Prostatitis Empiric Therapy

Updated: Jul 14, 2023
  • Author: Akansha Tiwari, MD, MSc; Chief Editor: Thomas E Herchline, MD  more...
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Empiric Therapy Regimens

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] :

No risk for sexually transmitted diseases:

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:

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

Severely toxic and risk for antibiotic resistance:

Transrectal manipulation [6, 12] :

Transurethral manipulation [13, 14] :

Fluoroquinolone resistance [15, 16] :

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,  finasteridedutasteride) 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  amitriptylinenortriptyline 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