What are the recommended treatments for acute bacterial prostatitis, chronic bacterial prostatitis, and chronic prostatitis/chronic pelvic pain syndrome?

Treatment of Prostatitis

For acute bacterial prostatitis, start ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks in mild-to-moderate cases, or ciprofloxacin 400 mg IV twice daily for severe cases requiring hospitalization; for chronic bacterial prostatitis, use levofloxacin or ciprofloxacin for a minimum of 4-12 weeks; for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), prescribe tamsulosin or alfuzosin as first-line therapy. 1, 2

Acute Bacterial Prostatitis (NIH Category I)

Outpatient Management (Mild-to-Moderate Cases)

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks is first-line therapy when local fluoroquinolone resistance is below 10%. 1, 2
• Avoid fluoroquinolones if local resistance exceeds 10% or if the patient received them within the past 6 months. 1
• Avoid amoxicillin, ampicillin, or trimethoprim-sulfamethoxazole empirically due to high worldwide resistance rates. 1
• For men under 35 years, add doxycycline 100 mg orally every 12 hours for 7 days to cover Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species. 1
• Alternatively, use azithromycin 1 g orally as a single dose for atypical pathogen coverage. 1

Inpatient Management (Severe Cases)

• Hospitalize patients who cannot tolerate oral medications, show signs of systemic toxicity, risk urosepsis (occurs in 7.3% of cases), or have suspected prostatic abscess. 1
• Start ciprofloxacin 400 mg IV twice daily, or use piperacillin-tazobactam or ceftriaxone as broad-spectrum alternatives. 1, 2
• Switch to oral antibiotics once clinically improved, typically after 48-72 hours of IV therapy. 1
• Complete a total of 2-4 weeks of antibiotic therapy to prevent progression to chronic bacterial prostatitis. 1, 2

Special Populations

• For healthcare-associated infections with suspected enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility against Enterococcus faecalis. 1
• Consider carbapenems or novel broad-spectrum agents only when early culture results indicate multidrug-resistant organisms. 1

Diagnostic Essentials

• Obtain midstream urine culture to identify causative organisms (gram-negative bacteria in 80-97% of cases, predominantly E. coli). 1, 3
• Collect blood cultures in febrile patients. 1
• Avoid prostatic massage or vigorous digital rectal examination due to bacteremia risk; perform gentle digital rectal examination only. 1, 3
• Order transrectal ultrasound if prostatic abscess is suspected. 1

Common Pitfalls

• Stopping antibiotics prematurely leads to chronic bacterial prostatitis in approximately 10% of cases. 1, 4
• Local resistance patterns must guide antibiotic selection; empiric fluoroquinolone use requires resistance below 10%. 1

---

Chronic Bacterial Prostatitis (NIH Category II)

First-Line Antibiotic Therapy

• Levofloxacin or ciprofloxacin for a minimum of 4 weeks is the standard treatment. 2, 4
• Extend treatment to 4-12 weeks to prevent relapse, as shorter courses result in recurrent urinary tract infections from the same bacterial strain. 1, 4
• Fluoroquinolones exhibit superior prostatic tissue penetration compared to other antibiotic classes. 4

Diagnostic Confirmation

• Perform the Meares-Stamey 4-glass test (or simplified 2-specimen variant) to confirm diagnosis: a 10-fold higher bacterial count in expressed prostatic secretions versus midstream urine indicates bacterial prostatitis. 1, 3
• Up to 74% of chronic bacterial prostatitis cases are caused by gram-negative organisms, particularly E. coli. 1, 3

Atypical Pathogens

• Test for Chlamydia trachomatis and Mycoplasma species using nucleic acid amplification testing (NAAT), especially in men under 35 years. 1, 3
• Add doxycycline 100 mg orally every 12 hours for 7 days if atypical pathogens are suspected. 1

Antibiotic Resistance Considerations

• Fluoroquinolone resistance is increasing and poses significant clinical challenges. 4
• Avoid fluoroquinolones if local resistance exceeds 10% or if recent use within 6 months. 1
• Oral cephalosporins (e.g., cefpodoxime) have poor prostatic tissue penetration and are not recommended for prostatitis. 1

---

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

First-Line Therapy

• Alpha-blockers (tamsulosin or alfuzosin) are first-line for CP/CPPS with urinary symptoms, achieving a NIH-CPSI score improvement of -10.8 to -4.8 points versus placebo. 2
• CP/CPPS is defined as pelvic pain or discomfort for at least 3 months without documented uropathogenic infection. 1, 2

Adjunctive Therapies

• Anti-inflammatory drugs (e.g., ibuprofen) provide modest benefit with NIH-CPSI score improvement of -2.5 to -1.7 points versus placebo. 2
• Pregabalin achieves NIH-CPSI score improvement of -2.4 points versus placebo. 2
• Pollen extract shows NIH-CPSI score improvement of -2.49 points versus placebo. 2
• A 6-point change in NIH-CPSI score (scale 0-43) is considered clinically meaningful. 2

Diagnostic Approach

• Rule out bacterial infection with the Meares-Stamey 2- or 4-glass test. 1
• Exclude other causes: infection, cancer, urinary obstruction, urinary retention through history, physical examination, urine culture, and postvoid residual measurement. 2
• Approximately 50% of patients show signs of urethral inflammation without detectable microorganisms, suggesting prior sexually transmitted infections triggered persistent inflammatory changes. 1

Key Clinical Features

• Pain locations include perineum, suprapubic area, lower back, testicles, or penile tip, often worsened by urination or ejaculation. 1
• Urinary symptoms mirror chronic bacterial prostatitis: frequency, urgency, dysuria, incomplete emptying. 1
• Many patients describe "pressure" or "discomfort" rather than overt pain. 1
• Significant sexual dysfunction (dyspareuria, reduced libido) is frequently reported. 1

Multimodal Approach

• CP/CPPS requires symptom-specific treatment rather than antimicrobials, as it is not frequently caused by culturable infectious agents. 1, 5
• Consider physical therapy, myofascial trigger point release, and relaxation techniques for non-prostate-centered treatment. 6
• A subset of men fulfill criteria for both CP/CPPS and interstitial cystitis/bladder pain syndrome, necessitating combined therapeutic strategies. 1

Antimicrobial Trial

• A trial of antibiotics may be considered to rule out occult infection, but effectiveness has not been supported in clinical trials for true CP/CPPS. 7, 5

---

Prevention and Partner Management

• Consistent condom use during all sexual activity effectively lowers the risk of acquiring sexually transmitted infections that can lead to prostatitis. 1
• When prostatitis is linked to sexually transmitted pathogens, all sexual partners within the preceding 60 days must be evaluated and treated 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 partners have been treated. 1
• Limiting the number of sexual partners reduces prostatitis risk associated with sexually transmitted infections. 1