What are the treatment options for prostatitis?

Treatment of Prostatitis

The first-line treatment for prostatitis depends on its classification, with fluoroquinolones being the recommended therapy for bacterial forms due to their excellent prostatic penetration and broad antimicrobial coverage. 1

Classification of Prostatitis

• Prostatitis is classified into four main categories according to the National Institute of Diabetes, Digestive, and Kidney Diseases 1:
  • Acute Bacterial Prostatitis (Category I)
  • Chronic Bacterial Prostatitis (Category II)
  • Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Category III)
  • Asymptomatic Inflammatory Prostatitis (Category IV)

Treatment by Classification

Acute Bacterial Prostatitis (Category I)

• First-line therapy consists of broad-spectrum antibiotics such as:
  • Intravenous options: piperacillin-tazobactam, ceftriaxone 2
  • Oral option: ciprofloxacin (92-97% success rate when prescribed for 2-4 weeks) 2
• Treatment duration should be 2-4 weeks 3
• For cases with bacteremia, third-generation cephalosporins with gentamicin are recommended 4
• Prostatic abscesses may require drainage via transrectal ultrasound-guided aspiration, though small abscesses may resolve with antibiotics alone 1

Chronic Bacterial Prostatitis (Category II)

• First-line therapy is a minimum 4-week course of fluoroquinolones 2:
  • Ciprofloxacin 500 mg three times daily 4
  • Ofloxacin 200 mg twice daily 4
  • Levofloxacin 500 mg daily (clinical success rates of 92% at 5-12 days, decreasing to 61.9% at 6 months) 5
• Alternative: cotrimoxazole 960 mg twice daily for 4 weeks 4
• Fluoroquinolones are preferred due to their prostate:serum concentration ratios of up to 4:1 5, 1
• Treatment should not be continued beyond 6-8 weeks without evaluating effectiveness 3

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Category III)

• First-line oral therapy for CP/CPPS with urinary symptoms is α-blockers 2:
  • Tamsulosin, alfuzosin (NIH-CPSI score difference vs placebo = -10.8 to -4.8) 2
  • Longer durations of therapy show better responses in α-blocker-naïve patients 5
• Additional therapeutic options:
  • Anti-inflammatory drugs (e.g., ibuprofen) 2
  • Pregabalin 2
  • Pollen extract 2
• A stepwise approach involving antibiotics, followed by bioflavonoids and then α-blockers can effectively reduce symptoms for up to 1 year 5

Treatment Algorithm

1. Confirm diagnosis through history, physical examination, and appropriate tests (urine culture, prostatic fluid analysis) 1
2. Classify the type of prostatitis 1
3. Select therapy based on classification:
   • Acute bacterial prostatitis: Fluoroquinolones or broad-spectrum antibiotics for 2-4 weeks 1, 2
   • Chronic bacterial prostatitis: Extended course of fluoroquinolones (4+ weeks) 1, 2
   • CP/CPPS: α-blockers, anti-inflammatories, and multimodal approach 1, 2
4. For patients who fail to respond to antibiotics, consider imaging to rule out prostatic abscess 1
5. For patients with multiple unsuccessful treatment regimens, consider direct stimulation of pelvic muscles through electromagnetic or electroacupuncture therapy 5

Special Considerations

• Local resistance patterns should be considered when selecting empiric therapy 1
• Failure to identify the causative organism can lead to inadequate treatment; consider STI testing when appropriate 1
• Antibiotic treatment should not be initiated immediately (except in acute prostatitis) until proper work-up is completed, which should be done within one week 3
• During the diagnostic period, symptomatic relief can be provided with appropriate analgesia 3
• The increasing frequency of multiresistant bacteria complicates treatment selection, requiring careful consideration of in vitro activity and prostatic penetration 6