“I’ve got pain down below, burning when I wee and I feel feverish — is it just a water infection?”

PERINEAL/pelvic/low back pain with LUTS (dysuria, frequency, urgency, hesitancy), PAINFUL EJACULATION and FEVER/systemic illness in a man is ACUTE PROSTATITIS — a bacterial infection of the prostate, with an exquisitely tender/boggy prostate on gentle DRE at a same-day face-to-face assessment (not possible by video) — not "just a water infection", and a urinary infection in a man is itself uncommon and significant. Send a urine culture before antibiotics (and consider an STI screen where sexual history is relevant, as chlamydia/gonorrhoea can cause prostatitis), and assess the wider urinary tract. Critically, assess for SEPSIS (high fever, rigors, tachycardia, hypotension — NICE NG253; may need admission/IV antibiotics) and the key red flag of ACUTE URINARY RETENTION, because NICE NG110 advises hospital referral for sepsis, retention or a suspected prostatic abscess, and in prostatitis the catheterisation route (urethral or suprapubic) is a specialist decision — so retention warrants urgent hospital/urology assessment rather than a routine attempt. Treat with an antibiotic that PENETRATES the prostate — NICE NG110: a FLUOROQUINOLONE (ciprofloxacin/ofloxacin), or trimethoprim if a fluoroquinolone is not appropriate, weighing the MHRA January 2024 restriction (fluoroquinolones only when other commonly recommended antibiotics are inappropriate) and local guidance/culture — for a PROLONGED course (14 days, then review and stop or continue for a further 14 days) to prevent chronic prostatitis/abscess, with analgesia, counselling fluoroquinolone cautions (tendon/aortic/neuropsychiatric/QT) and adjusting to culture; admit if septic/severe. Distinguish acute prostatitis from CHRONIC prostatitis/CHRONIC PELVIC PAIN SYNDROME (persistent pelvic/perineal pain and LUTS >3 months, often non-bacterial, managed multimodally). Do NOT measure PSA during acute infection (falsely elevated; defer at least 6 weeks, UKHSA PCRMP), and safety-net for retention, worsening sepsis or non-improvement within 48 hours (hospital referral, NICE NG110), with culture-guided follow-up and urology referral if recurrent, abscess suspected or retention. The hidden agenda is the wish for "antibiotics for a water infection"; recognise prostatitis as more than a simple UTI and treat it adequately, not as simple cystitis.