What is the best plan of action for a patient with persistent prostatitis, incontinence, and constipation, who has completed two rounds of antibiotics, including Cipro (ciprofloxacin) 500 mg twice daily, and has not started Linzess (linaclotide) due to cost concerns?

From the Guidelines

The best plan of action for this patient is to adopt a multi-faceted approach that addresses prostatitis, incontinence, and constipation simultaneously, prioritizing affordable and evidence-based treatments. Given the patient's history of persistent prostatitis despite two rounds of antibiotics, including ciprofloxacin, and the presence of severe incontinence and constipation, a comprehensive evaluation is necessary. This should include urinalysis, urine culture, and possibly prostate fluid analysis to determine if the prostatitis is bacterial or non-bacterial, guiding further treatment decisions 1.

For bacterial prostatitis, considering a longer course (4-6 weeks) of an alternative antibiotic such as trimethoprim-sulfamethoxazole (Bactrim) 160/800 mg twice daily or doxycycline 100 mg twice daily may be beneficial. For non-bacterial prostatitis, symptom management with alpha-blockers like tamsulosin 0.4 mg daily can improve urinary flow and reduce incontinence.

Regarding constipation, the American Gastroenterological Association suggests starting with a gradual increase in fiber intake and inexpensive osmotic agents like polyethylene glycol (Miralax) 17g daily or milk of magnesia, with the option to add a stimulant laxative if necessary 1. Biofeedback therapy can also be effective for defecatory disorders, improving symptoms in over 70% of patients.

Lifestyle modifications are crucial, including increased water intake (2-3 liters daily), regular physical activity, warm sitz baths, and dietary changes to increase fiber and avoid bladder irritants. Pelvic floor physical therapy can address both incontinence and constipation by improving muscle coordination. Implementing an individualized bladder-training program and prompted voiding, as recommended for patients with urinary incontinence, can also be beneficial 1. Additionally, a bowel management program should be considered for the patient's constipation, as suggested for patients with persistent constipation or bowel incontinence 1.

Given the patient's Parkinson's disease and the cost concerns regarding Linzess, these affordable and evidence-based approaches should be prioritized to improve the patient's quality of life and manage morbidity and mortality associated with these conditions.

From the FDA Drug Label

The microbiologic eradication rate by patient infection at 5 to 18 days after completion of therapy was 75% in the levofloxacin group and 76.8% in the ciprofloxacin group (95% CI [-12.58,8. 98] for levofloxacin minus ciprofloxacin). Clinical success (cure + improvement with no need for further antibiotic therapy) rates in microbiologically evaluable population 5 to 18 days after completion of therapy were 75% for levofloxacin-treated patients and 72.8% for ciprofloxacin-treated patients (95% CI [-8.87,13. 27] for levofloxacin minus ciprofloxacin).

The best plan of action for this patient with persistent prostatitis, incontinence, and constipation, who has completed two rounds of antibiotics, including Cipro (ciprofloxacin) 500 mg twice daily, is to consider alternative antibiotic treatment.

• Levofloxacin may be considered as an alternative, given its similar efficacy to ciprofloxacin in treating chronic bacterial prostatitis, as shown in the study 2.
• However, it is essential to weigh the benefits and risks of changing antibiotics, considering the patient's overall clinical presentation and medical history.
• Additionally, the patient's constipation and incontinence should be addressed concurrently, and the use of Linzess (linaclotide), as prescribed by the neurologist, may be reconsidered to help manage constipation, despite the cost concerns.

From the Research

Patient Presentation and History

The patient presents with persistent prostatitis, incontinence, and constipation, despite completing two rounds of antibiotics, including Cipro (ciprofloxacin) 500 mg twice daily. He reports a stinging sensation during urination and severe incontinence that has worsened over the past four weeks.

Treatment Options for Prostatitis

• Antibiotic therapy is recommended for acute exacerbations of chronic prostatitis, chronic bacterial prostatitis, and chronic inflammatory prostatitis, if there is clinical, bacteriological, or supporting immunological evidence of prostate infection 3.
• Fluoroquinolones, such as ciprofloxacin, are preferred agents for treating bacterial causes of prostatitis due to their pharmacologic features and ability to penetrate prostatic tissue 4, 5.
• The minimum duration of antibiotic treatment should be 2-4 weeks, and if there is no improvement in symptoms, treatment should be stopped and reconsidered 3.

Management of Incontinence and Constipation

• The patient's incontinence and constipation should be addressed separately, with consideration of underlying causes, such as Parkinson's disease, and potential interactions with current medications.
• Linzess (linaclotide) may be considered for the treatment of constipation, but the patient has not started it due to cost concerns.

Next Steps

• Re-evaluation of the patient's prostatitis treatment, considering the lack of response to current antibiotics and potential need for alternative or additional therapies.
• Addressing the patient's incontinence and constipation, potentially through referral to a specialist, such as a urologist or gastroenterologist, and consideration of alternative treatments, such as pelvic floor physical therapy or bowel management strategies.
• Discussion of the patient's concerns and cost considerations regarding Linzess (linaclotide) and potential alternative treatments for constipation.