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Prostatitis Treatment & Management

  • Author: Paul J Turek, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Feb 11, 2016
 

Approach Considerations

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:

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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.[23]

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.

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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.[24]

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.[25]

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.

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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.

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Consultations

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.

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Long-Term Monitoring

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.[27] 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.

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Contributor Information and Disclosures
Author

Paul J Turek, MD Director, The Turek Clinic; Former Professor- in-Residence, Academy of Medical Educators Endowed Chair, Department of Urology, Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine

Paul J Turek, MD is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Western Section of the American Urological Association, American Association of Clinical Urologists, Society for the Study of Male Reproduction, Society for Male Reproduction and Urology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cellarity Biotechnologies, Inc; MandalMed, Inc; Healthloop,Inc: FertiltityPlanit.com; Doximity.com; Essential Beginnings Inc<br/>Received ownership interest from BioQuiddity, Inc for board membership; Received ownership interest from HealthLoop.com for board membership; Received intellectual property rights from MandalMed, Inc for management position; Received ownership interest from FertilityPlanit.com for board membership; Received ownership interest from Episona, inc for board membership.

Coauthor(s)

Tarlan Hedayati, MD Assistant Professor of Emergency Medicine, Rush Medical College, John H Stroger Hospital of Cook County

Tarlan Hedayati, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Christine R Stehman, MD Clinical Assistant Professor of Emergency Medicine, Indiana University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.
A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.
Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.
 
 
 
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