Treatment of Chronic Prostatitis
Distinguish Between Chronic Bacterial Prostatitis and Chronic Pelvic Pain Syndrome First
For chronic bacterial prostatitis (culture-positive), prescribe levofloxacin 500 mg orally once daily or ciprofloxacin 500 mg orally twice daily for a minimum of 4 weeks, as this is FDA-approved and guideline-recommended first-line therapy. 1, 2 For chronic pelvic pain syndrome (culture-negative, >90% of cases), antibiotics are not the primary treatment—instead use alpha-blockers like tamsulosin as first-line therapy. 2, 3
Diagnostic Workup Before Treatment
Perform the Meares-Stamey 2- or 4-glass test to definitively diagnose chronic bacterial prostatitis by demonstrating a 10-fold higher bacterial count in expressed prostatic secretions (EPS) compared to midstream urine. 4, 5 This test differentiates bacterial infection from chronic pelvic pain syndrome, which is critical because treatment differs fundamentally. 6
- Test for atypical pathogens including Chlamydia trachomatis, Mycoplasma, and Ureaplasma species, as these require different antimicrobial therapy. 4, 5
- Obtain midstream urine culture to identify causative organisms. 4
- Avoid vigorous prostatic massage in acute presentations due to bacteremia risk, but gentle examination is appropriate in chronic cases. 4
Treatment Algorithm for Chronic Bacterial Prostatitis
First-Line Antibiotic Therapy
Fluoroquinolones are the cornerstone of treatment due to superior prostatic tissue penetration and coverage of common uropathogens (E. coli causes up to 74% of cases). 4, 2, 6
- Levofloxacin 500 mg orally once daily for minimum 4 weeks is FDA-approved for chronic bacterial prostatitis caused by E. coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis. 1, 2
- Ciprofloxacin 500 mg orally twice daily for minimum 4 weeks is an equivalent alternative. 1, 2, 7
- Verify local fluoroquinolone resistance is <10% before empiric use; if resistance exceeds this threshold, obtain culture results first to guide therapy. 4, 5
Duration of Therapy
- Minimum 4 weeks of treatment is required, with some guidelines recommending 4-6 weeks. 8, 2, 7
- Assess clinical response at 2-4 weeks—if symptoms improve, continue for the full course; if no improvement, stop antibiotics and reconsider the diagnosis. 8
- If symptoms recur after successful treatment, consider a repeat 4-6 week course, potentially combined with alpha-blockers or analgesics. 3
Special Pathogen Considerations
For Chlamydia trachomatis prostatitis, azithromycin shows superior eradication and clinical cure rates compared to ciprofloxacin. 7 Use azithromycin 500 mg on day 1, then 250 mg daily for 4 days, or doxycycline 100 mg twice daily for 7 days. 9
For Ureaplasma infections, azithromycin and doxycycline show comparable efficacy to fluoroquinolones. 7
Treatment of Chronic Pelvic Pain Syndrome (Non-Bacterial)
This accounts for >90% of chronic prostatitis cases and does not respond to prolonged antibiotics. 2, 3
- Alpha-blockers (tamsulosin, alfuzosin) are first-line therapy for patients with urinary symptoms, showing NIH-CPSI score improvements of 4.8-10.8 points compared to placebo. 2
- Consider a trial of antibiotics for 4-6 weeks only if there is clinical, bacteriological, or immunological evidence suggesting occult infection, but discontinue if no response. 8, 3
- NSAIDs (ibuprofen) provide modest symptom relief (NIH-CPSI score difference -1.7 to -2.5 vs placebo). 2
- Pregabalin may help neuropathic pain components (NIH-CPSI score difference -2.4 vs placebo). 2
Critical Pitfalls to Avoid
- Do not use amoxicillin or ampicillin empirically—global E. coli resistance rates are 75% (range 45-100%). 5
- Do not prescribe oral cephalosporins like cefpodoxime for prostatitis—they have poor prostatic tissue penetration despite efficacy in other urogenital infections. 4
- Do not continue antibiotics beyond 6-8 weeks without reassessing effectiveness, as prolonged unnecessary antibiotic use increases resistance and adverse effects. 8
- Stopping antibiotics prematurely can lead to relapse, so complete the full 4-week minimum course if bacterial infection is confirmed. 4
- Avoid fluoroquinolones if the patient used them in the last 6 months or is from a urology department, due to increased resistance risk. 5
When to Refer to Urology
- Recurrent infections despite appropriate antibiotic therapy warrant urological evaluation for anatomic abnormalities or prostatic calculi. 3
- Symptoms persisting beyond 3 months without response to initial treatments should prompt specialist consultation. 3
- Consider transrectal ultrasound in selected cases to rule out prostatic abscess, especially if fever persists. 5