What is the treatment for prostatitis?

Treatment of Prostatitis

The treatment of prostatitis depends on the specific type, with fluoroquinolones being the first-line therapy for bacterial prostatitis and a multimodal approach recommended for non-infectious prostatitis/chronic pelvic pain syndrome. 1, 2

Types of Prostatitis and Their Treatments

1. Acute Bacterial Prostatitis

• First-line therapy: Broad-spectrum antibiotics for 2-4 weeks 2

  • Intravenous options: Piperacillin-tazobactam, ceftriaxone
  • Oral options: Ciprofloxacin 500 mg twice daily, levofloxacin 500 mg once daily
  • Success rate: 92-97% 2

• For severe cases with bacteremia: Third-generation cephalosporin with gentamicin 3

• Follow-up:

  • Clinical reassessment after 2 weeks
  • Urine culture at the end of treatment
  • Consider PSA measurement 3 months after resolution if elevated during infection 1

2. Chronic Bacterial Prostatitis

• First-line therapy: Fluoroquinolones for minimum 4 weeks 2, 4

  • Levofloxacin 500 mg once daily (preferred due to better prostatic penetration) 5, 6
  • Ciprofloxacin 500 mg twice daily 5
  • Microbiologic eradication rate: 75% for levofloxacin, 76.8% for ciprofloxacin 5

• Diagnosis confirmation:

  • Meares-Stamey four-glass test or two-glass test to differentiate from chronic pelvic pain syndrome 6
  • Most common pathogens: Escherichia coli, Enterococcus faecalis, Staphylococcus epidermidis 5

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

• Pharmacotherapy options:

  • Alpha-blockers (first-line for urinary symptoms): Alfuzosin, doxazosin, tamsulosin, or terazosin 1, 2
  • Amitriptyline: Start at 10 mg and titrate gradually to 75-100 mg if tolerated 1
  • Cimetidine: Improves symptoms, pain, and nocturia 1
  • Hydroxyzine: Particularly effective in patients with systemic allergies 1
  • Pentosan polysulfate: Requires monitoring for macular damage 1

• Physical therapy:

  • Pelvic floor muscle relaxation (focus on relaxation rather than strengthening) 1
  • Manual therapy targeting pelvic floor muscles for patients with pelvic floor tenderness 1

• Behavioral modifications:

  • Stress management techniques (meditation, imagery)
  • Lifestyle changes (weight loss, regular physical exercise, smoking cessation)
  • Self-care practices (dietary changes, fluid management, heat/cold application) 1

Treatment Algorithm

1. Identify the type of prostatitis:

   • Acute bacterial: Fever, chills, severe symptoms, UTI symptoms
   • Chronic bacterial: Recurrent UTIs from same strain, positive cultures
   • CP/CPPS: Pelvic pain for ≥3 months, negative cultures

2. For bacterial prostatitis:

   • Collect urine and/or prostatic secretion cultures before starting antibiotics
   • Select appropriate antibiotic based on likely pathogens (gram-negative bacteria in 80-97% of cases) 2
   • Monitor response and adjust therapy based on culture results

3. For CP/CPPS:

   • Assess symptoms using NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
   • Start with alpha-blockers if urinary symptoms predominate
   • Add other pharmacotherapies based on specific symptoms
   • Incorporate physical therapy and behavioral modifications

Common Pitfalls and Caveats

• Inadequate treatment duration: Minimum 2-4 weeks for acute bacterial prostatitis and 4 weeks for chronic bacterial prostatitis 4
• Failure to differentiate types: Only 10% of patients with chronic prostatitis symptoms actually have bacterial infection 6
• Overlooking non-pharmacological approaches: Physical therapy and behavioral modifications are essential components of CP/CPPS management 1
• Antibiotic overuse: Avoid antibiotics without confirmed bacterial infection, especially in CP/CPPS 4
• Insufficient follow-up: Monitor treatment response using symptom indices (NIH-CPSI, IPSS) 1

Special Considerations

• For atypical pathogens like Chlamydia trachomatis: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days 1
• For Mycoplasma genitalium: Azithromycin 500 mg on day 1, then 250 mg for 4 days; if macrolide-resistant, use moxifloxacin 400 mg daily for 7-14 days 1
• Patient education about the chronic nature of the condition and realistic expectations for symptom control is essential 1