent cremasteric reflex; it is a surgical emergency diagnosed clinically without delaying for imaging, and testicular viability falls from 90-100% within 6 hours of symptom onset to under 10% beyond 24 hours, so immediate surgical exploration with detorsion and bilateral orchiopexy is the definitive treatment.

Erectile dysfunction is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance for at least 6 months, most often from vascular, neurologic, medication, endocrine, or psychological causes, and is a significant marker of coronary risk. Diagnosis is clinical from history and exam with targeted labs, and first-line treatment is an oral phosphodiesterase-5 inhibitor unless the patient takes nitrates.

Fibromyalgia is a chronic centralized pain syndrome causing widespread musculoskeletal pain with nonrestorative sleep, fatigue, and cognitive difficulty, driven by central sensitization rather than peripheral inflammation or structural damage. It is a positive clinical diagnosis made with the widespread pain index and symptom severity scale, not a diagnosis of exclusion. First-line treatment is patient education plus a graded aerobic exercise program, with duloxetine, milnacipran, or pregabalin as adjunctive pharmacotherapy.

Irritable bowel syndrome is a functional disorder of gut-brain interaction diagnosed clinically by Rome IV criteria, recurrent abdominal pain related to defecation, stool frequency, or stool form, without alarm features. Management is subtyped by stool pattern, with fiber and dietary change first, then IBS-C secretagogues or IBS-D antidiarrheals and antibiotics, and low-dose tricyclics or antispasmodics for pain.

Urinary incontinence is involuntary urine loss classified as stress, urge, mixed, or overflow by history and simple office testing. Stress incontinence is treated with pelvic floor muscle training then a midurethral sling, and urge incontinence/overactive bladder with bladder training then an antimuscarinic or beta-3 agonist, after a postvoid residual and urinalysis exclude overflow and infection.

Urinary tract infection spans uncomplicated cystitis, presenting with dysuria, frequency, and suprapubic pain, through pyelonephritis, presenting with fever, flank pain, and costovertebral angle tenderness, most often from ascending Escherichia coli. Uncomplicated cystitis is treated empirically without culture using nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, while pyelonephritis requires a pre-treatment urine culture and empiric fluoroquinolone or cephalosporin therapy, escalated to hospitalization and broader parenteral coverage for hemodynamic instability, obstruction, or failure to improve.