What is the treatment for acute prostatitis?

From the Guidelines

Acute prostatitis is best treated with a 2-4 week course of antibiotics targeting gram-negative organisms, particularly fluoroquinolones like ciprofloxacin (500mg twice daily) or levofloxacin (500mg once daily), as recommended by recent guidelines 1. The treatment of acute prostatitis should prioritize the use of antibiotics that can effectively target the causative pathogens, which are often gram-negative bacteria.

• The choice of antibiotic should be based on local resistance patterns and the severity of the infection.
• Alternative options include trimethoprim-sulfamethoxazole (160/800mg twice daily) or a third-generation cephalosporin, as suggested by the European Association of Urology & European Society for Paediatric Urology guidelines 1.
• For severe cases requiring hospitalization, initial treatment should include intravenous antibiotics such as ampicillin plus gentamicin, or a third-generation cephalosporin with or without an aminoglycoside.
• Supportive measures are equally important, including adequate hydration, pain management with NSAIDs like ibuprofen (400-600mg three times daily) or acetaminophen (1000mg four times daily), and stool softeners to reduce pressure on the prostate.
• Alpha-blockers such as tamsulosin (0.4mg daily) may help relieve urinary symptoms by relaxing the bladder neck and prostatic urethra, as noted in the guidelines for the management of urinary tract infections 1.
• Patients should avoid activities that may worsen symptoms, including alcohol, caffeine, and spicy foods.
• If urinary retention occurs, catheterization may be necessary, preferably using a suprapubic catheter to avoid further irritation of the prostate.
• The optimal duration of treatment for acute prostatitis is unknown and has not been established by high-quality studies, as noted in the guidelines for the prevention, diagnosis, and management of urinary tract infections 1.
• However, most cases respond well to appropriate antibiotic therapy within 48-72 hours, but complete resolution of symptoms may take several weeks, as suggested by the effectiveness of antibiotic treatment in achieving adequate tissue penetration into the inflamed prostate 1.

From the Research

Treatment Options for Acute Prostatitis

• Acute bacterial prostatitis can be treated with oral antibiotics and supportive measures as an outpatient, but hospitalization and broad-spectrum intravenous antibiotics may be necessary for systemically ill patients 2.
• Typical antibiotic regimens for acute prostatitis include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam 2.
• For severely ill patients, initial treatment with intravenous administration of high doses of bactericidal antimicrobials, such as broad-spectrum penicillins, third-generation cephalosporins, or fluoroquinolones, is recommended in combination with an aminoglycoside 3.

Treatment Options for Chronic Prostatitis

• The treatment of chronic prostatitis is more difficult due to the relative impermeability of the non-inflamed prostate to most antimicrobial agents 4.
• Trimethoprim or doxycycline are preferred agents for treating chronic prostatitis, with doxycycline having the advantage of being active against chlamydia 4.
• Fluoroquinolones, such as levofloxacin, are commonly used as a first-line agent for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) 5.
• Combination therapies, such as fluoroquinolones with an alpha-blocker, may yield better results than antibiotic therapies alone 6.
• Other treatment options for CP/CPPS include alpha-blockers, 5-alpha reductase inhibitors, anti-inflammatories, steroids, glycosaminoglycans, and phytotherapy 5.

Multidisciplinary Approach to Prostatitis

• A multidisciplinary approach to prostatitis, including urology, microbiology, and immunology, is necessary for effective management 3.
• The UPOINT system can be used to identify groups of clinicians with homogeneous clinical presentation and recognize phenotypes to be submitted to specific treatments 3.
• Prostatic ultrasound and multiparametric magnetic resonance imaging (mpMRI) can be used as imaging tests in the work-up of prostatitis 3.
• Dietary changes and regulation of intestinal flora through probiotics or hydrocolontherapy may also be beneficial in managing prostatitis symptoms 3.