What is the treatment approach for prostatitis?

Treatment Approach for Prostatitis

Fluoroquinolones are the first-line treatment for bacterial prostatitis 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 - sudden infection with systemic symptoms
  • Chronic Bacterial Prostatitis - persistent bacterial infection causing recurrent UTIs
  • Chronic Prostatitis/Chronic Pelvic Pain Syndrome - pelvic pain without confirmed infection
  • Asymptomatic Inflammatory Prostatitis - incidental finding without symptoms

Diagnostic Approach

• For acute bacterial prostatitis, avoid prostatic massage or vigorous digital rectal examination due to risk of bacteremia 2
• Obtain midstream urine for culture to identify causative organisms and guide antibiotic therapy 2
• For chronic bacterial prostatitis, confirm diagnosis with the Meares-Stamey 2- or 4-glass test to isolate the causative pathogen 3, 4
• The 4-glass test includes collection of first-void urine, midstream urine, expressed prostatic secretions, and post-massage urine 2

Treatment Algorithm

Acute Bacterial Prostatitis

• First-line therapy: Broad-spectrum antibiotics targeting common uropathogens (E. coli and other Enterobacterales) 2, 5
• For hospitalized patients: Consider IV antibiotics such as piperacillin-tazobactam or ceftriaxone 5, 6
• For outpatients: Oral fluoroquinolones such as ciprofloxacin or levofloxacin 1, 4
• Duration: 2-4 weeks of antibiotic therapy 5, 7
• Monitor clinical response after 48-72 hours of treatment 2
• Consider transrectal ultrasound in patients who fail to respond to antibiotics to rule out prostatic abscess 1

Chronic Bacterial Prostatitis

• First-line therapy: Fluoroquinolones (levofloxacin or ciprofloxacin) for a minimum of 4 weeks 4, 5
• Levofloxacin is FDA-approved for chronic bacterial prostatitis due to E. coli, E. faecalis, or methicillin-susceptible S. epidermidis 4
• Clinical trials have shown microbiologic eradication rates of 75% with levofloxacin and 76.8% with ciprofloxacin 4
• If symptoms improve after 4 weeks, continue treatment for an additional 2-4 weeks 8
• For recurrent infections with the same organism, consider another course of antibiotics, possibly in combination with alpha blockers 9

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

• First-line therapy for urinary symptoms: Alpha-blockers (e.g., tamsulosin, alfuzosin) 5, 9
• Additional therapies with modest benefit:
  • Anti-inflammatory drugs (e.g., ibuprofen) 5
  • Pregabalin 5
  • Pollen extract 5
• Consider multimodal approach based on the UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, tenderness) system 9
• Pelvic floor physical therapy may be beneficial for patients with tenderness on examination 9

Special Considerations

• Local resistance patterns should guide antibiotic selection, with fluoroquinolone resistance ideally being less than 10% for empiric use 2
• For patients who fail multiple antibiotic treatments for chronic bacterial prostatitis caused by E. faecalis, consider phage therapy by sending the bacterial isolate to a specialized phage therapy center 3
• For prostatic abscess, drainage may be required via transrectal ultrasound-guided aspiration 1
• Small abscesses may resolve with antibiotics alone 1

Treatment Pitfalls to Avoid

• Do not initiate antibiotic treatment immediately except in cases of acute prostatitis or acute episodes of chronic bacterial prostatitis; complete appropriate investigations first 8
• Avoid antibiotic treatment for 6-8 weeks without appraising its effectiveness 8
• Do not perform prostatic massage in acute bacterial prostatitis due to risk of bacteremia 2
• Consider alternative diagnoses if no improvement is seen after appropriate treatment 1