What is the initial evaluation and treatment for prostatitis?

From the Guidelines

The initial evaluation for prostatitis includes a thorough history and physical examination, digital rectal examination to assess prostate tenderness, urinalysis and urine culture to identify infection, and sometimes prostate-specific antigen (PSA) testing. Treatment depends on the type of prostatitis identified. For acute bacterial prostatitis, fluoroquinolones like ciprofloxacin (500mg twice daily) or levofloxacin (500mg once daily) are first-line antibiotics for 2-4 weeks 1. Trimethoprim-sulfamethoxazole (160/800mg twice daily) is an alternative. For chronic bacterial prostatitis, the same antibiotics are used but for 4-6 weeks or longer. Chronic pelvic pain syndrome/chronic nonbacterial prostatitis requires multimodal therapy including alpha-blockers like tamsulosin (0.4mg daily), anti-inflammatory medications such as ibuprofen (400-600mg three times daily), and sometimes muscle relaxants. Supportive measures for all types include adequate hydration, sitz baths, avoiding irritants like alcohol and caffeine, and regular ejaculation. Patients should complete the full course of antibiotics even if symptoms improve quickly, and follow-up is important to ensure resolution, particularly for bacterial forms. Treatment success varies, with acute bacterial prostatitis responding well to antibiotics while chronic forms may require longer management strategies.

Some key points to consider in the evaluation and treatment of prostatitis include:

• A thorough history and physical examination to identify underlying causes and contributing factors
• Digital rectal examination to assess prostate tenderness and guide further evaluation
• Urinalysis and urine culture to identify infection and guide antibiotic therapy
• PSA testing to rule out prostate cancer, particularly in older men or those with risk factors
• Consideration of other diagnostic tests, such as transrectal ultrasound or biopsy, in certain cases

It's also important to note that the optimal duration of treatment for prostatitis is not well established, and further research is needed to determine the most effective treatment strategies 1. However, based on current evidence and guidelines, the above approach provides a reasonable framework for evaluating and managing prostatitis.

From the FDA Drug Label

1. 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)].

2. 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.

The initial evaluation of prostatitis involves a clinical diagnosis and microbiological culture results from urine samples or expressed prostatic secretion specimens. The treatment for chronic bacterial prostatitis is levofloxacin 500 mg, once daily for a total of 28 days, which is effective against Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis 2.

From the Research

Initial Evaluation of Prostatitis

• The initial evaluation of prostatitis typically involves a physical examination, including abdominal, genital, and digital rectal examination to assess for a tender, enlarged, or boggy prostate 3.
• Diagnosis is predominantly made based on history and physical examination, but may be aided by urinalysis and urine cultures to determine the responsible bacteria and its antibiotic sensitivity pattern 3, 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 of Prostatitis

• The mainstay of therapy for prostatitis is an antimicrobial regimen, with typical antibiotic regimens including ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam 3.
• For chronic bacterial prostatitis, levofloxacin and ciprofloxacin have been shown to be effective in reducing serum prostate specific antigen (PSA) levels and eradicating the pathogen 5, 6, 7.
• The choice of antibiotic should be based on the results of urine cultures and antibiotic sensitivity testing, as well as the severity of the illness and the presence of any underlying medical conditions 3, 4.
• Hospitalization and broad-spectrum intravenous antibiotics should be considered in patients who are systemically ill, unable to voluntarily urinate, unable to tolerate oral intake, or have risk factors for antibiotic resistance 3.

Classification of Prostatitis

• There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic 4.
• Each classification has its own unique characteristics and treatment approaches, and a thorough evaluation is necessary to determine the correct classification and develop an effective treatment plan 4.