eMedicine World Medical Library

Chronic Bacterial Prostatitis

Last Updated: July 8, 2004
Synonyms and related keywords: chronic prostatitis, CBP, urinary tract infection, UTI, prostatitis symptom complex, nonbacterial prostatitis, non-bacterial prostatitis, urethral stricture, acute prostatitis, prostatic stones, prostate cancer, urinary stricture disease, bladder neck obstruction

  AUTHOR INFORMATION  

Author: Sunil K Ahuja, MD, Chief of Minimally Invasive Urology, Director of Clinical Clerkship Training, Department of Surgery, Division of Urology, Madigan Army Medical Center

Sunil K Ahuja, MD, is a member of the following medical societies: American Urological Association

Editor(s): Jong M Choe, MD, FACS, Director of Continence and Urodynamic Center, Assistant Professor, Department of Surgery; Division of Urology, University of Cincinnati; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Allen Frank Morey, MD, Chief, Urology Service, Brooke Army Medical Center; Clinical Assistant Professor, Department of Surgery, Uniformed Services University of the Health Sciences; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director, Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
  INTRODUCTION  

Background: The symptoms of chronic bacterial prostatitis (CBP) are caused by bacteria. The nonbacterial form of chronic prostatitis is covered in Nonbacterial Prostatitis. CBP is a recurrent urinary tract infection due to the same organism, which persists in the prostatic fluid, and has an associated symptom complex.

The prostatitis symptom complex is very common. Approximately half of all men develop symptoms consistent with prostatitis at some time in their lives. This accounts for approximately 25% of the men evaluated for a urologic problem, which is approximately 8% of urology visits.

Although the prostatitis symptom complex is not always caused by a bacterial infection, traditional teaching states that bacteria are the cause and require an antibiotic for treatment. This may explain why 50% of the patients with symptoms consistent with CBP are treated with antibiotics; yet, only 5-10% of the men actually have a true bacteriologic condition that improves with treatment.

A confounding factor is that fastidious organisms (eg, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis) can cause prostatitis but do not grow in standard culture conditions; therefore, the condition may be interpreted as nonbacterial prostatitis. Continuing research, using sophisticated research methods, further elucidates that bacterial infection is the cause for more cases of prostatitis. Results from recent studies show that bacterial ribosomal ribonucleic acid (rRNA), by a reverse transcriptase–polymerase chain reaction (RT-PCR), assists in predicting a successful response to antibiotic treatment in patients with chronic prostatitis.

Pathophysiology: The prostate, because of its anatomic configuration, is the reservoir for the recurrent infections.

The normal prostate weighs approximately 18 g and measures 3 cm by 4 cm by 2 cm in length, width, and depth, respectively. It is located in the pelvis, underneath the symphysis pubis at the base of the bladder and on top of the rectum. The prostate is divided into 3 distinct zones, termed the central, transitional, and peripheral zones. These 3 zones fuse into a single glandular structure that completely surrounds the urethra. It is enclosed by a capsule composed of collagen, elastin, and smooth muscle.

The prostate is 70% glandular and 30% fibromuscular stroma. The glandular elements of the prostate are relatively simple tubuloalveolar glands and are lined with simple cuboidal or columnar epithelium. There are approximately 20 of these glands, and they branch out into the fibromuscular stroma. The prostate is innervated by sympathetic nerves from T-10 to L-1.

The peripheral zone of the prostate is composed of a system of ducts with a poor drainage system, which prevents the dependent drainage of secretions. As the prostate enlarges as individuals become older and as patients develop obstructive symptoms, the urine refluxes into the prostatic ducts.

Urine reflux also may occur in urethral stricture disease. Refluxing urine, even when sterile, may cause chemical irritation and initiate tubule fibrosis and prostatic stone formation, which then lead to intraductal obstruction and stagnation of intraductal secretions. If trapped in these ducts, the infected material can serve as a nidus for relapsing infections, causing the symptoms of prostatitis. Infection of the prostate occurs via ascending urethral infection or reflux of infected urine into the prostatic ducts.

Infection often persists because antibiotics do not penetrate the prostate easily and no active transport mechanism exists whereby antibiotics can enter the prostatic ducts. Therefore, antibiotics depend on passive diffusion to enter the epithelial-lined prostatic glandular acini. The epithelial cells do not allow the free passage of antibiotics unless they meet certain criteria, ie, un-ionized, lipid-soluble, and not firmly protein-bound.

Another inhibiting factor is that prostatic fluid is acidic (pH of 6.4) compared to plasma (pH of 7.4), thus creating a pH gradient further inhibiting diffusion of acidic antibiotics into the prostatic fluid. Basic antibiotics are able to dissociate and concentrate in the prostatic fluid because of ion trapping within the prostatic fluid due to the pH gradient. Therefore, the best antibiotics for use in prostatitis have high dissociation constants (ie, measure of acid strength), are basic instead of acidic, and are not tightly protein-bound. This combination can allow up to a 6-fold higher concentration of antibiotic in the prostatic fluid compared to plasma.

Natural host defenses that prevent prostatitis are the flushing of the prostatic urethra by emptying the bladder, ejaculation, and the presence of a zinc-rich antibacterial polypeptide that has antibacterial effects against gram-positive and gram-negative bacteria. The prostate has the highest level of zinc concentration of any organ. Healthy men have very high zinc levels, whereas men with CBP have low prostatic zinc levels and normal serum zinc levels. Interestingly, oral zinc supplementation does not increase the prostatic zinc levels in men with CBP.

Spermine and spermidine also are natural host defenses in prostatic fluid. These impart the characteristic odor on ejaculate, and their antibacterial activity is directed mainly at gram-positive bacteria.

Frequency:

  • In the US: At some point in their lives, 35-55% of men have prostatitis symptoms. This accounts for approximately 25% of the men evaluated for a urologic problem, which is approximately 8% of all urology visits.

Mortality/Morbidity:

  • Prostatitis impairs the patient's quality of life to the same degree as coronary artery disease or Crohn disease.
  • Recent studies show that prostatitis has the same effect on a patient's mental health as does diabetes mellitus and congestive heart failure.

Age:

  • Symptoms of prostatitis are very common in men aged 36-50 years.
  • Prostatitis is the most common urologic problem in men younger than 50 years and the third most common in older men.
  • Recent studies using the US National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) found that the prevalence of prostatitis symptoms was 10% in a population of men aged 20-74 years. See Image 1 for the NIH-CPSI or the NIH-CPSI can be downloaded from www.prostatitis.org/index.html.
  CLINICAL  

History: Patients often present with myriad subjective complaints. Only a few of these complaints offer diagnostic clues for CBP because often the complaints are not of an unusual nature and are not specific for CBP. If culture results are positive, an expressed prostatic secretion (EPS) that contains bacteria or more than 10 WBCs per high-power field (WBCs/hpf) confirms diagnosis.

  • Genitourinary pain occurs in the perineal area, penile tip, testicles, rectum, lower abdomen, and back.
  • Patients also can have irritative or obstructive urologic symptoms such as frequency, urgency, dysuria, decreased force of the urinary stream, nocturia, and postvoid dribbling.
  • Other symptoms include a clear-to-milky urethral discharge, ejaculatory pain, hematospermia, and sexual dysfunction.

Physical: Physical examination findings often are nonspecific.

  • The classic presentation of a symptomatic patient is one with an enlarged, soft, or, boggy gland that is moderately-to-severely tender upon palpation.
  • Occasionally, an examiner may be able palpate prostatic stones. Because stones may be a nidus for recurrent infections, they may offer a significant clue to the cause of the recurrences.

Causes: Causative organisms include following:

  • Escherichia coli
  • Klebsiella pneumoniae
  • Pseudomonas aeruginosa
  • Proteus species
  • Staphylococcus species
  DIFFERENTIALS  

Nonbacterial Prostatitis
[Prostate Cancer: Biology, Diagnosis, Pathology, Staging, And Natural History]

Ureteral Stricture
Urethritis


Other Problems to be Considered:

Acute prostatitis
Prostatic stones
Anatomic obstruction due to prostatic hyperplasia, urinary stricture disease, or bladder neck dysfunction


  WORKUP  

Lab Studies:

  • Microscopic examination
    • Commonly, the diagnosis of chronic prostatitis is made after microscopic examination of the EPS. If a patient presents with symptoms of an acute urinary tract infection and/or the patient is febrile, an EPS should not be obtained because the patient likely has acute prostatitis. In this situation, a vigorous prostatic massage may result in urinary sepsis.
    • The generally accepted level of WBCs in an EPS for diagnosis of chronic prostatitis is more than 10 WBCs/hpf (40X objective) or an observation of clumping WBCs with the presence of oval fat bodies.
    • Finding WBCs in an EPS is not diagnostic of CBP because this commonly is associated with nonbacterial prostatitis, urethritis, prostatic stones, or recent ejaculation.
  • Positive urine culture after a prostatic massage
    • Performing this procedure helps confirm the diagnosis of CBP.
    • The classic 4-glass Meares-Stamey test for localization of the infection to the prostate is cumbersome and impractical. A more sensitive and practical test that is simpler to perform is preprostatic and postprostatic massage urine culture.
    • Carefully observe the culture for a colony count that is 10 times higher in the postprostatic massage culture compared to the preprostatic massage culture, which confirms CBP. This is the widely accepted standard.
    • Perform the prostatic massage during the rectal examination by kneading the prostate from front to back and from lateral to medial until a milky fluid is obtained from the urethra. This may require as long as a minute of fairly vigorous massage; therefore, inform the patient of the intended plan and goal. Sometimes, milking the urethra hastens the appearance of the fluid. Then, touch the fluid to a microscopic slide for examination.
    • The pH of prostatic fluid rises when infection is present, from 6.5 to higher than 8.0.
    • Prostate-specific antigen (PSA) levels often are elevated. Do not construe this finding as an elevation associated with prostate cancer unless the level remains elevated after repeat testing. Repeat testing should be performed 6 weeks after resolution of the prostatitis.

Imaging Studies:

  • Transrectal ultrasonography
    • This study is not helpful unless an abscess is present. Abscesses are extremely rare, but if present, patients also may have a high fever and appear quite ill. A CT scan also may be helpful in this situation if transrectal ultrasound is not available. MRI also may be used but usually is not as readily available in most acute situations.
    • Transrectal ultrasound findings also may help identify prostatic stones. In certain patients with frequent recurrences, prostatic stones may be causing the CBP.

Procedures:

  • Prostate biopsy
    • This is the most definitive but least practical modality used to diagnose bacterial prostatitis. It also is potentially dangerous for the patient.
    • Viewing the specimen under microscopy can help identify a focal infiltration of inflammatory cells into the prostatic stroma. The specimen also serves as a source from which to culture organisms. However, in the face of an active infection such as acute prostatitis, performing a biopsy could precipitate sepsis. Therefore, prostate biopsy is not recommended as a diagnostic modality.
    • On the other hand, category IV prostatitis is diagnosed using prostate biopsy. Category IV prostatitis is asymptomatic but may be responsible for elevations in PSA levels, resulting in the need for a diagnostic biopsy to help exclude prostate cancer.
  • If the patient has frequent recurrences of chronic prostatitis, other tests may help exclude an anatomic obstruction due to prostatic hyperplasia, urinary stricture disease, or bladder neck dysfunction. If this is the case, appropriate treatment (eg, transurethral incision of a urethral stricture, transurethral resection of the prostate or bladder neck) may be indicated.
  • Retrograde urethrogram, uroflowmetry, and postvoid residual testing are described as follows:
    • Retrograde urethrogram is performed to help confirm the presence of a urethral stricture. It is performed by injecting contrast into the urethral meatus and taking a pelvic radiograph. If a stricture is present, narrowing of urethral caliber is observed.
    • Uroflowmetry is a simple urodynamic test to help evaluate the rate of urine flow over time. It is used in patients with prostatitis to help evaluate for obstruction secondary to a urethral stricture or prostatic enlargement. Results are obtained in graphical form. Normal study results show a rapid rise to a peak and then a gradual drop-off back to baseline. A urethral stricture is indicated by a rapid rise to a low point, a plateau for the remainder of the study, and then a drop-off at the termination of the study. In prostatic enlargement, a wide variety of patterns is present, but the peak flow is usually less than 15 mL/s, and a stop-start pattern may also be present. To help delineate abnormalities and to differentiate a stricture from prostatic enlargement, cystoscopy should be performed.
    • Postvoid residual testing measures the volume of urine left in the bladder immediately after voiding. This volume can be measured by catheterizing the bladder or by using a bladder scanner. Although the results are nonspecific, they can give clues to the presence of lower tract dysfunction, which may require surgical intervention to relieve prostatic obstruction or urethral stricture.
Histologic Findings: Chronic inflammation is common after biopsy specimens have been obtained to help evaluate for prostate cancer. Findings usually include large focal lymphocytic infiltrates amid the normal prostatic stroma; however, biopsy rarely, if ever, is used to diagnose prostatitis. If an asymptomatic patient is found to have inflammation in the prostatic tissue, this is categorized as category IV prostatitis, ie, asymptomatic inflammatory prostatitis.

  TREATMENT  

Medical Care: If the postprostatic massage urine culture results are positive, then successful treatment is likely. However, because of the difficulty in obtaining sufficient material for culture, a trial of antibiotics is worthwhile if clinical evidence strongly suggests chronic prostatitis.

Recent studies using extensive research methods (eg, RT-PCR) show evidence of bacterial infection despite negative findings after urine culture. Negative culture results occur for various reasons, including insufficient sample volume, initiation of antibiotics prior to obtaining an EPS, and the presence of fastidious organisms. These patients often have symptom improvement after antibiotic treatment.

A query of high-risk behaviors, multiple partners, unprotected anal intercourse, and the possibility of sexually transmitted diseases may help. If doubt remains, conduct a 2-week trial of an appropriate antimicrobial therapy to try to alleviate the symptoms. If the symptoms improve, prescribe a complete course of antibiotics. Because this is a not an acute infection, as in most cases, help alleviate the symptoms using symptomatic treatment with analgesics and alpha-blockers until confirmatory culture results are available. Sitz baths also may provide symptomatic improvement.

  • Antimicrobial therapy
    • The choice of antimicrobial is critical because the prostate has an epithelial lining and a pH gradient that inhibits antimicrobials from entering the prostatic acini. Ideal antibiotics have a higher dissociation constant to allow diffusion of their un-ionized components into the prostate. In addition, if the antibiotic is basic, it can readily concentrate much higher in prostatic fluid than in the plasma because of the pH gradient.

    • Prostatic stones (if present) may be a nidus for recurrent infection, and they are difficult to treat with antibiotic therapy; therefore, surgical therapy in the form of a transurethral resection of the prostate (TURP) may be indicated.

    • The best antibiotic choices are trimethoprim-sulfamethoxazole (TMP-SMZ) at 80-400 mg given twice a day and fluoroquinolone antibiotics (eg, ciprofloxacin at 500 mg or ofloxacin at 400 mg) given twice a day. TMP-SMZ has a 33-50% cure rate with a 4- to 6-week course of treatment. Fluoroquinolones have a similar cure rate with a 4-week course.

    • TMP-SMZ is significantly less expensive; however, consider a fluoroquinolone (eg, Floxin) if the patient is younger than 35 years and sexually active with multiple partners because it also has activity against chlamydial and gonorrheal organisms.

    • For those patients in whom oral antibiotic therapy fails, use other antibiotics to treat CBP. These may include carbenicillin or doxycycline or injections of gentamicin, either parenterally or directly into the prostate.

    • Patients with persistent infections, especially those who have symptom improvement while on antibiotics but quickly have a recurrence after finishing a course of antibiotics, may benefit from suppressive therapy with low daily doses of antibiotics. Good choices are tetracycline, nitrofurantoin, nalidixic acid, cephalexin, or trimethoprim. Bacteria in CBP usually are sensitive strains, even after a number of antibiotic treatment regimens have been tried.
  • Other medical treatments
    • The addition of nonsteroidal anti-inflammatory drugs and alpha-blockers (eg, terazosin at 1-10 mg, doxazosin at 1-8 mg) help with symptom relief. They can help decrease recurrences by diminishing urinary obstruction due to prostate enlargement or congestion secondary to inflammation. In addition, instruct the patient to ejaculate a minimum of every 3 days while on antibiotic therapy to help with drainage of the prostatic ducts.
    • Sitz baths also may provide some symptom improvement.

Surgical Care: Surgery usually is not indicated for chronic prostatitis. However, in select situations when a patient has recurrent episodes of chronic prostatitis and improves with antibiotics, a TURP may remove a nidus of infection. This nidus may be in the form of prostatic stones. These stones usually are visible on transrectal ultrasound images.

  • TURP is performed in a standard fashion after preoperative antibiotics have been administered.
    • Routine preoperative evaluation should be performed when planning for TURP.
    • A routine TURP should be performed.
    • Routine postoperative care for TURP should be employed for these patients.

  MEDICATION  

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the context of this clinical setting.
Drug Name
Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS) -- Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult Dose 80 mg TMP/400 mg SMZ PO bid for 4-6 wk
Pediatric Dose Not established
Contraindications Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Interactions May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, persons with chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Drug Name
Ciprofloxacin (Cipro) -- Fluoroquinolone with activity against pseudomonas, streptococci, MRSA, Streptococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult Dose 500 mg PO bid for 4 wk
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
Ofloxacin (Floxin) -- Penetrates prostate well and is effective against Neisseria gonorrhea and C trachomatis. Derivative of pyridine carboxylic acid with broad-spectrum bactericidal effects.
Adult Dose 400 mg PO bid for 4 wk
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
Carbenicillin (Geocillin) -- Inhibitor of cell wall mucopeptides and effective during stage of active growth. Indicated for prostatitis caused by E coli, Enterobacter species, Proteus mirabilis, and enterococci.
Adult Dose 2 tab PO q6h
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Effects are reduced with tetracycline coadministration; at high concentrations in an IV line, may physically inactivate aminoglycosides; levels are increased with probenecid; coadministration with aminoglycosides has synergistic effects
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Perform CBC count prior to therapy and weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; urinalysis, BUN, and creatinine determinations should be performed during therapy and dose adjusted if these values become elevated; in known or suggested renal impairment, adjust dose and monitor blood levels (these measures help prevent possible neurotoxic reactions)
Drug Name
Doxycycline (Doryx, Periostat, Vibra-Tabs) -- Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose 200-300 mg PO divided bid
Pediatric Dose Not established
Contraindications Documented hypersensitivity; severe hepatic dysfunction
Interactions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy D - Unsafe in pregnancy
Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Drug Name
Gentamicin (Garamycin, Jenamicin) -- Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider if other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Adult Dose 1.5 mg/kg/dose IV/IM
Pediatric Dose Not established
Contraindications Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy D - Unsafe in pregnancy
Precautions Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Drug Category: Alpha-adrenergic blocking agents -- These agents relax the smooth muscle to the bladder neck, thus reducing bladder outlet obstruction.
Drug Name
Terazosin (Hytrin) -- Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, facilitating urinary flow in presence of prostate inflammation.
Adult Dose 1 mg PO qhs; increase slowly to effect; not to exceed 10 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in renal impairment; may cause marked hypotension following first dose and coadministration with beta-blockers
Drug Name
Doxazosin (Cardura) -- Counteracts alpha1–induced adrenergic contractions of bladder neck, facilitating urinary flow in presence of prostate inflammation.
Adult Dose 1 mg PO qd; may increase to 2 mg qd thereafter and titrate to higher doses over several wk as necessary; not to exceed 8 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in renal impairment; may cause marked hypotension following first dose
  FOLLOW-UP  

Further Outpatient Care:

  • If the patient is treated long-term with antibiotics, ensure that relocalization studies of the prostate (ie, preprostatic and postprostatic massage urine cultures after treatment) are conducted to conclude that the bacteria are eliminated. If repeat cultures return positive results, prescribe a second course of antibiotics with a drug that has a different mechanism of action.

In/Out Patient Meds:

  • If repetitive courses fail and the patient has improved symptomatology while on antibiotics, consider long-term low-dose suppressive therapy. Examples of suppressive therapy are Bactrim (single strength qhs), trimethoprim (100 mg qhs), ciprofloxacin (250 mg qhs), and ofloxacin (200 mg qhs).

Complications:

  • Infection often persists because antibiotics do not penetrate the prostate easily and no active transport mechanism exists whereby antibiotics can enter the prostatic ducts. Another inhibiting factor is that prostatic fluid is acidic compared to plasma, thus creating a pH gradient further inhibiting diffusion of acidic antibiotics into the prostatic fluid. See Antimicrobial therapy for guidance on antibiotic selection.

Prognosis:

  • Treatment success rates with TMP-SMZ approach 30-40%, and success rates with fluoroquinolones are 60-90%.
  • Treat relapses with a 3-month course of antibiotics. If this fails, consider a low suppressive dose of antibiotics (eg, Bactrim at single strength qhs, trimethoprim at 100 mg qhs, ciprofloxacin at 250 mg qhs, ofloxacin at 200 mg qhs).

Patient Education:

  • For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy, Prostate Infections, and Urinary Tract Infections.
  MISCELLANEOUS  

Special Concerns:

  • Continued research of occult bacterial infections as the cause of prostatitis syndrome is ongoing and will lead to further effective treatments for prostatitis symptoms.
  PICTURES  

Caption: Picture 1. Chronic Bacterial Prostatitis. US National Institutes of Health chronic prostatitis symptom index.
Click to see larger picture
Picture Type: Graph
  BIBLIOGRAPHY  

  • Association of Genitourinary Medicine, Medical Society for the Study of Venereal Diseases: National guideline for the management of prostatitis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999 Aug; 75 Suppl 1: S46-50.
  • Britton JJ, Carson CC: Prostatitis. AUA Update Series 1998; 17: 154-9.
  • Collins MM, Stafford RS, O'Leary MP: How common is prostatitis? A national survey of physician visits. J Urol 1998 Apr; 159(4): 1224-8.
  • Collins MM, Stafford RS, O'Leary MP: How common is prostatitis? A national survey of physician visits. J Urol 1998 Apr; 159(4): 1224-8.
  • Kirby RS, ed: An Atlas of Prostatic Diseases. 1st ed. Boca Raton, Fla:CRC Press: 1997: 11-24.
  • Lipsky BA: Prostatitis and urinary tract infection in men: what's new; what's true? Am J Med 1999 Mar; 106(3): 327-34.
  • Litwin MS, McNaughton-Collins M, Fowler FJ Jr: The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999 Aug; 162(2): 369-75.
  • Meares EM: Prostatitis: a review. Urol Clin North Am 1975; 2: 3-27.
  • Nickel JC: Prostatitis. In: Mulholland SG, ed. Antibiotic Therapy in Urology. 1st ed. Philadelphia, Pa: Lippincott-Raven; 1996: 57-69.
  • Shoskes DA, Shahed A: Presence of Bacterial Signal in Expressed Prostatic Secretions Predicts Response to Antibiotic Therapy in Men with the Chronic Pelvic Pain Syndrome. J Urol 2000; 163(4): 99A.
  • Spaine DM, Mamizuka EM, Cedenho AP: Microbiological Aerobic Studies of the Normal Male Urethra. J Urol 1998; 161(4): 33A.

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