What are the treatment options for prostatitis?

Treatment of Prostatitis

For acute bacterial prostatitis, initiate broad-spectrum antibiotics immediately—fluoroquinolones (ciprofloxacin 500mg PO BID or levofloxacin 500mg PO daily) for outpatients if local resistance is <10%, or intravenous ceftriaxone 1g daily plus doxycycline for hospitalized patients, continuing for 2-4 weeks total. 1, 2

Acute Bacterial Prostatitis

Diagnostic Approach

• Obtain midstream urine culture and blood cultures before initiating antibiotics to identify causative organisms and guide therapy 3, 1
• Check complete blood count to assess for leukocytosis 1
• Perform gentle digital rectal examination to assess for tender, enlarged, or boggy prostate 1, 4
• Never perform vigorous prostatic massage due to risk of bacteremia 1, 5
• Consider transrectal ultrasound if patients fail to respond after 48-72 hours to rule out prostatic abscess 6, 1

Treatment Regimens

Outpatient therapy (mild-to-moderate illness):

• Ciprofloxacin 500mg PO BID for 2-4 weeks (only if local resistance <10%) 1, 7, 2
• Alternative: Levofloxacin 500mg PO daily for 2-4 weeks 1

Inpatient therapy (severe illness or systemic symptoms):

• Ceftriaxone 1g IV daily plus doxycycline 100mg PO BID 1, 2
• Alternative: Piperacillin-tazobactam 4.5g IV every 6-8 hours 2
• Switch to oral fluoroquinolones when clinically stable 7

Critical Pitfalls

• Never use amoxicillin/ampicillin empirically—global E. coli resistance rates are 45-100% 1, 5
• Never stop antibiotics prematurely—complete the full 2-4 week course to prevent chronic infection 1
• Enterobacterales (particularly E. coli) cause 80-97% of acute bacterial prostatitis cases 3, 2

Chronic Bacterial Prostatitis

Diagnostic Approach

• Perform Meares-Stamey 4-glass test (or simplified 2-glass variant) to localize infection to the prostate 3, 1, 8
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when clinically appropriate 3, 1
• Up to 74% of cases are caused by gram-negative organisms, particularly E. coli 1, 2

Treatment Regimens

First-line therapy:

• Levofloxacin 500mg PO daily for minimum 4 weeks 1, 2
• Alternative: Ciprofloxacin 500mg PO BID for minimum 4 weeks 1, 7, 2
• Extend treatment duration if symptoms improve but are not fully resolved 1

Rationale for fluoroquinolones:

• Achieve excellent prostatic penetration with prostate:serum ratios up to 4:1 6, 9
• Clinical success rates of 92% at 5-12 days, declining to 62% at 6 months post-treatment 9

Treatment Duration

• Minimum 4 weeks required for chronic bacterial prostatitis 1, 2
• FDA-approved dosing for chronic bacterial prostatitis is ciprofloxacin 500mg PO BID for 28 days 7
• If improvement occurs after 2-4 weeks, continue for additional 2-4 weeks to achieve eradication 10
• Do not continue antibiotics for 6-8 weeks without reassessing effectiveness 10

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

Diagnostic Criteria

• Pelvic pain or discomfort for at least 3 months with urinary symptoms 2
• Diagnosis made when urine culture, physical examination, and postvoid residual measurement exclude infection, cancer, obstruction, or retention 2
• Use NIH-CPSI score to measure symptom severity (scale 0-43; 6-point change is clinically meaningful) 2

First-Line Treatment

Alpha-blockers for urinary symptoms:

• Tamsulosin, alfuzosin, doxazosin, or terazosin are equally effective 1, 5
• Provide greatest symptom improvement with NIH-CPSI score reduction of 4.8-10.8 points 1, 5
• Longer treatment durations (14-24 weeks) yield better responses in alpha-blocker-naïve patients 9
• Common adverse effects: orthostatic hypotension, dizziness, ejaculatory dysfunction, nasal congestion 5

Second-Line Options

• 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

• Combine alpha-blockers, anti-inflammatories, and supportive measures (sitz baths, muscle relaxants, psychological support) for optimal symptom relief 1
• Stepwise approach: antibiotics (4-6 week trial) → bioflavonoids → alpha-blockers can reduce symptoms for up to 1 year 9
• Consider pelvic floor training/biofeedback for refractory cases 8

Critical Pitfalls

• Never prescribe prolonged antibiotics for CP/CPPS without evidence of infection—focus on symptom management instead 1
• Do not use 5-alpha reductase inhibitors (finasteride, dutasteride) for CP/CPPS—they are only effective for benign prostatic hyperplasia with demonstrable enlargement 5
• Trial of fluoroquinolones for 4-6 weeks may provide relief in 50% of men, particularly if prescribed early after symptom onset 8

Special Considerations

Prostatic Abscess

• Suspect if patient fails to respond to antibiotics after 48-72 hours 6, 1
• Transrectal ultrasound-guided drainage required for larger abscesses 6
• Small abscesses may resolve with antibiotics alone 6

Resistance Patterns

• Always consider local antimicrobial resistance data when selecting empiric therapy 6, 5
• Avoid fluoroquinolones if patient used them in last 6 months or if local resistance exceeds 10% 1, 5
• Alternative regimens: amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside 5

Sexually Transmitted Infections

• Test for Chlamydia trachomatis and Mycoplasma species when appropriate 3, 1
• Treat sexual partners while maintaining patient confidentiality 3, 5