What are the diagnostic and treatment approaches for a patient presenting with prostatitis symptoms?

Diagnostic and Treatment Approaches for Prostatitis

Prostatitis requires specific diagnostic testing and targeted antimicrobial therapy based on the classification, with fluoroquinolones being the first-line treatment for bacterial forms due to their favorable antibacterial spectrum and pharmacokinetic profile. 1

Classification of Prostatitis

Prostatitis is classified into four main categories:

1. Acute Bacterial Prostatitis (ABP)

   • Presents with fever, perineal pain, and urinary symptoms
   • Primarily caused by Enterobacterales 2

2. Chronic Bacterial Prostatitis (CBP)

   • Characterized by recurrent UTIs
   • Involves a broader spectrum of pathogens, including atypical microorganisms 2

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

   • Most common form (>90% of cases)
   • No confirmed bacterial infection 3

4. Asymptomatic Inflammatory Prostatitis

   • Incidental finding during evaluation for other urologic problems 3

Diagnostic Approach

For Acute Bacterial Prostatitis:

• Do not perform prostatic massage (Strong recommendation) 2
• Midstream urine dipstick to check for nitrites and leukocytes 2
• Midstream urine culture to guide diagnosis and tailor antibiotic treatment 2
• Blood culture and total blood count 2
• Transrectal ultrasound in selected cases to rule out prostatic abscess 2

For Chronic Bacterial Prostatitis:

• Meares and Stamey 2- or 4-glass test (Strong recommendation) 2
  • Involves collection of:
    1. First-void urine (VB1)
    2. Midstream urine (VB2)
    3. Expressed prostatic secretions (EPS)
    4. Post-massage urine (VB3)
• Microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species 2
• Do not routinely perform microbiological analysis of ejaculate alone 2

Symptom Assessment:

• AUA Symptom Index/International Prostate Symptom Score (IPSS) is recommended for symptom assessment 2
  • Quantifies both irritative (frequency, urgency, nocturia) and obstructive symptoms
  • Classification: mild (0-7), moderate (8-19), severe (20-35)

Treatment Approach

For Acute Bacterial Prostatitis:

Parenteral therapy options:

• Ciprofloxacin 400 mg IV twice daily
• Levofloxacin 750 mg IV once daily
• Ceftriaxone 1-2 g IV once daily
• Piperacillin/tazobactam 2.5-4.5 g IV three times daily 1

Duration: 2-4 weeks 1

Switch to oral therapy when clinically improved:

• Fluoroquinolones (first-line) such as ciprofloxacin or levofloxacin 1

Monitor for complications:

• Prostatic abscess requires drainage in addition to antibiotics 1

For Chronic Bacterial Prostatitis:

Oral therapy options:

• Levofloxacin 500 mg once daily for 28 days (FDA-approved) 4
• Ciprofloxacin 500 mg twice daily for 28 days 4

Duration: 4-6 weeks, may be extended to 6-12 weeks if improvement occurs 1

For specific pathogens:

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

For Chronic Prostatitis/Chronic Pelvic Pain Syndrome:

Multimodal approach based on symptom pattern:

• For urinary symptoms: Alpha-blockers like alfuzosin 10 mg daily 5
• For pain: Anti-inflammatory agents and analgesics 6
• For psychosocial symptoms: Cognitive behavioral therapy 6

Important Clinical Considerations

1. Antibiotic stewardship:

   • Avoid repeated use of antibiotics, especially quinolones, if no symptomatic benefit or negative cultures 6
   • Do not initiate antibiotics without proper diagnosis unless patient presents with fever (acute prostatitis) 1

2. Treatment failures:

   • Consider prostatic abscess in patients not responding to antibiotics
   • Transrectal ultrasound-guided needle aspiration or small-bore pigtail catheter placement may be necessary 1

3. Sexual activity:

   • Abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1
   • Partner notification and treatment may be necessary to prevent reinfection 1

4. Common pitfalls:

   • Relying on ejaculation instead of proper medical treatment can lead to delayed treatment, progression of infection, complications, spread to partners, and antibiotic resistance 1
   • Inadequate treatment duration can lead to recurrence 1
   • Treating asymptomatic prostatitis is generally unnecessary 3

5. Follow-up:

   • Assess treatment success or failure and possible adverse events
   • Time for assessment varies: 2-4 weeks for alpha-blocker therapy, 3 months for 5α-reductase inhibitors 2

By following these diagnostic and treatment approaches, clinicians can effectively manage patients with prostatitis, improving outcomes and quality of life.