What is the initial approach and treatment for prostatitis?

Initial Approach and Treatment for Prostatitis

The initial approach for prostatitis should include classification of the type (acute bacterial, chronic bacterial, chronic nonbacterial/chronic pelvic pain syndrome, or asymptomatic inflammatory), followed by appropriate antibiotic therapy with fluoroquinolones (ciprofloxacin 500 mg twice daily for 2-4 weeks for acute and 4-6 weeks for chronic bacterial prostatitis) as first-line treatment, along with alpha-blockers for symptomatic relief. 1

Classification and Diagnosis

Prostatitis is classified into four categories:

• Acute bacterial prostatitis - acute infection with systemic symptoms
• Chronic bacterial prostatitis (CBP) - recurrent UTIs with the same pathogen
• Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CNP/CPPS) - accounts for >90% of cases
• Asymptomatic inflammatory prostatitis 1

Diagnostic Approach

1. Clinical evaluation:

   • Assess for pelvic pain, pressure, discomfort (hallmark symptoms)
   • Evaluate urinary symptoms (frequency, urgency, retention)
   • Check for systemic symptoms (fever, chills) in acute cases 1

2. Physical examination:

   • Digital rectal examination to assess for tender, enlarged, or boggy prostate
   • Abdominal and genital examination 1, 2

3. Laboratory testing:

   • Meares and Stamey 2- or 4-glass test (strongly recommended) 1
   • Midstream urine dipstick for nitrite and leukocytes
   • Midstream urine culture to guide antibiotic selection
   • Blood culture and complete blood count in acute cases
   • Testing for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 1

4. Validated questionnaires:

   • NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
   • AUA Symptom Index/International Prostate Symptom Score (IPSS) 1

5. Imaging:

   • Transrectal ultrasound in selected cases to rule out prostatic abscess 1

Treatment Approach

1. Acute Bacterial Prostatitis

• First-line antibiotics:

  • Ciprofloxacin 500 mg twice daily for 2-4 weeks 1
  • Levofloxacin 500 mg once daily for 2-4 weeks 1

• Alternative regimens:

  • For patients <35 years or STI suspected: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1
  • For patients >35 years or enteric organisms suspected: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1

• Supportive measures:

  • Adequate hydration
  • Analgesics for pain control
  • Consider hospitalization and IV antibiotics for systemically ill patients or those with urinary retention 2

2. Chronic Bacterial Prostatitis

• First-line antibiotics:

  • Ciprofloxacin 500 mg twice daily for 4-6 weeks (superior prostatic tissue penetration) 1
  • Doxycycline 100 mg twice daily for 4-6 weeks (particularly for atypical pathogens) 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

3. Chronic Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome

• Alpha-blockers are recommended for symptomatic relief:

  • Tamsulosin 0.4 mg once daily 1, 3
  • Alfuzosin 1, 4
  • Doxazosin or terazosin 1
  • Longer duration of therapy is more effective in alpha-blocker-naïve patients 1

• Anti-inflammatory agents for pain management 5

• Consider a trial of antibiotics (4-6 weeks of fluoroquinolones) even without documented infection, as this provides relief in approximately 50% of men 5

Follow-up and Monitoring

1. Reevaluation within 3 days if no improvement is seen in acute cases 1

2. Clinical reassessment after 2 weeks to evaluate symptom improvement 1

3. Urine culture at the end of treatment to confirm eradication 1

4. PSA measurement 3 months after resolution if elevated during infection 1

Common Pitfalls and Considerations

• Inadequate treatment duration can lead to treatment failure; ensure complete course of antibiotics even when symptoms improve early 1

• Poor antibiotic selection - choose antibiotics with good prostatic tissue penetration 1

• Overlooking complications such as prostatic abscess in patients who fail to respond to appropriate antibiotic therapy 1

• Neglecting atypical pathogens (Chlamydia trachomatis, Mycoplasma species) can lead to treatment failure 1

• Partner notification and treatment are essential if STI is confirmed or suspected 1

• Rule out testicular torsion in all cases of acute scrotal pain, as it is a surgical emergency 1