What is the initial treatment approach for a male patient with symptoms of prostatitis, such as pelvic pain, urinary frequency, and discomfort?

Prostatitis Treatment

Initial Treatment Approach

For acute bacterial prostatitis, initiate broad-spectrum antibiotics immediately (intravenous piperacillin-tazobactam, ceftriaxone, or oral ciprofloxacin for 2-4 weeks), while chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) requires a trial of fluoroquinolones for 4-6 weeks as first-line therapy, followed by α-blockers if urinary symptoms predominate. 1, 2

Diagnostic Classification First

Before initiating treatment, distinguish between the three main categories:

Acute Bacterial Prostatitis (NIH Category I)

• Presents with fever, chills, systemic symptoms, and tender prostate on examination 1, 2
• Caused by gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) in 80-97% of cases 1
• Do not perform prostatic massage due to bacteremia risk 3
• Obtain urine culture before starting antibiotics 1

Chronic Bacterial Prostatitis (NIH Category II)

• Recurrent urinary tract infections with the same uropathogen 1, 2
• Pelvic pain, urinary symptoms, and ejaculatory pain 2
• Requires prostatic localization cultures (Meares-Stamey 4-glass test) for diagnosis, which are 90% accurate 2
• Up to 74% caused by gram-negative organisms 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS, NIH Category III)

• Pelvic pain for at least 3 months without documented bacterial infection 1, 3
• Pain localized to perineum, suprapubic region, testicles, or tip of penis 3
• Pain exacerbated by urination or ejaculation 3
• Associated with urinary frequency, urgency, nocturia, and sense of incomplete emptying 3
• Critical pitfall: Many patients describe "pressure" rather than "pain"—do not dismiss these patients 4, 3

Treatment Algorithm

For Acute Bacterial Prostatitis

• First-line: Broad-spectrum IV or oral antibiotics for 2-4 weeks 1
  • Intravenous piperacillin-tazobactam 1
  • Ceftriaxone 1
  • Oral ciprofloxacin 1
• Success rate: 92-97% 1
• Ensure bladder drainage as inflamed prostate may obstruct urinary flow 2

For Chronic Bacterial Prostatitis

• First-line: Fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4 weeks 1, 3
• Alternative: Trimethoprim-sulfamethoxazole for 6-12 weeks 5
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 3
• For recurrent infections, consider long-term suppressive therapy 5

For CP/CPPS (Most Common Form)

Step 1: Initial Antibiotic Trial (4-6 weeks)

• Fluoroquinolone (ciprofloxacin or levofloxacin) for 4-6 weeks 2
• Provides relief in 50% of men, more efficacious if prescribed early after symptom onset 2
• If initial course provides relief, may repeat 2

Step 2: Symptom-Directed Therapy

• For urinary symptoms (frequency, urgency, incomplete emptying): α-blockers (tamsulosin, alfuzosin) 1, 2
  • NIH-CPSI score improvement: -10.8 to -4.8 points versus placebo 1
  • This is the most effective oral therapy for CP/CPPS with urinary symptoms 1
• For pain symptoms: Anti-inflammatory drugs (ibuprofen) 1, 2
  • NIH-CPSI score improvement: -2.5 to -1.7 points versus placebo 1

Step 3: Additional Pharmacotherapy

• Pregabalin for neuropathic pain component (NIH-CPSI score improvement: -2.4 points) 1
• Pollen extract (NIH-CPSI score improvement: -2.49 points) 1
• 5α-reductase inhibitors for select patients 2

Step 4: Non-Pharmacologic Interventions

• Pelvic floor training/biofeedback for pelvic floor dysfunction 2, 6
• Physical therapy and myofascial trigger point release 6

Step 5: Refractory Cases

• Transurethral microwave therapy for treatment-refractory patients 2

Critical Overlap with IC/BPS

CP/CPPS and interstitial cystitis/bladder pain syndrome (IC/BPS) have overlapping presentations, and some men meet criteria for both conditions. 4, 3

• IC/BPS should be strongly considered in men whose pain is perceived to be bladder-related 4, 3
• When both conditions are present, treatment can include established IC/BPS therapies alongside CP/CPPS-specific treatments 4
• Both conditions share symptoms: pelvic pain, urinary frequency, nocturia, and pain throughout the pelvis 4, 3

Key Clinical Pitfalls

• Do not rely on symptoms alone for re-treatment—require objective signs or laboratory evidence of urethral inflammation 4
• Persistence of symptoms beyond 3 months without infection suggests CP/CPPS, not ongoing bacterial infection 4, 3
• Most CP/CPPS treatments benefit only a subset of patients, and no treatment reliably benefits all patients 4
• Appropriate classification is crucial—bacterial forms require prolonged antibiotics, while CP/CPPS may respond better to non-antibiotic strategies 6
• Consider sexually transmitted infections in sexually active men under 35 years—test for N. gonorrhoeae and C. trachomatis 4, 3