What is the treatment for prostatitis?

Treatment of Prostatitis

The treatment of prostatitis depends on the specific type, with fluoroquinolones being the first-line therapy for bacterial prostatitis: ciprofloxacin 500 mg three times daily or ofloxacin 200 mg twice daily for 2-4 weeks in acute bacterial prostatitis, and 4-6 weeks in chronic bacterial prostatitis. 1

Classification of Prostatitis

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

1. Acute bacterial prostatitis (Category I)
2. Chronic bacterial prostatitis (Category II)
3. Chronic prostatitis/chronic pelvic pain syndrome (Category III) - most common form (90% of cases)
4. Asymptomatic inflammatory prostatitis (Category IV)

Diagnostic Approach

Acute Bacterial Prostatitis

• Clinical presentation: fever, perineal pain, urinary symptoms
• Do not perform prostatic massage as it may cause bacteremia 2
• Midstream urine dipstick and culture to guide diagnosis and antibiotic treatment 2
• Blood culture and complete blood count 2
• Transrectal ultrasound in selected cases to rule out prostatic abscess 2, 1

Chronic Bacterial Prostatitis

• Meares and Stamey 2- or 4-glass test is strongly recommended for diagnosis 2, 1
• Accurate microbiological evaluation for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 2
• Do not rely on ejaculate analysis alone for diagnosis 2

Treatment Recommendations

Acute Bacterial Prostatitis (Category I)

• First-line therapy:

  • Fluoroquinolones for 2-4 weeks 1
    • Ciprofloxacin 500 mg three times daily 1, 3
    • Ofloxacin 200 mg twice daily 1, 3
  • Alternative: Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 1, 3

• For severe cases or systemic illness:

  • Hospitalization with IV antibiotics (ceftriaxone or piperacillin/tazobactam) 1
  • Switch to oral therapy once clinically improved

Chronic Bacterial Prostatitis (Category II)

• First-line therapy:

  • Fluoroquinolones for 4-6 weeks 1, 4, 5
    • Ciprofloxacin 500 mg three times daily 1, 6, 4
    • Ofloxacin 200 mg twice daily 1, 4
    • Norfloxacin 400 mg twice daily 4
  • Alternative: Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 4
  • Longer duration (6-12 weeks) may be needed for persistent cases 1

• For specific pathogens:

  • Chlamydia trachomatis:

    • Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 2, 1
    • Azithromycin shows improved eradication and clinical cure rates compared to ciprofloxacin 5

  • Mycoplasma genitalium:

    • Azithromycin 500 mg on day 1, then 250 mg for 4 days 2, 1
    • If macrolide-resistant: Moxifloxacin 400 mg daily for 7-14 days 2, 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Category III)

• Treatment is more complex and often requires multimodal therapy
• Alpha-blockers may help with urinary symptoms 1
• Anti-inflammatory medications for pain management 1
• Antibiotics may be tried in inflammatory (IIIA) subtype, but evidence is limited 7

Management of Complications

Prostatic Abscess

• Small abscesses may respond to antibiotics alone 1
• Larger abscesses require drainage via transrectal ultrasound-guided needle aspiration or small-bore pigtail catheter placement 1

Treatment Failure Considerations

• Ensure correct diagnosis - only 10% of prostatitis cases have confirmed bacterial infection 1
• Adequate duration of antibiotic treatment is crucial 1
• If no improvement after 2-4 weeks, reevaluate diagnosis and consider alternative antibiotics 1
• Replace or remove any indwelling catheter before starting antimicrobial therapy 1
• Sexual partners should be treated in cases of sexually transmitted infections 1

Important Caveats

• Fluoroquinolones have the best prostatic penetration due to their high lipid solubility and favorable pKa 7
• Ciprofloxacin is FDA-approved for chronic bacterial prostatitis caused by Escherichia coli or Proteus mirabilis 6
• Overlooking acute bacterial prostatitis can lead to treatment failure, progression to chronic prostatitis, or missing underlying diseases 8
• Minimum duration of antibiotic treatment should be 2-4 weeks; if there is improvement, continue for an additional 2-4 weeks 4
• Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness 4