What is the treatment for prostatitis?

Treatment of Prostatitis

Treatment of prostatitis depends critically on the specific category: 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 for urinary symptoms rather than antibiotics. 1, 2

Acute Bacterial Prostatitis

Initial Assessment and Diagnostic Approach

• Perform a gentle digital rectal examination only—avoid vigorous prostatic massage or vigorous examination due to risk of bacteremia 1
• Obtain midstream urine culture to identify causative organisms 1
• Collect blood cultures, especially in febrile patients 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 severely ill or febrile patients requiring hospitalization:

• Initiate IV broad-spectrum antibiotics: piperacillin-tazobactam, third-generation cephalosporins (ceftriaxone), or ciprofloxacin 400 mg IV twice daily 1, 2
• Switch to oral antibiotics once clinically improved 1

For outpatients or after clinical improvement:

• Oral ciprofloxacin or levofloxacin are first-line choices with 92-97% success rates 2
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates 1
• Consider local resistance patterns—fluoroquinolone resistance should ideally be <10% for empiric use 1
• For patients with risk factors for antibiotic resistance or healthcare-associated infections, consider broader spectrum options initially 1

Duration and Follow-up

• Complete 2-4 weeks total of antibiotic therapy 1, 2
• Assess clinical response after 48-72 hours of treatment 1
• Stopping antibiotics prematurely can lead to chronic bacterial prostatitis—complete the full treatment course 1

Common Causative Organisms

• Gram-negative bacteria (80-97% of cases): E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa 1, 2
• Gram-positive bacteria: Staphylococcus aureus, Enterococcus species, Group B streptococci 1

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Chronic Bacterial Prostatitis

Diagnostic Confirmation

• Use the Meares-Stamey 4-glass test (gold standard) or simplified 2-glass variant 1, 3
• Positive result requires 10-fold higher bacterial count in expressed prostatic secretions (EPS) compared to midstream urine 1
• This distinguishes chronic bacterial prostatitis from CP/CPPS, which is not caused by culturable infectious agents 1

Antibiotic Treatment

First-line therapy:

• Levofloxacin 500 mg once daily for chronic bacterial prostatitis is FDA-approved 4
• Alternative: ciprofloxacin 500 mg twice daily 4, 2
• Minimum duration: 4 weeks, with treatment extending up to 12 weeks if needed 2, 3

Microbiologic efficacy:

• Levofloxacin achieves 75% microbiologic eradication rate at 5-18 days post-therapy 4
• Clinical success rates (cure + improvement) are 75% for levofloxacin-treated patients 4

Common Causative Organisms

• Up to 74% are gram-negative organisms, particularly E. coli 1
• Other pathogens: Proteus mirabilis, Enterobacter species, Serratia marcescens, Enterococcus faecalis, Staphylococcus epidermidis 1, 4

Special Considerations

• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, as these require specific antimicrobial therapy 1, 5
• For treatment-refractory cases with confirmed E. faecalis, phage therapy may be considered at specialized centers, though this is not yet standardized or widely available 6

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

Key Diagnostic Distinction

• CP/CPPS presents with pelvic pain or discomfort for at least 3 months with urinary symptoms 2, 7
• Not caused by culturable infectious agents—requires different management focused on symptom relief rather than antimicrobials 1, 2
• Diagnosis requires ruling out bacterial infection via Meares-Stamey test, negative urine cultures, and exclusion of other causes (cancer, obstruction, retention) 1, 2

First-Line Treatment

Alpha-blockers for urinary symptoms:

• Tamsulosin or alfuzosin are first-line for CP/CPPS with urinary symptoms 2, 7
• Provide significant symptom improvement (NIH-CPSI score difference vs placebo: -10.8 to -4.8) 2

Second-Line and Adjunctive Therapies

Anti-inflammatory agents for pain:

• NSAIDs (ibuprofen) provide modest benefit (NIH-CPSI score difference: -2.5 to -1.7) 2
• Long-term NSAID use is limited by side effect profile 5

Other pharmacologic options:

• Pregabalin (NIH-CPSI score difference: -2.4) 2
• Pollen extract (NIH-CPSI score difference: -2.49) 2

Antibiotics (limited role):

• A 4-6 week trial of fluoroquinolones provides relief in 50% of men, particularly if prescribed soon after symptom onset 7
• However, CP/CPPS is not an infectious condition—antibiotics should not be the primary treatment 1

Multimodal Approach

• Combination therapy with alpha-blockers, antibiotics (if early in course), and anti-inflammatories shows better symptom control than single-drug treatment 5
• Pelvic floor training/biofeedback is potentially more effective but requires specialized referral 7

Third-Line Options

• 5-alpha-reductase inhibitors, quercetin, Serenoa repens extract 7, 5
• For treatment-refractory patients: transurethral microwave therapy 7

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Critical Pitfalls to Avoid

1. Do not perform vigorous prostatic massage in acute bacterial prostatitis—this can cause bacteremia 1

2. Do not use amoxicillin/ampicillin empirically—resistance rates are too high 1

3. Do not stop antibiotics prematurely in bacterial prostatitis—this leads to chronic infection 1

4. Do not treat CP/CPPS primarily with prolonged antibiotics—it is not an infectious condition and requires symptom-directed therapy 1, 2

5. Verify local fluoroquinolone resistance patterns before empiric use—resistance should be <10% 1

6. Distinguish chronic bacterial prostatitis from CP/CPPS using localization cultures—treatment differs fundamentally 1, 3