Treatment of Prostatitis

Introduction to Prostatitis

The European Urology guideline recommends that the treatment of prostatitis depends on the specific type, with antibiotics being the cornerstone of therapy for bacterial forms, while chronic pelvic pain syndrome requires a multimodal approach including alpha-blockers, anti-inflammatories, and other supportive measures 1

Prostatitis affects approximately 9.3% of men in their lifetime, with fewer than 10% of cases confirmed to have bacterial infection 2
The European Urology guideline advises against performing prostatic massage in acute bacterial prostatitis due to the risk of bacteremia 3
Diagnostic workup for acute bacterial prostatitis should include midstream urine dipstick, midstream urine culture, blood culture, and total blood count, as recommended by the European Urology guideline 3
Transrectal ultrasound may be used in selected cases to rule out prostatic abscess, according to the European Urology guideline 3

The European Urology guideline recommends first-line therapy with broad-spectrum antibiotics, such as ceftriaxone plus doxycycline, for hospitalized patients with severe illness 4
For outpatient treatment, the European Urology guideline suggests oral fluoroquinolones if local resistance is less than 10% 1
The European Urology guideline recommends a combination of amoxicillin plus an aminoglycoside or a second-generation cephalosporin plus an aminoglycoside as alternative antibiotic options 1

The European Urology guideline recommends performing the Meares and Stamey 2- or 4-glass test for diagnosis of chronic bacterial prostatitis 3
Accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species is necessary, according to the European Urology guideline 3

The European Urology guideline advises against using fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months due to increased risk of resistance 1
Sexual partners should be treated while maintaining patient confidentiality in cases of sexually transmitted infections, as recommended by the European Urology guideline 4

For mild-to-moderate bacterial prostatitis, ciprofloxacin is the first-line treatment if local resistance patterns allow its use, while severe cases require ceftriaxone or cefotaxime, as recommended by the Clinical Microbiology and Infection guidelines 5, 6
The WHO Expert Committee classifies severe pyelonephritis/prostatitis treatment with ceftriaxone or cefotaxime as "Watch" category antibiotics, with amikacin as second-choice, according to the Clinical Microbiology and Infection guidelines 5, 6
Local/national antimicrobial resistance data should guide empiric therapy selection, as stated in the Clinical Microbiology and Infection guidelines 5, 6

Do not use amoxicillin alone for urinary tract infections—global data shows 75% median E. coli resistance (range 45-100%), as reported in the Clinical Microbiology and Infection guidelines 5, 6

The American Urological Association recommends alpha-blockers, such as tamsulosin, alfuzosin, doxazosin, or terazosin, as equally effective options for the treatment of sterile prostatitis, with a reduction in NIH-CPSI score of 4.8 to 10.8 points 7, 8
Alpha-blockers have common adverse effects, including orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion, with tamsulosin having a lower risk of orthostatic hypotension but a higher risk of ejaculatory dysfunction compared to other alpha-blockers 7
The use of 5-alpha reductase inhibitors, such as finasteride or dutasteride, is not appropriate for the treatment of sterile prostatitis, as they are only effective for benign prostatic hyperplasia with demonstrable prostatic enlargement 7, 8