What is the treatment approach for an adult male patient with prostatitis and no significant medical history?

Treatment of Prostatitis

For acute bacterial prostatitis, initiate broad-spectrum intravenous or oral antibiotics such as piperacillin-tazobactam 4.5 g IV every 6-8 hours, ceftriaxone, or ciprofloxacin for 2-4 weeks, which achieves a 92-97% success rate. 1

Acute Bacterial Prostatitis

Immediate Management

• Start empiric broad-spectrum antibiotics immediately after obtaining urine and blood cultures in febrile patients presenting with acute urinary tract infection symptoms, fever, chills, and prostatic tenderness 2, 1
• First-line IV options include piperacillin-tazobactam 4.5 g every 6-8 hours, ceftriaxone, or oral ciprofloxacin 2, 1
• For multidrug-resistant organisms, consider carbapenems: ertapenem 1 g once daily, meropenem 1 g every 8 hours IV, or imipenem-cilastatin 1 g every 6-8 hours IV 2

Diagnostic Approach

• Obtain midstream urine culture as the primary diagnostic test 3
• Collect blood cultures and complete blood count in febrile patients 3
• Never perform prostatic massage in acute bacterial prostatitis—this risks bacteremia and sepsis 4, 3
• Assess for urinary retention or obstruction that may require bladder drainage 5

Treatment Duration

• Continue antibiotics for 2-4 weeks total 1
• Gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) cause 80-97% of cases 1

Critical Pitfall

• If a prostatic abscess develops, antibiotics alone are insufficient—drainage is mandatory for source control 4
• Transrectal ultrasound-guided percutaneous drainage is first-line for abscess management 4

Chronic Bacterial Prostatitis

Diagnosis

• Characterized by recurrent UTIs from the same bacterial strain with pelvic pain, urinary symptoms, and ejaculatory pain 5
• The Meares-Stamey 2- or 4-glass test is the gold standard for diagnosis, requiring a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 3
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species 3
• Do not rely on semen culture alone—it lacks standardization and cannot differentiate prostatic infection from urethral contamination 3

Treatment

• Prescribe a minimum 4-week course of levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily as first-line therapy 6, 1, 5
• Up to 74% of cases are caused by gram-negative organisms, particularly E. coli 1
• Levofloxacin 500 mg once daily for 28 days achieved 75% microbiologic eradication in clinical trials 6

Treatment Algorithm

• If symptoms improve after 2-4 weeks, continue antibiotics for an additional 2-4 weeks to achieve clinical cure 7
• Do not continue antibiotics for 6-8 weeks without assessing effectiveness 7
• If no improvement after initial 2-4 weeks, stop treatment and reconsider the diagnosis 7
• Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin) are preferred due to favorable prostatic penetration and antibacterial spectrum 7

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

Diagnosis

• Defined as pelvic pain or discomfort for at least 3 months with urinary symptoms (frequency, urgency) but no documented UTIs with uropathogens 1, 5
• Diagnosis of exclusion after ruling out infection, cancer, urinary obstruction, and retention through history, physical examination, urine culture, and postvoid residual measurement 1
• Use the NIH Chronic Prostatitis Symptom Index (NIH-CPSI, scale 0-43) to measure symptom severity; a 6-point change is clinically meaningful 1

First-Line Treatment

• For patients with urinary symptoms, prescribe α-blockers (tamsulosin or alfuzosin) as first-line therapy, which reduce NIH-CPSI scores by 4.8-10.8 points compared to placebo 1
• Initial trial of fluoroquinolones for 4-6 weeks provides relief in 50% of men, particularly if prescribed soon after symptom onset 5

Second-Line Treatment

• Anti-inflammatory drugs (ibuprofen) reduce NIH-CPSI scores by 1.7-2.5 points compared to placebo 1
• Pregabalin reduces NIH-CPSI scores by 2.4 points 1

Third-Line Options

• Pollen extract (Cernilton) reduces NIH-CPSI scores by 2.49 points 1
• Consider 5α-reductase inhibitors, glycosaminoglycans, quercetin, or saw palmetto for refractory cases 5
• Pelvic floor training/biofeedback may be more effective than pharmacotherapy but requires specialized referral 5

Treatment Algorithm for CP/CPPS

1. Start with 4-6 week course of fluoroquinolones 5
2. If initial course provides relief, may repeat 5
3. Add α-blockers for urinary symptoms and anti-inflammatories for pain 5
4. If relief is not significant, refer for pelvic floor biofeedback 5
5. Reserve minimally invasive surgical options (transurethral microwave therapy) for treatment-refractory patients 5

Important Caveat

• CP/CPPS may result from an infectious or inflammatory initiator causing neurological injury and pelvic floor dysfunction with increased muscle tone 5
• This explains why non-prostate-centered treatments like physical therapy and myofascial trigger point release can be effective 8

Asymptomatic Inflammatory Prostatitis

• By definition asymptomatic and often diagnosed incidentally during infertility or prostate cancer evaluation 5
• No treatment is required 5, 9
• Clinical significance is unknown 5

Key Diagnostic Distinctions

• Acute bacterial prostatitis: Febrile UTI with prostatic infection, systemic symptoms 1, 5
• Chronic bacterial prostatitis: Recurrent UTIs from same strain, documented by localization cultures 5
• CP/CPPS: Pelvic pain ≥3 months without documented uropathogen infections 1, 5
• Asymptomatic: Incidental finding, no symptoms 5, 9

Common Pitfalls to Avoid

• Do not perform prostatic massage in suspected acute bacterial prostatitis 4, 3
• Do not rely on antibiotics alone if prostatic abscess is present 4
• Do not use semen culture alone to diagnose chronic bacterial prostatitis 3
• Do not continue empiric antibiotics beyond 2-4 weeks without documented improvement 7
• Do not assume all prostatitis is infectious—CP/CPPS is the most common form and is not caused by bacteria 8, 5