What is the approach to diagnose and treat prostatitis?

From the Guidelines

Diagnosing and treating prostatitis requires a systematic approach based on the specific type present, with a focus on distinguishing between bacterial and non-bacterial forms to guide appropriate treatment. The approach to diagnose prostatitis involves a thorough history and physical examination, including digital rectal examination to assess prostate tenderness and swelling, as well as laboratory tests such as urinalysis, urine culture, and expressed prostatic secretions analysis 1. According to the European Association of Urology guidelines, the classification proposed by the National Institute of Diabetes, Digestive, and Kidney Diseases should be used to distinguish between bacterial prostatitis and chronic pelvic pain syndrome 1.

For diagnosis, the following steps are recommended:

• Take a midstream urine dipstick to check nitrite and leukocytes in patients with clinical suspicion of acute bacterial prostatitis (ABP) 1
• Take a midstream urine culture in patients with ABP symptoms to guide diagnosis and tailor antibiotic treatment 1
• Perform accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species in patients with chronic bacterial prostatitis (CBP) 1
• Perform the Meares and Stamey 2- or 4-glass test in patients with CBP 1

Treatment for acute bacterial prostatitis involves 2-4 weeks of antibiotics such as fluoroquinolones, trimethoprim-sulfamethoxazole, or doxycycline, while chronic bacterial prostatitis requires longer antibiotic courses of 4-12 weeks. For chronic pelvic pain syndrome (non-bacterial prostatitis), treatment is multimodal, including alpha-blockers, anti-inflammatory medications, and sometimes muscle relaxants 1. Supportive measures for all types include adequate hydration, warm sitz baths, avoiding irritants like alcohol and caffeine, and pelvic floor physical therapy. 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 1.

From the FDA Drug Label

The determination of dosage for any particular patient must take into consideration the severity and nature of the infection, the susceptibility of the causative organism, the integrity of the patient’s host-defense mechanisms, and the status of renal function and hepatic function.

ADULT DOSAGE GUIDELINES Infection Severity Dose Frequency Usual Durations

• used in conjunction with metronidazole ** Drug administration should begin as soon as possible after suspected or confirmed exposure Chronic Bacterial Prostatits Mild/Moderate 500 mg q 12 h 28 Days

The approach to diagnose prostatitis is not directly addressed in the FDA drug label. However, for treatment, the FDA drug label recommends ciprofloxacin 500 mg every 12 hours for 28 days for mild to moderate chronic bacterial prostatitis 2.

From the Research

Diagnosis of Prostatitis

To diagnose prostatitis, a combination of approaches is used, including:

• History and physical examination to assess symptoms and identify any abnormalities 3, 4, 5
• Urine culture to identify bacterial infections and determine antibiotic sensitivity 3, 4, 5
• Urinalysis to check for signs of infection or inflammation 3, 4
• Lower urinary tract localization tests to determine the source of the infection 3
• Symptom index and flow rate measurements to assess the severity of symptoms 3
• Residual urine determination and urine cytology to rule out other conditions 3

Classification of Prostatitis

Prostatitis can be classified into four categories:

• Category I: Acute bacterial prostatitis, characterized by sudden onset of symptoms and positive urine culture 3, 4, 5
• Category II: Chronic bacterial prostatitis, characterized by recurring infections and positive urine culture 3, 4
• Category III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), characterized by chronic pain and inflammation without evidence of infection 3, 4
• Category IV: Asymptomatic inflammatory prostatitis, characterized by inflammation without symptoms 3, 4

Treatment of Prostatitis

Treatment of prostatitis depends on the category and severity of the condition:

• Acute bacterial prostatitis: treated with oral antibiotics and supportive measures 5
• Chronic bacterial prostatitis: treated with long-term antibiotic therapy and may require multiple courses of treatment 6
• CP/CPPS: treatment is often challenging and may involve a combination of antimicrobials, alpha blockers, and anti-inflammatory agents, as well as non-pharmacologic modalities 4
• Asymptomatic inflammatory prostatitis: may not require treatment, but may be monitored for development of symptoms 4

Diagnostic Challenges

Diagnosing prostatitis can be challenging due to:

• Lack of abnormal findings on physical examination, laboratory tests, and radiographic images 7
• Similarity of symptoms to other conditions, such as acute cystitis, benign prostatic hyperplasia, and urinary tract stones 4
• Need for individualized diagnostic approach for each patient 3