How should acute and chronic prostatitis be evaluated and managed, including appropriate antibiotic regimens and supportive therapies?

Prostatitis: Evaluation and Management

Acute Bacterial Prostatitis

For acute bacterial prostatitis, initiate empiric broad-spectrum antibiotics immediately—ciprofloxacin 500-750 mg orally twice daily for mild-to-moderate cases or intravenous piperacillin-tazobactam/ceftriaxone for severe cases—and continue for 2-4 weeks total. 1, 2, 3

Diagnostic Workup

• Obtain midstream urine culture before starting antibiotics to identify the causative organism (E. coli in 80-97% of cases, also Klebsiella, Pseudomonas, or gram-positive organisms like Staphylococcus aureus). 1, 2
• Collect blood cultures in febrile patients to assess for bacteremia. 1
• Perform gentle digital rectal examination only—the prostate will be tender, boggy, and warm—but avoid vigorous prostatic massage or manipulation as this can precipitate bacteremia and sepsis. 1, 2
• Order complete blood count to assess for leukocytosis. 1
• Consider transrectal ultrasound if prostatic abscess is suspected (persistent fever despite 48-72 hours of appropriate antibiotics, or severe systemic toxicity). 1

Treatment Algorithm

Outpatient oral therapy (mild-to-moderate cases):

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance is <10% and the patient has not received fluoroquinolones in the past 6 months. 1, 2
• Avoid amoxicillin/ampicillin empirically due to very high worldwide resistance rates. 1
• Avoid trimethoprim-sulfamethoxazole empirically unless the organism is known to be susceptible, as resistance rates are high. 1

Inpatient IV therapy (severe cases):

• Hospitalize patients who cannot tolerate oral medications, show signs of systemic toxicity/risk of urosepsis (occurs in 7.3% of cases), or have suspected prostatic abscess. 1
• Ciprofloxacin 400 mg IV twice daily or piperacillin-tazobactam or ceftriaxone plus gentamicin for severe cases with bacteremia. 1, 4, 3
• Transition to oral antibiotics once clinically improved (typically after 48-72 hours), completing a total of 2-4 weeks. 1, 2

Special Populations

• For men under 35 years old, add doxycycline 100 mg orally every 12 hours for 7 days (or azithromycin 1 g orally as a single dose) to cover Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species. 1
• For healthcare-associated infections with suspected enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility; consider carbapenems only when early culture results indicate multidrug-resistant organisms. 1

Critical Pitfall

Stopping antibiotics prematurely leads to chronic bacterial prostatitis in approximately 10% of cases—always complete the full 2-4 week course. 1, 5

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Chronic Bacterial Prostatitis

For chronic bacterial prostatitis, prescribe fluoroquinolones for a minimum of 4 weeks (up to 12 weeks may be required) as these agents achieve superior prostatic tissue penetration compared to other antibiotic classes. 1, 2

Diagnostic Workup

• Perform the Meares-Stamey 4-glass test (first-void urine, midstream urine, expressed prostatic secretions, post-massage urine) as the gold standard for diagnosis. 1, 2
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretions only) can be used in routine practice. 1, 2
• A positive result requires a 10-fold higher bacterial count in the expressed prostatic secretions compared to midstream urine. 1
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species as these require specific antimicrobial therapy. 1

Treatment Regimen

First-line therapy:

• Levofloxacin 500 mg orally once daily for minimum 4 weeks (microbiologic eradication rate 75%, clinical success rate 75%). 2
• Ciprofloxacin 500 mg orally twice daily for minimum 4 weeks (microbiologic eradication rate 76.8%, clinical success rate 72.8%). 2, 4
• Both regimens are equivalent in efficacy. 2

Alternative agents:

• Norfloxacin 400 mg orally twice daily for 4 weeks or cotrimoxazole 960 mg twice daily for 4 weeks may be used if fluoroquinolones are contraindicated. 4

Key Considerations

• Up to 74% of chronic bacterial prostatitis cases are caused by gram-negative organisms, particularly E. coli, with other pathogens including Proteus mirabilis, Enterobacter species, and Serratia marcescens. 1, 2
• Avoid fluoroquinolones if local resistance is >10% or if the patient has received them in the last 6 months. 1
• If 4-6 weeks of antibiotic therapy is effective but symptoms recur, prescribe another course, perhaps in combination with alpha blockers or nonopioid analgesics. 6

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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, as these provide the greatest symptom improvement (NIH-CPSI score difference vs placebo = -10.8 to -4.8). 3

Diagnostic Approach

• CP/CPPS is diagnosed when evaluation does not identify other causes such as infection (negative urine culture), cancer, urinary obstruction, or urinary retention. 3
• Symptoms include pelvic pain or discomfort for at least 3 months associated with urinary frequency, urgency, nocturia, or dysuria. 1, 6, 3
• Perform the Meares-Stamey 2- or 4-glass test to rule out bacterial infection—fewer than 10% of prostatitis cases are confirmed bacterial. 1, 2
• Approximately half of individuals show signs of urethral inflammation without a detectable microorganism, suggesting prior sexually transmitted infections may trigger persistent inflammatory changes. 1

Treatment Algorithm

First-line pharmacologic therapy:

• Alpha blockers (tamsulosin, alfuzosin) for patients with urinary symptoms—most effective agent with NIH-CPSI score improvement of 4.8-10.8 points. 3

Adjunctive pharmacologic therapies (modest benefit):

• Anti-inflammatory drugs (ibuprofen) with NIH-CPSI score difference of -1.7 to -2.5 vs placebo. 3
• Pregabalin with NIH-CPSI score difference of -2.4 vs placebo. 3
• Pollen extract with NIH-CPSI score difference of -2.49 vs placebo. 3

Empiric antibiotics (weak evidence):

• A 4-6 week course of fluoroquinolones may be tried if atypical pathogens are suspected, though CP/CPPS is not caused by culturable bacterial infection. 1, 6

Non-Pharmacologic Therapies

• Refer to pelvic floor physical therapy for patients with pelvic floor muscle tenderness. 6
• Refer to a psychologist experienced in managing chronic pain for patients with significant psychosocial factors. 6
• Consider urology referral when appropriate treatment is ineffective. 6

Key Distinction

CP/CPPS accounts for more than 90% of chronic prostatitis cases and requires management focused on symptom relief rather than antimicrobials, as it is not caused by culturable bacterial infection. 2, 6

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Prevention and Partner Management

• Unprotected sexual intercourse raises the risk of bacterial prostatitis by facilitating transmission of sexually transmitted pathogens—consistent condom use is highly effective at lowering this risk. 1
• When prostatitis is linked to sexually transmitted pathogens, all sexual partners within the preceding 60 days should be referred for evaluation and treatment to prevent reinfection. 1
• Patients should abstain from sexual activity until at least 7 days after initiating antimicrobial therapy, provided symptoms have resolved and all recent partners have been treated. 1