Acute Bacterial Prostatitis Treatment & Management

Updated: Jul 20, 2022
  • Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS  more...
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Approach Considerations

The intense inflammation in acute bacterial prostatitis (ABP) makes the prostate gland highly responsive to antibiotics, which otherwise penetrate poorly into the prostate. Consequently, outpatient therapy with oral antibiotics and supportive measures will suffice for most patients. [19] Antipyretics, analgesics, stool softeners, bed rest, and increased fluid intake provide supportive therapy. Hospitalization is required for patients in whom acute urinary retention develops and in those who require intravenous antimicrobial therapy.

A Foley catheter can be inserted gently for drainage if severe obstruction is suspected. A punch suprapubic tube can be used if a catheter cannot be passed easily or is not tolerated by the patient. The catheter can be removed 24-36 hours later.

Alpha-blocker therapy should also be considered for acute bacterial prostatitis. Because the bladder neck and prostate are rich in alpha-receptors, alpha blockade may improve outflow obstruction and diminish intraprostatic urinary reflux. Terazosin, 5 mg/d orally for 4-52 weeks, is the usual first choice. [20] Tamsulosin (Flomax), alfuzosin (Uroxatral), and doxazosin (Cardura) are acceptable alternative agents.

Medical management is often unsuccessful in cases of prostatic abscess. In such situations, transrectal or perineal aspiration or, less preferably, transurethral resection of the prostate and drainage of the cavity are possible surgical approaches.


Antibiotic Therapy

The choice of antibiotic for treatment of acute bacterial prostatitis (ABP) is based on the results of the initial culture and sensitivity. However, initial therapy should be directed at gram-negative enteric bacteria. Useful agents include fluoroquinolones, trimethoprim-sulfamethoxazole, and ampicillin with gentamicin. In sexually active men under 35 years of age and men over 35 years of age who practice high-risk sex, regimens covering Neisseria gonorrhoeae and Chlamydia trachomatis are recommended. [19, 21]

If the initial clinical response to therapy is satisfactory and the pathogen is susceptible to the chosen antibiotic, treatment is continued orally (PO) for 30 days to prevent sequelae such as chronic bacterial prostatitis and prostatic abscess formation.

The rapid rise in drug resistance, especially to fluoroquinolones, must be considered. Of particular concern, especially in patients undergoing transrectal ultrasound (TRUS)–guided prostate biopsy, are Gram-negative uropathogens such as extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae. [22] Local resistance patterns and sensitivities should help guide initial treatment. [12]

In a study of 3000 men who received a prophylactic fluroquinolone-based regimen for 7 days to minimize the risk of iatrogenic acute prostatitis after undergoing TRUS-guided biopsy, fewer than 1% (n=20) developed acute bacterial prostatitis within a week of the procedure. In all 20 cases the only bacteria isolated was Escherichia coli.

Testing revealed resistance to the following antibiotics: fluroquinolone and amoxicillin (95%), amoxicillin-clavulanate and trimethoprim/sulfamethoxazole (70%), third-generation cephalosporin (25%) and amikacin (5%). No resistance to imipenem was reported. The investigators concluded that fluroquinolone-based prophylaxis remains effective in minimizing the risk of acute prostatitis secondary to prostate biopsy. [23]

A review of acute prostatitis after TRUS-guided biopsy in Korean patients found that ESBL-producing E coli had been detected continuously since 2008; those E coli were susceptible to imipenem, amikacin, and cefoxitin but resistant to fluoroquinolones. These authors concluded that fluoroquinolones are not an effective antimicrobial of choice for the treatment of acute prostatitis after TRUS-guided biopsy. [24]

An increase in infection rates after transrectal prostate biopsy due to fluoroquinolone-resistant bacteria in feces has been reported. Targeted prophylaxis after rectal flora swabbing has been shown to be efficacious compared with empirical antibiotic prophylaxis. Use of a perineal prostate biopsy has only limited data support and further study is needed. [25]

Some resistant strains may require prolonged intravenous (IV) therapy. For IV therapy, use trimethoprim/sulfamethoxazole, 8-10 mg/kg/d (based on the trimethoprim component) in 2-4 doses two to four times daily until the culture and sensitivity results are known. An alternative regimen is gentamicin, 3-5 mg/kg/d IV in three divided doses, plus ampicillin 2 g in four divided doses. In addition, two approved β-lactam/β-lactamase inhibitor combinations, ceftolozane/tazobactam and ceftazidime/avibactam, have promising activity against multidrug-resistant Gram-negative organisms. [26]

For prostatitis from ESBL-producing multidrug-resistant E coli, off-label treatment with oral fosfomycin has proved effective. The usual regimen is 3 g/24 hr for 1 week followed by 3 g/48 hr, for a total treatment duration of 6-12 weeks. [27, 28]

After the patient is afebrile for 24 hours, an appropriate oral agent can be substituted for an additional 30 days. For oral therapy, use double-strength trimethoprim/sulfamethoxazole twice daily for 30 days. Alternatives for oral therapy include the following:

  • Levofloxacin 500-750 mg daily
  • Ciprofloxacin, 500 mg twice daily
  • Norfloxacin, 400 mg twice daily
  • Ofloxacin, 400 mg twice daily
  • Enoxacin, 400 mg twice daily

If an abscess is diagnosed, anaerobic antimicrobial therapy should be added to the treatment regimen. Clindamycin 600-900 mg IV or 150-450 mg orally every 8 hours is a good choice. Medical management is often unsuccessful, however, in which case surgical drainage is required. Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially if symptoms do not improve after 1 week of medical therapy.


Surgical Intervention

A potential indication for surgery is a prostatic abscess, which is an uncommon but well-described complication of acute bacterial prostatitis. Medical management of prostatic abscess is often unsuccessful. Thus, surgical drainage via either transrectal or perineal aspiration, transurethral resection, or transrectal ultrasound–guided placement of a transrectal drainage tube may be considered. [2]

Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially in patients whose symptoms have not improved after 1 week of medical therapy. Transurethral resection of the prostate (TURP) and drainage of the cavity is another approach, but is less desirable because of the potential hematogenous spread of bacteria.

However, TURP may be an effective treatment for recurrent acute bacterial prostatitis. In a retrospective analysis, Decaestecker and Oosterlinck reported that 12 of 21 patients who underwent TURP for treatment of refractory recurrent acute bacterial prostatitis were symptom free during a median followup of 44 months. No incontinence or bladder neck contracture were reported. [29]

Prostatic abscesses should be allowed to drain, or some type of drainage should be performed if the abscess is larger than 1 cm. [30, 31] Monitor the abscess closely if a spontaneous rupture occurs into the urethra. Recurrent abscesses are rare.

Because of the potential for systemic infection and bacteremia, urethral instrumentation should be avoided in patients with acute bacterial prostatitis, especially if the patient is clinically unstable or is already showing signs of sepsis, although placement of a small drainage catheter is safe in experienced hands. Pretreatment with appropriate antibiotics is mandatory.

Transurethral or perineal surgical approaches in the treatment of a prostatic abscess should be undertaken with caution and are currently not advised unless other drainage techniques have failed. Perineal incision can cause impotence due to nerve injury, and transurethral resection can facilitate hematogenous spread of bacteria, leading to sepsis. [32]

In patients with sepsis, transurethral resection may be lifesaving and should be considered if their condition is not responding to conservative therapy.

In patients with acute urinary retention, insertion of a Foley catheter may be attempted first, as tolerated by the patient; however, this may cause extreme discomfort. In some cases, the transurethral catheter may obstruct drainage of an acutely inflamed prostate and cause bacteremia or prostatic abscess. If the catheter cannot be passed easily, a suprapubic punch cystostomy is indicated.



Prevention of Prostate Biopsy Infection

A number of strategies have been used to prevent acute bacterial prostatitis following post-transrectal prostate biopsy. These include antibiotic prophylaxis and rectal preparation with an enema, povidone-iodine, or chlorhexidine. [33, 34, 35]

Guidelines from major urology and infectious disease societies currently lack agreement regarding antibiotic prophylaxis for prostate biopsy, mainly due to differences in drug resistance and availability of medication. [33] A meta-analysis of different antibiotic regimens recommended a minimum of a full 1-day administration of fluoroquinolones for antibiotic prophylaxis. Targeted therapy was advised in cases of fluoroquinolone resistance. Fosfomycin was the best alternative in countries where fluoroquinolones are unavailable. [34]

A meta-analysis of nonantibiotic prevention found that a transperineal biopsy approach significantly reduced infectious complications compared with a transrectal approach (relative risk 0.55, 95% CI 0.33-0.92, P=0.02).  If a transrectal approach was used, preparation with povidone-iodine reduced both infections and hospitalizations following biopsy. [35]


Future and Controversies

Despite the fact that prostatitis syndromes are common urologic disease processes, little is known about prostatitis and the factors associated with the condition. Several important questions need to be answered, including the following:

  • Is prostatitis associated with prostate cancer?
  • What are the natural history and the epidemiology of prostatitis?
  • What is the best way to elucidate the exact etiology, diagnosis, and management of prostatitis?

Prostatitis, BPH, and prostate cancer

The first question is important, considering efforts in recent years to find the most accurate and most expedient method of diagnosing and treating prostate cancer. Prostatitis is more common in younger men, whereas benign prostatic hyperplasia (BPH) and prostate cancer are more common in men older than 50 years. An important research question is whether prostatitis in younger men leads to BPH or prostate cancer later in life, because approximately 5% of acute bacterial prostatitis cases lead to chronic prostatitis.

Although one study reported that nearly 50% of prostate specimens resected for prostate cancer showed evidence of prostatitis, no causal association has been demonstrated. [36] A meta-analysis found statistically significant evidence of an association between prostatitis and prostate cancer, but most of the studies included did not provide separate classification of acute and chronic prostatitis. [37]

Public health burden

The exact public health burden of prostatitis should also be addressed. Most urologists agree about the ever-growing need for both community-based cross-sectional and longitudinal epidemiologic prostatitis studies. Active research and a more aggressive effort are needed to generate hypotheses regarding the etiology of prostatitis.

Elucidating risk factors

Formulating risk factors associated with prostatitis is important. For example, the incidence of prostatitis in men with a history of a prostatic biopsy requires investigation. With increased screening for prostate cancer, more men are undergoing biopsy based on elevated serum prostate-specific antigen (PSA) levels. These biopsies may trigger an inflammatory response in the prostate, leading to prostatitis, or, alternatively, a biopsy may introduce organisms into the prostate gland.

The above examples outline potential research directions in the field of prostatitis. Results of these and other studies could promote an increased awareness of prostatitis and increase the knowledge about the disease. This research should improve diagnosis and treatment, promote an appropriate allocation of resources to the management of the disease, and reduce the incidence and public health burden of prostatitis.