Once the diagnosis of prostatitis has been made and patients are classified into an appropriate category, treatment can be initiated. The treatment of category I prostatitis consists of supportive measures that include resuscitation with fluids, antipyretics, and parenteral antibiotics. Catheterization should be reserved for patients in retention, as instrumentation, especially if traumatic, can result in bacteremia. Category II patients should be treated with one six-week course of antibiotics. If that fails, no further antibiotics are to be given. Beyond this, supportive and conservative measures can be instituted in all CP/CPPS patients.
These include diet modification (avoidance of food or drink such as coffee, spicy foods, etc., that exacerbate the pain and voiding symptoms, an exercise program (although patients should be cautioned about high impact exercise or activities that result in perineal pressure such as bicycle riding), the use of perineal support (ring cushion), and local heat therapy (hot water bottle or heating pad applied to perineum). Definitive therapies, including their rationale and evidence for efficacy, are listed below.
Category I and II prostatitis syndromes are accepted to be secondary to a bacterial infection, and the use of antimicrobial agents is therefore justified. However, antibiotics tend to be the most commonly prescribed medications for all categories of prostatitis. In the case of ABP, broad-spectrum parenteral antibiotics followed by a course of oral antibiotics (trimethoprim or a fluoroquinolone) for two to four weeks are usually recommended. This approach is universally successful provided the patient does not have a concurrent anatomic abnormality or a prostatic abscess.14
Trimethoprim-sulfamethoxazole (TMP-SMX) and trimethoprim alone have been a cornerstone of Category II treatment for more than 40 years. Bacterial eradication rates have ranged from 0% to 67%, with most studies reporting a rate between 30% and 50%.15 The best clinical results are generally obtained with a duration of therapy of 90 days. Bacterial eradication and cost effectiveness has been shown to be superior with fluoroquinolones.16 Naber reviewed the use of quinolones for category II patients and identified 11 trials examining norfloxacin, ciprofloxacin, ofloxacin, and lemofloxacin.17 Bacteriologic cure ranged from 57% to 86%. Duration of treatment tends to be shorter (one month) compared with TMP-SMX.
Antimicrobials remain the initial treatment of choice for many physicians even when no bacteria can be cultured. This has been confirmed by many studies examining physicians’ practice patterns.4,7 The speculated mechanisms of action of antibiotics in this clinical setting include treatment of non-cultured organisms, an anti-inflammatory effect, and a placebo effect. Two randomized controlled trials, however, failed to show any efficacy of antibiotics in heavily treated CP/CPPS patients. Nickel et al compared levofloxacin to placebo while Alexander et al compared ciprofloxacin and placebo. Symptom amelioration was found to be similar with the fluoroquinolone or placebo in both studies.18,19