Burning on urination, a dull pressure in the perineum, pain after ejaculation. Many men stay silent about symptoms below the belt, often for months. That is understandable, but medically it is a problem. With prostatitis (inflammation of the prostate gland), how quickly it is investigated decides whether an acute episode turns into a chronic condition. This article shows you what distinguishes the four forms, how to recognise them, and why your GP is the right place to start.

What prostatitis is and which form affects you

In brief
Prostatitis is an inflammation of the prostate, a walnut-sized gland directly beneath the bladder. It is not prostate cancer and does not raise the risk of it. The international standard classification (NIH categories I to IV) distinguishes four forms: acute bacterial prostatitis (category I, sudden onset, with fever, a medical emergency), chronic bacterial prostatitis (category II, recurrent, bacteria detectable), chronic pelvic pain syndrome (category III, the most common form, usually without detectable bacteria) and asymptomatic inflammatory prostatitis (category IV, an incidental finding, as a rule not treated) [Krieger JN et al., JAMA 1999]. The EAU Guideline on Urological Infections recommends a prompt, structured work-up with a midstream urine culture, a four-glass test where appropriate, and targeted antibiotic therapy guided by sensitivity testing where a bacterial cause is confirmed [Bonkat G et al., EAU 2024]. First contact without a referral, appointments usually within a week.

The four NIH categories in everyday clinical practice

The form of prostatitis determines the treatment. An acute bacterial inflammation is a different clinical situation from chronic pelvic pain syndrome, in which no pathogens are found. After the initial work-up we assign you to one of the four categories and adjust the plan accordingly.

  • NIH I, acute bacterial prostatitis. Sudden onset, fever, chills, severe pain on urination, sometimes urinary retention. Mostly gram-negative organisms, above all Escherichia coli. Prompt antibiotic therapy (typically two to four weeks), close follow-up [Bonkat G et al., EAU 2024].
  • NIH II, chronic bacterial prostatitis. Recurrent or persistent infections over at least three months, the same organism in the midstream urine or the expressed prostatic secretion (EPS) culture. Symptoms are milder than in NIH I but stubborn. Antibiotic therapy often runs four to six weeks, using substances that penetrate prostate tissue.
  • NIH III, chronic pelvic pain syndrome (CPPS). The most common form, around 90 per cent of all prostatitis diagnoses. Pelvic pain without detectable pathogens. The causes are multifactorial: pelvic floor dysfunction, neuropathic components, psychosocial triggers. Treatment is interdisciplinary.
  • NIH IV, asymptomatic inflammatory prostatitis. Signs of inflammation without any complaints, usually an incidental finding during an examination for another concern. As a rule no treatment is needed.

Symptoms that should stop you waiting any longer

The signs of prostatitis are rarely dramatic. They creep in, get played down and only lead to a consultation after weeks or months. Three groups of symptoms should put you on alert.

  • Urination. Frequent urge to urinate, especially at night, burning on urination, a weak stream, a sense of incomplete emptying.
  • Pain. Pain in the perineum (between the testicles and the anus), in the testicles, in the penis, in the lower abdomen or in the lower back. In the acute form, sitting can become unbearable.
  • Sexual function. Pain during or after ejaculation, erectile problems, loss of libido.

If fever, chills or a marked feeling of illness are also present, that is a warning sign for an acute bacterial form. Then every hour counts. Book an appointment the same day or go to the emergency department.

How we investigate: from the consultation to sensitivity testing

A prostatitis work-up based on a urine dipstick alone is not enough. Particularly with recurrent complaints, we need precision. Our approach follows the EAU Guideline [Bonkat G et al., EAU 2024]:

  • A structured history using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify pain, urinary symptoms and quality of life.
  • Physical examination including a digital rectal examination. In acute bacterial prostatitis we do not perform prostatic massage, as it can trigger bacteraemia.
  • Midstream urine with culture and sensitivity testing. In chronic forms, the Meares-Stamey four-glass test or the simplified two-glass test complements the work-up.
  • Blood tests: inflammatory markers (CRP, full blood count), plus PSA in men over 50 or where clinically suspected, to differentiate from other prostate conditions.
  • Imaging for complications or treatment failure: transrectal ultrasound, MRI where an abscess is suspected.

The goal is clear. We want to know whether bacteria are involved and which antibiotic will work against them. Indiscriminate use of broad-spectrum antibiotics promotes resistance and cannot be justified medically.

Treatment by type

Treatment depends on the NIH category. There is no blanket answer.

  • NIH I, acute bacterial prostatitis. Antibiotic therapy guided by sensitivity testing, often started with fluoroquinolones or cephalosporins, adjusted once the culture is available. Treatment duration two to four weeks. Close follow-up, hospital admission if signs of sepsis appear.
  • NIH II, chronic bacterial prostatitis. An antibiotic with good prostate penetration (for example fluoroquinolones or trimethoprim-sulfamethoxazole, according to sensitivity testing), for four to six weeks. If it recurs, we look for reservoirs such as chronic concurrent infections and review the sexual history.
  • NIH III, chronic pelvic pain syndrome. Multimodal, because the causes are multifactorial. Depending on the phenotype, the components are: alpha blockers to improve urination, non-steroidal anti-inflammatory drugs during acute phases, targeted physiotherapy with a pelvic floor focus, neuropathic pain modulation, treatment of accompanying depression or anxiety, and lifestyle interventions (exercise, stress reduction, a balanced diet) [Magri V et al., Arch Ital Urol Androl 2018].
  • NIH IV. No treatment, with observation where appropriate as part of other urological findings.

In all forms we consider whether herbal preparations (e.g. saw palmetto or pollen extracts) can be a useful addition. The evidence is mixed, the tolerability is good. That is something we decide together in the consultation.

Why the GP practice is the right place to start

A prostatitis work-up with a specialist often begins with a waiting list. Your GP can act sooner, usually has sufficient diagnostics in-house, and knows your history. We look at the whole person rather than an isolated symptom.

  • Easy access. You do not have to wait for a urology appointment first.
  • Coordination. If a urologist is needed, we make a targeted referral and remain your central point of contact. At Dein Team fürs Leben we work within a network of colleagues in internal medicine, urology and pain medicine.
  • Continuity. Particularly in NIH III, regular check-ups and adjusting the strategy over months make sense. That works better in a GP practice than in a hospital setting.

Consultation at Dein Team fürs Leben

Discreet first contact without a referral. Appointments usually within a week. In the case of acute fever with chills and severe pain when passing urine, call the emergency number.

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Frequently asked questions

Is prostatitis contagious?
No. Bacterial prostatitis is not a sexually transmitted disease in the classic sense. The organisms usually come from your own gut flora and reach the prostate via the urethra. In individual cases, sexually transmitted pathogens can play a role; we check this when taking your history.

Does prostatitis increase the risk of prostate cancer?

According to current data there is no causal link. An inflammation-related PSA rise must, however, be considered in the differential diagnosis. We repeat the PSA test once the inflammation has settled.

How long does treatment take?

We treat acute bacterial prostatitis with antibiotics for two to four weeks, and the chronic bacterial form for four to six weeks. Chronic pelvic pain syndrome is measured in months rather than weeks, because several elements of the treatment have to work together.

Do I have to see a urologist?

No. Most cases of prostatitis can be managed well by a GP, especially in categories II and III. We refer you when imaging, a suspected abscess, treatment failure or invasive diagnostics become necessary.

Can I exercise and have sex during treatment?

With NIH I, pause during the acute phase until fever and pain have subsided. In the chronic forms, moderate exercise and sexual activity are usually allowed and sometimes even part of the treatment. We discuss this with you individually.

Author: Prof. Dr. C.K. Fritz M.Sc., Physician Associate for General Internal Medicine, Pain Medicine, Practice Lead Dein Team fürs Leben.