What is the treatment guideline for prostatitis?

Treatment Guidelines for Prostatitis

For bacterial prostatitis, fluoroquinolones (such as ciprofloxacin 500 mg twice daily) are the first-line treatment, with therapy duration of 2-4 weeks for acute bacterial prostatitis and 4-6 weeks for chronic bacterial prostatitis. 1, 2

Classification of Prostatitis

Prostatitis is classified into four categories according to the National Institute of Diabetes, Digestive, and Kidney Diseases:

1. Acute Bacterial Prostatitis (Category I)
2. Chronic Bacterial Prostatitis (Category II)
3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Category III)
   • IIIA: Inflammatory
   • IIIB: Non-inflammatory
4. Asymptomatic Inflammatory Prostatitis (Category IV)

Diagnostic Approach

Acute Bacterial Prostatitis

• Do not perform prostatic massage (strong recommendation) 1
• Midstream urine dipstick to check nitrite and leukocytes 1
• Midstream urine culture to guide diagnosis and antibiotic treatment 1
• Blood culture and total blood count 1
• Transrectal ultrasound in selected cases to rule out prostatic abscess 1

Chronic Bacterial Prostatitis

• Perform the Meares and Stamey 2- or 4-glass test (strong recommendation) 1
• Microbiological evaluation for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 1
• Do not routinely perform microbiological analysis of ejaculate alone 1

Treatment Guidelines

Acute Bacterial Prostatitis

First-line treatment:

• For severely ill patients with risk of sepsis: IV antibiotics
  • Broad-spectrum penicillins, third-generation cephalosporins, or fluoroquinolones with an aminoglycoside 3
  • Consider piperacillin-tazobactam or meropenem for multi-resistant gram-negative pathogens 3

For less severe cases:

• Oral fluoroquinolones:
  • Ciprofloxacin 500 mg twice daily for 2-4 weeks 2, 4
  • Ofloxacin 200 mg twice daily for 2-4 weeks 4
• Alternative: Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 4

Chronic Bacterial Prostatitis

First-line treatment:

• Ciprofloxacin 500 mg twice daily for 4-6 weeks 2, 4, 5
• Ofloxacin 200 mg twice daily for 4-6 weeks 4
• Norfloxacin 400 mg twice daily for 4-6 weeks 4
• Trimethoprim-sulfamethoxazole 960 mg twice daily for 4-6 weeks 4, 6

For Chlamydial prostatitis:

• Macrolides (more effective than fluoroquinolones) 3
• Tetracyclines (similar efficacy to macrolides) 3

For quinolone-resistant infections:

• Aminoglycosides or fosfomycin 3

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Multimodal approach:

1. Alpha-blockers for urinary symptoms (e.g., tamsulosin, terazosin, alfuzosin) 7, 3
   • Greater response with longer duration of therapy (6-24 weeks) 7
2. Analgesics and NSAIDs for pain management 3
3. Antibiotics if there is suspicion of infection despite negative cultures 3
4. Phytotherapy as primary or adjunctive therapy:
   • Quercetin, pollen extract, Serenoa repens extract 3

Special Considerations

• Duration of therapy is critical:

  • Acute bacterial prostatitis: 2-4 weeks 4, 5
  • Chronic bacterial prostatitis: 4-6 weeks (minimum) 2, 5
  • Some cases may require 6-12 weeks of therapy 6

• Pharmacokinetic considerations:

  • Fluoroquinolones are preferred due to their ability to penetrate prostatic tissue
  • Penetration ratios (prostate:serum) of up to 4:1 7
  • Acidic environment of chronically inflamed prostate can trap certain antibiotics 7

• Treatment assessment:

  • If no improvement in symptoms after 2-4 weeks, reconsider diagnosis and treatment 5
  • If improvement occurs, continue for at least another 2-4 weeks 5
  • Do not continue antibiotics for 6-8 weeks without evaluating effectiveness 5

Common Pitfalls to Avoid

1. Inadequate treatment duration - Chronic bacterial prostatitis requires at least 4 weeks of therapy
2. Performing prostatic massage in acute bacterial prostatitis - Can lead to bacteremia
3. Relying solely on ejaculate analysis for diagnosis of chronic bacterial prostatitis
4. Failing to evaluate for atypical pathogens in chronic cases
5. Not considering antibiotic resistance - Especially important with increasing fluoroquinolone resistance
6. Overlooking the need for partner treatment in cases of sexually transmitted infections

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with prostatitis while minimizing unnecessary antibiotic use and ensuring appropriate diagnostic evaluation.