What is the appropriate treatment for prostatitis, including acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis?

Treatment of Prostatitis

The treatment of prostatitis depends entirely on the specific category: acute bacterial prostatitis requires immediate broad-spectrum antibiotics for 2-4 weeks, chronic bacterial prostatitis demands fluoroquinolones for a minimum of 4 weeks, while chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is managed primarily with alpha-blockers and symptom-directed therapy rather than antibiotics. 1

---

Acute Bacterial Prostatitis (NIH Category I)

Immediate Diagnostic Steps

• Obtain midstream urine culture before starting antibiotics to identify the causative organism and guide therapy. 1
• Collect blood cultures and complete blood count, especially in febrile patients. 2
• Perform gentle digital rectal examination only—vigorous prostatic massage is absolutely contraindicated due to risk of inducing bacteremia and sepsis. 2, 1
• Order transrectal ultrasound in selected cases to rule out prostatic abscess. 2

Antibiotic Selection and Duration

For mild-to-moderate cases (outpatient):

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

For severe cases requiring hospitalization:

• Ciprofloxacin 400 mg IV twice daily or broad-spectrum beta-lactams (piperacillin-tazobactam, ceftriaxone) initially. 2, 1, 3
• Transition to oral antibiotics once clinically improved (typically after 48-72 hours). 2
• Complete a total of 2-4 weeks of antibiotic therapy. 2, 1

Hospitalization Criteria

Admit patients who:

• Cannot tolerate oral medications. 2
• Show signs of systemic toxicity or risk of urosepsis (occurs in 7.3% of cases). 2
• Have suspected prostatic abscess. 2

Pathogen Profile

• Gram-negative bacteria cause 80-97% of cases, predominantly E. coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. 2, 3
• Gram-positive organisms (Staphylococcus aureus, Enterococcus species, Group B streptococci) account for the remainder. 2

---

Chronic Bacterial Prostatitis (NIH Category II)

Diagnostic Approach

• Perform the Meares-Stamey 4-glass test (or simplified 2-specimen variant) as the gold standard for diagnosis. 2, 1
• A positive result shows a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine. 2
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, which require specific antimicrobial therapy. 2

First-Line Antibiotic Therapy

Fluoroquinolones are mandatory due to superior prostatic tissue penetration:

• Levofloxacin 500 mg orally once daily for minimum 4 weeks, OR 1
• Ciprofloxacin 500 mg orally twice daily for minimum 4 weeks. 1
• Both regimens demonstrate 75-77% microbiologic eradication rates and similar clinical success rates. 1
• Minimum treatment duration is 4 weeks (28 days), though more prolonged therapy (up to 12 weeks) may be required to prevent relapse. 2, 1

Special Considerations for Young Men (<35 years)

• Add doxycycline 100 mg orally every 12 hours for 7 days to cover Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species. 2
• Alternatively, azithromycin 1 g orally as a single dose for Mycoplasma coverage. 2

Pathogen Profile

• Up to 74% of cases are caused by gram-negative organisms, particularly E. coli. 2, 1, 3
• Chronic bacterial prostatitis encompasses a broader spectrum than acute prostatitis, potentially including atypical organisms. 1

If Initial Treatment Fails

• If a 4-6 week course provides relief but symptoms recur, repeat the antibiotic course, perhaps in combination with alpha-blockers or nonopioid analgesics. 4, 5

---

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS, NIH Category III)

Key Diagnostic Distinction

• CP/CPPS is NOT caused by culturable bacterial infection and requires different management focused on symptom relief rather than antimicrobials. 2, 1
• Fewer than 10% of prostatitis cases are confirmed bacterial—the majority are CP/CPPS. 2, 1
• Diagnosis requires pelvic pain for ≥3 months of the preceding 6 months without documented uropathogenic infection. 2

First-Line Therapy

Alpha-blockers are first-line for urinary symptoms:

• Tamsulosin or alfuzosin demonstrate the strongest evidence, with NIH-CPSI score improvements of -10.8 to -4.8 points compared to placebo. 3
• This represents a clinically meaningful change (≥6 points on the 0-43 scale). 3

Second-Line Pharmacotherapy

• Anti-inflammatory agents (e.g., ibuprofen) for pain symptoms, with NIH-CPSI score improvements of -2.5 to -1.7 points. 4, 3
• Pregabalin for neuropathic pain component, with NIH-CPSI score improvement of -2.4 points. 3

Trial of Antibiotics (Controversial but Common Practice)

• A 4-6 week course of fluoroquinolone provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. 4, 5
• This approach is supported by weak evidence but remains common practice. 5
• If the initial course provides relief, it may be repeated. 4

Third-Line and Alternative Therapies

• Pelvic floor physical therapy/biofeedback is potentially more effective than pharmacotherapy, though randomized controlled trials are needed. 4
• Pollen extract (Cernilton) with NIH-CPSI score improvement of -2.49 points. 3
• 5α-reductase inhibitors, glycosaminoglycans, quercetin, and saw palmetto have limited evidence. 4

Refractory Cases

• Refer to a psychologist experienced in managing chronic pain. 5
• Consider transurethral microwave therapy to ablate prostatic tissue. 4
• Urology referral when appropriate treatment is ineffective. 5

UPOINT Phenotyping Approach

The UPOINT system (Urinary, Psychosocial, Organ-specific, Infection, Neurologic/systemic, Tenderness) can guide individualized combination therapy tailored to the patient's phenotypic presentation. 5

---

Asymptomatic Inflammatory Prostatitis (NIH Category IV)

• This entity is, by definition, asymptomatic and often diagnosed incidentally during evaluation of infertility or prostate cancer. 4
• The clinical significance is unknown and it is often left untreated. 4

---

Common Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute bacterial prostatitis—this can precipitate bacteremia and sepsis. 6, 2, 1
• Do not stop antibiotics prematurely in bacterial prostatitis—this can lead to chronic bacterial prostatitis. 2
• Do not use fluoroquinolones empirically if local resistance exceeds 10% or if the patient received them in the last 6 months. 2
• Do not prescribe prolonged antibiotics for CP/CPPS unless there is documented bacterial infection—fewer than 10% of prostatitis cases are bacterial. 2, 1
• Do not overlook atypical pathogens (Chlamydia, Mycoplasma) in young men (<35 years) or those with risk factors for sexually transmitted infections. 2

---

Differential Diagnosis Considerations

When evaluating chronic pelvic pain, differentiate prostatitis from:

• Interstitial cystitis/bladder pain syndrome (IC/BPS)—a subset of men fulfill criteria for both CP/CPPS and IC/BPS. 2
• Pelvic floor dysfunction—may manifest as increased pelvic muscle tone. 4
• Prostate and bladder cancers, benign prostatic hyperplasia, urolithiasis. 5