From the Guidelines
Prostatitis treatment should be guided by the type of prostatitis, with acute bacterial prostatitis requiring immediate antibiotic therapy, and chronic bacterial prostatitis needing longer antibiotic courses, despite the lack of clear recommendations for duration of treatment 1.
Diagnosis and Treatment
The clinical presentation, diagnostic approach, and treatment for acute and chronic prostatitis are crucial in managing the condition. According to the guidelines for the prevention, diagnosis, and management of urinary tract infections, the clinical review found insufficient quality of evidence to enable a clear recommendation for the treatment of prostatitis 1.
- Acute bacterial prostatitis (ABP) often presents abruptly with febrile UTI symptoms, while chronic bacterial prostatitis (CBP) involves more persistent symptoms or recurrent UTIs.
- Diagnosis for ABP relies on clinical presentation and laboratory tests, while CBP diagnosis involves comparing bacteria levels in prostatic fluid and urinary cultures.
- The optimal durations of treatment for ABP or CBP are unknown and have not been established by high-quality studies 1.
Recommendations
Based on the available evidence, the following recommendations can be made:
- Do not perform prostatic massage in ABP 1.
- Take a midstream urine dipstick to check nitrite and leukocytes in patients with clinical suspicion of ABP 1.
- Take a midstream urine culture in patients with ABP symptoms to guide diagnosis and tailor antibiotic treatment 1.
- Perform accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species in patients with CBP 1.
Treatment Options
Despite the lack of clear recommendations for duration of treatment, the following treatment options can be considered:
- Acute bacterial prostatitis: immediate antibiotic therapy, typically ciprofloxacin 500mg twice daily or trimethoprim-sulfamethoxazole 160/800mg twice daily for 2-4 weeks.
- Chronic bacterial prostatitis: longer antibiotic courses of 4-12 weeks.
- Chronic pelvic pain syndrome (non-bacterial prostatitis): treatment includes alpha-blockers like tamsulosin 0.4mg daily, anti-inflammatories such as ibuprofen 400-800mg three times daily, and pelvic floor physical therapy.
Supportive Measures
Supportive measures for all types of prostatitis include:
- Warm sitz baths
- Increased fluid intake
- Avoiding irritants like alcohol and caffeine
- Over-the-counter pain relievers It is essential to note that if symptoms persist despite treatment, further evaluation is necessary to rule out other conditions like prostate cancer.
From the FDA Drug Label
8 Chronic Bacterial Prostatitis Levofloxacin tablets are indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis [see Clinical Studies (14.6)].
6 Chronic Bacterial Prostatitis Adult patients with a clinical diagnosis of prostatitis and microbiological culture results from urine sample collected after prostatic massage (VB3) or expressed prostatic secretion (EPS) specimens obtained via the Meares-Stamey procedure were enrolled in a multicenter, randomized, double-blind study comparing oral levofloxacin 500 mg, once daily for a total of 28 days to oral ciprofloxacin 500 mg, twice daily for a total of 28 days.
Levofloxacin is indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis. The recommended treatment duration is 28 days. Key points include:
- Microbiologic eradication rate: 75% in the levofloxacin group and 76.8% in the ciprofloxacin group 2
- Clinical success rates: 75% for levofloxacin-treated patients and 72.8% for ciprofloxacin-treated patients 2
From the Research
Definition and Classification of Prostatitis
- Prostatitis is a collection of signs and symptoms that occur as a result of inflammation or swelling of the prostate gland 3
- There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic 4
- The National Institutes of Health (NIH) has a consensus classification for prostatitis, which includes these four categories 5
Diagnosis of Prostatitis
- Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage 4
- The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract 4
Treatment Options for Prostatitis
- The mainstay of therapy for prostatitis is an antimicrobial regimen 4
- Fluoroquinolones are the preferred agents for treating bacterial causes of prostatitis and have demonstrated efficacy in some cases of chronic prostatitis when an organism has not been identified 3
- Combination therapy with an α-blocker, an anti-inflammatory, and a muscle relaxant does not appear to offer significant advantages over monotherapy 3
- A stepwise approach to therapy involving antibiotics followed by bioflavonoids and then α-blockers appears to effectively reduce symptoms for up to 1 year in patients with chronic prostatitis 3
- Levofloxacin is more effective than doxazosin for chronic prostatitis/chronic pelvic pain syndrome 6
- Combination therapy with antibacterial agents, alpha-blockers, and Serenoa repens extracts can eradicate infecting organisms in chronic bacterial prostatitis 7
Treatment Outcomes and Response Rates
- Clinical success rates of 92% (95% CI 84.8%-96.5%), 77.4% (95% CI, 68.2-84.9%), 66.0% (95% CI, 56.2%-75.0%), and 61.9% (95% CI, 51.9%-71.2%) at 5-12 days, 1 month, 3 months, and 6 months after treatment with levofloxacin have been reported 3
- The response rate to levofloxacin was 50.3% at 6 weeks, compared to 21.1% for doxazosin 6
- The cumulative eradication rate of combination therapy for chronic bacterial prostatitis was 83.9% 7