What are the treatment options for prostatitis?

Treatment Options for Prostatitis

The treatment of prostatitis depends on the specific type, with antibiotics being the cornerstone of therapy for bacterial forms, while chronic pelvic pain syndrome requires a multimodal approach including alpha-blockers, anti-inflammatories, and other supportive measures. 1, 2

Classification of Prostatitis

• Prostatitis affects approximately 9.3% of men in their lifetime, with fewer than 10% of cases confirmed to have bacterial infection 3
• The National Institute of Diabetes, Digestive, and Kidney Diseases classification system distinguishes:
  • Category I: Acute bacterial prostatitis (ABP)
  • Category II: Chronic bacterial prostatitis (CBP)
  • Category III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
  • Category IV: Asymptomatic inflammatory prostatitis 4

Acute Bacterial Prostatitis (ABP)

Diagnosis

• Presents with fever, chills, pelvic pain, and urinary symptoms (dysuria, frequency, urgency, retention) 5
• Do not perform prostatic massage in ABP due to risk of bacteremia 1
• Diagnostic workup should include:
  • Midstream urine dipstick to check nitrite and leukocytes 1
  • Midstream urine culture to guide diagnosis and tailor antibiotic treatment 1
  • Blood culture and total blood count 1
  • Transrectal ultrasound in selected cases to rule out prostatic abscess 1

Treatment

• First-line therapy: Broad-spectrum antibiotics 2, 5
  • For hospitalized patients with severe illness: IV antibiotics such as:
    • Ceftriaxone plus doxycycline
    • Piperacillin/tazobactam
    • A combination of amoxicillin plus an aminoglycoside
    • A second-generation cephalosporin plus an aminoglycoside
    • An intravenous third-generation cephalosporin 2, 1
  • For outpatient treatment: Oral fluoroquinolones (if local resistance is <10%) 1, 2
• Duration: 2-4 weeks of antibiotic therapy 6, 7
• Supportive measures: Analgesics, adequate hydration, and urinary catheterization if needed for retention 5

Chronic Bacterial Prostatitis (CBP)

Diagnosis

• Characterized by recurrent UTIs from the same bacterial strain 2
• Perform the Meares and Stamey 2- or 4-glass test for diagnosis 1
• Accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species 1
• Up to 74% of cases are due to gram-negative organisms, particularly E. coli 2, 4

Treatment

• First-line therapy: Fluoroquinolones (levofloxacin or ciprofloxacin) due to their favorable pharmacokinetic profile and prostate penetration 8, 6
  • Levofloxacin 500 mg once daily for a total of 28 days 8
  • Ciprofloxacin 500 mg twice daily for a total of 28 days 8
• Alternative antibiotics if fluoroquinolone resistance or contraindications:
  • Trimethoprim-sulfamethoxazole (TMP-SMX)
  • Doxycycline (if the pathogen is susceptible)
  • Fosfomycin (for multidrug-resistant pathogens) 7
• Duration: Minimum 4 weeks, up to 12 weeks for difficult cases 7
• Clinical success rates with levofloxacin: 75% microbiological eradication rate 8

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

Diagnosis

• Defined as pelvic pain or discomfort for at least 3 months with urinary symptoms 2
• Diagnosis of exclusion when evaluation does not identify other causes like infection, cancer, or urinary obstruction 2
• National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) measures symptom severity (scale 0-43) 2

Treatment

• First-line therapy for urinary symptoms: Alpha-blockers (e.g., tamsulosin, alfuzosin) 2
• Additional therapeutic options:
  • Anti-inflammatory drugs (e.g., ibuprofen)
  • Pregabalin
  • Pollen extract 2
• Multimodal approach may be necessary as no single treatment is universally effective 2

Important Considerations and Pitfalls

• Avoid fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months due to increased risk of resistance 1
• Do not routinely perform microbiological analysis of the ejaculate alone to diagnose CBP 1
• If there is no improvement in symptoms after 2-4 weeks of antibiotic treatment, therapy should be reconsidered 6
• Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness 6
• Rising fluoroquinolone resistance is a significant clinical problem that may limit treatment options 4
• Biofilm formation by bacterial isolates may contribute to the development of chronic bacterial prostatitis and treatment failure 4

Special Populations

• For patients with febrile UTI and acute prostatitis, antibiotics have a 92-97% success rate when prescribed for 2-4 weeks 2
• Sexual partners should be treated while maintaining patient confidentiality in cases of sexually transmitted infections 1