What is the initial approach and treatment for prostatitis?

Initial Approach and Treatment for Prostatitis

The initial approach to prostatitis requires classification of the type (acute bacterial, chronic bacterial, or chronic prostatitis/chronic pelvic pain syndrome) followed by targeted therapy with broad-spectrum antibiotics for bacterial forms and multimodal therapy for non-bacterial forms. 1, 2

Classification and Diagnosis

Prostatitis is classified into three main types:

1. Acute Bacterial Prostatitis (ABP)

   • Presents with fever, chills, urinary symptoms, and tender prostate on examination
   • Caused by gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) in 80-97% of cases 2
   • Diagnosis: clinical presentation, urine culture, physical exam with tender prostate

2. Chronic Bacterial Prostatitis (CBP)

   • Persistent bacterial infection with recurrent UTIs from the same strain
   • Up to 74% caused by gram-negative organisms 2
   • Diagnosis: Meares-Stamey 4-glass test or modified 2-glass test 3

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

   • Pelvic pain/discomfort for ≥3 months with urinary symptoms
   • No identifiable infection or other cause 2
   • Diagnosis: NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) for symptom quantification 1

Treatment Algorithm

1. Acute Bacterial Prostatitis

• First-line therapy: Broad-spectrum antibiotics for 2-4 weeks (92-97% success rate) 1, 2
  • IV options: Piperacillin-tazobactam, ceftriaxone
  • Oral options: Ciprofloxacin 500mg twice daily, Levofloxacin 500mg once daily
• Monitoring: Clinical reassessment after 2 weeks and urine culture at end of treatment 1
• Follow-up: Consider PSA measurement 3 months after resolution if elevated during infection 1

2. Chronic Bacterial Prostatitis

• First-line therapy: Fluoroquinolones for minimum 4-12 weeks 2, 3, 4
  • Ciprofloxacin 500mg twice daily or Levofloxacin 500mg once daily
  • Alternative: Trimethoprim-sulfamethoxazole if pathogen susceptible 3
• For atypical pathogens:
  • Chlamydia: Azithromycin 1.0-1.5g single dose or Doxycycline 100mg twice daily for 7 days 1
  • Mycoplasma: Azithromycin 500mg on day 1, then 250mg for 4 days; if macrolide-resistant, Moxifloxacin 400mg daily for 7-14 days 1

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

• Multimodal approach:

  1. Alpha-blockers (first-line for urinary symptoms) 1, 2

     • Alfuzosin, doxazosin, tamsulosin, or terazosin
     • Longer duration more effective in alpha-blocker-naïve patients
     • NIH-CPSI score reduction of 4.8-10.8 points versus placebo 2

  2. Pharmacotherapy options:

     • Amitriptyline: Start 10mg, titrate to 75-100mg if tolerated 1
     • Cimetidine: Improves symptoms, pain, and nocturia 1
     • Hydroxyzine: Particularly effective in patients with systemic allergies 1
     • Pentosan polysulfate: Requires ophthalmologic monitoring 1

  3. Physical therapy:

     • Pelvic floor muscle relaxation (not strengthening) 1
     • Manual therapy for pelvic floor tenderness 1

  4. Behavioral modifications:

     • Stress management techniques (meditation, imagery) 1
     • Lifestyle changes (weight loss, exercise, smoking cessation) 1
     • Dietary modifications and fluid management 1

Important Considerations and Pitfalls

• Pitfall #1: Initiating antibiotics without proper diagnosis

  • Unless fever is present, complete diagnostic workup before starting antibiotics 4
  • Inappropriate antibiotic use contributes to resistance

• Pitfall #2: Inadequate treatment duration

  • ABP: Minimum 2-4 weeks of antibiotics 1, 2
  • CBP: Minimum 4 weeks, up to 12 weeks 3, 4
  • Insufficient duration leads to recurrence and chronic infection

• Pitfall #3: Failure to recognize treatment response

  • Reassess after 2 weeks of therapy 1
  • If no improvement after 6-8 weeks, reconsider diagnosis and treatment 4

• Pitfall #4: Missing underlying conditions

  • Exclude anatomic or functional conditions that complicate UTIs in men 5
  • Consider prostatic abscess in severe or non-responsive cases 3

• Caveat: Fluoroquinolones are preferred due to prostate penetration (ratios up to 4:1) 6, but consider growing resistance patterns and use alternatives when indicated 3