Prostatitis Empiric Therapy

Empiric therapeutic regimens for prostatitis are outlined below, including those for acute prostatitis and chronic prostatitis.

Outpatient therapy for acute prostatitis

At risk for sexually transmitted diseases  ^{[1, 2, 3, 4]} :

• Ceftriaxone 500 mg IM single dose or
• Cefixime 400 mg PO single dose, then  doxycycline 100mg BID for 10 days

No risk for sexually transmitted diseases:

• Ciprofloxacin 500 mg PO BID for 10-14 days  or
• Levofloxacin 500-750 mg PO daily for 10-14 days  or
• Trimethoprim/sulfamethoxazole (TMP/SMX) 160/800mg PO BID for 10-14 days

Treatment can be extended for an additional 2 weeks if the patient remains symptomatic. Antibiotics can be adjusted based on culture results prior to extending treatment. ^[5]

Inpatient therapy for acute prostatitis: acutely ill and/or suspected sepsis

If the patient appears toxic (presents with systemic illness, fever, urinary incontinence, does not tolerate oral intake, or is at risk for antibiotic resistance), broad-spectrum antibiotics and hospitalization must be considered. After initial improvement with parenteral antibiotics, acute bacterial prostatitis may be managed with outpatient care to complete a 2-4 week course of oral antibiotics with urologic follow-up. Therapy can be tailored based on previous cultures. Transrectal imaging (ultrasonography, non-contrast CT/ MRI) should be conducted to rule out abscess. Urine culture should be repeated 1 week post completion of antibiotic regimen.

Non-toxic and no antibiotic resistance risk factors:

• Ciprofloxacin 400 mg IV q12h  or
• Levofloxacin 50-750 mg IV q24h ^[6]   or
• Ceftriaxone 1-2 g IV q24h and  l evofloxacin 500-750 mg IV q24h  or
• Piperacillin/tazobactam 3.375 g IV q6h

Toxic/unstable and no antibiotic resistance risk factors  ^{[1, 2, 7, 8, 9, 10, 11]} :

• Piperacillin/tazobactam 3.375 mg IV q6h and   gentamicin 7 mg/kg IV q24h  or
• Piperacillin/tazobactam 3.375 mg IV q6h and   amikacin 15 mg/kg IV q24h  or
• Cefotaxime 2 g IV q4h and   gentamicin 7 mg/kg IV q24h  or
• Ceftazidime 2 g IV q8h and   gentamicin 7 mg/kg IV q24h  or
• Ciprofloxacin 400 mg IV q12h and   gentamicin 7 mg/kg IV q24h  or
• Ertapenem 1 g IV q24h  or
• Imipenem/cilastatin 500 mg IV q6h  or
• Meropenem 500 mg IV q8h

Severely toxic and risk for antibiotic resistance:

Transrectal manipulation ^{[6, 12]} :

• Piperacillin/tazobactam 3.375 mg IV q6h and   gentamicin 7 mg/kg IV q24h  or
• Piperacillin/tazobactam 3.375 mg IV q6h and   amikacin 15 mg/kg IV q24h

Transurethral manipulation ^{[13, 14]} :

• Piperacillin/tazobactam 3.375 mg IV q6h with or without   gentamicin 7 mg/kg IV q24h  or   ceftazidime 2 g IV q8h with or without   gentamicin 7 mg/kg IV q24h  or
• Cefepime 2 g IV q12h with or without   gentamicin 7 mg/kg IV q24h

Fluoroquinolone resistance ^{[15, 16]} :

• Piperacillin/tazobactam 3.375 mg IV q6h with or without   gentamicin 7 mg/kg IV q24h  or
• Ceftazidime 2 g IV q8h with or without   gentamicin 7 mg/kg IV q24h  or
• Cefepime 2 g IV q12h with or without   gentamicin 7 mg/kg IV q24h

Chronic bacterial prostatitis (CBP)

Considerations for chronic bacterial prostatitis (CBP) include the following:

• 75% of patients will show resolution with antibiotic therapy (ex, fosfomycin or a zithromycin) for 4-12 weeks or may need long-term low dose of antibiotics for pain management, up to 6 months ^{[17, 18, 19]}
• Alpha-antagonists may be administered for long-term management to maintain adequate urinary flow, (ex,  silodosin )
• 5-alpha reductase (ex,  finasteride,  dutasteride) may be used to maintain urinary flow ^[20]
• Non-steroidal anti-inflammatory drugs and muscle relaxants may reduce chronic inflammation and reduce CBP-associated pain (ex, ibuprofen, aspirin, naproxen sodium, cyclobenzaprine, clonazepam)
• Glycosaminoglycans such as  chondroitin sulfate and neuromodulators such as  amitriptyline,  nortriptyline and  pregabalin may be used as supplemental agents
• Prostatic massage may be performed to express fluids from prostatic ducts to alleviate pressure from inflammatory fluids
• Physiotherapy, specifically, pelvic floor exercises can help reduce pelvic tension (ex, myofascial release, Kegel exercises, paradoxical relaxation)
• Warm sitz baths, heating pads, donut-shaped cushions and acupuncture may help alleviate pelvic pressure and pain
• Prostatic or ureteral surgery may be required for refractory disease
• Diet and exercise may play a role in CBP management, higher water intake may be recommended