What is the diagnosis and treatment for prostatitis (inflammation of the prostate gland)?

From the Guidelines

Prostatitis treatment should be guided by the type of prostatitis, with acute bacterial prostatitis typically requiring a 2-4 week course of antibiotics, while chronic bacterial prostatitis may need a longer 4-12 week course, and chronic prostatitis/chronic pelvic pain syndrome treated with a multimodal approach including alpha-blockers, anti-inflammatories, and supportive measures. The diagnosis of prostatitis is based on clinical presentation, laboratory tests, and in some cases, comparison of bacteria levels in prostatic fluid and urinary cultures 1. The optimal duration of treatment for acute and chronic bacterial prostatitis is unknown due to a lack of high-quality studies, with historical durations ranging from 14 days for acute bacterial prostatitis to 6 weeks or longer for chronic bacterial prostatitis 1.

Key Considerations

• The European Association of Urology guidelines emphasize the importance of a thorough medical history and physical examination for patients with urological infections, including prostatitis 1.
• Antimicrobial stewardship is crucial to combat the rising threat of antimicrobial resistance, with recommendations for antibiotic selection, dosing, and duration based on the latest evidence 1.
• Supportive measures, such as increased fluid intake, warm sitz baths, avoiding caffeine and alcohol, and pelvic floor physical therapy, are important for all types of prostatitis.

Treatment Approaches

• Acute bacterial prostatitis: 2-4 week course of antibiotics like ciprofloxacin or trimethoprim-sulfamethoxazole.
• Chronic bacterial prostatitis: longer 4-12 week course of the same antibiotics.
• Chronic prostatitis/chronic pelvic pain syndrome: multimodal approach including alpha-blockers like tamsulosin, anti-inflammatories like ibuprofen, and sometimes muscle relaxants.

Important Notes

• Prompt treatment is essential to prevent complications like abscess formation or chronic pain.
• The quality of evidence for prostatitis treatment is limited, and additional prospective studies are needed to determine the appropriate duration of treatment for acute and chronic bacterial prostatitis 1.

From the Research

Definition and Classification of Prostatitis

• Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, most prevalent in men aged between 35 and 50 2.
• Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis 2.

Symptoms of Prostatitis

• Acute bacterial prostatitis presents with acute onset pelvic pain, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors 2.
• Chronic bacterial prostatitis is characterized by a documented history of recurrent urinary tract infections, with duration of symptoms > 3 months defining chronicity 2.
• The key symptom of chronic pelvic pain syndrome is pain, with patients describing pain during or after ejaculation as their predominant symptom 2.

Diagnosis of Prostatitis

• Clinical assessment includes a thorough history and examination, with a digital rectal examination performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture 2.
• In acute bacterial prostatitis, the MSU is the only laboratory investigation required 2.
• Urine cultures should be obtained in all patients who are suspected of having acute bacterial prostatitis to determine the responsible bacteria and its antibiotic sensitivity pattern 3.

Treatment of Prostatitis

• Ciprofloxacin has been used for the treatment of refractory chronic bacterial prostatitis, with eradication of Escherichia coli in seven of ten and of other pathogens in two of five cases 4.
• Typical antibiotic regimens for acute bacterial prostatitis include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam 3.
• Trimethoprim-sulfamethoxazole is the current drug of choice for chronic bacterial prostatitis, but carbenicillin indanyl sodium and erythromycin appear to be effective alternatives 5.
• Long-term therapy with trimethoprim-sulfamethoxazole has been shown to be effective in treating chronic bacterial prostatitis, with 31.6% of patients totally cured and 39.1% of gram-negative organisms permanently cleared from prostatic fluid 6.