What are the treatment options for prostatitis?

Treatment Options for Prostatitis

For prostatitis treatment, fluoroquinolones (particularly levofloxacin 500 mg daily for 28 days) are the first-line therapy for bacterial prostatitis due to their superior prostatic penetration and broad coverage against common pathogens. 1, 2

Classification of Prostatitis

Prostatitis is classified into four categories:

1. Acute Bacterial Prostatitis (Category I)

   • Sudden onset with systemic symptoms
   • Fever, chills, pelvic pain, urinary symptoms
   • Tender, swollen prostate on examination

2. Chronic Bacterial Prostatitis (Category II)

   • Recurrent UTIs with the same organism
   • Persistent symptoms >3 months
   • Less than 10% of prostatitis cases

3. Chronic Pelvic Pain Syndrome (Category III)

   • Inflammatory (IIIA) or non-inflammatory (IIIB)
   • No identifiable bacterial cause
   • Most common form (90% of cases)

4. Asymptomatic Inflammatory Prostatitis (Category IV)

   • Incidental finding during evaluation for other conditions

Diagnostic Approach

• Acute bacterial prostatitis: Clinical presentation plus urinalysis/urine culture
• Chronic bacterial prostatitis: Meares-Stamey 4-glass test or simplified 2-glass test
• Imaging: Prostatic ultrasound may show calcifications in chronic bacterial prostatitis 3

Treatment Algorithm

1. Acute Bacterial Prostatitis

• Outpatient (mild-moderate):

  • Fluoroquinolones: Levofloxacin 500 mg daily or Ciprofloxacin 500 mg twice daily for 2-4 weeks 1, 4
  • Alternative: Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 4

• Inpatient (severe/septic):

  • IV broad-spectrum antibiotics: Third-generation cephalosporins plus aminoglycosides 4, 5
  • Consider piperacillin-tazobactam or meropenem for multi-resistant organisms 3
  • Switch to oral therapy when clinically improved

• Supportive measures:

  • Adequate hydration
  • Analgesics for pain control
  • Alpha-blockers for urinary symptoms

2. Chronic Bacterial Prostatitis

• First-line:

  • Levofloxacin 500 mg daily for 28 days (preferred) 2, 6
  • Ciprofloxacin 500 mg twice daily for 4-6 weeks 7, 4
  • Ofloxacin 200 mg twice daily for 4-6 weeks 4

• Alternative options (for fluoroquinolone-resistant cases):

  • Trimethoprim-sulfamethoxazole 960 mg twice daily for 4-6 weeks 7
  • Aminoglycosides or fosfomycin in selected cases 3
  • For Chlamydia/Mycoplasma: Macrolides or tetracyclines 3

3. Chronic Pelvic Pain Syndrome (CPPS)

• Multimodal approach:
  • Alpha-blockers (tamsulosin, alfuzosin) for urinary symptoms 6, 3
  • Anti-inflammatory medications for pain 3
  • Trial of antibiotics if inflammatory (IIIA) subtype 3
  • Phytotherapy: quercetin, pollen extract, Serenoa repens 3

Special Considerations

• Prostatic abscess: May require drainage via transrectal ultrasound-guided aspiration or placement of small-bore catheters 1

• Recurrent/refractory cases:

  • Consider longer antibiotic courses (6-12 weeks)
  • Evaluate for structural abnormalities
  • Consider probiotics for microbiota restoration 3

• Sexual partners: Should be evaluated and treated if STIs are identified as causative agents 1, 3

Common Pitfalls to Avoid

1. Inadequate duration of therapy: Treating for less than 2-4 weeks often leads to relapse

2. Inappropriate antibiotic selection: Choose antibiotics with good prostatic penetration (fluoroquinolones preferred)

3. Failure to distinguish between categories: Treatment differs significantly between bacterial and non-bacterial forms

4. Overuse of antibiotics: Not all prostatitis is bacterial; avoid prolonged empiric antibiotics in CPPS without evidence of infection

5. Neglecting supportive measures: Alpha-blockers and anti-inflammatories are important adjuncts to antibiotics

6. Missing STIs: Always consider Chlamydia and Mycoplasma in sexually active patients with prostatitis

The evidence strongly supports fluoroquinolones as first-line therapy for bacterial prostatitis, with levofloxacin having excellent documentation of efficacy in chronic bacterial prostatitis with clinical success rates of 75% 2, 6.