What are the management guidelines for prostatitis?

Management of Prostatitis

Management of prostatitis depends critically on accurate classification into acute bacterial, chronic bacterial, or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), as each requires fundamentally different treatment approaches.

Diagnostic Classification Framework

Acute Bacterial Prostatitis

• Presents with fever, chills, pelvic pain, and urinary symptoms (dysuria, frequency, retention) with a tender prostate on gentle digital rectal examination 1, 2
• Avoid vigorous prostatic massage or vigorous digital rectal examination due to risk of bacteremia 1
• Obtain midstream urine culture to identify causative organisms 1
• Collect blood cultures in febrile patients 1
• Check complete blood count for leukocytosis 1
• Consider transrectal ultrasound in selected cases to rule out prostatic abscess 1

Chronic Bacterial Prostatitis

• Characterized by recurrent urinary tract infections from the same bacterial strain, with persistent prostatic infection 2
• Diagnose using the Meares-Stamey 4-glass test (first-void urine, midstream urine, expressed prostatic secretions, post-massage urine), requiring a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretions only) can be used 1

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

• Diagnosed when pelvic pain or discomfort persists for at least 3 months with urinary symptoms, but evaluation excludes infection, cancer, obstruction, or retention 2
• This is NOT an infectious condition and does not require antimicrobials 1

Treatment Algorithms

Acute Bacterial Prostatitis Management

Empiric Antibiotic Selection:

• Target gram-negative bacteria (E. coli, Klebsiella, Pseudomonas), which cause 80-97% of cases 1, 2
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates 1

Outpatient Treatment (mild to moderate cases):

• Ciprofloxacin 500 mg orally twice daily for 2-4 weeks 3, 2
• Alternative: Levofloxacin 500 mg orally once daily for 2-4 weeks 4
• Ensure local fluoroquinolone resistance is less than 10% for empiric use 1

Inpatient Treatment (severe cases, systemic illness, urinary retention, inability to tolerate oral intake):

• Ciprofloxacin 400 mg IV twice daily, switching to oral once clinically improved 1, 5
• Alternative: Piperacillin-tazobactam IV or ceftriaxone IV 2, 5
• Assess clinical response after 48-72 hours and complete a total of 2-4 weeks of therapy 1

Critical Pitfall:

• Stopping antibiotics prematurely can lead to chronic bacterial prostatitis—complete the full 2-4 week course 1

Chronic Bacterial Prostatitis Management

First-Line Antibiotic Therapy:

• Levofloxacin 500 mg orally once daily for 28 days (minimum 4 weeks) 4, 2
• Alternative: Ciprofloxacin 500 mg orally twice daily for 28 days 4, 3, 2
• In the FDA trial, levofloxacin achieved 75% microbiologic eradication and 75% clinical success at 5-18 days post-therapy 4

Duration Considerations:

• Minimum duration is 4 weeks 2, 6
• Some sources recommend 6-12 weeks for difficult cases 7
• If no improvement after 2-4 weeks, stop treatment and reconsider the diagnosis 6
• If improvement occurs, continue for at least an additional 2-4 weeks 6

Antibiotic Selection Rationale:

• Fluoroquinolones (levofloxacin, ciprofloxacin) are preferred due to excellent prostatic tissue penetration and favorable antibacterial spectrum against gram-negative organisms 6, 8
• Up to 74% of chronic bacterial prostatitis cases are caused by gram-negative organisms, particularly E. coli 1

Refractory Cases:

• Long-term suppressive antibiotic therapy may be considered for recurrent bacteriuria 7
• Phage therapy is investigational and not yet standardized or widely available, requiring specialized phage banks and compassionate use authorization 9

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

First-Line Therapy for Urinary Symptoms:

• α-blockers (tamsulosin, alfuzosin) provide the greatest symptom improvement (NIH-CPSI score difference vs placebo = -10.8 to -4.8) 2

Adjunctive Therapies (modest benefit):

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score difference = -2.5 to -1.7 2
• Pregabalin: NIH-CPSI score difference = -2.4 2
• Pollen extract: NIH-CPSI score difference = -2.49 2

Key Point:

• Antibiotics are NOT indicated for CP/CPPS unless there is clinical, bacteriological, or immunological evidence of prostatic infection 1, 6

Common Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute bacterial prostatitis—this can cause bacteremia 1
• Do not start antibiotics immediately without proper diagnostic workup (except in acute prostatitis with fever)—complete evaluation within 1 week 6
• Do not prescribe antibiotics for 6-8 weeks without assessing effectiveness at 2-4 weeks 6
• Do not treat CP/CPPS with prolonged antibiotics—this is not an infectious condition 1
• Consider local antibiotic resistance patterns before selecting empiric fluoroquinolones 1