What is the recommended treatment approach for a patient presenting with prostatitis?

Treatment of Prostatitis

Immediate Classification is Essential

The treatment of prostatitis depends entirely on accurate classification into one of three distinct categories: acute bacterial prostatitis (requiring 2-4 weeks of antibiotics), chronic bacterial prostatitis (requiring minimum 4 weeks of fluoroquinolones), or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS, requiring symptom-directed therapy without antibiotics). 1, 2, 3, 4

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Acute Bacterial Prostatitis

Clinical Presentation

• Fever or chills with acute urinary symptoms (dysuria, frequency, urgency) and a tender prostate on gentle digital rectal examination 4
• Critical: Avoid vigorous prostatic massage or manipulation—this can induce life-threatening bacteremia 1, 2, 3

Diagnostic Workup

• Obtain midstream urine culture before initiating antibiotics to identify the causative organism 2, 3
• Collect blood cultures in febrile patients 2
• Gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) cause 80-97% of cases 2, 4

Treatment Algorithm

First-line empiric therapy:

• Oral ciprofloxacin 500-750 mg twice daily for 2-4 weeks if patient can tolerate oral medications and local fluoroquinolone resistance is <10% 2, 3, 5, 4
• Intravenous therapy (piperacillin-tazobactam, ceftriaxone, or ciprofloxacin 400 mg IV twice daily) for patients unable to tolerate oral medications, with risk of urosepsis, or severe systemic symptoms 2, 3, 4

Duration: 2-4 weeks total, with clinical reassessment at 48-72 hours 2, 5

Common pitfalls to avoid:

• Do not use amoxicillin/ampicillin empirically due to very high worldwide resistance rates 2
• Do not use trimethoprim-sulfamethoxazole empirically unless susceptibility is confirmed 2
• Stopping antibiotics prematurely can lead to chronic bacterial prostatitis—complete the full 2-4 week course 2

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Chronic Bacterial Prostatitis

Clinical Presentation

• Recurrent urinary tract infections from the same bacterial strain, often with pelvic discomfort or voiding symptoms lasting >3 months 4, 6
• Up to 74% caused by gram-negative organisms, particularly E. coli 2, 3

Diagnostic Workup

• Meares-Stamey 4-glass test is the gold standard: collect first-void urine, midstream urine, expressed prostatic secretions (EPS), and post-massage urine 2, 3
• A 10-fold higher bacterial count in EPS compared to midstream urine confirms the diagnosis 2, 3
• A simplified 2-specimen variant (midstream urine and EPS only) can be used in routine practice 3

Treatment Algorithm

First-line therapy (fluoroquinolones are superior due to prostatic tissue penetration):

• Levofloxacin 500 mg orally once daily for minimum 4 weeks 3, 7
• OR ciprofloxacin 500 mg orally twice daily for minimum 4 weeks 3, 5, 7
• Both achieve 75-77% microbiologic eradication rates with similar clinical success 3

Duration: Minimum 4 weeks (28 days), though more prolonged therapy may be required for severe or complicated infections 3, 7, 6

Key distinction: Chronic bacterial prostatitis encompasses a broader spectrum of pathogens than acute prostatitis, potentially including atypical organisms like Chlamydia trachomatis and Mycoplasma species—test for these if standard therapy fails 2, 3

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

Clinical Presentation

• Pelvic pain or discomfort for ≥3 months with urinary symptoms (frequency, urgency) but no culturable bacterial infection 1, 2, 3, 4
• This is the most common form of prostatitis, accounting for >90% of cases 2, 3

Diagnostic Approach

• CP/CPPS is a diagnosis of exclusion—rule out infection (urine culture), cancer, urinary obstruction, and urinary retention (postvoid residual measurement) 4, 8
• Perform Meares-Stamey test to definitively exclude bacterial infection 2, 3
• Use the NIH Chronic Prostatitis Symptom Index (NIH-CPSI, scale 0-43) to measure symptom severity; a 6-point change is clinically meaningful 4

Treatment Algorithm

CP/CPPS is NOT caused by culturable bacterial infection and requires symptom-directed therapy, not antimicrobials 2, 3, 4

First-line therapy for CP/CPPS with urinary symptoms:

• α-blockers (tamsulosin, alfuzosin) provide the greatest symptom improvement (NIH-CPSI score difference vs placebo = -10.8 to -4.8) 4

Second-line options with modest benefit:

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score difference = -2.5 to -1.7 4
• Pregabalin: NIH-CPSI score difference = -2.4 4
• Pollen extract: NIH-CPSI score difference = -2.49 4

Critical pitfall: Do not prescribe prolonged antibiotics for CP/CPPS—fewer than 10% of prostatitis cases have confirmed bacterial infection, and inappropriate antibiotic use contributes to resistance without improving outcomes 1, 2, 3

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Special Considerations

Healthcare-Associated Infections

• For suspected enterococcal infections, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility 2
• Consider carbapenems or novel broad-spectrum agents only when early culture results indicate multidrug-resistant organisms 2

Local Resistance Patterns

• Fluoroquinolone resistance should ideally be <10% for empiric use 2
• If local resistance is high, consider broader spectrum options initially for patients with risk factors for antibiotic resistance 2