Acute Bacterial Prostatitis Treatment & Management
- Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS more...
The intense inflammation in acute bacterial prostatitis (ABP) makes the prostate gland highly responsive to antibiotics, which otherwise penetrate poorly into the prostate. Hospitalization is required for patients in whom acute urinary retention develops and in those who require intravenous antimicrobial therapy. Antipyretics, analgesics, stool softeners, bed rest, and increased fluid intake provide supportive therapy.
A Foley catheter can be inserted gently for drainage if severe obstruction is suspected. A punch suprapubic tube can be used if a catheter cannot be passed easily or is not tolerated by the patient. The catheter can be removed 24-36 hours later.
Alpha-blocker therapy should also be considered for acute bacterial prostatitis. Because the bladder neck and prostate are rich in alpha-receptors, alpha blockade may improve outflow obstruction and diminish intraprostatic urinary reflux. Terazosin, 5 mg/d orally for 4-52 weeks, is the usual first choice. Tamsulosin (Flomax), alfuzosin (Uroxatral), and doxazosin (Cardura) are acceptable alternative agents.
Medical management is often unsuccessful in cases of prostatic abscess. In such situations, transrectal or perineal aspiration or, less preferably, transurethral resection of the prostate and drainage of the cavity are possible surgical approaches.
A potential indication for surgery is a prostatic abscess, which is an uncommon but well-described complication of acute bacterial prostatitis (ABP). Medical management of prostatic abscess is often unsuccessful. Thus, surgical drainage via either transrectal or perineal aspiration, transurethral resection, or transrectal ultrasound–guided placement of a transrectal drainage tube may be considered.
Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially if the patient's symptoms do not improve after 1 week of medical therapy. Transurethral resection of the prostate and drainage of the cavity is another approach. However, this approach is less desirable because of the potential hematogenous spread of bacteria.
The abscess should be allowed to drain, or some type of drainage should be performed if the abscess is larger than 1 cm.[16, 17] Monitor the abscess closely if a spontaneous rupture occurs into the urethra. Recurrent abscesses are rare.
Because of the potential for systemic infection and bacteremia, urethral instrumentation should be avoided in patients with acute bacterial prostatitis, especially if the patient is clinically unstable or is already showing signs of sepsis, although placement of a small drainage catheter is safe in experienced hands. Pretreatment with appropriate antibiotics is mandatory.
Transurethral or perineal surgical approaches in the treatment of a prostatic abscess should be undertaken with caution and are currently not advised unless other drainage techniques have failed. Perineal incision can cause impotence due to nerve injury, and transurethral resection can facilitate hematogenous spread of bacteria, leading to sepsis.
In patients with sepsis, transurethral resection may be lifesaving and should be considered if they are not responding to conservative therapy.
In patients with acute urinary retention, insertion of a Foley catheter may be attempted first as tolerated by the patient; however, this may cause extreme discomfort. In some cases, the transurethral catheter may obstruct drainage of an acutely inflamed prostate and cause bacteremia or prostatic abscess. If the catheter is not easy to pass, a suprapubic punch cystostomy is indicated.
The choice of antibiotic for treatment of acute bacterial prostatitis (ABP) is based on the results of the initial culture and sensitivity. However, initial therapy should be directed at gram-negative enteric bacteria. Useful agents include fluoroquinolones, trimethoprim-sulfamethoxazole, and ampicillin with gentamicin.
If the initial clinical response to therapy is satisfactory and the pathogen is susceptible to the chosen antibiotic, treatment is continued orally (PO) for 30 days to prevent sequelae such as chronic bacterial prostatitis and prostatic abscess formation.
There is currently a rapid rise in drug resistance, especially to fluoroquinolones, which must be considered. Of particular concern, especially in patients undergoing transrectal ultrasound-guided biopsy (TRUS), are Gram negative uropathogens such as extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae. Local resistance patterns and sensitivities should help guide initial treatment.
In a study of 3000 men who received a prophylactic fluroquinolone-based regimen for 7 days to minimize the risk of iatrogenic acute prostatitis after undergoing TRUS, fewer than 1% (n=20) developed acute bacterial prostatitis within a week of the procedure. In all 20 cases the only bacteria isolated was Escherichia coli.
Testing revealed resistance to the following antibiotics: fluroquinolone and amoxicillin (95%), amoxicillin-clavulanate and trimethoprim-sulfamethoxazole (70%), third-generation cephalosporin (25%) and amikacin (5%). No resistance to imipenem was reported. The investigators concluded that fluroquinolone-based prophylaxis remains effective in minimizing the risk of acute prostatitis secondary to prostate biopsy.
A review of acute prostatitis after TRUS-guided biopsy in Korean patients found that ESBL-producing E coli had been detected continuously since 2008; those E coli were susceptible to imipenem, amikacin, and cefoxitin but resistant to fluoroquinolones. These authors concluded that fluoroquinolones are not an effective antimicrobial of choice for the treatment of acute prostatitis after TRUS-guided biopsy.
An increase in infection rates after transrectal prostate biopsy due to floroquinolone-resistant bacteria in feces has been reported. Targeted prophylaxis after rectal flora swabbing has been shown to be efficacious compared with empirical antibiotic prophylaxis. Use of a perineal prostate biopsy has only limited data support and further study is needed.
Some resistant strains may require prolonged intravenous (IV) therapy. For IV therapy, use trimethoprim-sulfamethoxazole, 8-10 mg/kg/d (based on the trimethoprim component) in 2-4 doses twice daily (bid), thrice daily (tid), or four times daily (qid) until the culture and sensitivity results are known. An alternate regimen is gentamicin with ampicillin 3-5 mg/kg/d IV (gentamicin dose divided tid; ampicillin 2 g divided qid). In addition, two recently approved β-lactam/β-lactamase inhibitor combinations, ceftolozane/tazobactam and ceftazidime/avibactam, have promising activity against multidrug-resistant Gram negative organisms.
After the patient is afebrile for 24 hours, an appropriate oral agent can be substituted for an additional 30 days. For oral therapy, use trimethoprim-sulfamethoxazole, 160 mg of trimethoprim and 800 mg of sulfamethoxazole, PO bid for 30 days. Use levofloxacin (Levaquin) 500-750 mg PO daily; ciprofloxacin, 500 mg PO bid; norfloxacin, 400 mg PO bid; ofloxacin, 400 mg PO bid; or enoxacin, 400 mg PO bid for 30 days when the clinical response is favorable.
If an abscess is diagnosed, anaerobic antimicrobial therapy should be added to the treatment regimen. Clindamycin 600-900 mg IV every 8 hours ( q8h) or 150-450 mg PO q8h is a good choice. Medical management is often unsuccessful, however, in which case surgical drainage is required. Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially if symptoms do not improve after 1 week of medical therapy.
Future and Controversies
Despite the fact that prostatitis syndromes are common urologic disease processes, little is known about prostatitis and the factors associated with the condition. Several important questions need to be answered, including the following:
Is prostatitis associated with prostate cancer?
What are the natural history and the epidemiology of prostatitis?
What is the best way to elucidate the exact etiology, diagnosis, and management of prostatitis?
Prostatitis, BPH, and prostate cancer
The first question is important considering efforts in recent years to find the most accurate and most expedient method of diagnosing and treating prostate cancer. Prostatitis is more common in younger men, whereas benign prostatic hypertrophy (BPH) and prostate cancer are more common in men older than 50 years. An important research question is whether prostatitis in younger men leads to later BPH or prostate cancer, because approximately 5% of acute bacterial prostatitis (ABP) cases lead to chronic prostatitis. Although one study reported that nearly 50% of prostate specimens resected for prostate cancer showed evidence of prostatitis, no causal association has been demonstrated.
Public health burden
The exact public health burden of prostatitis should also be addressed. Most urologists agree about the ever-growing need for both community-based cross-sectional and longitudinal epidemiologic prostatitis studies. Active research and a more aggressive effort are needed to generate hypotheses regarding the etiology of prostatitis.
Elucidating risk factors
Formulating risk factors associated with prostatitis is important. For example, the incidence of prostatitis among men with a history of a prostatic biopsy requires investigation. With increased screening for prostate cancer, more men are undergoing biopsy based on elevated serum prostate-specific antigen (PSA) levels. These biopsies may trigger an inflammatory response in the prostate, leading to prostatitis, or, alternatively, a biopsy may be a source of transmission of organisms into the prostate gland.
The above examples outline potential research directions in the field of prostatitis. Results of these and other studies could promote an increased awareness of the disease and increase the knowledge about prostatitis. This research should improve diagnosis and treatment, promote an appropriate allocation of resources to the management of the disease, and reduce the incidence and public health burden of prostatitis.
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