What is the recommended treatment for sterile prostatitis?

Sterile Prostatitis Treatment

For sterile prostatitis (chronic prostatitis/chronic pelvic pain syndrome without bacterial infection), alpha-blockers such as tamsulosin or alfuzosin are the first-line treatment, particularly when urinary symptoms are present, with expected symptom score reductions of 4.8 to 10.8 points on the NIH-CPSI scale. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the absence of bacterial infection:

• Perform the Meares-Stamey 2- or 4-glass test to definitively rule out bacterial prostatitis (a 10-fold higher bacterial count in expressed prostatic secretions versus midstream urine indicates bacterial infection requiring antibiotics) 1, 3
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, as these require specific antimicrobial therapy 1, 3
• Midstream urine culture should be negative 1

First-Line Treatment: Alpha-Blockers

Alpha-blockers are the preferred initial therapy when urinary symptoms predominate:

• Tamsulosin, alfuzosin, doxazosin, or terazosin are equally effective options 4
• Expected benefit: NIH-CPSI score reduction of 4.8 to 10.8 points compared to placebo 2
• Duration matters: Longer treatment courses yield better results—6 weeks of tamsulosin reduced scores by 3.6 points, while 14 weeks of terazosin and 24 weeks of alfuzosin achieved reductions of 14.3 and 9.9 points respectively 5
• Common adverse effects: Orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion 4
• Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction compared to other alpha-blockers 4

Second-Line and Adjunctive Therapies

If alpha-blockers provide inadequate relief after 6-24 weeks:

Anti-Inflammatory Agents

• NSAIDs (e.g., ibuprofen) may reduce NIH-CPSI scores by 1.7 to 2.5 points compared to placebo 2, 6
• Low risk of adverse events 6

Phytotherapy

• Pollen extract may reduce NIH-CPSI scores by approximately 2.5 points 2
• Various plant extracts showed score reductions of 3.2 to 6.8 points in studies 6
• Generally well-tolerated with low adverse event rates 6

Pregabalin

• May reduce NIH-CPSI scores by 2.4 points for patients with neuropathic pain features 2

Stepwise Treatment Algorithm

A sequential approach appears most effective for long-term symptom control:

1. Start with alpha-blocker monotherapy for 6-24 weeks 5, 2
2. Add anti-inflammatory agent if partial response 5
3. Consider bioflavonoids/phytotherapy if symptoms persist 5
4. This stepwise approach achieved mean NIH-CPSI score reduction of 9.5 points maintained for up to 1 year 5

What NOT to Do

Avoid combination therapy as initial treatment: Combining alpha-blocker, anti-inflammatory, and muscle relaxant offers no advantage over monotherapy (12.7 vs 12.4 point NIH-CPSI reduction) 5

Do not use antibiotics empirically in confirmed sterile prostatitis—they provide no benefit when bacterial infection is excluded 1, 2

5-alpha reductase inhibitors (finasteride, dutasteride) are NOT appropriate for sterile prostatitis, as they are only effective for benign prostatic hyperplasia with demonstrable prostatic enlargement 4

Refractory Cases

For patients failing multiple pharmacologic regimens:

• Consider electromagnetic or electroacupuncture therapy for direct pelvic muscle stimulation 5
• Intraprostatic botulinum toxin A injection may cause large symptom reductions (25.8-point NIH-CPSI decrease), though evidence is limited to small studies 6

Monitoring and Follow-Up

• Clinically meaningful improvement is defined as a 6-point reduction in NIH-CPSI score (scale 0-43) 2
• Reassess symptoms at 6-week intervals initially, then extend to 3-6 months once stable 5
• Long-term follow-up (>6 months) is necessary as relapse is common 7