Approach

Antibiotics are the mainstay of treatment for acute prostatitis, with the most common choice being a fluoroquinolone.[7][12][41][42]​ ​The choice of antibiotics and duration of treatment are influenced by: the severity of the patient's symptoms; the risk of developing complications or having treatment failure; previous urine culture and susceptibility results; previous antibiotic use, which may have led to resistant bacteria; local resistance patterns and specific host factors (such as allergies).[12][42]​[43]​​ Initial empiric therapy should be tailored once urine culture results are available based on the causative organism identified and susceptibility, using a narrow spectrum wherever possible.[12][42]

General approach

Treat patients with acute prostatitis presenting with symptoms and signs of sepsis with parenteral antibiotics, guided by susceptibilities when available: a broad-spectrum penicillin, a third-generation cephalosporin, or a fluoroquinolone.[12][26][42][Evidence C]​ Any of these may be combined with an aminoglycoside if the patient is critically ill. As the patient improves, discontinue parenteral treatment and replace with an oral antibiotic. Treatment should continue for a total of 2 to 4 weeks.[12][26][42]​ See  Sepsis in adults.

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.[12][26][42][Evidence C]

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][27][42]​ Treatment should generally continue for 2 to 4 weeks.[12][26]

Acute bacterial prostatitis is a complicated urogenital infection and, as such, treatment with fluoroquinolones is indicated.

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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[44]

  • 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 information source for more information on suitability, contraindications, and precautions.

With urinary obstruction

Consider catheterization in patients with difficulty voiding; approximately 10% of men with acute bacterial prostatitis experience urinary retention.[12] 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 catheterization, and a urethral catheter is acceptable.

In patients with chronic prostatitis, the use of a concomitant alpha-blocker is known to help with symptoms of prostatitis.[45] Urodynamic studies in patients with prostatitis have shown increased urethral closing pressure.[46] The use of an alpha-blocker is still debated for the treatment of acute prostatitis with obstructive symptoms; however, longer periods of treatment have shown greater benefit in alpha-blocker naive patients.[41]

With pelvic and perineal pain

Give nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain, reduce inflammation, and alleviate smooth muscle (bladder) spasm.

With prostatic abscess

Rarely, a prostatic abscess may develop. Treat with intravenous antibiotic therapy; surgical intervention may also be required. Aspiration of pus with culture and sensitivity may guide choice of agent. Aspiration may be achieved through transrectal or perineal aspiration, which may be performed under ultrasound guidance. Agree the antibiotic regimen in consultation with an infectious disease specialist.

Endoscopic intervention using a Collins knife may be used to “uncap” the abscess. Transurethral resection of the prostate and cavity drainage may be necessary in patients with signs of sepsis.[37]

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