How would you treat calcifications in chronic bacterial prostatitis?

Treatment of Calcifications in Chronic Bacterial Prostatitis

For chronic bacterial prostatitis with prostatic calcifications, treatment should be extended to 12 weeks of antibiotic therapy rather than the standard 6 weeks to improve cure rates and reduce relapse risk. 1

Diagnostic Approach

• Perform the Meares and Stamey 2- or 4-glass test to confirm chronic bacterial prostatitis diagnosis (strong recommendation) 2
• Conduct transrectal ultrasound to identify and evaluate the extent of prostatic calcifications 2, 3
• Perform accurate microbiological evaluation for both typical pathogens and atypical organisms such as Chlamydia trachomatis and Mycoplasma species (weak recommendation) 2
• Digital-processing software can be used to calculate the extension of prostatic calcification area at ultrasound, as higher percentages of prostatic calcification are associated with chronic bacterial prostatitis 3

Antibiotic Treatment

• For patients with prostatic calcifications, extend antibiotic treatment to 12 weeks instead of the standard 6 weeks 1
• First-line therapy options include:
  • Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) for 12 weeks when calcifications are present 4, 3
  • Oral fosfomycin regimen: 3g every 24 hours for 1 week followed by 3g every 48 hours for a total of 12 weeks when calcifications are present 1

Alternative Antibiotics for Fluoroquinolone-Resistant Cases

• Fosfomycin has shown 82% clinical cure rate at end of treatment and 73% at 6 months for MDR pathogens 1
• Aminoglycosides can be considered as a therapeutic alternative for quinolone-resistant prostatitis 3
• For specific pathogens:
  • Macrolides are more effective than fluoroquinolones for Chlamydial prostatitis 3
  • Tetracyclines are equally effective as macrolides for intracellular pathogens 3

Adjunctive Therapies

• Consider multimodal therapeutic approach by combining:
  • Alpha-blockers for urinary symptoms 4, 3
  • Anti-inflammatory drugs for pain management 3
  • Phytotherapy (quercetin, pollen extract, Serenoa repens) as supplementary treatment 3

Treatment Monitoring and Follow-up

• Monitor treatment response through clinical symptom assessment and repeat microbiological testing
• Consider surgical intervention (modified retropubic prostatectomy) for patients with chronic bacterial prostatitis with calcifications who do not respond to extended antibiotic therapy 5

Common Pitfalls and Caveats

• Failure to extend antibiotic treatment duration in patients with prostatic calcifications significantly increases relapse risk 1
• Prostatic calcifications serve as a nidus for bacterial persistence and biofilm formation, making standard 4-6 week antibiotic courses often inadequate 1, 3
• Diarrhea is the most common adverse event (18%) with extended fosfomycin treatment 1
• Fluoroquinolone resistance is increasing (up to 75% in some studies), necessitating alternative antibiotic strategies 1, 3