From the Guidelines
The treatment approach for patients presenting with symptoms of prostatitis should be guided by the classification of the condition, with antibiotics being the cornerstone for bacterial forms, despite the lack of clear recommendations for duration of treatment due to insufficient quality of evidence 1.
Classification and Treatment
The treatment of prostatitis depends on its classification into acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), or chronic pelvic pain syndrome (non-bacterial prostatitis).
- For ABP, fluoroquinolones like ciprofloxacin or levofloxacin are typically prescribed, with trimethoprim-sulfamethoxazole as an alternative option.
- For CBP, a longer course of antibiotics is necessary, using the same agents as for ABP.
- For chronic pelvic pain syndrome, a multimodal approach including alpha-blockers, anti-inflammatory medications, and possibly muscle relaxants is required.
Supportive Measures
Supportive measures for all types of prostatitis include:
- Adequate hydration
- Warm sitz baths
- Avoiding irritants like alcohol, caffeine, and spicy foods
- Pain management with acetaminophen or NSAIDs may be necessary
Duration of Treatment
The optimal durations of treatment for ABP or CBP are unknown and have not been established by high-quality studies 1. Historical durations range from 14 days for ABP to 6 weeks or longer for CBP. However, due to the lack of clear recommendations, treatment should be individualized based on clinical response and patient factors.
Clinical Considerations
Diagnosis for ABP relies on clinical presentation and laboratory tests, while CBP diagnosis involves comparing bacteria levels in prostatic fluid and urinary cultures. Testing for prostate-specific antigen (PSA) appears to be of limited utility. Maneuvers to express prostatic fluid, such as prostate massage, are of limited clinical utility, and urology consultation may be needed.
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.
The treatment approach for patients presenting with symptoms of chronic bacterial prostatitis is levofloxacin 500 mg, once daily for a total of 28 days 2 2.
- Key pathogens targeted by this treatment include:
- Escherichia coli
- Enterococcus faecalis
- Methicillin-susceptible Staphylococcus epidermidis
- The microbiologic eradication rate by patient infection at 5 to 18 days after completion of therapy was 75% in the levofloxacin group 2.
- 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 2.
From the Research
Prostatitis Symptoms
- Prostatitis is characterized by pelvic pain, lower urinary tract symptoms, and ejaculatory pain 3, 4, 5
- The National Institutes of Health divides prostatitis into four syndromes: acute bacterial prostatitis, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis 3, 5
Treatment Approach
- CBP is treated with a prolonged course of an antibiotic that adequately penetrates the prostate, and may also involve alpha blockers or nonopioid analgesics 3, 4
- CNP/CPPS is treated with a combination of alpha blockers, pain medications, and a four- to six-week course of antibiotics, as well as referral to a psychologist experienced in managing chronic pain 3, 5
- The UPOINT approach summarizes the various factors that may contribute to presentation and can guide treatment 3, 6
- Other treatments include pelvic floor physical therapy, phytotherapy, and pain management techniques 3, 7, 6
Treatment Outcomes
- A combination regimen including ciprofloxacin, doxazosin, allopurinol, and biofeedback perineal massage has been shown to be effective in treating chronic prostatitis 7
- A stepwise approach involving multimodal therapy is often successful for treating patients with category III prostatitis 6
- Novel therapies such as alpha-blocker, anti-inflammatory phytotherapy, physiotherapy, and neuroleptics may also be effective in treating prostatitis 6