Prostatitis is a collection of signs and symptoms that occur as a result of
inflammation or swelling of the prostate gland. There are many different causes for
prostatitis, including
infection; occasionally no clear etiology for the
inflammation is found. Effective treatment often depends on identification of the cause, but a microbiologic organism is not always detectable, especially in cases of chronic
prostatitis.
OBJECTIVE: Relevant information was identified through a search of MEDLINE (1966-June 2010), International
Pharmaceutical Abstracts (1970-June 2010), and EMBASE (1947-June 2010). Randomized, controlled trials that examined
prostate cancer,
benign prostatic hypertrophy, or procedures related to the prostate (ie, biopsies) were excluded.
RESULTS: A working classification system for
prostatitis was developed in 1999, but there are few randomized controlled trials that distinguish between the various treatment options. Bacterial
prostatitis can be acute or chronic but always requires some degree of antimicrobial
therapy. Pharmacologic features of
fluoroquinolones make them the preferred agents for most patients. These
antibiotics can become trapped in a chronically inflamed prostate due to pH differences between prostatic tissue and serum. Many
fluoroquinolones have penetration ratios (prostate level:serum level) of up to 4:1. A study in European men (N = 117) who received
levofloxacin 500 mg/d with a diagnosis of
chronic bacterial prostatitis demonstrated clinical success rates of 92% (95% CI 84.8%-96.5%), 77.4% (95% CI, 68.2-84.9%), 66.0% (95% CI, 56.2%-75.0%), and 61.9% (95% CI, 51.9%-71.2%) at 5-12 days, 1 month, 3 months, and 6 months
after treatment. Additionally, there have been numerous randomized, placebo-controlled trials in patients with chronic
prostatitis that have studied α-blockers,
steroid inhibitors,
anti-inflammatory agents, and
bioflavonoids. Treatment responses to α-blockers appear to be greater with longer durations of
therapy in α-blocker-naïve patients (National Institutes of Health-Chronic
Prostatitis Symptom Index [NIH-CPSI] score reduction of at least 3.6 points after 6 weeks of
tamsulosin therapy [P = 0.04] and up to 14.3 and 9.9 point NIH-CPSI score reductions with 14 weeks of
terazosin and 24 weeks of
alfuzosin therapy, respectively [P = 0.01 for both]). Combination
therapy with an α-blocker, an anti-inflammatory, and a muscle relaxant does not appear to offer significant advantages over monotherapy (12.7 vs 12.4 point reduction in NIH-CPSI scores) and a stepwise approach to
therapy involving
antibiotics followed by
bioflavonoids and then α-blockers appears to effectively reduce symptoms for up to 1 year in patients with chronic
prostatitis (mean NIH-CPSI point reduction of 9.5 points compared with baseline, P < 0.0001). Patients who have had multiple unsuccessful treatment regimens may benefit from direct stimulation of the pelvic muscles through electromagnetic or
electroacupuncture therapy.
CONCLUSIONS:
Prostatitis can resemble various other medical conditions but proper classification and an understanding of the pharmacologic features and expectations of the medications used to treat it can help identify effective treatment strategies.
Fluoroquinolones are the preferred agents for treating bacterial causes of
prostatitis and have demonstrated efficacy in some cases of chronic
prostatitis when an organism has not been identified. However, the use of agents with anti-inflammatory or antiadrenergic properties may be necessary in combination with or after trying
antimicrobial agents.