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Prostatitis - acute - Management
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How should I treat acute prostatitis?
- Admit to hospital if the man is unable to take oral antibiotics, or is severely ill.
- Start antibiotic treatment immediately, while waiting for the urine culture results.
- A quinolone (ciprofloxacin 500 mg twice daily, or ofloxacin 200 mg twice daily) for 28 days is recommended.
- If ciprofloxacin and ofloxacin cannot be taken, trimethoprim 200 mg twice daily for 28 days is recommended.
- Treat the pain:
- Paracetamol and/or ibuprofen (taken regularly) is recommended first-line.
- For severe pain, offer codeine with paracetamol.
- If defecation is painful, offer a stool softener such as docusate or lactulose.
- Advise the man to seek urgent medical advice if the condition deteriorates before their follow-up appointment.
- Reassess after 24–48 hours:
- Review the culture results and ensure that an appropriate antibiotic is being used.
- Refer to urology if the infection is not responding adequately to treatment — prostatic abscess may need to be excluded or treated.
- Following recovery, refer for investigation to exclude structural abnormality of the urinary tract.
Basis for recommendation
These recommendations are in line with UK guidelines [RCGP and BASHH, 2006; BASHH, 2008; HPA and Association of Medical Microbiologists, 2008], and international guidelines [Naber et al, 2001; European Association of Urology, 2008; Ludwig, 2008].
Choice of antibiotic
- These recommendations are based on expert opinion because there is no evidence from controlled clinical trials of quinolones or trimethoprim for acute prostatitis.
- Treatment with a quinolone or trimethoprim results in high concentrations of these drugs in the prostate.
- Quinolones and trimethoprim are effective treatments for most of the likely pathogens.
- Other antibiotics either do not penetrate the prostate as well, or are less effective against urinary pathogens.
- Quinolones are preferred to trimethoprim because they are effective against a wider range of urinary pathogens.
- There is no evidence to suggest that any particular quinolone is more effective or more hazardous than any other. CKS recommendations of ciprofloxacin or ofloxacin are consistent with those made by the British Association for Sexual Health and HIV (BASHH) [BASHH, 2008].
- The benefits of antibiotic treatment outweigh any increased risk of infection with Clostridium difficile or meticillin-resistant Staphylococcus aureus (MRSA), and the risk of promoting resistance to quinolones.
Duration of antibiotic treatment
- CKS recommendations are in line with UK guidelines, which recommend treatment for at least 4 weeks to prevent the development of chronic prostatitis [BASHH, 2008]. However, European guidelines would consider 10 days' treatment adequate [European Association of Urology, 2008].
Choice of stool softener
- Laxatives other than docusate and lactulose are not recommended:
- Bulk-forming agents may not ease defecation, and it will be several days before they take effect.
- Stimulant agents will not soften the stool.
- Enemas and rectal preparations are likely to be painful to insert.
- Co-danthrusate has limited prescribing indications.
- Liquid paraffin is generally not recommended.
When should I refer a man with acute prostatitis?
- Admit when there is:
- Acute urinary retention — suprapubic catheterization is required (inserting a urethral catheter may spread the infection through the blood).
- Deteriorating symptoms despite appropriate antibiotic treatment.
- Refer urgently if the man has:
- An inadequate response to appropriate antibiotic treatment — complications such as prostatic abscess should be assessed for, and this may require transrectal ultrasound examination or computed tomography (CT) scan of the prostate.
- Pre-existing urological conditions (such as benign prostatic hypertrophy or an indwelling catheter) — specialist urological management may be required.
- Consider urgent referral for any man who is immunocompromised or has diabetes.
- Refer all men when they have recovered. Investigation of the urinary tract is required to exclude structural abnormality.
Basis for recommendation
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
1st-line antibiotics: quinolones
Age from 18 years onwards
Ciprofloxacin tablets: 500mg twice a day
Ciprofloxacin 500mg tablets
Take one tablet twice a day for 28 days.
Supply 56 tablets.
Ofloxacin tablets: 200mg twice a day
Ofloxacin 200mg tablets
Take one tablet twice a day for 28 days.
Supply 56 tablets.
Alternative antibiotic: trimethoprim
Age from 16 years onwards
Trimethoprim tablets: 200mg twice a day
Trimethoprim 200mg tablets
Take one tablet twice a day for 28 days.
Supply 56 tablets.
Analgesia use when required
Age from 16 years onwards
Paracetamol tablets: 1g up to four times a day
Paracetamol 500mg tablets
Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Add on if severe pain: codeine tablets
Codeine 30mg tablets
Take one to two tablets every 4 to 6 hours when required for additional pain relief. Maximum of 8 tablets in 24 hours.
Supply 28 tablets.
Ibuprofen 400mg three times a day
Ibuprofen 400mg tablets
Take one tablet three times a day when required for pain relief. Do not exceed the stated dose.
Supply 84 tablets.
Stool softeners: docusate or lactulose
Age from 16 years onwards
Docusate capsules: 100mg to 200mg once or twice a day
Docusate 100mg capsules
Take one to two capsules once or twice a day when required.
Supply 30 capsules.
Lactulose solution: 15ml twice a day
Lactulose 3.1-3.7g/5ml oral solution
Take three 5ml spoonfuls twice a day.
Supply 300 ml.
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