What are the treatment options for prostatitis?

Treatment of Prostatitis

Treat acute bacterial prostatitis with fluoroquinolones (ciprofloxacin 500mg PO BID or levofloxacin) for 2-4 weeks in outpatients when local resistance is <10%, or use IV ceftriaxone plus doxycycline for hospitalized patients with severe illness. 1

Classification-Based Treatment Algorithm

The treatment approach depends entirely on which of the four categories your patient falls into 2:

Acute Bacterial Prostatitis

For outpatients:

• Start fluoroquinolones immediately (ciprofloxacin 500mg PO BID or levofloxacin) if local fluoroquinolone resistance is <10% 1
• Continue for 2-4 weeks total 1
• Obtain midstream urine culture and blood cultures before starting antibiotics to identify the causative organism 1, 3

For hospitalized patients with severe illness:

• Use IV ceftriaxone plus doxycycline 1
• Switch to oral fluoroquinolones once clinically improved 3
• Assess clinical response after 48-72 hours 3

Critical diagnostic maneuvers:

• Perform a gentle digital rectal examination to assess for tender, enlarged, or boggy prostate 1
• Never perform vigorous prostatic massage or manipulation due to bacteremia risk 1, 3
• Order transrectal ultrasound if the patient fails to respond after 48-72 hours to rule out prostatic abscess 1, 3

Chronic Bacterial Prostatitis

• Prescribe fluoroquinolones (levofloxacin or ciprofloxacin) for a minimum of 4 weeks 1
• Extend treatment duration if symptoms improve but are not fully resolved 1
• Use the Meares-Stamey 4-glass test (or simplified 2-specimen variant) to confirm diagnosis, requiring a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 3
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when appropriate, as up to 74% of cases are caused by gram-negative organisms, particularly E. coli 1, 3

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

This is NOT an infectious condition and requires completely different management:

• Prescribe alpha-blockers (tamsulosin or alfuzosin) as first-line therapy for patients with urinary symptoms, which provide NIH-CPSI score reduction of 4.8-10.8 points 1
• Combine alpha-blockers with anti-inflammatories and supportive measures (sitz baths, relaxants, psychological support) for optimal symptom relief 1
• Do NOT prescribe prolonged antibiotics without evidence of infection 1

Asymptomatic Inflammatory Prostatitis

• This is an incidental finding without symptoms and typically requires no treatment 2

Prostatic Abscess Management

• Drain via transrectal ultrasound-guided aspiration for confirmed abscesses 2
• Small abscesses may resolve with antibiotics alone 2
• Consider imaging in patients who fail to respond to antibiotics to rule out abscess formation 2

Critical Pitfalls to Avoid

• Never use amoxicillin/ampicillin empirically due to global resistance rates of 45-100% 1, 3
• Never perform vigorous prostatic massage in acute bacterial prostatitis due to bacteremia risk 1, 3
• Never stop antibiotics prematurely in bacterial prostatitis, as this leads to chronic infection 1, 3
• Never prescribe prolonged antibiotics for CP/CPPS without evidence of infection; focus on symptom management instead 1
• Always consider local resistance patterns when selecting empiric fluoroquinolone therapy, using them only if resistance is <10% 1, 3

Antibiotic Selection Rationale

Fluoroquinolones are first-line for bacterial prostatitis because they achieve excellent prostatic penetration with prostate:serum ratios of up to 4:1 2, and provide broad antimicrobial coverage against the gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) responsible for 80-97% of acute cases 3. However, local resistance patterns must guide selection 2, 3.