Prostatitis

Prostatitis is an infection or inflammation of the prostate gland that presents as several syndromes with varying clinical features. The term prostatitis is defined as microscopic inflammation of the tissue of the prostate gland and is a diagnosis that spans a broad range of clinical conditions.

The National Institutes of Health (NIH) has recognized and defined a classification system for prostatitis in 1999.[1] The 4 syndromes of prostatitis are as follows:

• I - Acute bacterial prostatitis ^[2]
• II - Chronic bacterial prostatitis ^[2]
• III - Chronic prostatitis and chronic pelvic pain syndrome (CPPS; further classified as inflammatory or noninflammatory)
• IV - Asymptomatic inflammatory prostatitis

Acute prostatitis and chronic bacterial prostatitis are defined by documented bacterial infections of the prostate and are treated with antibiotic therapy and supportive care (see Treatment).[2]

CPPS is characterized primarily by urological pain complaints in the absence of urinary tract infection and is the most common form of prostatitis, representing 90% of all cases.[2, 3]  This syndrome excludes the presence of active urethritis, urogenital cancer, urinary tract disease, significant urethral stricture, or neurological disease affecting the bladder. It is subdivided into inflammatory and noninflammatory subtypes. Inflammatory CPPS is defined by the presence of white blood cells in the semen, expressed prostatic secretions, or voided bladder urine after prostatic massage, whereas noninflammatory CPPS is defined by the absence of white blood cells. While the etiology of CPPS is poorly understood, it likely is multifactorial and could be influenced by occult infections, autoimmune, psychological, or neuromuscular conditions.[4, 5, 6] This condition can have impacts on sperm quality and fertility.  A meta-analysis conducted by Fu et al demonstrated an association between impaired metrics of sperm quality (concentration, motility, and morphology) and CPPS,[7]  potentially due to the increase in cytokines associated with impaired sperm quality found in analyses of semen from patients with CPPS.[8, 9, 10]

Asymptomatic inflammatory prostatitis is characterized by elevated white blood cells in the ejaculate (leukocytospermia) and elevated prostate-specific antigen (PSA) levels in the absence of associated infection and genitourinary symptoms.[11, 6]  Typically, this condition is diagnosed incidentally during workups for infertility and is associated with benign prostatic hypertrophy.[12]  Though some physicians will treat this condition with antibiotics for potential occult infection there is little evidence to support this practice and due to its lack of clinical symptoms treatment is not required.[6, 13] Additionally, while prostate cancer is also associated with elevated levels of PSA, a study by Stancik et. al demonstrated that the two conditions can be differentiated by the ratio of free-to-total PSA.[14] See the following for more information:

• Acute Bacterial Prostatitis

• Chronic Bacterial Prostatitis

• Chronic Pelvic Pain in Men

• Granulomatous Prostatitis

• Nonbacterial Prostatitis

Patient education

For patient education information, see the Prostate Health Center, as well as Prostate Infections.

In bacterial prostatitis, sexual transmission of bacteria is common, but hematogenous, lymphatic, and contiguous spread of infection from surrounding organs must also be considered.[2]

A history of sexually transmitted diseases is associated with an increased risk for prostatitis symptoms.

Prostatitis is characterized by the presence of acute inflammatory cells in the glandular epithelium and lumens of the prostate, with chronic inflammatory cells in the periglandular tissue (see the image below). However, the presence and quantity of inflammatory cells in urine or prostatic secretions does not correlate with the severity of the clinical symptoms.

Chronic pelvic pain syndrome is diagnosed based on pain in the setting of negative cultures of urine and prostatic secretions. Neuromuscular dysfunction or congenital reflux of urine into the ejaculatory and prostatic ducts may be a precipitating factor.

Viral and granulomatous prostatitis may be associated with HIV infection and is another cause of culture-negative disease. A common viral pathogen of prostatitis in HIV-infected patients is cytomegalovirus (CMV).[15] Mycobacteria, such as Mycobacterium tuberculosis, and fungi, such as Candida albicans, have also been associated with culture-negative disease in this population.[16]

Acute bacterial prostatitis may be caused by ascending infection through the urethra, refluxing urine into prostate ducts, or direct extension or lymphatic spread from the rectum. Approximately 80% of the pathogens are gram-negative organisms (eg, Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species).[2, 17, 18] Mixed bacterial infections are uncommon. Though the majority of cases can be attributed to the aforementioned bacteria, there is one case report of prostatitis secondary to Aeromonas hydrophila and A caviae that the patient acquired while cave diving in Florida.[19]

Consider Neisseria gonorrhoeae and Chlamydia trachomatis infection in any male younger than 35 years presenting with urinary tract symptoms.

Nursing home patients with indwelling urethral catheters may also be at increased risk for acute bacterial prostatitis. Sclerotherapy for rectal prolapse may also increase risk.[20]

Chronic bacterial prostatitis may be due to the following[2] :

• A primary voiding dysfunction problem, either structural or functional

• E coli is responsible for 75-80% of chronic bacterial prostatitis cases. Enterococci and gram-negative aerobes such as Pseudomonas are usually isolated in the remainder of cases.

• C trachomatis,Ureaplasma species, Trichomonas vaginalis

• Uncommon organisms, such as M tuberculosis and Coccidioides, Histoplasma, and Candida species must also be considered. Tuberculous prostatitis may be found in patients with renal tuberculosis

• Human immunodeficiency virus

• Cytomegalovirus

• Inflammatory conditions (eg, sarcoidosis)

The etiology of chronic prostatitis and chronic pelvic pain syndrome is poorly understood but may involve an infectious or inflammatory initiator that results in neurologic injury and pelvic floor dysfunction characterized by increased pelvic tone.[21] The most prevalent site of pain is perineal (63% of patients), followed by testicular, pubic, and penile. Urogenital pain appears to be more bothersome to patients than urinary symptoms. Inflammatory bowel disease is present in 25% of patients with CPPS.[22] About 5-8% of men with this syndrome eventually have a bacterial pathogen isolated from urine or prostatic fluid.

Causes of chronic prostatitis and chronic pelvic pain syndrome may include the following:

• Functional or structural bladder pathology, such as primary vesical neck obstruction, pseudodyssynergia (failure of the external sphincter to relax during voiding), impaired detrusor contractility, or acontractile detrusor muscle
• Ejaculatory duct obstruction
• Increased pelvic side wall tension
• Nonspecific prostatic inflammation

The causes of asymptomatic inflammatory prostatitis are poorly understood.

United States statistics

Prostatitis is one of the most common diseases seen in urology practices in the United States, accounting for nearly 2 million outpatient visits per year.[23, 24, 25] The diagnosis is made in approximately 25% of male patients presenting with genitourinary symptoms. Autopsy studies have revealed a histologic prevalence of prostatitis of 64-86%.

Approximately 8.2% of men have prostatitis at some point in their lives.[21] Among the 4 categories of prostatitis, the most common is chronic prostatitis/chronic pelvic pain syndrome, accounting for 90-95% of prostatitis cases. Acute bacterial prostatitis and chronic bacterial prostatitis each make up another 2-5% of cases. Because asymptomatic inflammatory prostatitis is only identified incidentally, its overall prevalence is difficult to estimate. 

International statistics  

 The prevalence of prostatitis amongst men in North America, Europe, and Asia is estimated to be between 2-10%  [26]

Age-related demographics

In patients younger than 35 years, the most common variant of the syndrome is acute bacterial prostatitis. HIV-related disease is also predominantly seen in younger patients.

Among older patients, nonbacterial prostatitis (National Institutes of Health [NIH] types II and IV) are the most common. Of importance, rare causes of prostatitis should be sought during evaluation. According to case reports of Wegener granulomatosis in the fourth and fifth decades of life, prostatitis can be a presenting feature of Wegener granulomatosis and a clinical manifestation of relapse.[27, 28, 29] Fungal infection with  coccidioidomycosis, blastomycosis, histoplasmosis, cryptococcosis, candidiasis, aspergillus and paracocci-dioidomycosis and mycobacterial infection with M tuberculosis also have been reported.[6]

The prognosis in patients with the first occurrence of acute bacterial prostatitis is good with aggressive antibiotic therapy and good patient compliance. Lack of treatment with antibiotics increases risk for impaired fertility, epididymitis, chronic prostatitis, and prostatic abscess formation. [30]  In patients with chronic prostatitis with acute exacerbations, causative underlying factors may affect overall prognosis.

Prostatitis may lead to urosepsis with significant associated mortality in patients with diabetes mellitus, patients on dialysis for chronic renal failure, patients who are immunocompromised, and postsurgical patients who have had urethral instrumentation.

Chronic prostatitis and asymptomatic inflammatory prostatitis have not been definitively linked to the development of prostate cancer. 

Patients with acute bacterial prostatitis may present with the following[2] :

• Fever

• Chills

• Malaise

• Arthralgias

• Myalgias

• Perineal/prostatic pain

• Dysuria

• Obstructive urinary tract symptoms, including frequency, urgency, dysuria, nocturia, hesitancy, weak stream, and incomplete voiding

• Low back pain

• Low abdominal pain

• Spontaneous urethral discharge

• History of sclerotherapy for rectal prolapse

Patients with chronic bacterial prostatitis typically have no systemic symptoms. Instead, these patients may present with the following[31] :

• Intermittent dysuria

• Intermittent obstructive urinary tract symptoms

• Recurrent urinary tract infections[21]

Patients with chronic prostatitis and chronic pelvic pain syndrome may present with the following[32] :

• Pelvic pain or discomfort, including perineal, suprapubic, coccygeal, rectal, urethral, and testicular/scrotal pain for more than 3 of the previous 6 months without documented urinary tract infections from uropathogens[21]

• Obstructive urinary tract symptoms, including frequency, dysuria, and incomplete voiding

• Ejaculatory pain

• Erectile dysfunction

Asymptomatic inflammatory prostatitis by definition produces no symptoms.

Consider a diagnosis of sexually transmitted prostatitis in sexually active adolescents.

Do not overlook the prostate gland when searching for a source of sepsis in patients with diabetes mellitus, patients on dialysis for chronic renal failure, patients who are immunocompromised, and postsurgical patients who have had urethral instrumentation. In all those settings, prostatitis can lead to urosepsis.

Of importance, the physical examination findings, especially the rectal examination, are not specific for each diagnostic category of prostatitis. However, the examination in patients with acute bacterial prostatitis may reveal the following:

• Tender, nodular, hot, boggy, or normal-feeling gland on digital rectal examination

• Suprapubic abdominal tenderness

• Enlarged tender bladder due to urinary retention

Avoid prostatic massage in patients with acute bacterial prostatitis.

Physical examination in patients with chronic bacterial prostatitis may reveal the following:

• Normal examination findings between acute episodes

• Tender, nodular, or normal gland on digital rectal examination

• Suprapubic tenderness during acute episodes

Physical examination in patients with chronic prostatitis and chronic pelvic pain syndrome may reveal the following:

• Mildly tender or normal prostate on digital rectal examination

• Tight anal sphincter on digital rectal examination

Digital rectal examination in patients with asymptomatic inflammatory prostatitis may reveal a normal prostate.

Potential complications of prostatitis include the following:

• Bladder outlet obstruction/urinary retention

• Abscess - Typically in immunocompromised patients

• Infertility due to scarring of the urethra or ejaculatory ducts

• Recurrent cystitis

• Pyelonephritis

• Renal damage

• Sepsis

Urinalysis and urine culture can confirm the presence of infection and identify pathogens. Fractional urine studies (urethral and bladder urine) and cytology of expressed prostatic secretions can help differentiate prostatitis from urethritis and cystitis. Further studies may be indicated in patients with possible complications (eg, urinary tract obstruction). There is no gold-standard diagnostic test for chronic abacterial prostatitis.[35]

On urinalysis, obtain quantitative values for the white blood count and bacterial count, presence of oval fat bodies, and lipid-laden macrophages. A urine culture can be used to identify the causative organism, if any. Escherichia coli is the pathogen most often identified on positive cultures (see the image below).

Fractional urine examination

The use of fractional urine specimens may be useful in the diagnosis of prostatitis. Although not practical in most emergency departments, this technique is used by urologists if the diagnosis of prostatitis remains unclear.

The initial 10 mL of voided urine represents urine from the urethra and is termed voided urine 1 (V1). Elevated bacterial counts in V1 suggest urethritis. The next 200 mL of voided urine is discarded, and a midstream urine sample (V2) is collected, which represents bladder urine. Bacterial counts elevated in the midstream sample suggest cystitis without prostatitis.

Next, the physician performs a prostatic massage and the expressed prostatic secretions (EPS) are collected from the urethral meatus (see the image below). Finally, the 10 mL of voided urine following prostatic massage (V3) are collected. The bacterial findings of the EPS and V3 samples represent the microbiologic characteristics of the prostate gland.

Chronic bacterial prostatitis can be diagnosed if the culture of the EPS and V3 samples produce the same bacteria as the first-voided specimen and the colony count of the 2 cultures is at least 10 times as great as the first-void specimen.

A complete blood count (CBC) with differential and blood cultures are indicated in cases of acutely toxic patients or suspected sepsis.

Obtain an electrolyte panel, including blood urea nitrogen (BUN) and creatinine values, in patients presenting with urinary retention or obstruction.

Prostate inflammation can lead to elevation of serum prostate-specific antigen (PSA). PSA is used primarily as a cancer screening tool and should not be routinely used for the diagnosis of prostatitis.[36]

Transabdominal ultrasonography or a bladder scan is used to assess for volume of retained urine in cases of prostatitis associated with significant voiding dysfunction.[21]

On transrectal ultrasonography, characteristic features of prostatitis are capsular thickening and prostatic calculi. A hypoechoic halo in the periurethral region, a heterogeneous echo pattern, and enlargement and thickening of the septa of the seminal vesicles may be seen.[37]

Interpretation of transrectal ultrasound is highly subjective and therefore not very reliable for the diagnosis of prostatitis. This study is not routinely indicated in patients with prostatitis, except when prostatic abscess is suspected.

Computed tomography (CT) studies of the pelvis also may be useful in the evaluation of prostatic abscess or suspected neoplasm. Cystoscopy is useful in refractory cases with significant voiding dysfunction symptoms to rule out neoplasm of the bladder or interstitial cystitis. Voiding cystourethrography (VCUG) or retrograde urethrography (RUG) may be appropriate for evaluation of the bladder neck anatomy and penile and anterior urethra in cases of suspected bladder neck dyssynergia or urethral stricture.

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.[34, 38]

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 are acutely ill, have evidence of sepsis, are unable to voluntarily urinate or tolerate oral intake, or have risk factors for antibiotic resistance require hospital admission for parenteral antibiotics and supportive care.[39] Antibiotic therapy initially should include parental bactericidal agents such as fluoroquinolones, aminoglycosides with or without penicillin derivatives, and third-generation cephalosporins.[40]

Since April 2007, the Centers for Disease Control and Prevention (CDC) has no longer recommended fluoroquinolone antibiotics to treat gonorrhea in the United States.[41, 42] Current CDC treatment guidelines for gonococcal infection recommend single-dose IM ceftriaxone, plus single-dose oral azithromycin or 7 days of oral doxycycline.[42, 18] 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 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.[43]

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 also is 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. Recurrences of chronic bacterial prostatitis are common, possibly in part because few antibacterial agents distribute well into the prostatic tissue and achieve sufficient concentrations to eradicate infections. Preferred antimicrobial agents include fluoroquinolones, macrolides, tetracyclines, and trimethoprim.[44] 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.[45] A Cochrane review of 18 studies that compared the various fluoroquinolone antibiotics suggested that there were no differences in clinical efficacy or adverse events among them in treating chronic bacterial prostatitis.[44] Fosfomycin has been used to effectively treat multidrug-resistant gram-negative prostatitis.[46]

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.[47]

Some evidence suggests that pelvic floor training/biofeedback can be effective in controlling the symptoms of chronic prostatitis and chronic pelvic pain syndrome.[21]

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.

Chronic prostatitis/chronic pelvis pain syndrome (NIH Category III prostatitis) appears to be a collection of clinical phenotypes that may manifest as urinary symptoms, pain, sexual symptoms, and/or psychiatric issues. As a result, it largely has been resistant to monotherapy. Recently, a tailored multimodal approach to this condition has been advocated with success. Based on clinical phenotype, patients are placed into the "UPOINT" system, which classifies symptoms into urinary, psychological, organ-specific, infection, neurologic/systemic, and tenderness domains.[48] Based on the patient-specific symptom domains, multimodality therapy that is tailored to each patient is prescribed.

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.[15, 4] Recognition of underlying psychosomatic disease in chronic cases and appropriate psychiatric referral and treatment lessen 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 physician, urologist, or both.

PSA levels may increase with acute prostatitis; with appropriate antibiotic treatment, levels usually return to normal within 1-3 months.[49] 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.

The different prostatitis categories are treated with various medical therapies, depending on the underlying pathology. Penetration of the prostate represents a barrier to adequate antibiosis and is essential for the treatment of bacterial prostatitis.[40]  If the patient is having systemic symptoms, admission is warranted for intravenous antibiotics, hydration, and analgesia. 

While the majority of chronic prostatitis cases can be treated with a 4-week course of fluoroquinolone therapy,[40]  antibiotic regimens can vary with the species of bacteria or local drug resistance, and some patients may require long-term antibiosis.[50]

Chronic prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis also may be treated with alpha-blocking agents or diazepam with sitz baths.

Class Summary

Empiric antibiotics should be tailored toward treating gram-negative pathogens. Sexually transmitted diseases (STDs), where Neisseria gonorrhoeae and Chlamydia trachomatis are the primary suspected pathogens, also should be considered, especially in patients younger than 35 years.

Current Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection recommend single-dose IM ceftriaxone, plus single-dose oral azithromycin or 7 days of oral doxycycline.[42] Cotreatment offers the benefits of hindering the development of antimicrobial resistant gonococci and providing coverage against C trachomatis infection, which often accompanies gonococcal infection. Fluoroquinolone antibiotics no longer are recommended to treat gonorrhea in the United States. Consider pseudomonal coverage with cefepime in the setting of acute bacterial prostatitis with a history of recent instrumentation. 

For the treatment of chronic bacterial prostatitis, where Enterobacteriaceae, enterococci, and Pseudomonas aeruginosa are common pathogens, consider trimethoprim/sulfamethoxazole (Bactrim), cefepime, or fluoroquinolones for 28 days or more as empiric agents.

For nonbacterial prostatitis caused by Chlamydia and Ureaplasma species, which are difficult to culture, an empiric trial of doxycycline or erythromycin should be instituted.

Levofloxacin (Levaquin)

This fluoroquinolone is indicated to treat acute and chronic bacterial prostatitis due to Escherichia coli, E faecalis, or Staphylococcus epidermidis. It has good concentration in the prostate. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. It provides good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Levofloxacin acts by inhibition of DNA gyrase activity.

Ofloxacin

Ofloxacin is a fluoroquinolone that is a pyridine carboxylic acid derivative with a broad-spectrum bactericidal effect.

Ciprofloxacin (Cipro, Cipro XR, Proquin XR)

This agent is a fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Ciprofloxacin has no activity against anaerobes. Continue treatment for at least 2 days (7-14 d typical) after signs and symptoms have disappeared.

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra DS)

Trimethoprim inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except P aeruginosa.

Ceftriaxone (Rocephin)

A third-generation cephalosporin with broad-spectrum, gram-negative activity, ceftriaxone has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Its bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins.

This agent exerts its antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.

Ceftriaxone is highly stable in the presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of the dose is excreted unchanged in urine, and the remainder is secreted in bile and ultimately in feces as microbiologically inactive compounds. Ceftriaxone reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations of less than 25 mcg/mL to 85% bound at 300 mcg/mL.

Doxycycline (Adoxa, Monodox, Doryx, Vibramycin)

Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Doxycycline is used to treat nonbacterial prostatitis caused by Chlamydia species. Chlamydia and Ureaplasma are difficult to culture; therefore, an empiric trial of doxycycline should be instituted.

Class Summary

These agents are used in the treatment of benign prostatic hypertrophy. Studies suggest that combining alpha-blockers with antibiotics may reduce the risk for prostatitis recurrence in chronic prostatitis. Alpha-blockers reduce bladder outlet obstruction and thus improve voiding dysfunction that may be associated with prostatic swelling with prostatitis. Alpha-blockers also may have a role to improve symptoms in chronic pelvic pain syndrome.

Terazosin

Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, terazosin facilitates urinary flow in the presence of prostate inflammation.

Tamsulosin (Flomax)

An alpha-adrenergic blocker, specifically targeting the A1 receptors, tamsulosin has the advantage of causing relatively less orthostatic hypotension, and it requires no gradual up-titration from the initial introductory dosage. On the other hand, a higher incidence of ejaculatory dysfunction exists with this medication (8.4-18.1%).