What is the treatment for chronic prostatitis?

Treatment for Chronic Prostatitis

The treatment for chronic prostatitis requires a multimodal therapeutic approach tailored to the specific type of prostatitis, with antibiotics recommended for bacterial forms and a combination of alpha-blockers, physical therapy, and pain management for non-bacterial chronic pelvic pain syndrome. 1

Types of Prostatitis and Diagnostic Approach

Prostatitis is classified into four main categories:

1. Acute bacterial prostatitis
2. Chronic bacterial prostatitis (CBP)
3. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
4. Asymptomatic inflammatory prostatitis

Proper diagnosis is essential before initiating treatment:

• Confirm diagnosis using the Meares-Stamey technique for bacterial forms
• Use NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms and monitor treatment response 1

Treatment for Chronic Bacterial Prostatitis (CBP)

Antibiotic Therapy

• First-line treatment: Fluoroquinolones for a minimum of 4 weeks 2

  • Levofloxacin 500 mg once daily for 28 days 3
  • Ciprofloxacin 500 mg twice daily for 28 days 3

• Clinical efficacy rates:

  • Levofloxacin: 75% clinical success rate at 5-18 days post-treatment 3
  • Ciprofloxacin: 72.8% clinical success rate at 5-18 days post-treatment 3

• Microbiological eradication rates:

  • Levofloxacin: 75% eradication rate 3
  • Ciprofloxacin: 76.8% eradication rate 3

Treatment Duration

• Minimum duration should be 2-4 weeks 4
• If symptoms improve, continue for an additional 2-4 weeks 4
• Do not continue antibiotic treatment beyond 6-8 weeks without reassessment 4

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

CP/CPPS accounts for more than 90% of chronic prostatitis cases and requires a comprehensive approach:

Pharmacotherapy

1. Alpha-blockers (Grade B evidence) 1

   • Alfuzosin, doxazosin, tamsulosin, or terazosin
   • Most effective in alpha-blocker-naïve patients
   • First-line therapy for CP/CPPS with urinary symptoms 2

2. Tricyclic Antidepressants (Grade B evidence) 1

   • Amitriptyline: Start at 10 mg and titrate gradually to 75-100 mg if tolerated
   • Side effects include sedation, drowsiness, and nausea

3. Other Medications (Grade B-C evidence) 1

   • Cimetidine: Improves symptoms, pain, and nocturia with minimal side effects
   • Hydroxyzine: Particularly effective in patients with systemic allergies
   • Pentosan polysulfate: Requires monitoring for macular damage

Physical Therapy

• Pelvic floor muscle relaxation (not strengthening exercises) 1
• Manual physical therapy targeting pelvic floor muscles for patients with pelvic floor tenderness 1
• Techniques include releasing muscular trigger points, lengthening muscle contractures, and myofascial release

Behavioral Modifications and Lifestyle Changes

• Stress management techniques (meditation, imagery) 1
• Weight loss, regular physical exercise, smoking cessation 1
• Dietary changes, fluid management, heat or cold application 1

Treatment Pitfalls and Considerations

1. Antibiotic overuse in non-bacterial prostatitis

   • Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS in randomized controlled trials 5
   • Reserve antibiotics for confirmed bacterial infections

2. Inadequate treatment duration for bacterial prostatitis

   • Too short courses lead to relapse
   • Too long courses increase antibiotic resistance risk

3. Failure to address psychosocial factors

   • Patient education about the chronic nature of the condition is essential 1
   • Setting realistic expectations for symptom control improves outcomes

4. Special considerations for atypical pathogens

   • For chlamydial prostatitis: Azithromycin shows improved eradication and clinical cure rates compared to ciprofloxacin 6
   • For ureaplasmal prostatitis: Ofloxacin, minocycline, azithromycin, or doxycycline may be used 6

Monitoring and Follow-up

• Clinical reassessment after 2 weeks of treatment
• Urine culture at the end of treatment
• Use NIH-CPSI and AUA Symptom Index/IPSS to quantify symptoms and monitor response 1
• Consider PSA measurement 3 months after resolution if elevated during infection

By following this structured approach to the treatment of chronic prostatitis, clinicians can optimize outcomes and minimize symptom recurrence while addressing the underlying causes of this challenging condition.