What is the treatment for prostatitis or urethritis?

Treatment for Prostatitis and Urethritis

For urethritis, first-line treatment is azithromycin 1g orally in a single dose or doxycycline 100mg orally twice daily for 7 days. For bacterial prostatitis, fluoroquinolones are the first-line treatment with duration of 2-4 weeks for acute and 4-6 weeks for chronic cases. 1

Urethritis Treatment

Diagnosis

• Perform a Gram stain of urethral discharge or smear for preliminary diagnosis 1
• Conduct nucleic acid amplification test (NAAT) on first-void urine sample or urethral smear to diagnose chlamydial and gonococcal infections 1
• If symptoms are mild, delay treatment until NAAT results are available 1

Treatment Regimens for Urethritis

1. First-line options:

   • Azithromycin 1g orally in a single dose 1, 2
   • Doxycycline 100mg orally twice daily for 7 days 1

2. Alternative regimens:

   • Erythromycin base 500mg orally four times daily for 7 days 1
   • Erythromycin ethylsuccinate 800mg orally four times daily for 7 days 1
   • Ofloxacin 300mg orally twice daily for 7 days 1
   • Levofloxacin 500mg orally once daily for 7 days 1

For Recurrent/Persistent Urethritis

• 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

Prostatitis Treatment

Classification

1. Acute Bacterial Prostatitis (ABP)

   • Presents with fever, perineal pain, urinary symptoms
   • Primarily caused by Enterobacterales 1

2. Chronic Bacterial Prostatitis (CBP)

   • Characterized by recurrent UTIs
   • Broader spectrum of pathogens including atypical microorganisms 1

Diagnosis

• For ABP: Clinical presentation, urine dipstick, midstream urine culture, blood culture 3
• For CBP: Meares and Stamey 2- or 4-glass test (Strong recommendation) 1, 4

Treatment Regimens for Prostatitis

Acute Bacterial Prostatitis

• First-line treatment:

  • Fluoroquinolones (e.g., ciprofloxacin, ofloxacin) 1, 4
  • Treatment duration: 2-4 weeks 4, 3

• Alternative regimens:

  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin 1

Chronic Bacterial Prostatitis

• First-line treatment:

  • Fluoroquinolones (e.g., ciprofloxacin, ofloxacin) 4, 3
  • Treatment duration: 4-6 weeks, may be extended to 6-12 weeks if improvement occurs 3

• Alternative regimens:

  • Trimethoprim-sulfamethoxazole (if pathogen is susceptible) 5, 3
  • Doxycycline (especially if Chlamydia is suspected) 5, 6

Important Considerations

For Urethritis

• Patients should abstain from sexual intercourse until 7 days after therapy is initiated 1
• Sexual partners within the preceding 60 days should be referred for evaluation and treatment 1
• Symptoms alone without signs or laboratory evidence of urethral inflammation are not sufficient for re-treatment 1

For Prostatitis

• Do not initiate antibiotics without proper diagnosis unless the patient presents with fever (acute prostatitis) 4
• Consider prostatic abscess in patients not responding to antibiotics 3
• For chronic prostatitis, if there is improvement after initial 2-4 weeks, continue treatment for at least another 2-4 weeks 4
• Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness 4

Potential Pitfalls

• Inadequate treatment duration can lead to recurrence 7
• Relying on empiric treatment without proper diagnosis can lead to antibiotic resistance 1, 7
• Non-bacterial causes of prostatitis require different management approaches 7
• Fluoroquinolones should not be used for empirical treatment if local resistance rate is ≥10% or if the patient has used fluoroquinolones in the last 6 months 1

By following these evidence-based treatment guidelines, clinicians can effectively manage prostatitis and urethritis, minimizing morbidity and improving quality of life for affected patients.