What are the treatment options for prostatitis?

Treatment of Prostatitis

Fluoroquinolones are the first-line treatment for bacterial prostatitis, with levofloxacin 500 mg daily for 28 days being the recommended regimen for chronic bacterial prostatitis based on its superior prostate penetration and documented efficacy. 1

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 Pelvic Pain Syndrome (Category III)
   • IIIA: Inflammatory
   • IIIB: Non-inflammatory
4. Asymptomatic Inflammatory Prostatitis (Category IV)

Diagnostic Approach

• Acute bacterial prostatitis: Diagnosis based on clinical presentation (fever, perineal pain, urinary symptoms) and laboratory tests 2
• Chronic bacterial prostatitis: Diagnosis involves comparing bacteria levels in prostatic fluid and urinary cultures 2
• Microbiological testing: Urine culture and prostatic fluid examination are essential for bacterial identification 2
• Imaging: Not routinely required but may be helpful in complicated cases

Treatment Algorithms by Type

1. Acute Bacterial Prostatitis

• First-line treatment:

  • For severely ill patients: IV antibiotics (broad-spectrum penicillins, third-generation cephalosporins, or fluoroquinolones) plus an aminoglycoside 3
  • For less severe cases: Oral fluoroquinolones (ciprofloxacin 500 mg twice daily or levofloxacin 500 mg daily) 4

• Duration: 4 weeks 4

• Alternative regimens (for fluoroquinolone resistance or allergies):

  • Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 4
  • Piperacillin-tazobactam or meropenem for multi-resistant gram-negative pathogens 3

2. Chronic Bacterial Prostatitis

• First-line treatment:

  • Levofloxacin 500 mg daily for 28 days (preferred due to documented efficacy in clinical trials) 1, 5
  • Ciprofloxacin 500 mg three times daily or ofloxacin 200 mg twice daily for 4-6 weeks 4, 6

• For specific pathogens:

  • Chlamydia trachomatis: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 2
  • Mycoplasma genitalium: Azithromycin 500 mg on day 1, then 250 mg for 4 days; if macrolide-resistant, use moxifloxacin 400 mg daily for 7-14 days 2

3. Chronic Pelvic Pain Syndrome (CPPS)

• Multimodal approach:
  1. Alpha-blockers: For urinary symptoms (tamsulosin, alfuzosin, terazosin) 5, 3
  2. Anti-inflammatory agents: For pain control 3
  3. Antibiotics: If inflammatory markers are present, even without identified pathogen 3
  4. Phytotherapy: Quercetin, pollen extract, Serenoa repens as adjunctive therapy 3

4. Prostatic Abscess Management

• Small abscesses: May respond to antibiotics alone 2
• Larger abscesses: Require drainage via:
  • Transrectal ultrasound-guided needle aspiration or small-bore pigtail catheter placement 2
  • Transurethral drainage for larger or multiloculated abscesses 2

Special Considerations

• Fluoroquinolone advantages: Superior penetration into prostatic tissue with prostate-to-serum ratios up to 4:1 5
• Treatment duration: Minimum 2-4 weeks; if improvement occurs, continue for additional 2-4 weeks 6
• Treatment monitoring: If no improvement after 2-4 weeks, reevaluate diagnosis and treatment 6
• Sexual partners: Should be treated in cases of sexually transmitted infections 2

Common Pitfalls to Avoid

1. Inadequate treatment duration: Treating for less than 2-4 weeks often leads to relapse 6
2. Failure to identify causative organism: Proper microbiological sampling is essential 2
3. Overlooking non-bacterial causes: Only 10% of prostatitis cases have confirmed bacterial infection 2
4. Continuing ineffective antibiotics: Reassess if no improvement after 2-4 weeks 6
5. Missing prostatic abscess: Consider imaging in patients not responding to antibiotics 2

By following these evidence-based guidelines, clinicians can effectively manage prostatitis while minimizing complications and improving patient outcomes.