Treatment for Pus Cells in Semen Analysis
For a male patient of reproductive age with pus cells (leukocytospermia) in semen analysis and chronic prostatitis, antibiotic therapy is only recommended if chronic bacterial prostatitis (Type II) is confirmed through proper microbiological testing, not based on leukocytospermia alone. 1
Critical Diagnostic Distinction
The presence of pus cells (white blood cells) in semen does not automatically warrant antibiotic treatment. The 2025 European Association of Urology guidelines explicitly state that leukocytospermia without evidence of infective organisms does not improve conception rates with treatment alone 1. This represents a significant shift from older practices of empirically treating all cases of pyospermia.
Required Diagnostic Workup Before Treatment
Before initiating antibiotics, you must establish whether this is true bacterial prostatitis:
- Perform the Meares-Stamey four-glass test (or simplified two-glass test in routine practice) to differentiate chronic bacterial prostatitis from chronic pelvic pain syndrome 2, 3
- Obtain urine culture and prostatic secretion cultures to identify specific pathogens 1, 4
- Test for sexually transmitted infections including Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Ureaplasma urealyticum using nucleic acid amplification tests (NAAT) on first-void urine or urethral swabs 1
- Evaluate the sexual partner for sexually transmitted infections, as these may be the underlying cause 1, 3
When Antibiotics ARE Indicated
Confirmed Chronic Bacterial Prostatitis (Type II)
If microbiological testing confirms bacterial infection, fluoroquinolones are first-line therapy 1, 4:
- Levofloxacin 500 mg orally once daily for minimum 4 weeks 5, 4, 2
- Alternative: Ciprofloxacin 500 mg orally twice daily for minimum 4 weeks 4, 2, 6
The 2025 EAU guidelines note that fluoroquinolones cure approximately 70% of chronic bacterial prostatitis cases when given for 2-4 weeks 1, 6. Levofloxacin is preferred over ciprofloxacin due to better prostatic penetration and once-daily dosing 2.
Sexually Transmitted Infections
If STI pathogens are identified:
- For Chlamydia trachomatis: Doxycycline 100 mg orally twice daily for 7 days 1, 7
- For Ureaplasma urealyticum: Doxycycline 100 mg orally twice daily for 7 days 1
- For Mycoplasma genitalium: Azithromycin 500 mg on day 1, then 250 mg daily for 4 days (or moxifloxacin 400 mg daily for 7-14 days if macrolide-resistant) 1
The 2025 EAU guidelines specifically note that Ureaplasma urealyticum and Mycoplasma hominis are associated with male infertility, but Ureaplasma parvum and Mycoplasma genitalium strains are not 1.
When Antibiotics Are NOT Indicated
Leukocytospermia Without Confirmed Infection
Do not treat leukocytospermia alone without documented bacterial infection 1. A 2025 meta-analysis demonstrated that leukocytospermia in subfertile men was not associated with lower fertility at assisted reproductive technology or altered semen quality in men without symptoms of genital tract infections 1.
Chronic Pelvic Pain Syndrome (Type III)
If testing excludes bacterial infection, this is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). There is no evidence that antibiotics increase the probability of natural conception in CP/CPPS 1. The 2025 EAU guidelines emphasize that randomized controlled trials with pregnancy and live birth rates as primary outcomes are needed to evaluate antibiotics in this setting 1.
Alternative Management for Non-Bacterial Cases
When bacterial infection is excluded:
- Alpha-blockers (tamsulosin, alfuzosin) for urinary symptoms show the strongest evidence with NIH-CPSI score improvements of -10.8 to -4.8 compared to placebo 4
- NSAIDs (ibuprofen) for pain with modest NIH-CPSI improvements of -2.5 to -1.7 4
- Lifestyle modifications including weight loss, physical exercise, and smoking cessation can enhance sperm parameters 1
- Antioxidant therapy may improve live birth rates, though evidence quality is low 1
- Probiotic/prebiotic supplementation showed improvements in sperm parameters and DNA integrity in one RCT 1
Critical Pitfalls to Avoid
- Never prescribe antibiotics based solely on semen leukocyte count without microbiological confirmation of infection 1
- Do not continue antibiotics beyond 2-4 weeks without reassessing effectiveness 8
- Always treat sexual partners when sexually transmitted pathogens are identified to prevent reinfection 1
- Recognize that up to 90% of "chronic prostatitis" cases are actually CP/CPPS without bacterial infection and will not benefit from antibiotics 1, 3
- Consider antibiotic resistance patterns - obtain cultures before treatment when possible, especially for gonorrhea 1