What are the treatment options for prostatitis?

Treatment of Prostatitis

Treatment Algorithm Based on Prostatitis Type

Treatment of prostatitis depends critically on accurate classification into acute bacterial, chronic bacterial, or chronic pelvic pain syndrome, with fluoroquinolones serving as the cornerstone for bacterial forms and alpha-blockers for non-bacterial chronic pelvic pain syndrome. 1, 2

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Acute Bacterial Prostatitis

Initial Assessment and Diagnosis

• Perform a gentle digital rectal examination to assess for tender, enlarged, or boggy prostate, but never perform vigorous prostatic massage due to bacteremia risk 1, 3
• Obtain midstream urine culture and blood cultures to identify causative organisms (80-97% are gram-negative bacteria like E. coli, Klebsiella, or Pseudomonas) 2, 3
• Check complete blood count to assess for leukocytosis 1
• Consider transrectal ultrasound if patients fail to respond after 48-72 hours to rule out prostatic abscess 1, 4

Antibiotic Selection

For outpatients with mild-to-moderate disease:

• Prescribe oral fluoroquinolones (ciprofloxacin 500mg PO BID or levofloxacin) only if local resistance is <10% 1, 5
• Never use amoxicillin/ampicillin empirically due to global resistance rates of 45-100% 1, 5
• Treatment duration: 2-4 weeks total with 92-97% success rate 1, 2

For hospitalized patients with severe illness:

• Initiate intravenous ceftriaxone plus doxycycline, or piperacillin-tazobactam 1, 5, 2
• Alternative regimens include amoxicillin plus aminoglycoside or second-generation cephalosporin plus aminoglycoside 5

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Chronic Bacterial Prostatitis

Diagnostic Approach

• Perform the Meares-Stamey 4-glass test (gold standard) or simplified 2-specimen variant (midstream urine and expressed prostatic secretions) to compare bacterial levels 1, 5
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when appropriate, as up to 74% are caused by gram-negative organisms, particularly E. coli 1, 2
• Avoid fluoroquinolones for empirical treatment if patient is from urology department or used fluoroquinolones in last 6 months due to resistance risk 5

Antibiotic Treatment

• Prescribe fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4 weeks, with option to extend if symptoms improve but are not fully resolved 1, 2
• Fluoroquinolones achieve prostate:serum ratios up to 4:1 due to pH trapping in chronically inflamed prostate tissue 4, 6
• Clinical success rates with levofloxacin 500mg daily: 92% at 5-12 days, 77% at 1 month, 66% at 3 months, and 62% at 6 months 6
• Treat sexual partners while maintaining confidentiality in cases of sexually transmitted infections 5

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

Diagnosis

• Diagnose when pelvic pain or discomfort persists for at least 3 months with urinary symptoms (frequency, urgency), but evaluation excludes infection, cancer, obstruction, or retention 2, 7
• Use NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure severity (scale 0-43), with 6-point change considered clinically meaningful 2

First-Line Therapy

Alpha-blockers are first-line for CP/CPPS with urinary symptoms:

• Prescribe tamsulosin, alfuzosin, doxazosin, or terazosin (all equally effective) 5, 2
• Expected NIH-CPSI score reduction: 4.8 to 10.8 points 1, 2
• Greater treatment response with longer durations in alpha-blocker-naïve patients (14.3-point reduction with 14 weeks terazosin, 9.9-point reduction with 24 weeks alfuzosin) 6
• Common adverse effects: orthostatic hypotension, dizziness, tiredness, ejaculatory problems, nasal congestion (tamsulosin has lower orthostatic hypotension risk but higher ejaculatory dysfunction risk) 5

Second-Line and Adjunctive Therapies

• Trial of fluoroquinolones for 4-6 weeks may provide relief in 50% of men, especially if prescribed soon after symptom onset 7, 8
• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score reduction of 1.7-2.5 points 2
• Pregabalin: NIH-CPSI score reduction of 2.4 points 2
• Pollen extract: NIH-CPSI score reduction of 2.49 points 2
• Multimodal approach combining alpha-blockers, anti-inflammatories, and supportive measures (sitz baths, muscle relaxants, psychological support) may optimize symptom relief 1, 4

What NOT to Use

• Never prescribe 5-alpha reductase inhibitors (finasteride, dutasteride) for CP/CPPS, as they are only effective for benign prostatic hyperplasia with demonstrable prostatic enlargement 5
• Never prescribe prolonged antibiotics without evidence of infection; focus on symptom management instead 1

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Key Clinical Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute bacterial prostatitis due to bacteremia risk 1, 5
• Never stop antibiotics prematurely in bacterial prostatitis, as this leads to chronic infection 1
• Never use amoxicillin/ampicillin empirically (45-100% global resistance) 1, 5
• Always consider local resistance patterns when selecting empiric fluoroquinolone therapy 1, 5
• Never prescribe antibiotics for 6-8 weeks without appraising effectiveness at 2-4 week intervals 8

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Treatment-Refractory Cases

• Consider pelvic floor training/biofeedback for patients with multiple unsuccessful treatment regimens 7
• Transurethral microwave therapy to ablate prostatic tissue may be considered for surgical candidates 7
• Transrectal ultrasound-guided drainage for prostatic abscesses that fail antibiotic therapy (small abscesses may resolve with antibiotics alone) 4