Prostatitis Treatment
Acute Bacterial Prostatitis
For acute bacterial prostatitis, initiate broad-spectrum antibiotics immediately—either intravenous piperacillin-tazobactam, ceftriaxone, or oral ciprofloxacin—for 2 to 4 weeks, which achieves a 92% to 97% success rate. 1
First-Line Antibiotic Options
Outpatient oral therapy:
- Ciprofloxacin 500 mg twice daily for 2–4 weeks is the preferred oral fluoroquinolone, with excellent prostatic tissue penetration 2, 1, 3
- Levofloxacin 750 mg once daily for 2–4 weeks is an equally effective alternative 4, 1
- Avoid fluoroquinolones if local resistance exceeds 10% or recent fluoroquinolone exposure 5
Inpatient parenteral therapy (for systemically ill patients, urinary retention, inability to tolerate oral intake, or risk factors for resistance):
- Ceftriaxone 1–2 g IV once daily plus doxycycline 100 mg twice daily 1, 3
- Piperacillin-tazobactam 3.375–4.5 g IV every 6 hours 1, 3
- Cefepime 1–2 g IV every 12 hours when Pseudomonas coverage is needed 5
Duration and Monitoring
- Obtain urine culture before starting antibiotics to identify the pathogen and guide targeted therapy 1, 3
- Digital rectal examination should assess for a tender, enlarged, or boggy prostate, but avoid vigorous prostatic massage as it may precipitate bacteremia 3
- Continue antibiotics for 2–4 weeks total to prevent progression to chronic bacterial prostatitis 2, 1, 3
- Switch to oral therapy once afebrile for ≥48 hours and hemodynamically stable 5
Common Pitfalls
- Do not use nitrofurantoin or fosfomycin for prostatitis, as these agents lack adequate prostatic tissue penetration 5
- Do not perform vigorous prostatic massage during acute infection, as this increases the risk of bacteremia 3
- Do not discontinue antibiotics prematurely (before 2 weeks), as this leads to chronic bacterial prostatitis 1, 3
Chronic Bacterial Prostatitis
For chronic bacterial prostatitis, prescribe fluoroquinolones for a minimum of 4 weeks, which cures approximately 70% of infections. 6, 1
First-Line Therapy
- Levofloxacin 500 mg once daily for 28 days is the preferred regimen 4, 1
- Ciprofloxacin 500 mg twice daily for 28 days is an equally effective alternative, with 70–92% eradication rates at 3 months 2, 6, 7, 8
- Fluoroquinolones for 2–4 weeks cure approximately 70% of chronic bacterial prostatitis caused by gram-negative organisms 6
Alternative Therapy for Fluoroquinolone Failure or Contraindication
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 4–12 weeks can be used when fluoroquinolones are contraindicated or have failed 6, 8
- Long-term suppressive therapy with trimethoprim-sulfamethoxazole, fluoroquinolones, or nitrofurantoin eliminates symptomatic manifestations when cure is not achieved 6
Duration and Follow-Up
- Minimum 4-week course is required for chronic bacterial prostatitis, with some patients requiring up to 12 weeks 6, 1, 8
- Obtain pre-treatment cultures of expressed prostatic secretions (EPS) or post-prostatic massage urine to confirm bacterial etiology 4, 7, 8
- Follow-up cultures at 3,12, and 24 months to assess for recurrence, as eradication is unpredictable 7
- Eradication rates decline over time: 92% at 3 months, 70–80% at 12–24 months 7
Surgical Considerations
- Modified retropubic prostatectomy combined with antibiotics may be required for patients with benign prostatic enlargement, prostatic calculi, or failure of medical therapy alone 8
- Prostatic calculi do not predict treatment failure with fluoroquinolones 7
Common Pitfalls
- Do not use shorter durations (<4 weeks), as this leads to treatment failure and recurrence 6, 1
- Do not rely on symptom resolution alone; microbiological cure requires documented eradication on follow-up cultures 7
- Recognize that up to 30% of patients will not achieve cure despite appropriate therapy and may require long-term suppressive antibiotics 6, 7
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
For CP/CPPS with urinary symptoms, prescribe α-blockers (tamsulosin or alfuzosin) as first-line therapy, which reduces NIH-CPSI scores by 4.8 to 10.8 points compared to placebo. 1
First-Line Non-Antibiotic Therapy
- α-blockers (tamsulosin 0.4 mg once daily or alfuzosin 10 mg once daily) are the most effective first-line agents for CP/CPPS with urinary symptoms 1
- Antibiotics do not have a significant role in CP/CPPS, as this is not a bacterial infection 6, 1
Adjunctive Therapies
- NSAIDs (ibuprofen) reduce NIH-CPSI scores by 1.7–2.5 points compared to placebo 1
- Pregabalin reduces NIH-CPSI scores by 2.4 points compared to placebo 1
- Pollen extract reduces NIH-CPSI scores by 2.49 points compared to placebo 1
Diagnosis
- CP/CPPS is diagnosed when pelvic pain or discomfort persists for ≥3 months with urinary symptoms (frequency, urgency) and negative urine cultures 1
- Rule out infection, cancer, urinary obstruction, and urinary retention through history, physical examination, urine culture, and postvoid residual measurement 1
- NIH-CPSI score ≥6-point change is clinically meaningful for assessing treatment response 1
Common Pitfalls
- Do not prescribe antibiotics empirically for CP/CPPS, as this is not an infectious condition and antibiotics are ineffective 6, 1
- Do not confuse CP/CPPS with chronic bacterial prostatitis; the former has negative cultures and requires non-antibiotic therapy 1
Pathogen Coverage and Resistance Considerations
- Gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) cause 80–97% of acute bacterial prostatitis and up to 74% of chronic bacterial prostatitis 1
- Fluoroquinolones provide excellent coverage for E. coli, the predominant pathogen in both acute and chronic bacterial prostatitis 6, 1, 7, 8
- Avoid empiric fluoroquinolones when local resistance exceeds 10% or the patient has recent fluoroquinolone exposure 5
- Obtain urine cultures and susceptibility testing before initiating therapy to guide targeted treatment 1, 3