What is the treatment for prostatitis?

Treatment of Prostatitis

The treatment of prostatitis depends on its classification, with fluoroquinolones being the first-line therapy for bacterial forms due to their excellent prostatic penetration, typically given for 2-4 weeks in acute bacterial prostatitis and at least 4 weeks for chronic bacterial prostatitis. 1, 2

Classification of Prostatitis

• Prostatitis is classified into four main categories: Acute Bacterial Prostatitis (ABP), Chronic Bacterial Prostatitis (CBP), Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), and Asymptomatic Inflammatory Prostatitis 1, 3
• Diagnosis should be confirmed using the Meares-Stamey technique (four-glass test) or the simplified two-glass test in routine practice to differentiate between bacterial prostatitis and chronic pelvic pain syndrome 4, 5
• Urine cultures should be obtained in all patients suspected of having bacterial prostatitis to determine the responsible bacteria and antibiotic sensitivity patterns 6

Treatment of Acute Bacterial Prostatitis (ABP)

• First-line therapy includes broad-spectrum antibiotics such as intravenous piperacillin-tazobactam, ceftriaxone, or oral ciprofloxacin, with a 92-97% success rate when prescribed for 2-4 weeks 2, 6
• Hospitalization and intravenous antibiotics should be considered for patients who are systemically ill, unable to urinate voluntarily, unable to tolerate oral intake, or have risk factors for antibiotic resistance 6
• Historical treatment duration for ABP is approximately 14 days, though definitive evidence for optimal duration is lacking 7
• For outpatient treatment, fluoroquinolones are recommended due to their favorable antibacterial spectrum and pharmacokinetic profile 4, 5

Treatment of Chronic Bacterial Prostatitis (CBP)

• First-line therapy is a minimum 4-week course of fluoroquinolones, particularly levofloxacin or ciprofloxacin 2, 5
• Levofloxacin (500 mg once daily for 28 days) has shown comparable efficacy to ciprofloxacin (500 mg twice daily for 28 days) with microbiologic eradication rates of 75% and 76.8%, respectively 8
• Historical treatment durations range from 4 weeks to 6 weeks or longer for CBP 7
• The minimum duration of antibiotic treatment should be 2-4 weeks, with continuation for an additional 2-4 weeks if symptoms improve 4

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

• First-line oral therapy for CP/CPPS with urinary symptoms is α-blockers (e.g., tamsulosin, alfuzosin) 2
• Other oral therapies with modest benefits include anti-inflammatory drugs (e.g., ibuprofen), pregabalin, and pollen extract 2
• Antibiotics are not routinely recommended unless there is clinical, bacteriological, or supporting immunological evidence of prostate infection 4

Special Considerations

• For prostatic abscess, drainage may be required via transrectal ultrasound-guided aspiration, though small abscesses may resolve with antibiotics alone 1
• In cases of fluoroquinolone resistance or treatment failure, consider phage therapy for chronic bacterial prostatitis, particularly for E. faecalis infections, though this approach requires specialized facilities and is not widely available 9
• When treating complicated UTIs in men where prostatitis cannot be excluded, treatment should be extended to 14 days 7
• Local resistance patterns should be considered when selecting empiric therapy; ciprofloxacin should not be used if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the last 6 months 7

Treatment Algorithm

1. Confirm diagnosis through history, physical examination, and appropriate tests (urine culture, prostatic fluid analysis) 1
2. Classify type of prostatitis (acute bacterial, chronic bacterial, CP/CPPS, or asymptomatic) 1, 3
3. For acute bacterial prostatitis:
   • Initiate broad-spectrum antibiotics (fluoroquinolones preferred for outpatients) 5, 6
   • Treat for 2-4 weeks 2, 4
   • Consider hospitalization for severe cases 6
4. For chronic bacterial prostatitis:
   • Prescribe fluoroquinolones (levofloxacin 500 mg daily or ciprofloxacin 500 mg twice daily) 8, 5
   • Treat for at least 4 weeks, up to 6 weeks 7, 2
   • Evaluate response after 2-4 weeks and adjust treatment accordingly 4
5. For CP/CPPS:
   • Prescribe α-blockers for urinary symptoms 2
   • Consider anti-inflammatories or other supportive therapies 2
6. For asymptomatic inflammatory prostatitis:
   • No treatment required 3

Remember that antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness 4.