What is the treatment for prostatitis?

Treatment of 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

Types of Prostatitis and Their Treatment

Acute Bacterial Prostatitis (ABP)

• First-line therapy for hospitalized patients with severe illness includes broad-spectrum antibiotics, such as ceftriaxone plus doxycycline 1
• For outpatient treatment, oral fluoroquinolones (e.g., ciprofloxacin) are recommended if local resistance is less than 10% 1
• Alternative antibiotic options include amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside 1
• Treatment duration typically ranges from 2-4 weeks, with a 92-97% success rate 2
• Avoid prostatic massage in acute bacterial prostatitis due to risk of bacteremia 3, 1

Chronic Bacterial Prostatitis (CBP)

• First-line therapy is a minimum 4-week course of fluoroquinolones such as levofloxacin or ciprofloxacin 2, 4
• Treatment may extend up to 12 weeks in some cases 4
• Trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline are second-line options if the pathogen is susceptible 4
• Fosfomycin has emerged as a useful agent for multidrug-resistant pathogens 4
• Historical treatment durations range from 4 weeks to 6 weeks or longer 5

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 therapies with modest benefits include:
  • Anti-inflammatory drugs (e.g., ibuprofen) 2
  • Pregabalin 2
  • Pollen extract 2

Diagnostic Approach

Acute Bacterial Prostatitis

• Diagnostic workup should include midstream urine dipstick, midstream urine culture, blood culture, and total blood count 1
• Transrectal ultrasound may be used in selected cases to rule out prostatic abscess 1
• Gram-negative bacteria are responsible in 80-97% of cases, including Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa 3, 2

Chronic Bacterial Prostatitis

• Perform the Meares and Stamey 2- or 4-glass test for diagnosis 1, 6
• Up to 74% of cases are due to gram-negative organisms, particularly E. coli 3, 2
• Accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species is necessary 1

Important Considerations and Pitfalls

• Avoid using 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
• Overlooking acute bacterial prostatitis can lead to:
  • Treatment failure and potential progression to prostatic abscess requiring surgical intervention 7
  • Transition to chronic prostatitis, which is more difficult to treat 7
  • Missing underlying diseases such as benign prostatic hyperplasia, urinary stones, or malignant tumors 7
• Sexual partners should be treated while maintaining patient confidentiality in cases of sexually transmitted infections 1
• Ciprofloxacin is FDA-approved for chronic bacterial prostatitis caused by Escherichia coli or Proteus mirabilis 8

Treatment Duration Considerations

• Acute bacterial prostatitis: 2-4 weeks of antibiotics 2
• Chronic bacterial prostatitis: Minimum 4 weeks, up to 12 weeks of antibiotics 4
• Historical recommendations for chronic bacterial prostatitis suggested 2-3 months of therapy 9
• Current guidelines note insufficient evidence to provide a clear recommendation for optimal duration of treatment for either acute or chronic bacterial prostatitis 5