What are the treatment options for prostatitis?

Treatment of Prostatitis

Treatment of prostatitis depends critically on accurate classification into acute bacterial, chronic bacterial, or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), with fluoroquinolones as first-line for bacterial forms and alpha-blockers for CP/CPPS with urinary symptoms. 1

Acute Bacterial Prostatitis

Initiate broad-spectrum antibiotics immediately without waiting for culture results. 1

Antibiotic Selection:

• Outpatients with mild-to-moderate disease: Ciprofloxacin 500mg PO twice daily for 2-4 weeks, but only if local fluoroquinolone resistance is <10% 1, 2
• Hospitalized patients with severe illness: Intravenous ceftriaxone plus doxycycline 1, 3
• Alternative regimens: Amoxicillin plus aminoglycoside or second-generation cephalosporin plus aminoglycoside 3
• Success rate: 92-97% with appropriate therapy 4

Critical Diagnostic Steps:

• Obtain midstream urine culture and blood cultures before starting antibiotics 1
• Perform gentle digital rectal examination to assess for tender, enlarged, or boggy prostate 1
• Check complete blood count for leukocytosis 1
• Never perform vigorous prostatic massage due to bacteremia risk 1, 3

When to Image:

• Consider transrectal ultrasound if no clinical response after 48-72 hours to rule out prostatic abscess 1, 5
• Small abscesses may resolve with antibiotics alone; larger ones require transrectal ultrasound-guided drainage 5

Chronic Bacterial Prostatitis

Prescribe fluoroquinolones for a minimum of 4 weeks, with option to extend if symptoms improve but are not fully resolved. 1

First-Line Treatment:

• Levofloxacin or ciprofloxacin 500mg PO twice daily for at least 4 weeks 1, 2, 4
• Duration from FDA labeling: 28 days for chronic bacterial prostatitis 2
• One study showed clinical success rates of 92% at 5-12 days, declining to 62% at 6 months post-treatment 6

Diagnostic Confirmation:

• Meares-Stamey 4-glass test is the gold standard for diagnosis 1, 3
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretion only) is acceptable 1
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) when clinically appropriate 1, 3

Causative Organisms:

• Up to 74% are gram-negative organisms, particularly E. coli 1, 4
• Treat sexual partners while maintaining confidentiality if sexually transmitted infection is identified 3

Fluoroquinolone Resistance Considerations:

• Do not use fluoroquinolones empirically if patient is from urology department or has used fluoroquinolones in the last 6 months 3
• Always consider local resistance patterns 5, 3

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

Alpha-blockers are first-line therapy for CP/CPPS with urinary symptoms, providing the greatest symptom improvement. 1

First-Line: Alpha-Blockers

• Tamsulosin, alfuzosin, doxazosin, or terazosin are equally effective 3
• NIH-CPSI score reduction: 4.8-10.8 points compared to placebo 1, 4
• Greater response with longer treatment duration in alpha-blocker-naïve patients (6-24 weeks) 6
• Common adverse effects: orthostatic hypotension, dizziness, tiredness, ejaculatory problems, nasal congestion 3
• Tamsulosin has lower orthostatic hypotension risk but higher ejaculatory dysfunction risk 3

Second-Line Options:

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score reduction of 1.7-2.5 points 4
• Pregabalin: NIH-CPSI score reduction of 2.4 points 4
• Pollen extract: NIH-CPSI score reduction of 2.49 points 4

Multimodal Approach:

• Combine alpha-blockers, anti-inflammatories, and supportive measures (sitz baths, muscle relaxants, psychological support) for optimal symptom relief 1
• Combination therapy (alpha-blocker + anti-inflammatory + muscle relaxant) does not appear superior to monotherapy (12.7 vs 12.4 point NIH-CPSI reduction) 6

Empiric Antibiotics in CP/CPPS:

• A 4-6 week course of fluoroquinolones provides relief in 50% of men, more efficacious if prescribed soon after symptom onset 7
• May repeat if initial course provides relief 7
• Do not prescribe prolonged antibiotics without evidence of infection 1

What NOT to Use:

• 5-alpha reductase inhibitors (finasteride, dutasteride) are not appropriate for CP/CPPS unless there is demonstrable prostatic enlargement from benign prostatic hyperplasia 3

Refractory Cases:

• Refer for pelvic floor training/biofeedback 7
• Consider transurethral microwave therapy for treatment-refractory patients 7
• Electromagnetic or electroacupuncture therapy for direct pelvic muscle stimulation 6

Critical Pitfalls to Avoid

• Never use amoxicillin/ampicillin empirically due to global E. coli resistance rates of 45-100% 1, 3
• Never perform vigorous prostatic massage in acute bacterial prostatitis due to bacteremia risk 1, 3
• Never stop antibiotics prematurely in bacterial prostatitis as this leads to chronic infection 1
• Never prescribe prolonged antibiotics for CP/CPPS without documented infection; focus on symptom management instead 1
• Never use fluoroquinolones if local resistance is ≥10% 1, 3

Diagnostic Algorithm

1. Classify the prostatitis type based on history, physical examination, and urine culture 5
2. Acute bacterial prostatitis: Fever, chills, systemic symptoms with positive cultures → immediate broad-spectrum antibiotics 1, 4
3. Chronic bacterial prostatitis: Recurrent UTIs with same organism → Meares-Stamey test, then minimum 4 weeks fluoroquinolones 1, 8
4. CP/CPPS: Pelvic pain ≥3 months with urinary symptoms but negative cultures → alpha-blockers for urinary symptoms, consider trial of antibiotics if early in disease course 1, 7
5. Reassess at 4-6 weeks (early follow-up) and 6 months (late follow-up) after treatment completion 9