Chronic Bacterial Prostatitis Treatment & Management

The mainstay in the treatment of chronic bacterial prostatitis (CBP) 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.

If the postprostatic massage urine culture results are positive, then successful treatment is likely. However, because of the difficulty in obtaining sufficient material for culture, a trial of antibiotics is worthwhile if clinical evidence strongly suggests chronic prostatitis.

Studies using extensive research methods (eg, RT-PCR assay) show evidence of bacterial infection despite negative findings after urine culture. Negative culture results occur for various reasons, including insufficient sample volume, initiation of antibiotics prior to obtaining an EPS, and the presence of fastidious organisms. In such cases, patients often have symptom improvement after antibiotic treatment.

A query of high-risk behaviors, multiple partners, unprotected anal intercourse, and the possibility of sexually transmitted diseases may help. If doubt remains, conduct a 2-week trial of an appropriate antimicrobial therapy to try to alleviate the symptoms. If the symptoms improve, prescribe a complete course of antibiotics. Because this is a not an acute infection, as in most cases, help to alleviate the symptoms by using symptomatic treatment with analgesics and alpha blockers until confirmatory culture results are available. Sitz baths also may provide symptomatic improvement.

Surgery is usually not indicated for chronic prostatitis. However, in select situations when a patient has recurrent episodes of chronic prostatitis and improves with antibiotics, transurethral resection of the prostate (TURP) or transurethral vaporization of the prostate (TUVP) may remove a nidus of infection. This nidus may be in the form of prostatic stones. These stones are usually visible on transrectal ultrasonograms.

Activity and diet

Activity changes do not have a prominent role in the treatment of CBP, although the authors often advise patients to avoid bicycling or other activities that may put pressure on the perineal region.

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

The choice of antimicrobial is critical because the prostate has an epithelial lining and a pH gradient that inhibits antimicrobials from entering the prostatic acini. Ideal antibiotics have a higher dissociation constant to allow diffusion of their un-ionized components into the prostate. In addition, if the antibiotic is basic, it can readily reach much higher concentrations in prostatic fluid than in the plasma because of the pH gradient.

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.

The best antibiotic choices include TMP-SMZ at 80-400 mg given twice daily and fluoroquinolone antibiotics (eg, ciprofloxacin at 500 mg or ofloxacin at 400 mg) administered twice daily or gatifloxacin/moxifloxacin at 400 mg given daily. TMP-SMZ yields a 33-50% cure rate with a 4- to 6-week course of treatment. Fluoroquinolones yield a similar cure rate with a 4-week course.

TMP-SMZ is significantly less expensive; however, consider a fluoroquinolone (eg, ofloxacin [Floxin]) if the patient is younger than age 35 years and sexually active with multiple partners, because it also has activity against chlamydial and gonorrheal organisms.

High bactericidal activity has been demonstrated against the Enterobacteriaceae group of bacteria and against P aeruginosa using fluoroquinolones. (However, fluoroquinolones are generally ineffective against the streptococci, enterococci, and anaerobes.)

For patients in whom oral antibiotic therapy fails, use other antibiotics to treat chronic bacterial prostatitis (CBP). These may include carbenicillin or doxycycline or injections of gentamicin, either parenterally or directly into the prostate. Carbenicillin may be effective for Enterobacteriaceae or Pseudomonas infections. Large-scale studies are not available. Other penicillin derivatives, while effective against gram-positive organisms, are generally ineffective in treating bacterial prostatitis because of poor prostate penetration.

Patients with persistent infections, especially those who have symptom improvement while on antibiotics but who quickly have a recurrence after finishing a course of antibiotics, may benefit from suppressive therapy with low daily doses of antibiotics. Good choices are tetracycline, nitrofurantoin, nalidixic acid, cephalexin, and trimethoprim. Bacteria in CBP are usually sensitive strains, even after a number of antibiotic treatment regimens have been tried.

In a meta-analysis of randomized, controlled trials of pharmacologic therapy for the treatment of chronic prostatitis and chronic pelvic pain syndrome, Anothaisintawee et al concluded that alpha blockers and antibiotics, as well as combinations of these therapies, appear to achieve the greatest improvement in clinical symptom scores, compared with placebo. Anti-inflammatory therapies had a lesser, but measurable, benefit on selected outcomes; however, the investigators noted that sample sizes in many studies were small and that publication bias might have overestimated the benefits reported.^[14]

Prostatic stones (if present) may be a nidus for recurrent infection, and they are difficult to treat with antibiotic therapy; therefore, surgical therapy in the form of a TURP may be indicated. Preliminary findings, however, suggest that antinanobacterial therapy improves symptoms and decreases or eliminates prostatic calculi in patients with CBP that is recalcitrant to standard therapy. Further investigation is needed.^[15]

The addition of nonsteroidal anti-inflammatory drugs (NSAIDs) and alpha blockers (eg, terazosin at 1-10 mg, doxazosin at 1-8 mg) help with symptom relief. The alpha blockers can help to decrease recurrences by diminishing urinary obstruction due to prostate enlargement or congestion secondary to inflammation.

Saw palmetto, an herbal supplement well known as a treatment for prostatic enlargement, has also been used.^[16] Saw palmetto is hypothesized to act similar to 5-alpha-reductase inhibitors. Finasteride, a 5-alpha-reductase inhibitor, has been shown to be effective in relieving symptoms. Quercetin, a polyphenolic flavonoid with antioxidant properties found in green tea, onions, and oranges, has also has been shown to significantly decrease symptoms.

The role of ejaculation in the treatment of chronic bacterial prostatitis (CBP) is unknown. One theory is that frequent ejaculation may help to clear prostatitic secretions, thereby allowing for quicker resolution. Instruct the patient to ejaculate a minimum of every 3 days, either through intercourse or masturbation, while on antibiotic therapy to help with drainage of the prostatic ducts.

Daily sitz baths and perianal massage may help with the discomfort associated with chronic prostatitis.

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.

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.

Prostatectomy is rarely indicated in the treatment of chronic bacterial prostatitis (CBP). 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 1 series of 10 patients, most with prostatic calculi, has been reported, but all men were considered cured.^[17] 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.^[18] 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.

TURP and TUVP

Surgery is usually not indicated for chronic prostatitis. However, in select situations when a patient has recurrent episodes of chronic prostatitis and improves with antibiotics, TURP or TUVP may remove a nidus of infection. This nidus may be in the form of prostatic stones. These stones are usually visible on transrectal ultrasonograms.

TURP/TUVP is performed in a standard fashion after preoperative antibiotics have been administered. Routine preoperative evaluation should be performed when planning for TURP/TUVP, and routine postoperative care for TURP/TUVP should be administered in these patients.

If the patient is treated long-term with antibiotics, ensure that relocalization studies of the prostate (ie, preprostatic and postprostatic massage urine cultures after treatment) are conducted to conclude that the bacteria are eliminated. If repeat cultures return positive results, prescribe a second course of antibiotics with a drug that has a different mechanism of action.

If repetitive courses fail and the patient has improved symptomatology while on antibiotics, consider long-term, low-dose, suppressive therapy. Examples of suppressive therapy are Bactrim (single strength qhs), trimethoprim (100 mg qhs), ciprofloxacin (250 mg qhs), and ofloxacin (200 mg qhs).

Consultation with a urologist may be appropriate for men with relapsing chronic bacterial prostatitis (CBP) or for situations in which the diagnosis is unclear. A urologist may be able to properly perform the bacterial localization studies necessary to diagnose CBP. 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.