prostatitis
PROSTATITIS

Prostatitis is the inflammation of the prostate that may be caused by infection, chronic pelvic pain syndrome or asymptomatic prostate inflammation.

Prominent features are genitourinary, pelvic or rectal pain and lower urinary tract symptoms, eg urinary frequency, urgency, hesitancy, weak stream and straining on urination, dysuria, pain that increased with urination.

Principles of Therapy

General Principles
Acute Bacterial Prostatitis (ABP)
  • 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
Chronic Bacterial Prostatitis (CBP)
  • 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
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
  • 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
Asymptomatic Inflammatory Prostatitis (AIP)
  • No specific therapy is needed as treatment will be based on underlying conditions & primary reason for the urologic evaluation

Pharmacotherapy

Beta-Lactams
  • 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
Cephalosporins
  • 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 
Quinolones
  • 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
Macrolides
  • 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
Trimethoprim
  • 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
Other Medications
  • 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

Non-Pharmacological Therapy

  • 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
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