What is the recommended treatment for a patient with suspected prostatitis presenting with painful ejaculation?

Treatment of Prostatitis with Painful Ejaculation

For a patient with suspected prostatitis presenting with painful ejaculation, initiate empiric antibiotic therapy with a fluoroquinolone (ciprofloxacin 500-750 mg twice daily or levofloxacin) for 2-4 weeks if acute bacterial prostatitis is suspected, but if symptoms persist beyond 3 months without documented bacterial infection, shift focus to multimodal pain management with alpha-blockers, anti-inflammatory agents, and behavioral modifications for chronic prostatitis/chronic pelvic pain syndrome. 1, 2

Initial Diagnostic Approach

Determine the prostatitis category immediately as this fundamentally changes management:

• Perform a gentle digital rectal examination to assess for prostatic tenderness, but avoid vigorous prostatic massage in suspected acute bacterial prostatitis due to bacteremia risk 1
• Obtain midstream urine culture before initiating antibiotics to identify causative organisms 1, 3
• Collect blood cultures if febrile to assess for systemic infection 1
• Document symptom duration: pain/discomfort for less than 3 months suggests bacterial prostatitis, while 3 months or longer indicates chronic prostatitis/chronic pelvic pain syndrome 4, 2

Acute Bacterial Prostatitis (Fever, Chills, Acute Onset)

If the patient presents with systemic symptoms suggesting acute bacterial infection:

• Start broad-spectrum antibiotics immediately targeting gram-negative organisms (E. coli causes 80-97% of cases) 1, 2
• First-line oral therapy: Ciprofloxacin 500-750 mg twice daily for 2-4 weeks (92-97% success rate) 2
• Alternative oral options: Levofloxacin (preferred for once-daily dosing and superior prostatic penetration) 5
• Intravenous therapy (if unable to tolerate oral medications or risk of urosepsis): Piperacillin-tazobactam or ceftriaxone, then switch to oral fluoroquinolones once clinically improved 1, 2
• Avoid amoxicillin/ampicillin empirically due to very high worldwide resistance rates 1
• Complete the full 2-4 week course to prevent progression to chronic bacterial prostatitis 1

Chronic Bacterial Prostatitis (Recurrent UTIs, Same Organism)

If the patient has recurrent urinary tract infections with documented bacterial infection:

• Confirm diagnosis with Meares-Stamey 4-glass test (or simplified 2-specimen variant) showing 10-fold higher bacterial count in expressed prostatic secretions versus midstream urine 1, 3
• First-line therapy: Fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4-6 weeks 2, 5, 6
• Levofloxacin is preferred over ciprofloxacin due to better prostatic penetration and once-daily dosing 5
• Avoid trimethoprim-sulfamethoxazole empirically unless organism susceptibility is confirmed 1
• If symptoms improve after initial course, continue for additional 2-4 weeks to achieve eradication 7

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Pain >3 Months, No Infection)

This is the most likely diagnosis if painful ejaculation persists beyond 3 months without documented bacterial infection 4, 2:

First-Line Pharmacotherapy

• Alpha-blockers (tamsulosin, alfuzosin) are first-line for urinary symptoms, with NIH-CPSI score improvement of -10.8 to -4.8 points versus placebo 2
• Trial of fluoroquinolones for 4-6 weeks provides relief in 50% of men, particularly if prescribed soon after symptom onset 6
• Anti-inflammatory agents (ibuprofen) for pain symptoms (NIH-CPSI score improvement of -2.5 to -1.7 points) 2
• Urinary analgesics (phenazopyridine) for symptomatic relief 4

Multimodal Approach Required

Pain management alone is insufficient—combine pharmacological agents with behavioral modifications 4:

• Stress management practices and dietary modification 4
• Pelvic floor training/biofeedback may be more effective than pharmacotherapy alone 6
• Avoid chronic opioid therapy except after informed shared decision-making with periodic follow-ups 4

Second and Third-Line Options

If first-line therapy fails after 4-6 weeks:

• Pregabalin (NIH-CPSI score improvement of -2.4 points) 2
• Pollen extract (NIH-CPSI score improvement of -2.49 points) 2
• 5-alpha-reductase inhibitors, quercetin, or saw palmetto for treatment-refractory cases 6

Critical Pitfalls to Avoid

• Do not assume new pain in controlled chronic prostatitis is simply disease worsening—investigate for new pathology, opportunistic infections, or medication adverse effects 4
• Do not stop antibiotics prematurely in bacterial prostatitis, as this leads to chronic infection 1
• Do not use cefpodoxime as first-line for prostatitis due to poor prostatic tissue penetration, despite efficacy in other urogenital infections 1
• Persistence of pain beyond 3 months should alert you to CP/CPPS rather than acute urethritis—approximately 50% of men with chronic nonbacterial prostatitis have urethral inflammation without identifiable pathogens 4
• Refer to pain specialists for complex cases requiring collaborative chronic pain management 4

Treatment Algorithm Summary

1. Acute presentation with fever/chills: Fluoroquinolone × 2-4 weeks
2. Recurrent UTIs with same organism: Fluoroquinolone × 4-6 weeks minimum after confirming with localization cultures
3. Pain >3 months without infection: Alpha-blockers + anti-inflammatories + behavioral modifications, consider trial of fluoroquinolones for 4-6 weeks
4. Treatment failure: Pelvic floor biofeedback, alternative pharmacotherapy, or referral to pain specialist