The mainstay in the treatment of chronic bacterial prostatitis (CBP) is the use of oral antimicrobial agents. The most effective medications are fluoroquinolones and trimethoprim-sulfamethoxazole (TMP-SMZ). All other oral agents are unlikely to eradicate the infection. Relapse is not uncommon.
If the postprostatic massage urine culture results are positive, then treatment with appropriate antibiotics is likely to be successful. However, because of the difficulty in obtaining sufficient material for culture, a trial of antibiotics is worthwhile if clinical evidence strongly suggests chronic prostatitis.
Studies using extensive research methods (eg, reverse transcriptase polymerase chain reaction assay) 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 expressed prostatic secretion sample, and the presence of fastidious organisms. In such cases, patients often have symptom improvement after antibiotic treatment.
Querying the patient about high-risk behaviors (eg, 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 not an acute infection, in most cases symptomatic treatment with analgesics and alpha blockers may be used to alleviate symptoms until confirmatory culture results are available. Sitz baths also may provide symptomatic improvement.
Surgery is usually not indicated for chronic prostatitis. However, in select situations when a patient has episodes of chronic prostatitis that improve with antibiotics but then recur, transurethral resection of the prostate (TURP) or transurethral vaporization of the prostate (TUVP) may remove a nidus of infection. This nidus may be in the form of prostatic stones. These stones are usually visible on transrectal ultrasonograms.