What is the recommended workup and treatment for prostatitis?

Workup and Treatment for Prostatitis

The recommended workup for prostatitis should include urinalysis, urine culture, and the Meares and Stamey 2- or 4-glass test for accurate diagnosis, followed by appropriate antibiotic therapy based on the specific type of prostatitis identified. 1

Diagnostic Workup

Initial Assessment

• Digital rectal examination (DRE) to assess for a tender, enlarged, or boggy prostate 2
• Urinalysis and urine culture to identify causative organisms and determine antibiotic sensitivity 2
• Meares and Stamey 2- or 4-glass test (strongly recommended) for accurate microbiological evaluation 1
• Serum PSA measurement (note: may be elevated during active infection and should be interpreted with caution) 3

Additional Testing

• Transrectal ultrasound if prostatic abscess is suspected, particularly in non-responsive cases 1
• Microbiological evaluation for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) in resistant cases 1
• Full blood count, alkaline phosphatase, and creatinine to assess overall health status 3

Classification and Treatment

1. Acute Bacterial Prostatitis

• Clinical Presentation: Fever, chills, malaise, pelvic pain, dysuria, urinary frequency, and possibly urinary retention 2
• Treatment:
  • Outpatient (mild/moderate): Fluoroquinolones such as ciprofloxacin 500 mg PO twice daily for 4 weeks 4, 1
  • Inpatient (severe/complicated): Broad-spectrum IV antibiotics (ceftriaxone plus doxycycline, or piperacillin/tazobactam) 2
  • Switch to oral therapy when clinically improved and continue for a total of 4 weeks 5

2. Chronic Bacterial Prostatitis

• Clinical Presentation: Recurrent UTIs, variable pelvic pain, and voiding symptoms 5
• Treatment:
  • Fluoroquinolones (first choice): Ciprofloxacin 500 mg PO twice daily for 6-12 weeks 5, 4
  • Alternative: Trimethoprim-sulfamethoxazole if susceptible 1
  • Minimum duration of 6 weeks to achieve clinical cure and pathogen eradication 6

3. Chronic Inflammatory Prostatitis (Culture-negative)

• Clinical Presentation: Similar to chronic bacterial prostatitis but without identifiable pathogens
• Treatment:
  • Trial of antibiotics for 2-4 weeks if there is clinical or immunological evidence of infection 6
  • Symptomatic treatment if no improvement with antibiotics 5

4. Complex Prostatitis (Resistant Cases)

• Treatment:
  • For resistant infections: Meropenem 1g IV every 8 hours plus amikacin 15 mg/kg IV daily 1
  • Alternative options: Ceftolozane/tazobactam or ceftazidime/avibactam 1
  • For specific pathogens:
    • Chlamydia: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 1
    • Mycoplasma: Azithromycin 500 mg on day 1, then 250 mg for 4 days 1

Monitoring and Follow-up

• Clinical assessment after 2 weeks to evaluate symptom improvement 1
• Urine culture at the end of treatment to confirm eradication 1
• Repeat PSA measurement 3 months after resolution of infection if initially elevated 3
• Transrectal ultrasound for patients not responding to appropriate therapy to rule out abscess 1

Important Considerations and Pitfalls

Key Pitfalls to Avoid

1. Inadequate treatment duration: Minimum 4 weeks for acute and 6-12 weeks for chronic bacterial prostatitis 5, 6
2. Failure to identify prostatic abscesses: Consider imaging in non-responsive cases 1
3. Using antibiotics with poor prostatic penetration: Fluoroquinolones have superior penetration 6
4. Overlooking atypical pathogens: Test for Chlamydia and Mycoplasma in resistant cases 1
5. Initiating antibiotics before proper diagnosis: Complete diagnostic workup first, except in cases of acute prostatitis with fever 6
6. Overlooking underlying conditions: ABP is rare in healthy adult men without underlying disease 7

Special Populations

• Immunosuppressed patients: May have atypical infecting organisms requiring additional therapies 8
• Patients with recurrent UTIs: Consider long-term suppressive antibiotic therapy in selected cases 5
• Post-procedural prostatitis: Consider broader antibiotic coverage initially 8

By following this structured approach to diagnosis and treatment, clinicians can effectively manage prostatitis and reduce the risk of complications such as abscess formation or progression to chronic infection.