eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Prostatitis, Bacterial: Treatment & Medication

Author: Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Coauthor(s): Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Oct 8, 2009

Treatment

Medical Care

The mainstay in the treatment of chronic bacterial prostatitis is the use of oral antimicrobial agents. The most effective medications are fluoroquinolones and TMP-SMZ.

All other oral agents are unlikely to eradicate the pathogenic bacteria successfully within the prostate because of suboptimal tissue penetration. Longer courses of antibiotic use provide better treatment outcomes. Relapse is not uncommon.

• Relapsing urinary tract infections are due to poor penetration of most antimicrobial agents into the prostatic fluid and/or bacterial sequestration, which protects bacteria from antimicrobial exposure. Only small-molecular–sized, unionized, lipid-soluble drugs that are not firmly bound to plasma proteins are able to penetrate the epithelial membrane.
• Antimicrobial agents that most effectively penetrate into the prostatic fluid, such as fluoroquinolones and TMP-SMZ, are good treatment choices for chronic bacterial prostatitis.
• Treatment should be guided by urine culture results. Failure of an initial course of therapy (typically about 4 wk) should prompt longer courses of treatment. Best results have been observed with a 12-week course of therapy, although patient compliance may be difficult with longer durations of treatment.
• High bactericidal activity has been demonstrated against the Enterobacteriaceae group of bacteria and P aeruginosa using fluoroquinolones, a class of antimicrobial agents that inhibits bacterial DNA replication and protein synthesis.
• Fluoroquinolones are generally ineffective against the streptococci, including enterococcus, and anaerobes. Penicillin derivatives, while effective against gram-positive organisms, are generally ineffective in treating bacterial prostatitis because of poor prostate penetration.
• While zinc supplements have been suggested as a medical therapy, clinical results have not been significant. A zinc-containing polypeptide called prostatic antibacterial factor (PAF) may be an important antimicrobial factor within the prostate.
• Prostate fluid is also rich in spermine, which has activity against gram-positive bacteria. Other factors of potential importance in prostate fluid include magnesium, calcium, and lysozyme. Other local immune factors are also under investigation.
• Barbalias et al (1998) suggested that the use of alpha-blockers in combination with fluoroquinolones would offer significantly superior symptom resolution and bacteriologic cure rates compared with fluoroquinolone treatment alone.⁶ Further study is necessary to define the benefit of the addition of alpha-blocker therapy.
• Nonsteroidal anti-inflammatory agents and hot sitz baths are often used clinically for symptomatic relief. However, their benefit in bacteriologic eradication of organisms is not established. Frequent prostate massage was used extensively several decades ago and its use is still advocated by some in the treatment of difficult cases with persistent positive cultures despite appropriate antibiotic therapy.
• Tetracycline, minocycline, and doxycycline have also been used. They are not considered first-line therapy but may be helpful if Pseudomonas infection is present. Paulson and White (1978) reported a 70% bacteriologic cure rate with 4 weeks of minocycline, but the study involved only 10 men, and 30% developed significant vestibular toxicity.⁷ More recent studies indicate a 35% bacteriologic cure rate with minocycline.
• Penicillins are ineffective, with the exception of carbenicillin indanyl sodium at 500 mg/d. Carbenicillin may be effective for Enterobacteriaceae or Pseudomonas infections. Large-scale studies are not available.
• Preliminary findings suggest that antinanobacterial therapy improves symptoms and decreases or eliminates prostatic calculi in patients with chronic bacterial prostatitis that is recalcitrant to standard therapy. Further investigation is needed.
• A recent study in rats found that garlic was superior to placebo in terms of anti-inflammatory and antimicrobial effect. This study also demonstrated a statistically significant synergistic effect of ciprofloxacin plus garlic compared with ciprofloxacin alone. Studies in humans are needed to determine if these effects would translate into a clinical setting.⁸

Surgical Care

Prostatectomy is rarely indicated in the treatment of chronic bacterial prostatitis. When used, radical transurethral prostatectomy is suggested. This procedure may be more effective in men with prostatic calculi. Because most of the inflammation is located in the peripheral zone of the gland, an extensive resection of the gland is required to remove all infected and potentially infected tissue down to the level of the true prostatic capsule.

Only one series of 10 patients, most with prostatic calculi, has been reported, but all men were considered cured.⁹ This procedure is indicated, although only rarely, in men with well-documented bacterial infections in whom medical pharmacotherapy fails for one year.

For refractory cases, other authorities have suggested that transurethral microwave therapy to ablate prostate tissue has shown some benefit.¹⁰ At this time, this intervention should be considered only in patients who have failed less-invasive therapies yet do not desire radical transurethral prostatectomy. Larger series would be helpful to define the benefit of this procedure.

Intraprostatic injection of antimicrobial agents is suggested to obtain high concentrations of antimicrobial agents in the prostatic parenchyma. Plomp et al (1980) noted a 66% bacteriologic cure rate with thiamphenicol in 29 men.¹¹ Jiminez-Cruz et al (1988) noted a 59% cure rate with aminoglycoside injection in 51 men.¹² Unfortunately, these studies have significant methodological flaws, so the conclusions cannot be considered definitive. This technique is rarely used.

Consultations

Consultation with a urologist may be appropriate for men with relapsing chronic bacterial prostatitis or when the diagnosis is unclear. A urologist may be able to properly perform the bacterial localization studies necessary to diagnose chronic bacterial prostatitis. In the author's experience, most primary care physicians are not comfortable or experienced with obtaining VB₁, VB₂, EPS, and VB₃ specimens. Semen cultures or urine cultures collected before and following prostatic massage are simpler and represent effective alternatives to the 3-cup test.

Diet

Diet does not have an important role in treating chronic bacterial prostatitis. Some physicians have advocated the avoidance of spicy and caffeine-containing foods; however, no evidence has indicated any benefit in chronic bacterial prostatitis.

Activity

• Activity changes do not have a prominent role in the treatment of chronic bacterial prostatitis, although the authors often advise patients to avoid bicycling or other activities that may put pressure on the perineal region.
• The role of ejaculation in the treatment of chronic bacterial prostatitis is unknown. One theory is that frequent ejaculation may help clear prostatitic secretions, thereby allowing for quicker resolution.

Medication

The goals of pharmacotherapy are to treat the infection and to reduce morbidity.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Fluoroquinolones are frequently used because they are able to concentrate in the prostate and are lipid soluble. Sulfonamides are also used because they are lipid-soluble.

Ciprofloxacin (Cipro)

Bactericidal antibiotic that inhibits bacterial DNA synthesis, and consequently growth, by inhibiting DNA-gyrase in susceptible organisms.

Ofloxacin (Floxin)

Penetrates the prostate well and is effective against Neisseria gonorrhea and C trachomatis.

Levofloxacin (Levaquin)

Indicated for pseudomonal infections and those that are due to multidrug-resistant gram-negative organisms.

Trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrim)

Inhibits bacterial synthesis of dihydrofolic acid by competing with para -aminobenzoic acid. This results in the inhibition of bacterial growth.

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