How should prostatitis be evaluated and treated, including acute bacterial, chronic bacterial, and chronic prostatitis/chronic pelvic pain syndrome?

Prostatitis: Evaluation and Treatment

Classification and Initial Approach

Prostatitis must be classified into one of three distinct entities—acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)—because each requires fundamentally different diagnostic and therapeutic strategies. 1, 2, 3

Prostatitis affects approximately 9.3% of men during their lifetime, but fewer than 10% of cases are confirmed bacterial infections—the vast majority are CP/CPPS. 2, 4

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Acute Bacterial Prostatitis

Diagnostic Evaluation

In suspected ABP, perform a gentle digital rectal examination but absolutely avoid vigorous prostatic massage or manipulation, as this can precipitate life-threatening bacteremia. 1, 2, 3

Essential diagnostic steps include:

• Midstream urine dipstick to check for nitrites and leukocytes 1
• Midstream urine culture before initiating antibiotics to identify the causative organism 1, 2, 3
• Blood cultures and complete blood count in febrile patients, as up to 7.3% progress to urosepsis 1, 2
• Transrectal ultrasound in selected cases if prostatic abscess is suspected (failure to respond to therapy, severe toxicity) 1, 2

Clinical presentation typically includes fever, chills, dysuria, urinary frequency, pelvic or perineal pain, and a tender, boggy prostate on gentle examination. 2, 4 Suprapubic pain may accompany bladder involvement. 2

Pathogen Profile

Gram-negative bacteria cause 80-97% of ABP cases, with Escherichia coli being the most common, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. 2, 4 Gram-positive organisms (Staphylococcus aureus, Enterococcus species, Group B streptococci) account for the remainder. 2

Treatment Strategy

For mild-to-moderate ABP in patients who can tolerate oral medications, initiate ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance is less than 10%. 2, 3, 4

For severe ABP requiring hospitalization (inability to tolerate oral medications, systemic toxicity, risk of urosepsis), start intravenous therapy with ciprofloxacin 400 mg IV twice daily, piperacillin-tazobactam 4.5 g IV every 6-8 hours, or ceftriaxone 1-2 g IV daily, then transition to oral antibiotics once clinically improved. 2, 3, 4

Critical treatment considerations:

• Avoid fluoroquinolones if local resistance exceeds 10% or if the patient received them in the past 6 months 2
• Avoid amoxicillin/ampicillin empirically due to very high worldwide resistance rates 2
• Avoid trimethoprim-sulfamethoxazole empirically unless susceptibility is confirmed 2
• Total treatment duration is 2-4 weeks minimum—stopping prematurely can lead to chronic bacterial prostatitis 2, 3, 4
• Reassess clinical response after 48-72 hours and adjust antibiotics based on culture results 2

For healthcare-associated infections with suspected enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility; reserve carbapenems for confirmed multidrug-resistant organisms. 2

Special Population: Men Under 35

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 sexually transmitted pathogens including Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species. 2

All sexual partners within the preceding 60 days should be evaluated and treated, and patients should abstain from sexual activity until 7 days after initiating therapy and symptom resolution. 2

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Chronic Bacterial Prostatitis

Diagnostic Evaluation

The Meares-Stamey 4-glass test is the gold standard for diagnosing CBP, requiring a 10-fold higher bacterial count in expressed prostatic secretions (EPS) compared to midstream urine. 2, 3

The 4-glass test includes:

1. First-void urine (urethral specimen)
2. Midstream urine (bladder specimen)
3. Expressed prostatic secretions (after prostatic massage)
4. Post-massage urine (prostatic specimen)

A simplified 2-specimen variant (midstream urine and EPS only) can be used in routine practice. 2, 3

Perform accurate microbiological evaluation for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, as these require specific antimicrobial therapy. 1, 2

Clinical presentation includes recurrent urinary tract infections from the same bacterial strain, pelvic or perineal discomfort, and irritative voiding symptoms. 4, 5

Pathogen Profile

Up to 74% of CBP cases are caused by gram-negative organisms, particularly E. coli, with other pathogens including Proteus mirabilis, Enterobacter species, and Serratia marcescens. 2, 3

Treatment Strategy

First-line therapy for CBP is levofloxacin 500 mg orally once daily OR ciprofloxacin 500 mg orally twice daily for a minimum of 4 weeks (28 days), with treatment potentially extending to 12 weeks to prevent relapse. 2, 3, 4

Fluoroquinolones are preferred because they achieve superior prostatic tissue penetration compared to other antibiotic classes. 3, 6, 7 Levofloxacin and ciprofloxacin demonstrate equivalent efficacy, with microbiologic eradication rates of 75-77% and clinical success rates of 72.8-75%. 3

The minimum treatment duration is 4 weeks—shorter courses result in higher relapse rates. 2, 3, 7 Approximately 10% of ABP cases progress to CBP, and another 10% progress to CP/CPPS. 6

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

Diagnostic Approach

CP/CPPS is diagnosed when pelvic pain or discomfort persists for at least 3 months in association with urinary symptoms (frequency, urgency, dysuria), and evaluation excludes other causes such as bacterial infection, cancer, urinary obstruction, or retention. 4, 5

Essential diagnostic steps:

• History and physical examination focusing on pain location, duration, and urinary symptoms 4, 5
• Urine culture to exclude bacterial infection 4, 5
• Postvoid residual measurement to exclude urinary retention 4
• Meares-Stamey 2- or 4-glass test to rule out bacterial infection 2
• Testing for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) if indicated 1, 2

CP/CPPS is not caused by culturable bacterial infection and requires different management focused on symptom relief rather than antimicrobials. 2, 3 Approximately half of patients show signs of urethral inflammation without a detectable microorganism, suggesting prior infections may trigger persistent inflammatory changes. 2

The NIH Chronic Prostatitis Symptom Index (NIH-CPSI) measures symptom severity on a scale of 0-43, with a 6-point change considered clinically meaningful. 4

Treatment Strategy

First-line oral therapy for CP/CPPS with urinary symptoms is α-blockers such as tamsulosin or alfuzosin, which demonstrate NIH-CPSI score improvements of 4.8 to 10.8 points compared to placebo. 4

Other therapies with modest benefit include:

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score difference of -1.7 to -2.5 points 4
• Pregabalin: NIH-CPSI score difference of -2.4 points 4
• Pollen extract: NIH-CPSI score difference of -2.49 points 4

Antibiotics are not recommended for CP/CPPS unless there is clinical, bacteriological, or immunological evidence of prostate infection. 7, 5 The pathology of CP/CPPS is poorly understood, and antimicrobial therapy has not been supported in clinical trials for culture-negative cases. 5

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Common Pitfalls and Caveats

• Never perform vigorous prostatic massage in suspected ABP—this can cause bacteremia and sepsis 1, 2, 3
• Do not routinely perform microbiological analysis of ejaculate alone to diagnose CBP 1
• Avoid stopping antibiotics prematurely in bacterial prostatitis—this leads to chronic infection 2
• Do not use fluoroquinolones if local resistance exceeds 10% or if recently prescribed 2
• Recognize that most prostatitis is CP/CPPS, not bacterial—avoid unnecessary prolonged antibiotic courses 2, 3, 4
• Consider sexually transmitted pathogens in men under 35 and treat partners to prevent reinfection 2
• Oral cephalosporins like cefpodoxime have poor prostatic tissue penetration and are not recommended for prostatitis despite efficacy in pyelonephritis 2