What are the symptoms and treatment options for prostatitis?

Symptoms and Treatment of Prostatitis

Prostatitis should be treated with fluoroquinolones (levofloxacin 500mg once daily or ciprofloxacin 500mg twice daily) for 2-4 weeks in acute bacterial cases and 4-6 weeks in chronic bacterial cases, with alpha-blockers recommended for chronic prostatitis/chronic pelvic pain syndrome. 1

Classification and Symptoms

Prostatitis is classified into four categories according to the National Institutes of Health (NIH):

1. Acute Bacterial Prostatitis

   • Symptoms: Fever, chills, urinary symptoms (frequency, urgency, dysuria), perineal or low back pain, tender prostate on examination 1, 2
   • Often presents as a urinary tract infection with prostatic involvement 2

2. Chronic Bacterial Prostatitis

   • Symptoms: Recurrent UTIs from the same bacterial strain, persistent pelvic pain, urinary symptoms 1, 2
   • Less severe symptoms than acute form but longer duration (>3 months)

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

   • Symptoms: Pelvic pain or discomfort for at least 3 months, urinary frequency, pain with ejaculation 2
   • Subdivided into inflammatory (IIIA) and non-inflammatory (IIIB) forms 3

4. Asymptomatic Inflammatory Prostatitis

   • No symptoms; inflammation found incidentally during evaluation for other conditions 1

Diagnostic Approach

• Digital rectal examination (tender, swollen prostate in acute cases) 1, 4
• Urine culture and prostatic fluid analysis using the Meares-Stamey technique 1, 5
• NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms and monitor treatment response 1, 2
• Exclude underlying urological conditions (BPH, urinary stones, malignancy) 4

Treatment Recommendations

1. Acute Bacterial Prostatitis

• Initial Antibiotic Therapy:

  • Intravenous options: Piperacillin-tazobactam 2.5-4.5g three times daily, ceftriaxone 1-2g once daily, or ciprofloxacin 400mg twice daily 1, 2
  • Oral options: Ciprofloxacin 500mg twice daily, levofloxacin 500mg once daily, or doxycycline 100mg twice daily 1
  • Duration: 2-4 weeks 1, 2
  • Success rate: 92-97% 2

• For severe cases or sepsis:

  • Third-generation cephalosporin with aminoglycosides 3
  • Hospitalization for patients with systemic illness, urinary retention, or inability to tolerate oral intake 1

2. Chronic Bacterial Prostatitis

• First-line therapy:

  • Fluoroquinolones (American Urological Association recommendation) 1
  • Levofloxacin 500mg once daily or ciprofloxacin 500mg twice daily 6, 5
  • Minimum duration: 4-6 weeks 1, 2
  • Microbiological eradication rate: 75% for levofloxacin, 76.8% for ciprofloxacin 6

• Alternative options:

  • Trimethoprim-sulfamethoxazole 960mg twice daily for 4 weeks 3, 7
  • Reserve carbapenems and broad-spectrum antibiotics for multi-resistant organisms 1

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• First-line therapy for urinary symptoms:

  • Alpha-blockers (tamsulosin, alfuzosin, doxazosin, terazosin) 1, 2
  • Longer duration more effective in alpha-blocker-naïve patients 1

• Additional medication options:

  • Amitriptyline, cimetidine (Grade B evidence) 1
  • Anti-inflammatory drugs (e.g., ibuprofen) 2
  • Pregabalin, pollen extract for symptom management 2

• Non-pharmacological approaches:

  • Stress management techniques, pelvic floor muscle relaxation 1
  • Heat or cold application, dietary modifications 1

Management of Complications

• Transrectal ultrasound-guided drainage for prostatic abscess 1
• Early treatment of acute bacterial prostatitis is crucial to prevent progression to chronic prostatitis 1, 4
• Clinical reassessment after 2 weeks and urine culture at the end of treatment 1
• Consider PSA measurement 3 months after resolution if elevated during infection 1

Prevention

• Antimicrobial prophylaxis for transrectal prostate biopsy 1
• Lifestyle modifications: weight loss, regular physical exercise, smoking cessation 1
• Self-care practices: fluid management, stress management techniques 1

Common Pitfalls and Caveats

1. Delayed diagnosis: Prostatitis is often overlooked in non-urologic departments due to sometimes indeterminate symptoms 4
2. Inadequate treatment duration: Insufficient antibiotic course can lead to treatment failure and progression to chronic prostatitis 4, 7
3. Failure to identify underlying conditions: Acute bacterial prostatitis is rare in healthy men without underlying conditions 4
4. Premature antibiotic initiation: Unless fever is present, complete diagnostic workup should be done before starting antibiotics (except in acute prostatitis) 5
5. Overlooking non-bacterial causes: Most prostatitis cases are non-bacterial and require different management approaches 7