What are the treatment options for chronic prostatitis?

Treatment for Chronic Prostatitis

The treatment of chronic prostatitis should follow a multimodal approach, with antibiotics (fluoroquinolones like levofloxacin 500 mg daily for 28 days or ciprofloxacin 500 mg twice daily for 28 days) as the cornerstone therapy for bacterial forms, while non-bacterial forms require alpha-blockers, pain management, and lifestyle modifications. 1

Classification and Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Diagnostic Testing:

  • Meares and Stamey 2- or 4-glass test (strongly recommended) 1
  • Midstream urine dipstick and culture
  • Complete blood count
  • Transrectal ultrasound in selected cases
  • NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms

• Types of Chronic Prostatitis:

  1. Chronic Bacterial Prostatitis (culture-positive)
  2. Chronic Inflammatory Prostatitis/Chronic Pelvic Pain Syndrome (culture-negative)

Treatment Algorithm

1. Chronic Bacterial Prostatitis

• First-line Antibiotic Therapy (28-day minimum course) 1, 2, 3:

  • Levofloxacin 500 mg once daily for 28 days
  • Ciprofloxacin 500 mg twice daily for 28 days
  • Doxycycline 100 mg twice daily for 2-4 weeks (if fluoroquinolones contraindicated)

• For Specific Pathogens 1:

  • 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
  • Enterococcal infections: Daptomycin, ampicillin, or linezolid based on susceptibility

• Important Considerations:

  • Avoid repeated antibiotic courses without evidence of bacterial infection 1
  • Minimum treatment duration should be 2-4 weeks; continue for additional 2-4 weeks if symptoms improve 4
  • Clinical reassessment after 2 weeks to evaluate improvement 1

2. Chronic Pelvic Pain Syndrome (CPPS)

• Alpha-blockers 1:

  • Alfuzosin, doxazosin, tamsulosin, or terazosin
  • More effective in alpha-blocker-naïve patients
  • Particularly helpful when voiding symptoms are present

• Pain Management 1:

  • Non-narcotic analgesics
  • Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate

• Self-care and Behavioral Modifications 1:

  • Dietary changes and elimination diet
  • Fluid management
  • Heat or cold application
  • Stress management techniques
  • Pelvic floor muscle relaxation (with caution as it may worsen symptoms in some patients)

Follow-up and Monitoring

• Reevaluation if no improvement within 3 days 1
• Urine culture at the end of treatment to confirm eradication 1
• PSA measurement 3 months after resolution if elevated during infection 1
• Monitor for adverse effects of medications:
  • Weekly CPK levels for daptomycin
  • Complete blood count weekly for linezolid

Common Pitfalls and Caveats

• Avoid:

  • Prolonged antibiotic use without evidence of bacterial infection 1
  • Relying on monotherapy for CPPS (multimodal management is required) 1
  • Prescribing pelvic floor exercises without proper assessment 1
  • Focusing solely on laboratory values rather than quality of life 1

• Important Considerations:

  • Ineffective treatments should be discontinued after adequate trial 1
  • Treatment of sexual partners is necessary when sexually transmitted infections are identified 1
  • Psychosocial aspects of chronic pain should be addressed 1
  • Regular reassessment of treatment efficacy is essential 1

By following this structured approach to chronic prostatitis management, clinicians can optimize outcomes and improve quality of life for patients suffering from this challenging condition.