What is the appropriate management for a 47-year-old male with symptoms of prostatitis, weak erections, and a history of diabetes, hypertension, and hepatitis C, who is also a heavy tobacco user?

Management of Prostatitis and Erectile Dysfunction in a 47-Year-Old Male with Multiple Comorbidities

For this 47-year-old male with symptoms of prostatitis and erectile dysfunction, the recommended treatment is a 14-day course of Levofloxacin 500 mg daily combined with PDE5 inhibitor therapy for erectile dysfunction, along with lifestyle modifications including smoking cessation and improved glycemic control. 1, 2

Prostatitis Management

Diagnosis and Classification

• Patient presents with symptoms consistent with prostatitis:
  • Urinary urgency, frequency, feeling of incomplete emptying
  • Prostate tenderness on examination
  • Heterogeneous prostate with calcifications on sonogram

Antibiotic Therapy

• Levofloxacin 500 mg daily for 14 days is appropriate for chronic bacterial prostatitis 1
  • FDA-approved for chronic bacterial prostatitis caused by E. coli, E. faecalis, or S. epidermidis
  • Provides excellent penetration into prostatic tissue
  • Once-daily dosing improves compliance

Supportive Measures

• Warm sitz baths as recommended are appropriate adjunctive therapy
• Follow-up evaluation after 2-4 weeks to assess treatment response 3
• If symptoms persist after 4 weeks, reassessment is necessary

Erectile Dysfunction Management

Risk Factor Assessment

• Patient has multiple risk factors for ED:
  • Diabetes
  • Hypertension
  • Heavy tobacco use
  • Hepatitis C

Recommended Treatment Approach

1. First-line therapy: PDE5 inhibitors 2

   • Strong recommendation based on Grade B evidence
   • Options include sildenafil, tadalafil, vardenafil, or avanafil
   • Dose should be titrated for optimal efficacy

2. Lifestyle modifications 2

   • Smoking cessation (critical as patient is a heavy tobacco user)
   • Regular aerobic exercise
   • Improved glycemic control (patient is on multiple diabetes medications)
   • Blood pressure management

Special Considerations

• Diabetic patients typically have more severe ED at baseline and may respond less robustly to PDE5 inhibitors 2
• Cardiac risk assessment is essential before initiating ED treatment 2
• Common side effects of PDE5 inhibitors include headache, flushing, dyspepsia, and nasal congestion 2

Integrated Management Approach

Priority Treatment Steps

1. Treat prostatitis with Levofloxacin 500 mg daily for 14 days
2. Initiate PDE5 inhibitor therapy for ED after ensuring no contraindications
3. Implement aggressive lifestyle modifications, particularly smoking cessation
4. Ensure optimal management of diabetes and hypertension

Follow-up Plan

• Evaluate prostatitis symptoms after completing antibiotic course
• Proceed with planned cystoscopy to evaluate microscopic hematuria
• Monitor response to ED treatment and adjust as needed
• Regular follow-up for diabetes and hypertension management

Important Caveats

• PDE5 inhibitors are contraindicated with nitrate medications 2
• Careful monitoring of hepatic function is necessary due to patient's hepatitis C history
• If no improvement in ED with PDE5 inhibitors, consider measuring testosterone levels 2
• Microscopic hematuria requires complete evaluation as planned, especially given smoking history as a risk factor for urothelial carcinoma

This comprehensive approach addresses both the infectious process and sexual dysfunction while accounting for the patient's multiple comorbidities and risk factors.