What is the treatment for chronic prostatitis?

Treatment for Chronic Prostatitis

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

Classification of Prostatitis

Prostatitis is classified into four categories:

1. Acute bacterial prostatitis
2. Chronic bacterial prostatitis (CBP)
3. Chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS) - accounts for >90% of cases
4. Asymptomatic inflammatory prostatitis

Diagnostic Approach

• Meares and Stamey 2- or 4-glass test is strongly recommended for diagnosis 1
• 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 Algorithm

1. Chronic Bacterial Prostatitis (CBP)

• First-line treatment: Ciprofloxacin 500 mg twice daily for 4-6 weeks 1, 2
• Alternative options:
  • Levofloxacin 500 mg once daily for 4-6 weeks
  • Doxycycline 100 mg twice daily for 4-6 weeks (particularly effective for atypical pathogens) 1
  • Trimethoprim-sulfamethoxazole (when local resistance rates <20%) 1

2. Chronic Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome (CNP/CPPS)

• Alpha-blockers: Alfuzosin, doxazosin, tamsulosin, or terazosin 3
  • More effective with longer duration of therapy in alpha-blocker-naïve patients 4
• Trial of antibiotics: 4-6 week course despite negative cultures 5
• Non-pharmacological interventions:
  • Acupuncture: Provides clinically meaningful reduction in symptoms 6
  • Extracorporeal shockwave therapy: Reduces symptoms and improves sexual function 6
  • Physical activity program: May cause small reduction in symptoms 6

Special Considerations

For Atypical 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

For Patients with Renal Impairment

Ciprofloxacin dosage adjustment based on creatinine clearance 2:

• 30-50 mL/min: 250-500 mg every 12 hours
• 5-29 mL/min: 250-500 mg every 18 hours
• Hemodialysis/peritoneal dialysis: 250-500 mg every 24 hours (after dialysis)

Treatment Pitfalls and Caveats

1. Inadequate treatment duration: Ensure complete 4-6 week course for chronic infections, even when symptoms improve early 1

2. Poor antibiotic selection: Choose antibiotics with good prostatic tissue penetration (fluoroquinolones have penetration ratios up to 4:1) 4

3. Overlooking complications: Rule out prostatic abscess in patients who fail to respond to appropriate antibiotic therapy 1

4. Fluoroquinolone side effects: FDA has issued warnings about side effects affecting tendons, muscles, joints, nerves, and central nervous system 1

5. Overlooking atypical pathogens: Consider testing for Chlamydia trachomatis and Mycoplasma species in resistant cases 1

6. Follow-up monitoring: Clinical reassessment after 2 weeks to evaluate symptom improvement and urine culture at the end of treatment to confirm eradication 1

Conclusion for Clinical Practice

The treatment of chronic prostatitis requires a targeted approach based on proper classification. For bacterial prostatitis, fluoroquinolones (particularly ciprofloxacin) remain the cornerstone of therapy due to their excellent prostatic penetration. For chronic nonbacterial prostatitis/CPPS, a combination of alpha-blockers, trial of antibiotics, and non-pharmacological interventions should be considered. Regardless of the type, adequate treatment duration is crucial for successful outcomes.