What are the treatment options for prostatitis?

Treatment of Prostatitis

Fluoroquinolones are the first-line antibiotic therapy for bacterial prostatitis due to their superior prostatic penetration (achieving prostate:serum ratios up to 4:1), but treatment must be tailored to the specific prostatitis category, with acute bacterial prostatitis requiring 2-4 weeks of therapy, chronic bacterial prostatitis requiring minimum 4 weeks, and chronic pelvic pain syndrome requiring alpha-blockers rather than antibiotics. 1, 2, 3

Classification-Based Treatment Algorithm

Acute Bacterial Prostatitis (Category I)

Outpatient Management:

• Prescribe oral ciprofloxacin 500 mg twice daily for 2-4 weeks if local fluoroquinolone resistance is <10% 2, 3
• Alternative: levofloxacin 500 mg daily for 2-4 weeks 2
• This achieves 92-97% clinical success rates 3

Inpatient Management (for severe illness, systemic symptoms, or inability to urinate):

• Initiate intravenous ceftriaxone 1 g every 24 hours plus doxycycline 100 mg twice daily 2, 4
• Alternative: piperacillin-tazobactam 4.5 g every 6-8 hours 3, 4
• Switch to oral fluoroquinolones when clinically stable to complete 2-4 weeks total 5

Critical Diagnostic Steps:

• Obtain midstream urine culture and blood cultures before initiating antibiotics 6, 2
• Check complete blood count to assess for leukocytosis 2
• Perform gentle digital rectal examination to assess for tender, enlarged, or boggy prostate 2, 4
• Never perform vigorous prostatic massage in acute bacterial prostatitis—this risks bacteremia and sepsis 2, 7
• Consider transrectal ultrasound if no clinical improvement after 48-72 hours to rule out prostatic abscess 1, 2

Chronic Bacterial Prostatitis (Category II)

First-Line Treatment:

• Prescribe fluoroquinolones for minimum 4 weeks: levofloxacin 500 mg daily or ciprofloxacin 500 mg twice daily 2, 3
• One study demonstrated 92% clinical success at 5-12 days, declining to 61.9% at 6 months with levofloxacin 8
• Extend treatment duration if symptoms improve but are not fully resolved 2

Diagnostic Confirmation:

• Perform the Meares-Stamey 4-glass test (or simplified 2-glass variant) to confirm prostatic localization of infection 6, 2, 9
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when clinically appropriate 6, 2
• Up to 74% of cases are caused by gram-negative organisms, particularly E. coli 2, 3

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Category III)

This condition requires symptom management, NOT antibiotics, as no bacterial infection is present.

First-Line Therapy:

• Prescribe alpha-blockers (tamsulosin, alfuzosin, doxazosin, or terazosin) for patients with urinary symptoms 2, 7, 3
• These provide the greatest symptom improvement with NIH-CPSI score reductions of 4.8-10.8 points 2, 3
• Longer treatment durations (6-24 weeks) yield better responses in alpha-blocker-naïve patients 8

Adjunctive Therapies:

• Add NSAIDs (ibuprofen) for pain symptoms (NIH-CPSI score reduction of 1.7-2.5 points) 3
• Consider pregabalin for neuropathic pain component (NIH-CPSI score reduction of 2.4 points) 3
• Pollen extract may provide modest benefit (NIH-CPSI score reduction of 2.49 points) 3

Multimodal Approach:

• Combine alpha-blockers with anti-inflammatories and supportive measures (sitz baths, pelvic floor physical therapy) 2, 7
• Pelvic floor biofeedback training shows promise for treatment-refractory cases 9

Critical Antibiotic Selection Considerations

When Fluoroquinolones Should NOT Be Used:

• Avoid fluoroquinolones if local resistance exceeds 10% 2, 7
• Do not use if patient has taken fluoroquinolones in the last 6 months 7
• Avoid in patients from urology departments due to increased resistance risk 7

Antibiotics to NEVER Use:

• Never use amoxicillin/ampicillin empirically—global E. coli resistance rates are 45-100% 2, 7

FDA-Approved Dosing for Chronic Bacterial Prostatitis:

• Ciprofloxacin 500 mg orally every 12 hours for 28 days 5
• Adjust dose for renal impairment: if creatinine clearance 30-50 mL/min, use 250-500 mg every 12 hours; if 5-29 mL/min, use every 18 hours 5

Common Pitfalls to Avoid

• Never prescribe prolonged antibiotics for CP/CPPS without documented infection—this leads to unnecessary antibiotic exposure and resistance 2
• Never stop antibiotics prematurely in bacterial prostatitis—this promotes chronic infection 2
• Never perform vigorous prostatic massage in acute bacterial prostatitis 2, 7
• Never delay obtaining cultures before initiating antibiotics in acute bacterial prostatitis 6, 2
• Never assume all prostatitis is bacterial—fewer than 10% of cases have confirmed bacterial infection 6, 7

Special Considerations

Sexually Transmitted Infections:

• When Chlamydia or Mycoplasma are suspected, test appropriately and treat sexual partners while maintaining confidentiality 6, 7

Treatment Failure:

• If no improvement after 4-6 weeks of fluoroquinolones in chronic bacterial prostatitis, reassess diagnosis and consider imaging to rule out prostatic abscess 1, 9
• For CP/CPPS refractory to medical management, consider referral for pelvic floor physical therapy or biofeedback 9
• Third-line options for CP/CPPS include 5-alpha reductase inhibitors (though not appropriate for prostatitis without prostatic enlargement), quercetin, or minimally invasive procedures 7, 9

Conversion from IV to Oral Therapy:

• Switch from IV to oral fluoroquinolones when clinically indicated: 200 mg IV every 12 hours equals 250 mg oral every 12 hours; 400 mg IV every 12 hours equals 500 mg oral every 12 hours 5