What is the treatment for acute and chronic prostatitis in a male patient?

Treatment of Acute and Chronic Prostatitis

Acute Bacterial Prostatitis

For acute bacterial prostatitis, initiate fluoroquinolone therapy (ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks) if local resistance is below 10%, or use intravenous broad-spectrum antibiotics (piperacillin-tazobactam or ceftriaxone) for severe cases requiring hospitalization. 1, 2

Initial Assessment and Hospitalization Criteria

• Hospitalize patients who cannot tolerate oral medications, show signs of systemic toxicity or risk of urosepsis (occurs in 7.3% of cases), or have suspected prostatic abscess 1
• Outpatient oral therapy is appropriate for mild-to-moderate cases without fever in patients able to tolerate oral medications 1
• Obtain midstream urine culture to identify causative organisms (E. coli in 64% of cases) 1, 3
• Collect blood cultures and complete blood count in febrile patients 1, 4
• Avoid prostatic massage or vigorous digital rectal examination due to bacteremia risk 1, 4

Antibiotic Selection Algorithm

For mild-to-moderate cases (outpatient):

• First-line: Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance is <10% 1, 5, 2
• Avoid fluoroquinolones if local resistance exceeds 10% or if patient received them in the last 6 months 1
• Avoid amoxicillin/ampicillin empirically due to very high worldwide resistance rates 1
• Avoid trimethoprim-sulfamethoxazole empirically unless organism is known to be susceptible 1

For severe cases (inpatient):

• Ciprofloxacin 400 mg IV twice daily, transitioning to oral once clinically improved 1
• Alternative IV options: Piperacillin-tazobactam or ceftriaxone 2
• For healthcare-associated infections with suspected enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility 1
• Consider carbapenems or novel broad-spectrum agents only when early culture results indicate multidrug-resistant organisms 1

For men under 35 years:

• Add doxycycline 100 mg orally every 12 hours for 7 days to cover Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species 1
• Alternative: Azithromycin 1 g orally as a single dose for Mycoplasma coverage 1

Treatment Duration and Follow-up

• Minimum 2-4 weeks of antibiotic therapy for acute bacterial prostatitis 1, 5, 2
• Assess clinical response after 48-72 hours of treatment 1
• Complete the full treatment course to prevent progression to chronic bacterial prostatitis 1
• Success rate of 92-97% when ciprofloxacin prescribed for 2-4 weeks 2

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Chronic Bacterial Prostatitis

For chronic bacterial prostatitis, prescribe fluoroquinolones (ciprofloxacin or levofloxacin) for a minimum of 4 weeks, extending to 4-12 weeks to prevent relapse. 1, 2

Diagnostic Confirmation

• Perform the Meares-Stamey 2- or 4-glass test (gold standard) requiring a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 4, 6
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretions only) can be used 1
• Do not use semen culture alone for diagnosis due to lack of standardization and inability to differentiate prostatic infection from urethral/seminal vesicle contamination 4
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species 1, 4

Antibiotic Treatment

• First-line: Ciprofloxacin 500 mg orally twice daily for minimum 4 weeks 1, 5
• Alternative: Levofloxacin for minimum 4 weeks 2
• Treatment duration: 4-12 weeks required to prevent relapse 1, 6
• Up to 74% of cases are due to gram-negative organisms, particularly E. coli 1, 2

Treatment Monitoring

• If no improvement in symptoms after 2-4 weeks, stop treatment and reconsider diagnosis 6
• If improvement occurs, continue for at least an additional 2-4 weeks to achieve clinical cure and pathogen eradication 6
• Do not continue antibiotic treatment for 6-8 weeks without appraising effectiveness 6
• Long-term suppressive antibiotic therapy may be useful in selected patients with recurrent bacteriuria 7

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

For CP/CPPS with urinary symptoms, prescribe alpha-blockers (tamsulosin or alfuzosin) as first-line therapy, which provide the greatest symptom improvement (NIH-CPSI score difference vs placebo = -10.8 to -4.8). 2

Diagnostic Approach

• CP/CPPS is diagnosed when evaluation (history, physical examination, urine culture, postvoid residual measurement) does not identify other causes such as infection, cancer, urinary obstruction, or urinary retention 2
• Defined as pelvic pain or discomfort for at least 3 months associated with urinary symptoms 2, 8
• This is not a bacterial infection and requires different management focused on symptom relief rather than antimicrobials 1

Treatment Algorithm

First-line therapy:

• Alpha-blockers (tamsulosin, alfuzosin) for urinary symptoms: NIH-CPSI score difference vs placebo = -10.8 to -4.8 2

Second-line therapy:

• Trial of fluoroquinolone for 4-6 weeks, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin 8
• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score difference vs placebo = -2.5 to -1.7 2

Third-line therapy:

• Pregabalin: NIH-CPSI score difference vs placebo = -2.4 2
• Pollen extract: NIH-CPSI score difference vs placebo = -2.49 2
• 5-alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton, or saw palmetto 8

Refractory cases:

• Pelvic floor training/biofeedback 8
• Transurethral microwave therapy for treatment-refractory patients 8

Clinical Significance

• CP/CPPS affects 10-15% of the male population and results in nearly 2 million outpatient visits annually 8
• A 6-point change in NIH-CPSI score (scale 0-43) is considered clinically meaningful 2

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Key Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis due to bacteremia and sepsis risk 1, 4
• Do not use oral cephalosporins (like cefpodoxime) for prostatitis due to poor prostatic tissue penetration, despite efficacy in other urogenital infections 1
• Do not stop antibiotics prematurely in bacterial prostatitis, as this leads to chronic bacterial prostatitis 1
• Do not rely on semen culture alone for chronic bacterial prostatitis diagnosis 4
• Do not prescribe prolonged antibiotics for CP/CPPS without evidence of bacterial infection 1, 8