What is the treatment for prostatitis caused by a sexually transmitted infection (STI)?

Treatment for Prostatitis Caused by Sexually Transmitted Infections

For prostatitis caused by sexually transmitted infections (STIs), the recommended first-line treatment is azithromycin 1g orally in a single dose OR doxycycline 100mg orally twice daily for 7 days. 1

Diagnostic Approach

Before initiating treatment, confirm the diagnosis with:

• Urethral swab or first-void urine for STI testing (particularly for N. gonorrhoeae and C. trachomatis)
• Gram-stained smear of urethral exudate to check for urethritis (≥5 WBC per high-power field)
• Evaluation for other STIs including syphilis and HIV

Treatment Algorithm Based on Specific STI Pathogens

Chlamydia trachomatis Prostatitis

• First-line:
  • Azithromycin 1g orally in a single dose 1, 2
  • OR Doxycycline 100mg orally twice daily for 7 days 1, 3

Neisseria gonorrhoeae Prostatitis

• Recommended regimen:
  • Ceftriaxone 250mg IM in a single dose PLUS
  • Doxycycline 100mg orally twice daily for 10 days 1

Mycoplasma genitalium Prostatitis

• Azithromycin 1g orally in a single dose (more effective than doxycycline for this pathogen) 1

Persistent/Recurrent Prostatitis After Initial Treatment

If symptoms persist after initial therapy and reinfection is excluded:

• Metronidazole 2g orally in a single dose OR Tinidazole 2g orally in a single dose
• PLUS Azithromycin 1g orally in a single dose (if not used for initial episode) 1

Duration of Treatment

• For uncomplicated STI-related prostatitis: 7-10 days of therapy
• For chronic bacterial prostatitis: Extended therapy of 2-4 weeks may be necessary 4
• For epididymo-orchitis caused by C. trachomatis: Doxycycline 100mg orally twice daily for at least 10 days 3

Partner Management

• All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1
• Partners should be treated empirically with regimens effective against chlamydia
• Patients should abstain from sexual intercourse until:
  • 7 days after single-dose therapy or completion of 7-day regimen
  • Symptoms have resolved
  • All partners have been adequately treated 1

Follow-Up Recommendations

• Patients should return for evaluation if symptoms persist or recur after completing therapy
• Symptoms alone without objective signs of inflammation are not sufficient basis for retreatment
• Persistence of pain, discomfort, and irritative voiding symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 1
• Repeat testing 3-6 months after treatment is recommended due to high reinfection rates 1

Important Caveats

• Single-dose regimens (azithromycin) have the advantage of improved compliance and directly observed treatment 1
• Medications should ideally be provided in the clinic with the first dose directly observed to improve compliance
• Fluoroquinolones (ofloxacin, levofloxacin) are alternative options but should be reserved for cases where first-line agents cannot be used due to increasing resistance concerns 1, 4
• For patients with HIV infection, the same treatment regimens should be used as for HIV-negative patients 1
• Untreated STI-related prostatitis can lead to serious complications including infertility and chronic pain 5

By following this evidence-based approach to treating STI-related prostatitis, clinicians can effectively manage this condition while minimizing complications and preventing transmission to partners.