What is the treatment for prostatitis?

Treatment of Prostatitis

Acute Bacterial Prostatitis (NIH Category I)

Initiate empiric broad-spectrum antibiotics immediately targeting Enterobacterales, with fluoroquinolones as first-line oral therapy for mild-to-moderate cases or intravenous beta-lactams for severe cases, continuing for 2-4 weeks total. 1

Outpatient Management (Mild-to-Moderate Cases)

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks is the preferred first-line regimen if local fluoroquinolone resistance is less than 10%. 2, 1
• Obtain midstream urine culture before starting antibiotics to identify the causative organism and guide therapy. 2, 1
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates. 2
• Avoid trimethoprim-sulfamethoxazole empirically unless the organism is known to be susceptible, as resistance rates are high. 2
• Do not use fluoroquinolones if local resistance exceeds 10% or if the patient has received them in the last 6 months. 2

Inpatient Management (Severe Cases)

• Hospitalize patients who cannot tolerate oral medications, show signs of systemic toxicity or risk of urosepsis (which occurs in 7.3% of cases), or have suspected prostatic abscess. 2, 1
• Ciprofloxacin 400 mg IV twice daily or piperacillin-tazobactam or ceftriaxone for severe cases, transitioning to oral therapy once clinically improved. 2, 3
• For healthcare-associated infections with enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility against Enterococcus faecalis. 2
• Consider carbapenems or novel broad-spectrum agents only when early culture results indicate multidrug-resistant organisms. 2

Special Populations

• For men under 35 years old, 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 can be used for coverage of Mycoplasma. 2

Follow-up and Duration

• Assess clinical response after 48-72 hours of treatment. 2
• Complete a total of 2-4 weeks of antibiotic therapy to prevent progression to chronic bacterial prostatitis. 2, 1
• Stopping antibiotics prematurely can lead to chronic bacterial prostatitis; complete the full treatment course. 2

Diagnostic Precautions

• Perform gentle digital rectal examination only—avoid vigorous prostatic massage or manipulation due to risk of inducing bacteremia and sepsis. 2, 1
• Blood cultures should be collected, especially in febrile patients. 2
• Transrectal ultrasound should be performed in selected cases to rule out prostatic abscess. 2

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Chronic Bacterial Prostatitis (NIH Category II)

Prescribe fluoroquinolones for a minimum of 4 weeks, as these agents achieve superior prostatic tissue penetration compared to other antibiotic classes. 1

First-Line Therapy

• Levofloxacin 500 mg orally once daily for minimum 4 weeks or ciprofloxacin 500 mg orally twice daily for minimum 4 weeks. 1
• Both regimens demonstrate 75-77% microbiologic eradication rates and 72.8-75% clinical success rates. 1
• Minimum treatment duration is 4 weeks (28 days), though more prolonged therapy (up to 4-12 weeks) may be required for severe or complicated infections to prevent relapse. 2, 1

Diagnostic Approach

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

Pathogen Profile

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

Treatment Considerations

• If there is no improvement in symptoms after 2-4 weeks, treatment should be stopped and reconsidered. 4
• If there is improvement, continue for at least a further 2-4 weeks to achieve clinical cure and eradication of the causative pathogen. 4
• Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness. 4

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

CP/CPPS is not caused by culturable bacterial infection and requires management focused on symptom relief rather than antimicrobials. 2, 1

Key Distinction

• Fewer than 10% of prostatitis cases are confirmed to have bacterial infection—the majority are CP/CPPS. 2, 1
• CP/CPPS is characterized by pelvic pain for at least 3 months of the preceding 6 months without documented urinary tract infections from uropathogens. 2, 5, 3
• Diagnosis relies on separating this entity from chronic bacterial prostatitis through negative localization cultures when patients are symptomatic. 5

First-Line Therapy

• A 4- to 6-week course of a fluoroquinolone provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. 5
• α-blockers (e.g., tamsulosin, alfuzosin) for urinary symptoms show significant benefit with NIH-CPSI score difference versus placebo of -10.8 to -4.8. 3

Second-Line Therapy

• Anti-inflammatory agents (e.g., ibuprofen) for pain symptoms, with NIH-CPSI score difference versus placebo of -2.5 to -1.7. 5, 3
• Pregabalin shows modest benefit with NIH-CPSI score difference of -2.4. 3

Third-Line Therapy

• Pollen extract (cernilton, CN-009) with NIH-CPSI score difference of -2.49. 5, 3
• 5α-reductase inhibitors, glycosaminoglycans, quercetin, and saw palmetto may be considered. 5

Advanced Therapy

• Pelvic floor training/biofeedback is potentially more effective than pharmacotherapy, though randomized controlled trials are needed to confirm this. 5
• For treatment-refractory patients, transurethral microwave therapy to ablate prostatic tissue has shown some promise. 5

Treatment Algorithm

1. Start with a 4- to 6-week course of fluoroquinolones, which may be repeated if the initial course provides relief. 5
2. Add anti-inflammatory agents and α-blockers for pain and urinary symptoms. 5
3. If relief is not significant, refer for biofeedback. 5
4. Reserve minimally invasive surgical options for treatment-refractory patients. 5

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Common Pitfalls and Caveats

• Never perform vigorous prostatic massage in acute bacterial prostatitis—this can precipitate bacteremia and sepsis. 2, 1
• Local resistance patterns should guide antibiotic selection; fluoroquinolone resistance should ideally be less than 10% for empiric use. 2
• Consider broader spectrum options initially for patients with risk factors for antibiotic resistance or healthcare-associated infections. 2
• Ensure all sexual partners within the preceding 60 days are referred for evaluation and appropriate treatment to prevent reinfection in sexually transmitted prostatitis. 2
• Patients should abstain from sexual activity until at least seven days after initiating antimicrobial therapy, provided symptoms have resolved and all recent partners have been treated. 2