From the Guidelines
The initial approach to prostatitis should focus on determining the specific type, as treatment varies accordingly, with acute bacterial prostatitis typically requiring antibiotics like fluoroquinolones for 2-4 weeks, and chronic bacterial prostatitis requiring a longer course of antibiotics, while chronic pelvic pain syndrome requires a multimodal approach including alpha-blockers, anti-inflammatory medications, and potentially muscle relaxants 1.
Key Considerations
- Determining the type of prostatitis is crucial for guiding treatment, with acute bacterial prostatitis (ABP) and chronic bacterial prostatitis (CBP) involving different diagnostic approaches and treatment durations 1.
- For ABP, diagnosis relies on clinical presentation and laboratory tests, while CBP diagnosis involves comparing bacteria levels in prostatic fluid and urinary cultures, although definitive testing is debated 1.
- The optimal durations of treatment for ABP or CBP are unknown and have not been established by high-quality studies, highlighting the need for additional prospective studies to determine the appropriate duration of treatment 1.
Diagnostic Approach
- The European Association of Urology guidelines recommend against performing prostatic massage in ABP, and suggest taking a midstream urine dipstick to check nitrite and leukocytes in patients with clinical suspicion of ABP, as well as taking a midstream urine culture to guide diagnosis and tailor antibiotic treatment 1.
- For CBP, the guidelines recommend performing accurate microbiological evaluation for atypical pathogens, and considering the Meares and Stamey 2- or 4-glass test, while transrectal ultrasound may be useful in selected cases to rule out prostatic abscess 1.
Treatment
- Treatment for ABP typically involves fluoroquinolones like ciprofloxacin or levofloxacin for 2-4 weeks, with trimethoprim-sulfamethoxazole as an alternative option, and patients with severe symptoms may require hospitalization for intravenous antibiotics.
- For CBP, a longer course of antibiotics (4-12 weeks) is necessary, using the same agents, while chronic pelvic pain syndrome requires a multimodal approach including alpha-blockers like tamsulosin, anti-inflammatory medications like ibuprofen, and potentially muscle relaxants.
Supportive Measures
- Supportive measures for all types of prostatitis include adequate hydration, warm sitz baths, avoiding irritants like alcohol and caffeine, and regular ejaculation to help drain the prostate, with pain management being important, particularly for chronic forms 1.
From the Research
Initial Approach to Prostatitis
The initial approach to prostatitis involves a thorough history and examination, including a digital rectal examination, to assess for a tender, enlarged, or boggy prostate 2, 3. A midstream urine (MSU) sample should be collected for urine dipstick, microscopy, and culture to aid in diagnosis 2, 3.
Diagnosis of Prostatitis
Diagnosis of prostatitis is predominantly made based on history and physical examination, but may be aided by urinalysis and urine cultures 2. The classification of prostatitis includes:
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Chronic pelvic pain syndrome
- Asymptomatic inflammatory prostatitis 3
Treatment of Prostatitis
Treatment of prostatitis depends on the classification and severity of the condition.
- Acute bacterial prostatitis can be treated with oral antibiotics, such as ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam, and supportive measures 2.
- Chronic bacterial prostatitis can be treated with antibiotics, such as ciprofloxacin, for a longer duration 4.
- Chronic pelvic pain syndrome may require a multifaceted approach, including treatment of underlying conditions, such as pelvic floor muscle abnormalities and altered neuroendocrine pathways 3.
- Asymptomatic inflammatory prostatitis may not require treatment, but should be monitored for symptoms 3.
Key Considerations
Key considerations in the management of prostatitis include:
- Careful assessment and diagnosis to determine the underlying cause of symptoms 3
- Individualized treatment plans to address the specific needs of each patient 5
- Consideration of new drugs and combination with phytotherapy as potential treatment options 5
- Awareness of the influence of all factors potentially involved in prostate symptoms to establish an effective treatment plan 5