What is the treatment for prostatitis?

Treatment of Prostatitis

Treatment of prostatitis depends critically on the specific type: acute bacterial prostatitis requires 2-4 weeks of broad-spectrum antibiotics (fluoroquinolones or IV beta-lactams for severe cases), chronic bacterial prostatitis requires at least 4 weeks of fluoroquinolones, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is treated with alpha-blockers as first-line therapy, not antibiotics. 1, 2

Acute Bacterial Prostatitis

Initial Assessment and Diagnosis

• Perform a gentle digital rectal examination only—avoid vigorous prostatic massage or vigorous examination as this can precipitate bacteremia 1
• Obtain midstream urine culture to identify causative organisms 1
• Collect blood cultures, especially if the patient is febrile 1
• Check complete blood count to assess for leukocytosis 1
• Consider transrectal ultrasound in selected cases to rule out prostatic abscess 1

Antibiotic Selection for Acute Bacterial Prostatitis

For outpatients or mild-moderate cases:

• First-line: Oral fluoroquinolones (ciprofloxacin or levofloxacin) with 92-97% success rate 2
• Ciprofloxacin 500-750 mg orally twice daily 2, 3
• Levofloxacin 500-750 mg orally once daily 4, 2
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates 1

For severely ill patients or those requiring hospitalization:

• Intravenous broad-spectrum antibiotics initially 2, 5
• Piperacillin-tazobactam IV 2, 5
• Third-generation cephalosporins (e.g., ceftriaxone) IV 2, 5
• Ciprofloxacin 400 mg IV twice daily 1
• Consider adding an aminoglycoside for combination therapy in severe cases 5
• For multidrug-resistant gram-negative pathogens, consider meropenem 5

Duration and Monitoring

• Total duration: 2-4 weeks of antibiotic therapy 1, 2
• Assess clinical response after 48-72 hours of treatment 1
• Switch from IV to oral antibiotics once clinically improved 1
• Critical pitfall: Stopping antibiotics prematurely can lead to chronic bacterial prostatitis—complete the full treatment course 1

Local Resistance Considerations

• Fluoroquinolone resistance should ideally be less than 10% for empiric use 1
• For patients with risk factors for antibiotic resistance or healthcare-associated infections, consider broader spectrum options initially 1

Chronic Bacterial Prostatitis

Diagnosis

• Use the Meares-Stamey 4-glass test (gold standard): collect first-void urine, midstream urine, expressed prostatic secretions (EPS), and post-massage urine 1
• A simplified 2-specimen variant (midstream urine and EPS only) can be used 1
• Positive result: 10-fold higher bacterial count in EPS compared to midstream urine indicates bacterial prostatitis requiring antibiotics 1
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, as these require specific antimicrobial therapy 1

Antibiotic Treatment

• First-line: Fluoroquinolones for a minimum of 4 weeks 2, 3
• Levofloxacin 500 mg orally once daily for 28 days 4
• Ciprofloxacin 500 mg orally twice daily for 28 days 4, 3
• Microbiologic eradication rate: approximately 75-77% 4

For Chlamydial prostatitis:

• Macrolides are more effective than fluoroquinolones 5
• Tetracyclines (e.g., doxycycline) show equivalent efficacy to macrolides for intracellular pathogens 3, 5

Alternative agents for fluoroquinolone-resistant cases:

• Trimethoprim-sulfamethoxazole (if susceptible) 3
• Fosfomycin (emerging as useful for multidrug-resistant pathogens) 3
• Aminoglycosides 5

Duration Considerations

• Minimum 4 weeks of therapy required 2, 6, 3
• May extend up to 12 weeks for refractory cases 3
• If no improvement after 2-4 weeks, stop and reconsider treatment 6
• If improvement occurs, continue for at least an additional 2-4 weeks 6
• Do not continue antibiotics for 6-8 weeks without appraising effectiveness 6

Treatment of Sexual Partners

• For sexually transmitted infection agents (Chlamydia trachomatis, Mycoplasma genitalium), investigate and treat sexual partners using molecular methods 5

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

Key Diagnostic Distinction

• CP/CPPS is NOT frequently caused by a culturable infectious agent and requires different management focused on symptom relief rather than antimicrobials 1
• Diagnosed when evaluation (history, physical exam, urine culture, postvoid residual) does not identify infection, cancer, urinary obstruction, or retention 2
• Symptoms: pelvic pain or discomfort for at least 3 months, associated with urinary symptoms like frequency 2

First-Line Treatment

• Alpha-blockers (e.g., tamsulosin, alfuzosin) for patients with urinary symptoms 2, 5
• NIH-CPSI score improvement: -10.8 to -4.8 points compared to placebo 2

Additional Therapies

• Analgesics and NSAIDs for pain: modest symptom reduction and quality of life improvement 2, 5
• NIH-CPSI score improvement with NSAIDs: -2.5 to -1.7 points 2
• Pregabalin: NIH-CPSI score improvement of -2.4 points 2
• Pollen extract: NIH-CPSI score improvement of -2.49 points 2
• Quercetin and Serenoa repens extract: positive effects on symptoms and quality of life without side effects 5

Multimodal Approach

• Combination therapy with alpha-blockers, antibiotics (if infection suspected), and anti-inflammatory agents shows better symptom control than single-drug treatment 5
• Consider probiotics to regulate intestinal flora, as dysbiosis correlates with CP/CPPS 5

Special Considerations

Prostatic Abscess

• If abscess develops, surgical intervention is often needed 7
• Transrectal ultrasound or multiparametric MRI can identify abscess formation 5

Refractory Cases

• For chronic bacterial prostatitis with multiple antibiotic failures due to Enterococcus faecalis, phage therapy may be considered at specialized centers, though not yet standardized or widely available 8
• Requires sending bacterial isolate to specialized phage therapy center for testing 8
• Regulatory frameworks vary by country, often requiring compassionate use authorization 8

Underlying Conditions

• Acute bacterial prostatitis is rare in healthy adult men—investigate for underlying diseases including sexually transmitted diseases, benign prostatic hyperplasia, urinary stones, and malignant tumors 7
• If chronic prostatitis progresses without recognition, patients may require long-term antibiotic administration with suboptimal response rates 7