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

• If improvement occurs after initial 2-4 weeks, continue for at least another 2-4 weeks to achieve clinical cure 6
• Some cases may require up to 12 weeks of therapy 3
• Do not continue antibiotics for 6-8 weeks without appraising effectiveness 6
• If no improvement in symptoms after initial course, stop and reconsider the diagnosis 6

Treatment Failure and Refractory Cases

• For multiple antibiotic treatment failures with confirmed E. faecalis infection, phage therapy may be considered at specialized centers, though this is not yet standardized or widely available 7
• Requires sending bacterial isolate to specialized phage therapy center for testing 7
• May require compassionate use authorization depending on country 7

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

Diagnosis

• Defined as pelvic pain or discomfort for at least 3 months associated with urinary symptoms (e.g., urinary frequency) 2
• Diagnosed when evaluation (history, physical exam, urine culture, postvoid residual) does not identify other causes such as infection, cancer, urinary obstruction, or retention 2
• Key distinction: CP/CPPS is not frequently caused by a culturable infectious agent and requires different management focused on symptom relief rather than antimicrobials 1
• Use NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure symptom severity (scale 0-43); a 6-point change is clinically meaningful 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 compared to placebo 2
• Demonstrated reduction of symptoms and improvement in quality of life 5

Additional Treatment Options

• Analgesics and NSAIDs for pain (NIH-CPSI score improvement: -2.5 to -1.7 vs placebo) 2, 5
• Note: Long-term NSAID use is limited by side effect profile 5
• Pregabalin (NIH-CPSI score improvement: -2.4 vs placebo) 2
• Pollen extract (NIH-CPSI score improvement: -2.49 vs placebo) 2
• Quercetin and Serenoa repens extract showed positive effects on symptoms and quality of life without side effects 5

Multimodal Therapy

• Combination of alpha-blockers, antibiotics (if infection suspected), and anti-inflammatory drugs showed better control of symptoms than single drug treatment 5
• Consider probiotics to regulate intestinal flora balance, as dysbiosis correlates with chronic prostatitis 5

When to Consider Antibiotics in CP/CPPS

• Only if there is clinical, bacteriological, or supporting immunological evidence of prostate infection 6
• Do not initiate antibiotics immediately unless acute exacerbation—complete appropriate investigations first (preferably within 1 week) 6
• During workup period, provide nonspecific treatment such as appropriate analgesia to relieve symptoms 6

Common Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute bacterial prostatitis—this can cause bacteremia 1
• Do not stop antibiotics prematurely in bacterial prostatitis—this leads to chronic infection 1
• Do not use amoxicillin/ampicillin empirically due to high resistance rates 1
• Do not treat CP/CPPS with prolonged antibiotics unless infection is documented—this is not an infectious condition in most cases 1
• Do not overlook underlying diseases when diagnosing acute bacterial prostatitis—consider sexually transmitted diseases, benign prostatic hyperplasia, urinary stones, and malignant tumors 8
• Do not miss prostatic abscess formation—if antibiotics fail in acute prostatitis, consider imaging to rule out abscess requiring surgical drainage 8