Prostatitis Treatment & Management
- Author: Paul J Turek, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
Treatment of prostatitis should be tailored to symptoms and culture findings and should be supportive. Suprapubic catheterization may be warranted in severe urinary obstruction and should be placed in consultation with a urologist. For further information, the European Association of Urology has treatment guidelines available on chronic pelvic pain and on prostatitis and chronic pelvic pain syndrome.[16, 20]
See the following for more information:
Acute Bacterial Prostatitis
Individuals with acute bacterial prostatitis who appear acutely ill, have evidence of sepsis, or both require hospital admission for parenteral antibiotics and supportive care. Antibiotic therapy should initially include parental bactericidal agents such as broad-spectrum penicillin derivatives, third-generation cephalosporins with or without aminoglycosides, or fluoroquinolones.
Since April 2007, the Centers for Disease Control and Prevention (CDC) has no longer recommended fluoroquinolone antibiotics to treat gonorrhea in the United States.[21, 22] Current CDC treatment guidelines for gonococcal infection recommend single-dose IM ceftriaxone, plus single-dose oral azithromycin or 7 days of oral doxycycline.[22, 7] Co-treatment offers the benefits of hindering the development of antimicrobial resistant gonococci and covering C trachomatis, which often accompanies gonococcal infection.
Patients without a toxic appearance can be treated on an outpatient basis with a 14- to 28-day course of oral antibiotics, usually a fluoroquinolone or trimethoprim-sulfamethoxazole. Urologic follow-up is necessary to ensure eradication and to provide continuity of care to prevent relapse.
Urinary retention may complicate acute infection and warrant hospitalization. Suprapubic catheters are considered safer than urethral catheterization in severe obstruction due to prostatic swelling from bacterial infection and may be placed in consultation with a urologist.
Provide supportive measures such as antipyretics, analgesics, hydration, and stool softeners as needed. Urinary analgesics such as phenazopyridine and flavoxate are also commonly used.
Avoid serial examinations of the prostate to avoid seeding of the blood and bacteremia in acute bacterial prostatitis.
In cases of prostatic abscess, the fluctuant site may be drained under local anesthesia either transrectally or transperineally. When performed transperineally, a pigtail catheter can be inserted as a drain. Cystoscopic, transurethral unroofing of an abscess is also possible with the patient under anesthesia.
Chronic Bacterial Prostatitis and Pelvic Pain
A 4- to 6-week trial of antibiotic therapy is indicated in chronic bacterial prostatitis and chronic pelvic pain syndrome with inflammation, but no consensus exists regarding its use in chronic pelvic pain syndrome without inflammation and asymptomatic prostatitis. Fluoroquinolones provide relief in about 50% of patients, and treatment is more effective if treatment starts earlier in the course of symptoms. The course of antibiotics can be repeated if the first course provides some relief.
Supportive measures such as analgesics (particularly nonsteroidal anti-inflammatory drugs [NSAIDs]), alpha-blocking agents, hydration, stool softeners, and sitz baths are often used. Alpha-blockers reduce bladder outlet obstruction and thus improve voiding dysfunction that may be associated with prostatic swelling that is common with prostatitis.
Some evidence suggests that pelvic floor training/biofeedback can be effective in controlling the symptoms of chronic prostatitis and chronic pelvic pain syndrome.
In cases where infected prostatic calculi serve as a nidus, transurethral resection or total prostatectomy may result in a cure.
If a patient has received no relief from antibiotics, NSAIDs, and alpha blockade, ensure prompt referral to a urologist.
Carefully treat associated septicemia in acutely ill patients. Carefully monitor for bladder outlet obstruction and renal failure. If urination issues do not resolve and incomplete emptying of bladder urine is suspected, refer the patient to a urologist for an evaluation of urination with flow rate and postvoid assessment of residual urine.
Prevention of Prostatitis
Protection against sexually transmitted diseases (STDs) also provides protection against many organisms associated with acute bacterial prostatitis, development of chronic prostatitis, and suspected causes of nonbacterial prostatitis.
Psychological stress has been associated with men who report symptoms of chronic prostatitis.[4, 26] Recognition of underlying psychosomatic disease in chronic cases and appropriate psychiatric referral and treatment lessens the recurrence rate.
After primary management and stabilization of the patient with acute prostatitis, care is appropriately transferred to a urologist.
Aggressive treatment can lessen the chance of developing chronic prostatitis. Chronic bacterial prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis also are probably best treated by or in consultation with a urologist.
Notify the health department if a reportable STD is documented. Consult a psychiatrist if psychosomatic disorder is suspected.
After initial improvement with parental antibiotics, acute bacterial prostatitis may be managed with outpatient care with a 2- to 4-week course of oral antibiotics and urologic follow-up. Management strategies for category II prostatitis, chronic bacterial prostatitis, include intraprostatic antibiotic injection, alpha-blocker therapy, transurethral resection of the prostate (TURP), and long-term antimicrobial suppression.
Additional therapeutic modalities studied for category III prostatitis include anti-inflammatories, phytotherapy, biofeedback, thermal therapy, and pelvic floor exercises.
Prostate-specific antigen (PSA) levels may be elevated with both prostatitis and prostate cancer. However, PSA levels typically fall after resolution of prostatitis but do not fall with prostate cancer. Patients found to have elevated PSA levels should have follow-up by their primary care physicians, urologists, or both.
PSA levels may increase with acute prostatitis; with appropriate antibiotic treatment, levels usually return to normal within 1-3 months. In some studies, a longer course of antibiotics has been shown to result in a decrease in PSA values in patients with category IV prostatitis.
Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999. 282:236-7. [Medline].
Murphy AB, Macejko A, Taylor A, Nadler RB. Chronic prostatitis: management strategies. Drugs. 2009. 69(1):71-84. [Medline].
Habermacher GM, Chason JT, Schaeffer AJ. Prostatitis/chronic pelvic pain syndrome. Annu Rev Med. 2006. 57:195-206. [Medline].
Mastroianni A, Coronado O, Manfredi R, Chiodo F, Scarani P. Acute cytomegalovirus prostatitis in AIDS. Genitourin Med. 1996 Dec. 72(6):447-8. [Medline].
Gebo KA. Prostatic tuberculosis in an HIV infected male. Sex Transm Infect. 2002 Apr. 78(2):147-8. [Medline].
Krieger JN, Dobrindt U, Riley DE, Oswald E. Acute Escherichia coli prostatitis in previously health young men: bacterial virulence factors, antimicrobial resistance, and clinical outcomes. Urology. 2011 Jun. 77(6):1420-5. [Medline].
Brede CM, Shoskes DA. The etiology and management of acute prostatitis. Nat Rev Urol. 2011 Apr. 8(4):207-12. [Medline].
Feneley M, Kirby RS, Parkinson C. Clinico-pathological findings simulating prostatic malignancy following sclerotherapy: a diagnostic pitfall. Br J Urol. 1996 Jan. 77(1):157-8. [Medline].
Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. 1998 Apr. 159(4):1224-8. [Medline].
Nickel JC, Downey J, Hunter D, Clark J. Prevalence of prostatitis-like symptoms in a population based study using the National Institutes of Health chronic prostatitis symptom index. J Urol. 2001 Mar. 165(3):842-5. [Medline].
Schaeffer AJ. Clinical practice. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med. 2006 Oct 19. 355(16):1690-8. [Medline].
Awadh B, Watson K, Abdou NI. Wegener prostatitis presenting with acute urinary retention. J Clin Rheumatol. 2006 Feb. 12(1):50-1. [Medline].
Huong DL, Papo T, Piette JC, Wechsler B, Bletry O, Richard F, et al. Urogenital manifestations of Wegener granulomatosis. Medicine (Baltimore). 1995 May. 74(3):152-61. [Medline].
Middleton G, Karp D, Lee E, Cush J. Wegener's granulomatosis presenting as lower back pain with prostatitis and ureteral obstruction. J Rheumatol. 1994 Mar. 21(3):566-9. [Medline].
Donovan DA, Nicholas PK. Prostatitis: diagnosis and treatment in primary care. Nurse Pract. 1997 Apr. 22(4):144-6, 149-56. [Medline].
[Guideline] Grabe M, Bishop MC, Bjerklund-Johansen TE, et al. Prostatitis and chronic pelvic pain syndrome. Guidelines on the management of urinary and male genital tract infections. Arnhem, The Netherlands: European Association of Urology (EAU). 2008 Mar. 79-88. [Full Text].
Loeb S, Gashti SN, Catalona WJ. Exclusion of inflammation in the differential diagnosis of an elevated prostate-specific antigen (PSA). Urol Oncol. 2009 Jan-Feb. 27(1):64-6. [Medline].
de la Rosette JJ, Giesen RJ, Huynen AL, Aarnink RG, van Iersel MP, Debruyne FM, et al. Automated analysis and interpretation of transrectal ultrasonography images in patients with prostatitis. Eur Urol. 1995. 27(1):47-53. [Medline].
[Guideline] Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, et al. General treatment of chronic pelvic pain. Guidelines on chronic pelvic pain. Arnhem, The Netherlands: European Association of Urology (EAU). 2008 Mar. 84-97. [Full Text].
Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].
Yoon BI, Han DS, Ha US, Lee SJ, Sohn DW, Kim HW. Clinical courses following acute bacterial prostatitis. Prostate Int. 2013. 1(2):89-93. [Medline].
Le BV, Schaeffer AJ. Genitourinary pain syndromes, prostatitis, and lower urinary tract symptoms. Urol Clin North Am. 2009 Nov. 36(4):527-36, vii. [Medline].
Berghuis JP, Heiman JR, Rothman I, Berger RE. Psychological and physical factors involved in chronic idiopathic prostatitis. J Psychosom Res. 1996 Oct. 41(4):313-25. [Medline].
Sindhwani P, Wilson CM. Prostatitis and serum prostate-specific antigen. Curr Urol Rep. 2005 Jul. 6(4):307-12. [Medline].
Mehik A, Hellström P, Sarpola A, Lukkarinen O, Järvelin MR. Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland. BJU Int. 2001 Jul. 88(1):35-8. [Medline].
Wise GJ, Shteynshlyuger A. How to diagnose and treat fungal infections in chronic prostatitis. Curr Urol Rep. 2006. 7(4):320-8. [Medline].
Kim JW, Oh MM, Bae JH, Kang SH, Park HS, Moon du G. Clinical and microbiological characteristics of spontaneous acute prostatitis and transrectal prostate biopsy-related acute prostatitis: Is transrectal prostate biopsy-related acute prostatitis a distinct acute prostatitis category?. J Infect Chemother. 2015 Jun. 21 (6):434-7. [Medline].
Etienne M, Pestel-Caron M, Chapuzet C, Bourgeois I, Chavanet P, Caron F. Should blood cultures be performed for patients with acute prostatitis?. J Clin Microbiol. 2010 May. 48 (5):1935-8. [Medline].
Gill BC, Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis. 2016 Feb. 29 (1):86-91. [Medline].
Breyer BN, Van den Eeden SK, Horberg MA, Eisenberg ML, Deng DY, Smith JF, et al. HIV status is an independent risk factor for reporting lower urinary tract symptoms. J Urol. 2011 May. 185 (5):1710-5. [Medline].