Chronic bacterial prostatitis

Background

Mild to moderate pelvic pain symptoms with recurrent urinary tract infections, typically with the same organism
Prostate is usually normal on physical or endoscopic assessment

The gold standard is the 4-glass test
- Sample 1: first void (5-10 mL)
- Sample 2: midstream
- Sample 3: expressed prostatic secretions
- Sample 4: first void after prostatic massage (5-10 mL)
- Positive if sample 4 has ≥10 times the colony count of sample 1
Can also do 2-glass pre- and post-massage test
- Sample 1: midstream urine (10 mL)
- Sample 2: first void after prostate massage (10 mL)
- Positive if sample 2 has ≥10 times the colony count of sample 1
Semen cultures are not recommended
Prostatic ultrasonography is not recommended

First-line treatment is fluoroquinolones for 4 to 6 weeks
- Ciprofloxacin 500 mg p.o. twice daily
- Levofloxacin 500 to 750 mg p.o. daily
Alternatives include, in order of preference:
- TMP-SMX DS 1 tablet p.o. twice daily for 6 weeks
- Doxycycline 100 mg p.o. twice daily for 6 weeks
- Fosfomycin 3 g p.o. every 1 to 3 days for 6 weeks
For chlamydial prostatitis, azithromycin 500 mg p.o. daily (or for 3 consecutive days every week) for 3 weeks
Acutely ill patients should be treated with a third-generation cephalosporin or carbapenem
Test-of-cure generally not needed