What is the recommended management for acute and chronic prostatitis in an adult male presenting with urinary symptoms, pelvic pain, and possible fever?

Management of Prostatitis

Immediate Classification and Diagnostic Approach

The management of prostatitis depends entirely on accurate classification into acute bacterial prostatitis, chronic bacterial prostatitis, or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), as each requires fundamentally different treatment strategies. 1, 2

Key Diagnostic Steps

For suspected acute bacterial prostatitis:

• Perform a gentle digital rectal examination only—avoid vigorous prostatic massage or manipulation, as this risks inducing bacteremia and sepsis 1, 3
• Obtain midstream urine culture before starting antibiotics 1, 3
• Collect blood cultures, especially if the patient is febrile 1
• Order complete blood count to assess for leukocytosis 1
• Consider transrectal ultrasound if prostatic abscess is suspected (inability to void, severe systemic toxicity, or failure to improve within 48-72 hours) 1, 4

For suspected chronic bacterial prostatitis:

• Use the Meares-Stamey 4-glass test (or simplified 2-specimen variant) to confirm bacterial localization—a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine confirms the diagnosis 1, 3
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, particularly in men under 35 years 1, 3

For suspected CP/CPPS:

• This is a diagnosis of exclusion after ruling out bacterial infection, cancer, urinary obstruction, and urinary retention 2
• Symptoms include pelvic pain for ≥3 months with urinary symptoms but negative cultures 2

---

Treatment of Acute Bacterial Prostatitis

Hospitalization vs Outpatient Decision

Hospitalize with IV antibiotics if:

• Unable to tolerate oral medications 1
• Signs of systemic toxicity or risk of urosepsis (occurs in 7.3% of cases) 1
• Suspected prostatic abscess 1

Outpatient oral therapy is appropriate for:

• Mild-to-moderate cases without fever who can tolerate oral medications 1

First-Line Antibiotic Selection

For outpatient mild-to-moderate cases:

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance is <10% 1, 3, 2
• Do not use fluoroquinolones if the patient received them in the last 6 months or if local resistance exceeds 10% 1, 3

For hospitalized severe cases:

• Ceftriaxone 1-2 g IV daily plus doxycycline 100 mg orally every 12 hours for broad coverage 3
• Alternative: Piperacillin-tazobactam 4.5 g IV every 6-8 hours 4, 2
• Ciprofloxacin 400 mg IV twice daily can be used parenterally, transitioning to oral once clinically improved 1, 2

For men <35 years old:

• 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

Antibiotics to Avoid

• Do not use amoxicillin or ampicillin empirically—worldwide resistance rates are 75% (range 45-100%) for E. coli 1, 3
• Do not use trimethoprim-sulfamethoxazole empirically unless the organism is known to be susceptible due to high resistance rates 1

Treatment Duration and Follow-Up

• Assess clinical response after 48-72 hours of treatment 1
• Complete a total of 2-4 weeks of antibiotic therapy 5, 1, 6, 2
• Do not stop antibiotics prematurely, as this can lead to chronic bacterial prostatitis 1

Special Consideration: Prostatic Abscess

If prostatic abscess is confirmed:

• Percutaneous drainage under transrectal ultrasound guidance is mandatory—antibiotics alone are insufficient 4
• Use transrectal needle aspiration or small-bore pigtail catheter placement 4
• Start piperacillin-tazobactam 4.5 g IV every 6-8 hours or a carbapenem (ertapenem 1 g daily, meropenem 1 g every 8 hours, or imipenem-cilastatin 1 g every 6-8 hours) for multidrug-resistant organisms 4
• Culture the abscess fluid to guide targeted therapy 4

---

Treatment of Chronic Bacterial Prostatitis

First-Line Antibiotic Therapy

Fluoroquinolones are first-line if local resistance is <10%:

• Levofloxacin or ciprofloxacin for a minimum of 4 weeks 2
• 4-12 weeks may be required to prevent relapse 1, 6

Treatment Duration

• The 2024 JAMA Network Open guideline acknowledges insufficient evidence for clear duration recommendations, with historical durations ranging from 6 weeks or longer for chronic bacterial prostatitis 5
• However, the European Urology guidelines recommend 4-12 weeks to prevent relapse 1
• If symptoms improve after 2-4 weeks, continue treatment for at least another 2-4 weeks to achieve clinical cure and pathogen eradication 6
• Do not continue antibiotics for 6-8 weeks without reassessing effectiveness 6

Special Considerations

• Test for atypical pathogens (Chlamydia, Mycoplasma) and treat accordingly 1, 3
• Treat sexual partners if sexually transmitted infections are identified 3
• Avoid fluoroquinolones if the patient has used them in the last 6 months 3

---

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

CP/CPPS is not caused by culturable bacteria and requires symptom-focused management, not prolonged antibiotics. 1, 2

First-Line Therapy

α-Blockers are first-line for urinary symptoms:

• Tamsulosin, alfuzosin, doxazosin, or terazosin are equally effective 3, 2
• These reduce NIH-CPSI score by 4.8 to 10.8 points compared to placebo 3, 2
• Common adverse effects include orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion 3
• Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 3

Second-Line Therapy

If α-blockers are insufficient:

• Anti-inflammatory drugs (e.g., ibuprofen) reduce NIH-CPSI score by 1.7 to 2.5 points 2
• Pregabalin reduces NIH-CPSI score by 2.4 points 2
• Pollen extract (cernilton) reduces NIH-CPSI score by 2.49 points 2

Role of Antibiotics in CP/CPPS

• A 4- to 6-week trial of a fluoroquinolone provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin 7
• However, prolonged antibiotics are not recommended if cultures are negative 1, 7

Third-Line and Refractory Options

• Pelvic floor training/biofeedback may be more effective but requires randomized controlled trials for confirmation 7
• Do not use 5α-reductase inhibitors (finasteride, dutasteride) for CP/CPPS—they are only effective for benign prostatic hyperplasia with demonstrable prostatic enlargement 3
• For treatment-refractory patients, consider transurethral microwave therapy 7

---

Common Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute prostatitis—this can cause bacteremia and sepsis 1, 3
• Never rely on antibiotics alone for prostatic abscess—drainage is mandatory for source control 4
• Never use amoxicillin/ampicillin or trimethoprim-sulfamethoxazole empirically due to high resistance rates 1, 3
• Never stop antibiotics prematurely in acute bacterial prostatitis—this leads to chronic bacterial prostatitis 1
• Never use fluoroquinolones if local resistance exceeds 10% or if the patient used them in the last 6 months 1, 3
• Never treat CP/CPPS with prolonged antibiotics if cultures are negative—focus on symptom management with α-blockers and anti-inflammatories 1, 7, 2