Prostatitis Treatment & Management

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.^{[14, 18]}

See the following for more information:

• Acute Bacterial Prostatitis
• Chronic Bacterial Prostatitis
• Chronic Pelvic Pain in Men
• Granulomatous Prostatitis
• Nonbacterial 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.^{[19, 20]} Current CDC treatment guidelines for gonococcal infection recommend single-dose IM ceftriaxone, plus single-dose oral azithromycin or 7 days of oral doxycycline.^[20] 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.

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.^[21]

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.^[22]

Some evidence suggests that pelvic floor training/biofeedback can be effective in controlling the symptoms of chronic prostatitis and chronic pelvic pain syndrome.^[2]

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.

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, 23]} 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.^[24] 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.