What is the initial approach and treatment for prostatitis?

Initial Approach and Treatment for Prostatitis

The initial approach to prostatitis should include proper classification of the type (acute bacterial, chronic bacterial, or chronic prostatitis/chronic pelvic pain syndrome) followed by targeted therapy with antibiotics for bacterial forms and multimodal management for non-bacterial forms. 1

Classification and Diagnosis

Prostatitis is categorized into four distinct types:

1. Acute Bacterial Prostatitis:

   • Presents with fever, chills, pelvic pain, urinary symptoms (dysuria, frequency, retention)
   • Physical exam reveals tender, enlarged, or boggy prostate
   • Requires immediate treatment

2. Chronic Bacterial Prostatitis:

   • Characterized by recurrent UTIs with the same pathogen
   • Causes pelvic pain, urinary symptoms, and ejaculatory pain
   • Diagnosed via Meares-Stamey 4-glass test (strongly recommended) 1

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

   • Most common form (90% of prostatitis cases)
   • Pelvic pain for >3 months, urinary symptoms, sexual dysfunction
   • No documented bacterial infection

4. Asymptomatic Inflammatory Prostatitis:

   • No symptoms, often incidental finding
   • Usually left untreated

Diagnostic Approach

• Required tests: Midstream urine dipstick, urine culture, complete blood count 1
• Recommended diagnostic tools: NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) and International Prostate Symptom Score (IPSS) 1
• Gold standard for bacterial forms: Meares-Stamey 2- or 4-glass test for accurate microbiological evaluation 1
• Additional tests: Transrectal ultrasound in selected cases 1

Treatment Algorithm

1. Acute Bacterial Prostatitis

• Initial therapy: Broad-spectrum antibiotics
  • Ciprofloxacin 500 mg twice daily for 2-4 weeks OR
  • Levofloxacin 500 mg once daily for 2-4 weeks OR
  • Doxycycline 100 mg twice daily for 2-4 weeks 1
• For severe cases: Hospitalization with IV antibiotics (ceftriaxone, piperacillin/tazobactam)
• Supportive measures: Adequate hydration, analgesics, bladder drainage if urinary retention occurs

2. Chronic Bacterial Prostatitis

• Antibiotic therapy: Extended course (4-16 weeks) 1, 2
  • Ciprofloxacin 500 mg twice daily OR
  • Levofloxacin 500 mg once daily OR
  • Doxycycline 100 mg twice daily
• For specific pathogens:
  • Chlamydia: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 1
  • Mycoplasma: Azithromycin 500 mg on day 1, then 250 mg for 4 days 1
  • Enterococcal infections: Daptomycin, ampicillin, or linezolid based on sensitivity 1

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

• Multimodal approach:

  1. Alpha-blockers (first-line): 1, 3, 4

     • Tamsulosin 0.4 mg once daily
     • Alfuzosin 10 mg once daily
     • Doxazosin or terazosin as alternatives

  2. Pain management:

     • Non-narcotic analgesics
     • Amitriptyline, cimetidine, or hydroxyzine (Grade B evidence) 1

  3. Self-care practices: 1

     • Dietary modifications (elimination diet)
     • Heat or cold application
     • Stress management techniques
     • Pelvic floor muscle relaxation

  4. Additional therapies:

     • Pentosan polysulfate
     • 5-alpha-reductase inhibitors for refractory cases

Follow-up and Monitoring

• Reevaluate within 3 days if no improvement in acute cases 1
• Clinical reassessment after 2 weeks to evaluate symptom improvement 1
• Urine culture at the end of treatment to confirm eradication 1
• Repeat PSA measurement 3 months after resolution if elevated during infection 1

Important Considerations

• Do not rely solely on urinary frequency or urgency for diagnosis, as these symptoms are common in other lower urinary tract disorders 1
• Avoid prolonged use of antibiotics without evidence of bacterial infection 1
• Caution when prescribing pelvic floor exercises, as they may worsen symptoms in certain patients 1
• Do not rely on monotherapy for CP/CPPS, as this condition typically requires multimodal management 1
• Alpha-blockers are more effective with longer duration of therapy in alpha-blocker-naïve patients 1
• Treatment should prioritize improving quality of life and reducing morbidity rather than focusing solely on laboratory values 1

By following this structured approach to diagnosis and treatment, most patients with prostatitis can achieve significant symptom relief and improved quality of life.