What are the treatment options for prostatitis?

Treatment of Prostatitis

Acute Bacterial Prostatitis

For acute bacterial prostatitis, initiate broad-spectrum antibiotics immediately—fluoroquinolones (ciprofloxacin 500mg PO BID or levofloxacin) for outpatients if local resistance is <10%, or intravenous ceftriaxone plus doxycycline for hospitalized patients with severe illness, continuing for 2-4 weeks total. 1, 2

Initial Assessment and Diagnosis

• Perform a gentle digital rectal examination only—avoid vigorous prostatic massage or manipulation due to risk of bacteremia 1, 3
• Look for a tender, enlarged, or boggy prostate on examination, along with fever, chills, dysuria, urinary frequency, or urinary retention 2, 4
• Obtain midstream urine culture and blood cultures (especially if febrile) to identify causative organisms 1, 3
• Check complete blood count to assess for leukocytosis 3
• Consider transrectal ultrasound only in selected cases to rule out prostatic abscess, particularly if patients fail to respond to antibiotics after 48-72 hours 1, 3

Antibiotic Selection Based on Severity

Outpatient Treatment (mild-to-moderate cases):

• First-line: Oral fluoroquinolones (ciprofloxacin or levofloxacin) if local resistance patterns show <10% fluoroquinolone resistance 1, 5
• Avoid: Amoxicillin or ampicillin empirically due to 75% median E. coli resistance globally (range 45-100%) 3, 5
• Success rate with fluoroquinolones: 92-97% when prescribed for 2-4 weeks 2

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

• First-line: Ceftriaxone plus doxycycline, or piperacillin-tazobactam intravenously 5, 2, 4
• Alternative: Amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside 5
• Transition to oral antibiotics once clinically improved (typically after 48-72 hours) 3

Duration and Follow-up

• Total treatment duration: 2-4 weeks to prevent progression to chronic bacterial prostatitis 6, 3, 2
• Reassess clinical response at 48-72 hours 3
• Critical pitfall: Stopping antibiotics prematurely leads to chronic bacterial prostatitis—complete the full course 3

Special Considerations for Prostatic Abscess

• Small abscesses may resolve with antibiotics alone 1
• Larger abscesses require drainage via transrectal ultrasound-guided aspiration 1
• Consider imaging if no response to antibiotics after 48-72 hours 1

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Chronic Bacterial Prostatitis

For chronic bacterial prostatitis, prescribe fluoroquinolones (levofloxacin or ciprofloxacin) for a minimum of 4 weeks, extending treatment if symptoms improve but not fully resolved. 2, 7, 8

Diagnosis

• Perform the Meares-Stamey 4-glass test (gold standard): collect first-void urine, midstream urine, expressed prostatic secretions (EPS), and post-massage urine 3, 5
• A simplified 2-specimen variant (midstream urine and EPS only) is acceptable 3
• Positive result: 10-fold higher bacterial count in EPS compared to midstream urine 3, 8
• Up to 74% of cases are caused by gram-negative organisms, particularly E. coli 3, 2
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when appropriate 5

Antibiotic Treatment

• First-line: Fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4 weeks 2, 7, 8
• Fluoroquinolones achieve prostate:serum ratios of up to 4:1, providing excellent prostatic penetration 1
• Do not use fluoroquinolones if patient is from urology department or has used fluoroquinolones in the last 6 months due to resistance risk 5
• If symptoms improve after initial 2-4 weeks, continue for an additional 2-4 weeks to achieve clinical cure and pathogen eradication 8
• Do not continue antibiotics for 6-8 weeks without reassessing effectiveness 8

Management of Recurrent UTIs

• Chronic bacterial prostatitis typically presents as recurrent UTIs from the same bacterial strain 2, 7
• Treat sexual partners while maintaining confidentiality if sexually transmitted infections are identified 5

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

For CP/CPPS with urinary symptoms, prescribe alpha-blockers (tamsulosin or alfuzosin) as first-line therapy, which provide the greatest symptom improvement (NIH-CPSI score reduction of 4.8-10.8 points). 2, 7

Diagnosis

• CP/CPPS is characterized by pelvic pain or discomfort for at least 3 months, associated with urinary symptoms (frequency, urgency) or painful ejaculation 2, 7
• Diagnosis of exclusion: Rule out infection (negative urine cultures), cancer, urinary obstruction, and urinary retention through history, physical examination, urine culture, and postvoid residual measurement 2
• Use the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure symptom severity (scale 0-43); a 6-point change is clinically meaningful 2
• Key distinction: CP/CPPS is not caused by culturable infectious agents and requires symptom-focused management, not antimicrobials 3

Treatment Algorithm

First-line therapy:

• Alpha-blockers (tamsulosin, alfuzosin) for urinary symptoms: NIH-CPSI score improvement of 4.8-10.8 points versus placebo 2, 7

Second-line therapy (if first-line inadequate):

• Trial of fluoroquinolones for 4-6 weeks if prescribed soon after symptom onset—provides relief in 50% of men 7
• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score improvement of 1.7-2.5 points versus placebo 2

Third-line therapy (if second-line inadequate):

• Pregabalin: NIH-CPSI score improvement of 2.4 points versus placebo 2
• Pollen extract (cernilton/CN-009): NIH-CPSI score improvement of 2.49 points versus placebo 2, 7
• 5-alpha-reductase inhibitors, quercetin, saw palmetto 7

Pelvic floor training/biofeedback:

• Potentially more effective than pharmacotherapy, but refer if relief from medications is not significant 7

Refractory cases:

• Transurethral microwave therapy to ablate prostatic tissue for treatment-refractory patients 7

Multimodal Approach

• Combine alpha-blockers, anti-inflammatories, and supportive measures (sitz baths, relaxants, psychological support) for optimal symptom relief 1, 7, 9
• Avoid prolonged antibiotic courses unless there is clinical, bacteriological, or immunological evidence of infection 8

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Key Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute bacterial prostatitis—risk of bacteremia 1, 3
• Never use amoxicillin/ampicillin empirically—global resistance rates are 45-100% 3, 5
• Never stop antibiotics prematurely in bacterial prostatitis—leads to chronic infection 3
• Never prescribe prolonged antibiotics for CP/CPPS without evidence of infection—focus on symptom management instead 3, 8
• Always consider local resistance patterns when selecting empiric fluoroquinolone therapy—use only if resistance <10% 1, 5
• Always obtain cultures before starting antibiotics when possible, except in acute severe cases requiring immediate treatment 8, 4