What are the treatment options for prostatitis?

Treatment Options for Prostatitis

The treatment of prostatitis depends on its specific type, with fluoroquinolones being the first-line therapy for bacterial forms, while chronic pelvic pain syndrome requires a multimodal approach including alpha-blockers, anti-inflammatories, and physical therapy. 1, 2

Classification of Prostatitis

Prostatitis is classified into four main categories:

1. Acute Bacterial Prostatitis (Category I)
2. Chronic Bacterial Prostatitis (Category II)
3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) (Category III)
   • IIIA: Inflammatory
   • IIIB: Non-inflammatory
4. Asymptomatic Inflammatory Prostatitis (Category IV)

Treatment by Type

Acute Bacterial Prostatitis

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

  • Intravenous options: Piperacillin-tazobactam, ceftriaxone
  • Oral option: Ciprofloxacin 500 mg twice daily

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

• Success rate: 92-97% when treated appropriately 2

• For prostatic abscess: Transrectal ultrasound-guided drainage may be necessary in addition to antibiotics 4

Chronic Bacterial Prostatitis

• First-line therapy: Fluoroquinolones for minimum 4 weeks 2, 5

  • Levofloxacin 500 mg daily 6
  • Ciprofloxacin 500 mg twice daily
  • Ofloxacin 200 mg twice daily

• Clinical success rates with levofloxacin: 92% at 5-12 days, declining to 61.9% at 6 months 7

• Rationale for fluoroquinolones: These antibiotics achieve high prostate tissue concentrations (up to 4:1 prostate:serum ratio) due to ion trapping in the acidic prostatic environment 7

• For atypical pathogens 1:

  • Chlamydia trachomatis: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days
  • 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

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

Multimodal approach required 1:

1. Alpha-blockers:

   • Options: Alfuzosin, doxazosin, tamsulosin, or terazosin
   • Most effective in alpha-blocker-naïve patients
   • Longer duration of therapy (14-24 weeks) shows better results with NIH-CPSI score reductions of 9.9-14.3 points 7

2. Anti-inflammatory medications:

   • NSAIDs like ibuprofen for pain management
   • Limited by side effects with long-term use 3

3. Physical therapy:

   • Pelvic floor muscle relaxation (not strengthening)
   • Manual therapy targeting pelvic floor trigger points 1

4. Other pharmacologic options 1:

   • Amitriptyline (10-100 mg, titrated gradually)
   • Cimetidine
   • Hydroxyzine (particularly for patients with systemic allergies)
   • Pentosan polysulfate (requires ophthalmologic monitoring)

5. Phytotherapy 3:

   • Quercetin
   • Pollen extract
   • Serenoa repens extract

6. Lifestyle modifications 1:

   • Weight loss
   • Regular physical exercise
   • Smoking cessation
   • Dietary changes
   • Stress management techniques

Monitoring and Follow-up

• For bacterial prostatitis: Clinical reassessment after 2 weeks and urine culture at the end of treatment 1

• For CP/CPPS: Use of NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms and monitor treatment response 1

• PSA measurement: Consider 3 months after resolution if elevated during infection 1

Treatment Pitfalls and Caveats

• Duration of therapy: Minimum 2-4 weeks for bacterial prostatitis; do not continue antibiotics beyond 6-8 weeks without reassessment 5

• Prostatic abscess: May require drainage in addition to antibiotics; can be approached via transrectal ultrasound guidance 4

• Recurrent infections: May indicate underlying structural abnormalities that should be evaluated

• Fluoroquinolone resistance: Increasing concern; alternatives include aminoglycosides and fosfomycin 3

• CP/CPPS treatment expectations: Set realistic expectations for symptom control rather than complete cure 1

• Gut-prostate connection: Consider evaluation of intestinal function and microbiota in resistant cases 3

The treatment of prostatitis requires careful classification of the type of prostatitis present, followed by targeted therapy based on that classification. Bacterial forms respond well to appropriate antibiotics, while CP/CPPS requires a more comprehensive approach addressing pain, urinary symptoms, and pelvic floor dysfunction.