Acute prostatitis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
signs of sepsis
intravenous antibiotic therapy
Patients with acute prostatitis presenting with fever and severe perineal pain require parenteral antibiotics, guided by susceptibilities when available: a broad-spectrum penicillin, a third-generation cephalosporin, or a fluoroquinolone.[12]European Association of Urology. Guidelines on urological infections. 2022 [internet publication]. https://uroweb.org/guidelines/urological-infections [26]Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202001 http://www.ncbi.nlm.nih.gov/pubmed/22031609?tool=bestpractice.com [42]National Institute for Health and Care Excellence. Prostatitis (acute): antimicrobial prescribing. Oct 2018 [internet publication]. https://www.nice.org.uk/guidance/ng110 [Evidence C]f3c7d077-a5e8-404c-b414-68e2fa8b7ccfguidelineCWhich parenteral antimicrobial pharmacological interventions are effective in managing acute prostatitis?[42]National Institute for Health and Care Excellence. Prostatitis (acute): antimicrobial prescribing. Oct 2018 [internet publication]. https://www.nice.org.uk/guidance/ng110 Prostatitis is a complicated urogenital infection and the use of fluoroquinolones is indicated.
Any of these may be combined with an aminoglycoside if the patient is critically ill.[12]European Association of Urology. Guidelines on urological infections. 2022 [internet publication]. https://uroweb.org/guidelines/urological-infections See Sepsis in adults.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system (CNS) effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[44]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 8 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g of tazobactam.
OR
cefotaxime: 1-2 g intravenously every 8-12 hours
OR
ceftazidime: 1-2 g intravenously every 8 hours
OR
ciprofloxacin: 400 mg intravenously every 12 hours
intravenous aminoglycoside
Additional treatment recommended for SOME patients in selected patient group
An aminoglycoside is required if the patient is critically ill.
Dose should be adjusted according to serum aminoglycoside level according to local guidelines.
Primary options
gentamicin: 5 mg/kg intravenously once daily
OR
tobramycin: 1 to 1.7 mg/kg intravenously every 8 hours
OR
amikacin: 15 mg/kg/day intravenously given in divided doses every 8-12 hours, maximum 1500 mg/day
non-steroidal anti-inflammatory drug (NSAID)
Treatment recommended for ALL patients in selected patient group
NSAIDs can be given to relieve pain, reduce inflammation, and alleviate smooth muscle (bladder) spasm.
Primary options
ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day
switch to oral antibiotic therapy
Treatment recommended for ALL patients in selected patient group
As the patient improves, parenteral treatment can be discontinued and replaced with oral treatment. Oral treatment is generally started after intravenous antibiotic treatment is completed (generally after 24 hours of defervescence).
Choice of antibiotic should be guided by sensitivities. Treatment should generally continue for 2 to 4 weeks.[12]European Association of Urology. Guidelines on urological infections. 2022 [internet publication]. https://uroweb.org/guidelines/urological-infections [26]Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202001 http://www.ncbi.nlm.nih.gov/pubmed/22031609?tool=bestpractice.com
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and CNS effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[44]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Primary options
ciprofloxacin: 500 mg orally twice daily
OR
levofloxacin: 500 mg orally once daily
OR
cefalexin: 500 mg orally four times daily
relief of obstruction
Treatment recommended for ALL patients in selected patient group
Patients with difficulty voiding may require catheterisation. Insertion of a suprapubic catheter has been recommended in the past because it was thought that the presence of a catheter in the urethra might obstruct the urethral ducts, increasing the risk of a prostatic abscess. However, most patients require only a brief period of catheterisation, and a urethral catheter is acceptable.
surgical intervention
Additional treatment recommended for SOME patients in selected patient group
Rarely, a prostatic abscess may develop. Such patients require intravenous antibiotic therapy and may require surgical intervention.
Aspiration of pus with culture and sensitivity may aid choice of agent. Aspiration may be achieved through transrectal or perineal aspiration, which may be performed under ultrasound guidance. The antibiotic regimen should be decided in consultation with an infectious disease specialist.
Endoscopic intervention using a Collins knife may be used to 'uncap' the abscess.
In patients with signs of sepsis, transurethral resection of the prostate and cavity drainage may be necessary.
without signs of sepsis
oral antibiotic therapy
Offer an oral antibiotic to patients with less severe acute bacterial prostatitis without signs of sepsis.
The recommended first-line treatment option is a fluoroquinolone (e.g., ciprofloxacin, ofloxacin, levofloxacin).[12]European Association of Urology. Guidelines on urological infections. 2022 [internet publication]. https://uroweb.org/guidelines/urological-infections [26]Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202001 http://www.ncbi.nlm.nih.gov/pubmed/22031609?tool=bestpractice.com [42]National Institute for Health and Care Excellence. Prostatitis (acute): antimicrobial prescribing. Oct 2018 [internet publication]. https://www.nice.org.uk/guidance/ng110 In the UK, the National Institute for Health and Care Excellence recommends ciprofloxacin or ofloxacin as first choice, reserving levofloxacin as second choice given its broader spectrum.[42]National Institute for Health and Care Excellence. Prostatitis (acute): antimicrobial prescribing. Oct 2018 [internet publication]. https://www.nice.org.uk/guidance/ng110 Trimethoprim/sulfamethoxazole (or trimethoprim alone) is a secondary option; however, Escherichia coli - the most common causative pathogen - may be resistant to this drug in some areas.[26]Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202001 http://www.ncbi.nlm.nih.gov/pubmed/22031609?tool=bestpractice.com [27]Coker TJ, Dierfeldt DM. Acute bacterial prostatitis: diagnosis and management. Am Fam Physician. 2016 Jan 15;93(2):114-20. https://www.aafp.org/afp/2016/0115/p114.html http://www.ncbi.nlm.nih.gov/pubmed/26926407?tool=bestpractice.com
Treatment should generally continue for 2 to 4 weeks.[12]European Association of Urology. Guidelines on urological infections. 2022 [internet publication]. https://uroweb.org/guidelines/urological-infections [26]Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202001 http://www.ncbi.nlm.nih.gov/pubmed/22031609?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and CNS effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[44]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Primary options
ciprofloxacin: 500 mg orally twice daily
OR
ofloxacin: 300 mg orally twice daily
OR
levofloxacin: 500 mg orally once daily
Secondary options
trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily
OR
trimethoprim: 200 mg orally twice daily
non-steroidal anti-inflammatory drug (NSAID)
Additional treatment recommended for SOME patients in selected patient group
Non-steroidal anti-inflammatory drugs (NSAIDs) can be given to relieve pain, reduce inflammation, and alleviate smooth muscle (bladder) spasm.
Primary options
ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day
relief of obstruction
Treatment recommended for ALL patients in selected patient group
Patients with difficulty voiding may require catheterisation. Insertion of a suprapubic catheter has in the past been recommended, as it was thought that the presence of a catheter in the urethra might obstruct the urethral ducts, increasing the risk of a prostatic abscess. However, most patients require only a brief period of catheterisation, and a urethral catheter is acceptable.
surgical intervention
Additional treatment recommended for SOME patients in selected patient group
Rarely, a prostatic abscess may develop. Such patients require intravenous antibiotic therapy and may require surgical intervention.
Aspiration of pus with culture and sensitivity may guide choice of agent. Agree the antibiotic regimen in consultation with an infectious disease specialist.
Aspiration may be achieved through transrectal or perineal aspiration, which may be performed under ultrasound guidance.
Endoscopic intervention using a Collins knife may be used to 'uncap' the abscess.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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