What are the treatment options for prostatitis?

Treatment Options for Prostatitis

Ciprofloxacin is recommended as the first-choice antibiotic for treating chronic bacterial prostatitis, with a dosing regimen of 500 mg twice daily for 4-6 weeks, due to its superior prostatic tissue penetration and documented efficacy. 1

Classification of Prostatitis

Prostatitis is classified into four main categories:

1. Acute Bacterial Prostatitis: Severe infection requiring immediate treatment
2. Chronic Bacterial Prostatitis: Persistent infection with identified pathogens
3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS): Symptoms without identified bacterial cause
4. Asymptomatic Prostatitis: Inflammation without symptoms

Diagnostic Approach

• Meares and Stamey 2- or 4-glass test: Strongly recommended for accurate diagnosis and pathogen identification 1
• Midstream urine culture: Essential to guide antibiotic selection 1
• Microbiological evaluation: Important for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 1
• Transrectal ultrasound: Indicated in non-responsive cases to rule out prostatic abscess 1

Treatment Recommendations by Type

1. Acute Bacterial Prostatitis

• First-line treatment: Intravenous broad-spectrum antibiotics for severely ill patients
  • Options include broad-spectrum penicillins, third-generation cephalosporins, or fluoroquinolones with an aminoglycoside 2
• Duration: 2-4 weeks of treatment, even when symptoms improve early 1
• For multidrug-resistant pathogens: Consider piperacillin-tazobactam or meropenem 2

2. Chronic Bacterial Prostatitis

• First-line treatment:

  • Ciprofloxacin 500 mg twice daily for 4-6 weeks 1
  • Levofloxacin 500 mg once daily for 28 days (FDA-approved for E. coli, E. faecalis, or S. epidermidis) 3
  • Doxycycline 100 mg twice daily for 4-6 weeks (particularly for atypical pathogens) 1

• Alternative options when fluoroquinolones are contraindicated:

  • Trimethoprim-sulfamethoxazole 1
  • Amoxicillin-clavulanate (limited prostatic penetration) 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
  • Enterococcal infections: Daptomycin, ampicillin IV, or linezolid 1

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

• Multimodal approach:
  • Alpha-blockers: For urinary symptoms - effective with longer treatment duration 4
  • Anti-inflammatory drugs: For pain management 2
  • Phytotherapy: Quercetin, pollen extract, Serenoa repens extract as adjuncts 2

Treatment Duration and Monitoring

• Acute bacterial prostatitis: 2-4 weeks 1
• Chronic bacterial prostatitis: 4-6 weeks minimum 1
• Clinical reassessment: After 2 weeks to evaluate response 1
• Urine culture: At the end of treatment to confirm eradication 1
• PSA measurement: If elevated during infection, repeat 3 months after resolution 1

Important Considerations and Pitfalls

• Insufficient treatment duration: Treating for less than 2-4 weeks can lead to treatment failure and progression to chronic bacterial prostatitis 1
• Prostatic abscess: Failure to identify abscess can lead to inadequate treatment; transrectal ultrasound should be performed in non-responsive cases 1
• Poor antibiotic penetration: Using antibiotics with poor prostatic penetration can lead to treatment failure 1
• Fluoroquinolone warnings: FDA has issued warnings about side effects affecting tendons, muscles, joints, nerves, and central nervous system 1
• Alpha-blocker side effects: Should be avoided in patients interested in fathering children due to risk of retrograde ejaculation 1

Treatment Success Rates

• Fluoroquinolones: Clinical trials demonstrate 75-80% success rates in chronic bacterial prostatitis 1
• Levofloxacin: Demonstrated 75% microbiologic eradication rate in chronic bacterial prostatitis 3

Fluoroquinolones remain the cornerstone of treatment for bacterial prostatitis due to their excellent prostatic tissue penetration and broad spectrum of activity against common uropathogens, with ciprofloxacin and levofloxacin showing the best evidence for efficacy.