What is the treatment approach for prostatitis?

Treatment Approach for Prostatitis

The treatment of prostatitis requires a targeted approach based on the specific type of prostatitis diagnosed, with antibiotics being the cornerstone therapy for bacterial forms and multimodal symptom management for non-bacterial forms. 1

Types of Prostatitis and Diagnostic Approach

Prostatitis is classified into four categories:

1. Acute Bacterial Prostatitis (ABP)

   • Presents with sudden onset of pelvic pain, urinary symptoms, and often systemic symptoms (fever, chills)
   • Diagnostic workup:
     • Midstream urine dipstick for nitrite and leukocytes
     • Urine culture to guide antibiotic therapy
     • Blood culture and complete blood count
     • Avoid prostatic massage (strong recommendation) 1
     • Consider transrectal ultrasound if prostatic abscess is suspected

2. Chronic Bacterial Prostatitis (CBP)

   • Presents with recurrent UTIs with the same organism
   • Diagnostic workup:
     • Meares and Stamey 2- or 4-glass test (strong recommendation) 1
     • Microbiological evaluation for atypical pathogens (Chlamydia, Mycoplasma)
     • Do not rely on ejaculate analysis alone for diagnosis

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

   • Most common form (>90% of cases) 2
   • Diagnosis of exclusion after ruling out bacterial causes

4. Asymptomatic Inflammatory Prostatitis

   • Incidental finding requiring no treatment 3

Treatment Algorithm

1. Acute Bacterial Prostatitis

• First-line treatment: Empiric antibiotics active against common uropathogens
• Duration: 2-4 weeks 1, 4
• Considerations:
  • Hospitalization for systemically ill patients
  • Catheterization may be needed for urinary retention
  • Evaluate for prostatic abscess if poor response

2. Chronic Bacterial Prostatitis

• First-line treatment: Antibiotics that penetrate the prostate
  • Recommended regimen: Ciprofloxacin 500 mg twice daily for 28 days 5
  • Alternative: Trimethoprim-sulfamethoxazole if fluoroquinolone resistance
• Duration: 4-6 weeks, may extend to 6-12 weeks in recurrent cases 6
• For recurrent infections: Consider long-term suppressive antibiotics 6

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Multimodal approach based on symptom presentation:
  • Alpha-blockers for urinary symptoms
  • Anti-inflammatory agents for pain
  • Short course of antibiotics (4-6 weeks) despite limited evidence 2
  • Pelvic floor physical therapy
  • Psychosocial support for chronic pain management

Special Considerations

1. Antibiotic Selection:

   • Choose antibiotics that penetrate prostatic tissue
   • Fluoroquinolones (e.g., ciprofloxacin) are preferred for adequate prostatic penetration
   • Adjust based on culture results and local resistance patterns

2. Prostatic Abscess:

   • Perform transrectal ultrasound if suspected
   • May require drainage in addition to antibiotics

3. Recurrent Infections:

   • Evaluate for underlying urologic abnormalities
   • Consider longer courses of antibiotics or suppressive therapy

4. Common Pitfalls:

   • Inadequate duration of antibiotic therapy for bacterial prostatitis
   • Overuse of antibiotics in non-bacterial prostatitis
   • Failure to address psychosocial aspects of chronic pain
   • Not performing proper diagnostic tests to differentiate between types of prostatitis

Monitoring and Follow-up

• Bacterial prostatitis: Follow-up cultures to confirm eradication
• CP/CPPS: Regular assessment of symptom improvement
• Consider urology referral for cases not responding to appropriate treatment 2

The treatment of prostatitis requires careful differentiation between bacterial and non-bacterial forms, with targeted therapy based on the specific diagnosis. While antibiotics remain the mainstay for bacterial prostatitis, a more comprehensive approach is needed for chronic pelvic pain syndrome.