What is the recommended workup and treatment for prostatitis?

Workup and Treatment for Prostatitis

The recommended workup for prostatitis should include the Meares and Stamey 4-glass test for diagnosis, along with a thorough evaluation for causative organisms, with treatment consisting of appropriate antibiotics for 4-6 weeks for bacterial prostatitis. 1

Diagnostic Workup

Initial Assessment

• Digital rectal examination (DRE) to assess prostate tenderness, size, and consistency 1
• Urinalysis and urine culture before and after prostatic massage (Meares-Stamey 4-glass test) 1, 2
• Serum PSA measurement (note that PSA may be elevated during active prostatitis) 3
• Transrectal ultrasound to assess prostate structure and rule out abscess in non-responsive cases 1

Microbiological Evaluation

• Specific cultures for common uropathogens (E. coli, Enterococcus spp.) 4
• Testing for atypical pathogens when indicated:
  • Chlamydia trachomatis
  • Mycoplasma species 1

Classification and Treatment

1. Acute Bacterial Prostatitis

• Presentation: Fever, chills, severe urinary symptoms, tender prostate on examination 4
• Treatment:
  • For severe cases: Parenteral antibiotics such as meropenem 1g IV every 8 hours plus amikacin 15 mg/kg IV daily 1
  • For moderate cases: Oral fluoroquinolones such as ciprofloxacin 500 mg twice daily for 4 weeks 5, 2
  • Consider hospitalization for patients with high fever, inability to void, or signs of sepsis 4
  • Duration: 4 weeks for acute bacterial prostatitis 2

2. Chronic Bacterial Prostatitis

• Presentation: Recurrent UTIs, persistent urinary symptoms, variable prostate examination 2
• Treatment:
  • First-line: Ciprofloxacin 500 mg twice daily for 6-12 weeks 5, 2
  • Alternative: Trimethoprim-sulfamethoxazole if susceptible 1
  • Duration: 6-12 weeks is typically required 2, 6
  • Clinical assessment after 2 weeks to evaluate symptom improvement 1

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Presentation: Pelvic pain, variable urinary symptoms, normal urinalysis 7
• Treatment:
  • Trial of antibiotics even when infection is not confirmed due to high rate of occult infection 7
  • Symptomatic relief with:
    • NSAIDs for pain management
    • Alpha-blockers for urinary symptoms
    • Anticholinergic agents for storage symptoms 7

Special Considerations

Prostatic Abscess

• Suspect in patients not responding to appropriate antibiotic therapy
• Transrectal ultrasound is essential for diagnosis
• Small abscesses (<1 cm) may respond to antibiotics alone
• Larger abscesses require drainage via transrectal ultrasound-guided aspiration 1

Immunocompromised Patients

• Require special attention as atypical organisms may be involved
• May need broader antimicrobial coverage and longer duration of therapy 4

Common Pitfalls to Avoid

1. Inadequate treatment duration (minimum 4-6 weeks for bacterial prostatitis) 1, 6
2. Failure to identify prostatic abscesses in non-responsive cases 1
3. Using antibiotics with poor prostatic penetration 6
4. Overlooking atypical pathogens such as Chlamydia and Mycoplasma 1
5. Not addressing underlying structural abnormalities that may contribute to recurrent infection 1
6. Premature discontinuation of antibiotics when initial symptom improvement occurs 6

Monitoring and Follow-up

• Clinical assessment after 2 weeks of treatment to evaluate symptom improvement 1
• Urine culture at the end of treatment to confirm eradication 1
• For chronic bacterial prostatitis, longer follow-up may be needed to monitor for recurrence 2
• Consider long-term suppressive antibiotic therapy for patients with recurrent bacteriuria 2

By following this structured approach to diagnosis and treatment, the morbidity associated with prostatitis can be significantly reduced, improving quality of life and preventing complications such as chronic infection or abscess formation.