What is the treatment for prostatitis?

Treatment for Prostatitis

The treatment for prostatitis depends on the specific type, with fluoroquinolones such as levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily for 2-4 weeks being the first-line therapy for bacterial prostatitis, achieving success rates of 75-92%. 1, 2, 3

Types of Prostatitis and Initial Management

Acute Bacterial Prostatitis

• Initial antibiotic therapy:
  • For severe cases: Parenteral antibiotics 1
    • Piperacillin-tazobactam 2.5-4.5 g three times daily
    • Ceftriaxone 1-2 g once daily
    • Cefotaxime 2 g three times daily
    • IV fluoroquinolones (ciprofloxacin 400 mg twice daily or levofloxacin 750 mg once daily)
  • For less severe cases: Oral fluoroquinolones 3
    • Ciprofloxacin 500 mg twice daily
    • Levofloxacin 500 mg once daily
• Duration: 2-4 weeks 1, 3
• Success rate: 92-97% 1, 3

Chronic Bacterial Prostatitis

• First-line therapy: 1, 2, 4
  • Levofloxacin 500 mg once daily for 4-12 weeks
  • Ciprofloxacin 500 mg twice daily for 4-12 weeks
• Alternative options: 1
  • Doxycycline 100 mg twice daily for 2-4 weeks
• Success rate: 75-76.8% 2, 4

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

• First-line therapy for urinary symptoms: 3
  • Alpha-blockers (tamsulosin, alfuzosin, doxazosin, or terazosin)
• Additional therapies: 1, 3
  • Non-narcotic analgesics
  • Amitriptyline or cimetidine
  • Stress management techniques
  • Pelvic floor muscle relaxation

Diagnostic Approach

1. Clinical evaluation:

   • Assess for pelvic pain, urinary symptoms (frequency, urgency, dysuria)
   • Digital rectal examination to check for tender, enlarged, or boggy prostate 5

2. Laboratory testing:

   • Urinalysis and urine culture 1, 5
   • For chronic bacterial prostatitis: Meares-Stamey "four-glass" test or collection of expressed prostatic secretions 2, 4

3. Avoid vigorous prostate massage in acute bacterial prostatitis 1

4. Consider imaging (CT scan or excretory urography) if fever persists after 72 hours of treatment 1

Treatment Monitoring and Adjustment

1. Adjust antibiotics based on culture and antibiogram results (needed in approximately 76.6% of cases) 1

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

3. Follow-up urine culture at the end of treatment to confirm eradication 1

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

5. Use symptom indices (NIH-CPSI or IPSS) to quantify symptoms and monitor response 1, 3

Common Pitfalls and Caveats

• Antibiotic resistance: Fluoroquinolone resistance is increasing; consider local resistance patterns when selecting antibiotics 1

• Recurrence: Approximately 10% of acute bacterial prostatitis cases evolve into chronic bacterial prostatitis 1

• Complications: Early and adequate treatment is crucial to prevent complications such as prostatic abscesses, sepsis, or progression to chronic prostatitis 1

• Atypical pathogens: For Chlamydia trachomatis, use azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days; for Mycoplasma genitalium, use azithromycin 500 mg on day 1, then 250 mg for 4 days 1

• Antimicrobial prophylaxis: Strongly recommended for all patients undergoing transrectal prostate biopsy to prevent acute bacterial prostatitis 1

By following this treatment algorithm and monitoring protocol, most patients with prostatitis can achieve significant symptom improvement and, in cases of bacterial prostatitis, eradication of the causative organism.