Prostatitis treatment strategies

Acute bacterial prostatitis is a sudden and painful infection of the prostate, usually caused by bacteria entering from the urinary tract, often following a urinary tract infection (UTI) or medical procedure, and sometimes sexually transmitted.

Symptoms include painful urination, increased frequency and urgency, perineal or rectal pain, fever, chills, low back pain, and a tender, swollen prostate on examination.

The BNF advises fluoroquinolones (ciprofloxacin or ofloxacin) as first line, typically taken for 14 days. Length of treatment may be longer and up to 28 days, depending on the severity and response. Trimethoprim is used in patients when a fluoroquinolone is not appropriate.

Fluoroquinolones are effective for treating acute prostatitis due to their excellent penetration into prostate tissue, but they carry several important clinical risks that pharmacists should be aware of.

In 2024, the MHRA advised that fluoroquinolone antibiotics should only be prescribed when other commonly recommended antibiotics are not appropriate.

Serious adverse reactions include tendon damage (e.g. tendonitis and tendon rupture), particularly in older adults and those taking corticosteroids, as well as musculoskeletal and nerve issues like joint pain, muscle weakness, and peripheral neuropathy. Fluoroquinolones can also prolong the QT interval, increasing the risk of serious arrhythmias.

As is the case when assessing any fluoroquinolone prescription, pharmacists should review concurrent medications for potential interactions and additive QT prolongation risk. Patients should be advised to report any tendon pain, muscle weakness or joint discomfort immediately, and be informed about possible mood changes or confusion, warned about serious heart symptoms, as well as the need to avoid strenuous exercise during treatment.

Supportive care

Supportive care includes pain relief with paracetamol or ibuprofen, stool softeners if defaecation is painful and maintaining good hydration.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a long-term condition that can affect men, with more than 90 per cent of cases being abacterial and less than 10 per cent due to chronic bacterial prostatitis.

It typically presents with persistent pelvic or genital pain lasting more than three months, lower urinary tract symptoms such as hesitancy and urgency, and sexual dysfunction including painful ejaculation.

If a bacterial cause is suspected, antibiotics like trimethoprim or doxycycline can prescribed for four weeks, followed by review to assess response.

For non-bacterial CP/CPPS, a multifaceted approach is recommended, addressing urinary symptoms with alpha-blockers, organ-specific pain with NSAIDs, psychosocial factors with counselling or antidepressants, and tenderness with physiotherapy, while considering neuropathic agents for systemic pain.

Patient education is key, with reassurance that the condition is not cancer or typically sexually transmitted, focusing on symptom control rather than cure, and providing access to self-care resources and support.