Prostatitis Treatment

• Empiric therapy should be started on evaluation bearing in mind local resistance patterns; however, antimicrobial therapy should be adjusted based on the results of culture & sensitivity
• Treatment course should be at least 3-4 weeks w/ optimal period being 6 weeks due to potential bacterial persistence
• Hospital admission may be needed in high-risk patients, eg diabetic, immunosuppressed, elderly; in those presenting w/ urosepsis-related symptoms or those unable to tolerate oral intake; or failed outpatient management
  • High doses of parenteral antibiotics, eg beta-lactam, broad-spectrum penicillin, quinolone, or third-generation cephalosporin, are usually required in serious infections as potential risks include septicemia & urosepsis
  • An aminoglycoside may be combined w/ any of the above agents in the initial therapy

• Oral therapy should be started promptly once patient’s condition improves & is given for another 2-4 weeks

• Recommended treatment course is 4-6 weeks; however, 6-12 weeks may be needed for elimination of causative organism & prevention of recurrence
• Consider suppressive low doses of antibiotics to prevent flare-up of symptoms in patients whose cultures are still positive
  • May also give intermittent antimicrobial therapy to treatment-refractory patients w/ acute symptomatic cystitis

• Treat appropriately the underlying pathology w/ management based on patient’s symptom pattern
• As the optimal treatment regimen of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unknown, individualize treatment making use of various medical (eg antimicrobials, alpha blockers, anti-inflammatory agents, etc) & physical & psychosocial modalities (eg sitz baths, physiotherapy, neuromodulation, biofeedback, cognitive behavioral therapy, psychotherapy, etc)
  • Studies show symptom score improvement w/ alpha blockers & antibiotic mono or combination therapy compared w/ placebo
• A focused multimodal therapy approach appears to be more effective than empiric monotherapy in patients w/ long-term symptoms
• A urological or specialist referral for treatment management is often required
• Please see the Chronic Pelvic Pain Disease Management Chart for more information

• No specific therapy is needed as treatment will be based on underlying conditions & primary reason for the urologic evaluation

• Given for uncomplicated acute bacterial prostatitis (ABP) w/ risk of an antimicrobial-resistant pathogen, eg quinolone-resistant Enterobacteriaceae or Pseudomonas, beta-lactamase producing Enterobacteriaceae, or complicated acute bacterial prostatitis (ABP) w/ bacteremia or suspected prostatic abscess
• Therapeutic levels attained in prostatic tissue can surpass the minimum inhibitory concentrations of most Enterobacteriaceae

• Third-generation cephalosporins, eg Ceftriaxone or Cefixime, may be given for uncomplicated acute bacterial prostatitis (ABP) w/ risk of sexually transmitted diseases (STD) pathogens C trachomatis & N gonorrhoeae, uncomplicated acute bacterial prostatitis (ABP) w/ quinolone-resistant Enterobacteriaceae, & complicated acute bacterial prostatitis (ABP) w/ bacteremia or suspected prostatic abscess 

• Recommended 1st-line agents for chronic bacterial prostatitis (CBP)
• May also be given as 1st-line therapy for early-stage chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
• Quinolones are also given for treatment of acute bacterial prostatitis (ABP)
• Penetration into the prostate is excellent & have general good safety profile
• Demonstrate good activity against P aeruginosa & other typical & atypical pathogens
• Have good bioavailability & favorable pharmacokinetic properties in both oral & parenteral forms

• Have good penetration into the prostate
• Active against Chlamydia; reasonably active against Gram-positive bacteria
• Have erratic activity against Gram-negative bacteria

Tetracyclines

• Have good activity against Mycoplasma & Chlamydia
• Inactive against P aeruginosa; have erratic activity against coagulase-negative staphylococci, E coli, enterococci, & other Enterobacteriaceae

• Whether alone or in combination w/ sulfamethoxazole, it is an alternative to patients who are resistant or cannot tolerate quinolones; may be given for 4-12 weeks
• Has good penetration into the prostate
• Active against common Gram-negative pathogens but is inactive against Pseudomonas, some enterococci, & some Enterobacteriaceae

• Alpha-Blockers
  • May be given in chronic bacterial prostatitis (CBP) & chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients w/ significant voiding lower urinary tract symptoms
  • Lessen urinary obstruction & decrease future occurrences in chronic ba cterial prostatitis (CBP)
  • A recent systematic review & meta-analysis showed significant differences in symptom scores w/ alpha-blockers compared w/ placebo
  • Please refer to the Benign Prostatic Hypertrophy Disease Management Chart for more information

• Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
  • Provide pain relief in prostatitis & faster healing through prostatic secretion liquefaction in acute bacterial prostatitis (ABP)
  • Offered in the short term to patients w/ early-stage chronic bacterial prostatitis (CBP) & chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) whose symptoms are deemed to be from an inflammatory process
  • Various nonsteroidal anti-inflammatory drugs (NSAIDs)are available. Please see the latest MIMS for specific formulations & prescribing information

• Surgery should be avoided in bacterial prostatitis treatment
• Suprapubic, intermittent or indwelling catheterization may be performed in patients with acute prostatitis, urinary retention or severe obstructive voiding symptoms
  
  • Patients intolerant of a urethral catheter may opt for placement of suprapubic tube
  • Risk of progression to chronic prostatitis is increased if catheterization is done in the absence of urinary retention

• Drainage & conservative treatment both appear feasible in managing prostatic abscess
  • A study showed abscess cavities <1 cm in diameter were successfully treated with conservative treatment while larger abscesses were better managed with continuous drainage or by single aspiration