What is the treatment for prostatitis?

Treatment of Prostatitis

The treatment of prostatitis should be tailored to the specific type of prostatitis, with fluoroquinolones being the first-line treatment for bacterial prostatitis due to their favorable antibacterial spectrum and pharmacokinetic profile. 1

Types of Prostatitis and Diagnosis

Prostatitis is classified into several categories according to the National Institute of Diabetes, Digestive, and Kidney Diseases:

1. Acute Bacterial Prostatitis (ABP)

   • Presents with fever, perineal pain, urinary symptoms
   • Diagnosis: Clinical presentation, urine dipstick for nitrites and leukocytes, midstream urine culture, blood culture, and total blood count 1
   • Do not perform prostatic massage in ABP (Strong recommendation) 1

2. Chronic Bacterial Prostatitis (CBP)

   • Presents with variety of pelvic pain and voiding symptoms
   • Characterized by recurrent UTIs
   • Diagnosis: Meares and Stamey 2- or 4-glass test (Strong recommendation) 1
   • Consider microbiological evaluation for atypical pathogens like Chlamydia trachomatis and Mycoplasma species 1

3. Chronic Pelvic Pain Syndrome (Non-bacterial prostatitis)

   • More common than bacterial forms
   • Etiology largely unknown

Treatment Algorithms

For Acute Bacterial Prostatitis:

1. First-line therapy:

   • Fluoroquinolones (e.g., ciprofloxacin, levofloxacin, ofloxacin)
   • Consider hospitalization and IV antibiotics for patients who are systemically ill, unable to urinate voluntarily, unable to tolerate oral intake, or have risk factors for antibiotic resistance 2
   • Typical IV regimens: ceftriaxone and doxycycline, ciprofloxacin, or piperacillin/tazobactam 2

2. Duration:

   • 4 weeks of treatment 3

3. Additional measures:

   • Perform transrectal ultrasound in selected cases to rule out prostatic abscess 1
   • If abscess is present, drainage may be required via transrectal ultrasound-guided needle aspiration or small-bore pigtail catheter placement 4

For Chronic Bacterial Prostatitis:

1. First-line therapy:

   • Fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin) 1, 5
   • Levofloxacin 500 mg daily for 28 days has shown 75% microbiologic eradication rate 5

2. For specific pathogens:

   • Chlamydia trachomatis: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 4
   • 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 4
   • Ureaplasma urealyticum: Doxycycline 100 mg twice daily for 7 days or azithromycin 1.0-1.5 g single dose 1

3. Duration:

   • Minimum 2-4 weeks, extend to 6-12 weeks if improvement occurs 6, 3
   • Do not continue antibiotics for 6-8 weeks without appraising effectiveness 6

4. If treatment fails:

   • Reassess diagnosis
   • Consider long-term suppressive antibiotic therapy for recurrent bacteriuria 3

Important Considerations

• Fewer than 10% of prostatitis cases are confirmed to have bacterial infection 1
• Enterobacterales are the primary pathogens in acute bacterial prostatitis 1
• Chronic bacterial prostatitis encompasses a broader spectrum of species, including atypical microorganisms 1
• Sexual partners should be treated in cases of sexually transmitted infections 4
• Effective antibiotics must penetrate prostatic tissue and secretions (fluoroquinolones, macrolides, tetracyclines, and trimethoprim) 7, 8

Common Pitfalls to Avoid

1. Initiating antibiotics without proper diagnosis:

   • Unless a patient presents with fever (acute prostatitis), antibiotic treatment should not be initiated immediately
   • Complete appropriate investigations first, within a reasonable time period (preferably not longer than 1 week) 6

2. Overlooking non-bacterial causes:

   • Only 10% of prostatitis cases have confirmed bacterial infection 1
   • Non-bacterial prostatitis requires different management approaches

3. Missing prostatic abscess:

   • Consider imaging in patients not responding to antibiotics 4

4. Inadequate treatment duration:

   • Too short courses lead to recurrence
   • Too long courses without reassessment lead to unnecessary antibiotic exposure

5. Failure to identify causative organism:

   • Proper microbiological sampling is essential for targeted therapy 4

By following these evidence-based guidelines, clinicians can optimize treatment outcomes for patients with prostatitis while minimizing unnecessary antibiotic use and improving quality of life.