eMedicine Specialties > Emergency Medicine > Infectious Diseases
Prostatitis: Treatment & Medication
Updated: Jul 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
No specific prehospital treatments of prostatitis exist; treatment should be tailored to symptoms and be supportive.
Emergency Department Care
- Individuals with acute bacterial prostatitis who appear acutely ill, have evidence of sepsis, or both require 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.
- Patients without a toxic appearance can be treated as outpatients with a 14- to 28-day course of oral antibiotics. 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 and may be placed in consultation with a urologist.
- Provide supportive measures such as antipyretics, analgesics, hydration, and stool softeners as needed.
- Avoid serial examinations of the prostate to avoid seeding of the blood and subsequent bacteremia in acute bacterial prostatitis.
- Chronic bacterial prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis are probably best treated by or in consultation with a urologist.
- A 4-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.
- Supportive measures such as analgesics (particularly nonsteroidal anti-inflammatory drugs [NSAIDs]), alpha-blocking agents, hydration, stool softeners, and sitz baths are often used.
- Some evidence suggests pelvic floor training/biofeedback can be effective in controlling the symptoms of CP/CPPS.1
- In cases where infected prostatic calculi serve as a nidus, transurethral resection or total prostatectomy may result in a cure.
For further information, the European Association of Urology has treatment guidelines available on chronic pelvic pain and prostatitis.4,5
Consultations
- Consult a urologist.
- Notify the health department, if reportable STD is cultured.
- Consult a psychiatrist, if psychosomatic disorder is suspected.
Medication
The different NIH prostatitic categories are treated with various medical therapies, depending on the underlying pathology.
Antibiotic therapy is essential in the treatment of acute bacterial prostatitis. If the patient is having systemic symptoms, then admission is warranted for intravenous antibiotics, hydration, and analgesia. If the patient has signs of urinary retention or obstruction, then placement of a Foley catheter is indicated.
Therapy for chronic bacterial prostatitis varies in regards to type and duration of antibiotics used as well as adjunctive medications. Treatment typically consists of 4-8 weeks of prostate-penetrating antibiotics, such a fluoroquinolone or trimethoprim-sulfamethoxazole.
Chronic prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis may be treated with alpha-blocking agents or diazepam with sitz baths. Some studies have shown that a longer course of antibiotics has been shown to result in a decrease in PSA values in patients with category IV prostatitis.
Antibiotics
Empiric antibiotics should be tailored toward treating gram-negative pathogens. STDs, where N gonorrhoeae and C trachomatis are the primary suspected pathogens, must also be considered, especially in patients younger than 35 years.
In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report.6 This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information see, the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.
For the treatment of chronic bacterial prostatitis, where Enterobacteriaceae, enterococci, and P aeruginosa are common pathogens, consider trimethoprim/sulfamethoxazole (Bactrim) or fluoroquinolones for 28 days or more as empiric agents.
For nonbacterial prostatitis caused by Chlamydia and Ureaplasma species, which are difficult to culture, an empiric trial of doxycycline or erythromycin should be instituted.
Levofloxacin (Levaquin)
Indicated to treat acute and chronic bacterial prostatitis due to E coli, E faecalis, or S epidermidis. Has good concentration in the prostate. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Agent acts by inhibition of DNA gyrase activity.
Adult
500 mg PO qd for 14-28 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations
Documented hypersensitivity; prolonged QT interval
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Ofloxacin (Floxin)
Quinolone that is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
Adult
400 mg PO once, then 300 mg PO bid for 14-28 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity; prolonged QT interval
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Ciprofloxacin (Cipro, Cipro XR)
Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Adult
500 mg PO bid for 14-28 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ciprofloxacin reduces therapeutic effects of phenytoin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
A white crystalline precipitate located in superficial portion of corneal defect may occur (onset starts in 1-7 d); precipitate is usually cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy
Trimethoprim/sulfamethoxazole DS (Bactrim)
Trimethoprim inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
1 DS tab (160 mg TMP) PO bid for 10-28 d
Pediatric
<2 years: Not recommended
>2 years: 8-10 mg/kg/d trimethoprim divided bid
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, those with chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in patients with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.
Adult
250 mg IM once (in conjunction with doxycycline 100 mg PO for 10 d)
Pediatric
Neonates >7 d: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breastfeeding women
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Used to treat nonbacterial prostatitis caused by Chlamydia species. Chlamydia and Ureaplasma are difficult to culture; therefore, an empiric trial of doxycycline should be instituted.
Adult
100 mg PO bid for 10 d (used in conjunction with ceftriaxone 250 mg IM once)
Pediatric
<8 years: Not recommended
>8 years: 100 mg PO bid for 10 d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Alpha-adrenergic antagonists
These agents are used in the treatment of benign prostatic hypertrophy.
Studies suggest that combining alpha-blockers with antibiotics may reduce the risk of prostatitis recurrence in chronic prostatitis. Alpha-blockers improve bladder outlet obstruction and thus improves voiding dysfunction that may be associated with the pathogenesis of prostatitis.
Alpha-blockers may also have role in chronic pelvic pain syndrome to improve symptoms.
Terazosin (Hytrin)
Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, facilitating urinary flow in presence of prostate inflammation.
Adult
1 mg PO qhs; increase slowly to effect; not to exceed 10 mg/d
Pediatric
Not established
Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment; may cause marked hypotension following first dose and coadministration with beta-blockers
Tamsulosin (Flomax)
An alpha-adrenergic blocker, specifically targeting the A1 receptors. Has the advantage of causing relatively less orthostatic hypotension, and it requires no gradual up-titration from the initial introductory dosage. On the other hand, a higher incidence of ejaculatory dysfunction exists with this medication (8.4-18.1%).
Adult
0.4-0.8 mg PO qd
Pediatric
Not established
Cimetidine may significantly increase plasma concentrations; tamsulosin may increase toxicity of warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for use as antihypertensive drug; may cause orthostasis; avoid situations that may result in injuries if syncope occurs; rule out presence of carcinoma or cancer before initiating treatment
More on Prostatitis |
| Overview: Prostatitis |
| Differential Diagnoses & Workup: Prostatitis |
 Treatment & Medication: Prostatitis |
| Follow-up: Prostatitis |
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Further Reading
Keywords
prostatitis, acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, prostatodynia, prostate gland, bacterial prostatitis, chronic pelvic pain syndrome, CPPS, asymptomatic inflammatory prostatitis, prostatic inflammation
