What are the treatment options for prostatitis?

Treatment Options for Prostatitis

The first-line treatment for bacterial prostatitis is fluoroquinolones, specifically ciprofloxacin 500 mg twice daily for 4-6 weeks, due to its superior prostatic tissue penetration and documented efficacy for chronic bacterial prostatitis. 1

Types of Prostatitis and Diagnosis

Prostatitis is classified into several categories according to the NIH classification:

1. Acute Bacterial Prostatitis

   • Characterized by sudden onset of fever, chills, and severe urinary symptoms
   • Requires prompt diagnosis and treatment to prevent complications

2. Chronic Bacterial Prostatitis

   • Persistent bacterial infection of the prostate
   • Often presents with recurrent UTIs and pelvic discomfort

3. Chronic Pelvic Pain Syndrome (CPPS)

   • Most common form (Category III)
   • May be inflammatory or non-inflammatory
   • No identifiable bacterial cause

4. Asymptomatic Inflammatory Prostatitis

   • Incidental finding without symptoms

Diagnostic Approach

• The Meares and Stamey 2- or 4-glass test is strongly recommended for accurate diagnosis 1
• Additional tests include:
  • Midstream urine dipstick to check nitrite and leukocytes
  • Midstream urine culture to guide antibiotic selection
  • Blood culture and complete blood count in acute cases
  • Transrectal ultrasound in selected cases to rule out prostatic abscess

Treatment Options by Type

1. Acute Bacterial Prostatitis

• Initial treatment for severe cases:
  • Intravenous broad-spectrum antibiotics (penicillins, third-generation cephalosporins, or fluoroquinolones)
  • Consider combination with aminoglycosides
  • For multi-resistant gram-negative pathogens, piperacillin-tazobactam or meropenem may be needed
• Duration: 2-4 weeks even when symptoms improve early 1
• Monitoring: Rule out prostatic abscess in patients who fail to respond to appropriate antibiotic therapy

2. Chronic Bacterial Prostatitis

• First-line treatment:
  • Ciprofloxacin 500 mg twice daily for 4-6 weeks 1
  • Alternative: Levofloxacin 500 mg once daily for 4-6 weeks 2
• For atypical pathogens:
  • Chlamydia trachomatis: azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days
  • 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
  • Enterococcal infections: daptomycin, ampicillin, or linezolid 1
• Alternative when fluoroquinolones are contraindicated:
  • Trimethoprim-sulfamethoxazole (when local resistance rates <20%)
  • Doxycycline 100 mg twice daily for 4-6 weeks (especially for atypical pathogens) 1

3. Chronic Pelvic Pain Syndrome (CPPS)

• Multimodal approach:
  • Alpha-blockers for urinary symptoms
  • Analgesics and/or NSAIDs for pain management
  • Consider short course of antibiotics if infection is suspected
  • Phytotherapy (quercetin, pollen extract, Serenoa repens) has shown positive effects 3

Important Considerations

Antibiotic Selection Principles

• Choose antibiotics with good prostatic penetration
• Fluoroquinolones achieve high prostate-to-serum concentration ratios (up to 4:1) 4
• FDA has issued warnings about fluoroquinolone side effects affecting tendons, muscles, joints, nerves, and central nervous system 1

Treatment Duration

• Acute bacterial prostatitis: 2-4 weeks
• Chronic bacterial prostatitis: 4-6 weeks
• Inadequate treatment duration is a common cause of treatment failure 1

Follow-up

• Clinical reassessment after 2 weeks to evaluate symptom improvement
• Urine culture at the end of treatment to confirm eradication
• Repeat PSA measurement 3 months after resolution if it was elevated during infection 1

Common Pitfalls to Avoid

1. Using antibiotics with poor prostatic penetration
2. Insufficient treatment duration
3. Overlooking complications such as prostatic abscess
4. Failing to test for atypical pathogens in resistant cases
5. Not treating sexual partners when sexually transmitted infections are identified 1

Special Considerations

• For elderly men with BPH-related prostatitis, careful monitoring for complications is essential
• Renal function monitoring and drug levels for aminoglycosides are necessary to prevent toxicity
• Weekly monitoring of CPK levels for patients on daptomycin and complete blood count for those on linezolid 1

By following these evidence-based treatment approaches and avoiding common pitfalls, most cases of prostatitis can be effectively managed with significant improvement in symptoms and quality of life.