azole). Treatment should be continued for

and should be avoided, although there are some

2–4 weeks. Patients that do not initially respond

case reports of cure after radical TURP and

to this course of therapy should be investigated

anecdotal reports of improvement after total or

for the possibility of development of a prostate

radical open prostatectomy in patients with

abscess (CAT scan or transrectal ultrasound)

persistently confirmed foci of infection in the

which should be dealt with as an emergency.

prostate.

Transurethral drainage is believed to be the

optimal therapy, however transrectal guided

Category III CP/CPPS

needle aspiration may be effective in small local­

ized abscesses.

The Goal of Treatment

The definitive therapy for Category II chronic

bacterial prostatitis is appropriate long term

The treatment options for patients diagnosed

antibiotic therapy.20,33 Optimal antibiotic ther­

apy includes trimethroprim (or trimethoprim­

with Category III CP/CPPS are more varied, but

unfortunately less successful. The most success­

sulfamethoxazole) and the fluoroquinolones.

ful therapeutic approach in this syndrome is for

Although trimethroprim­sulfamethoxazole is

both the physician and patient to have realistic

the most studied antibiotic in prostatitis, the

expectations or goals in relation to treatment.

penetration of

the fluoroquinolones

into the

The patient must realize that the condition is

prostate gland

and the increased

bacterial

not caused by infection (particularly if a trial of

susceptibility to this class of drug makes them

antibiotics have failed), that the symptom com­

superior to trimethoprim or trimethoprim­sul­

plex is not related to cancer or risk of develop­

famethoxazole. Clinical studies have confirmed

ing prostate cancer and that symptoms will

the improved efficacy of fluoroquinolones over

likely wax and wane but may burn themselves

trimethroprim

or trimethoprim­sulfamethox­

out over time. Everyone dealing with this condi­

azole.26 Levofloxacin and ciprofloxacin appear

to be superior to ofloxacin which is more effec­

tion (that includes the physician, patient and the

patient’s partner) must understand that cure

tive than norfloxacin34,35 The duration of ther­

apy is controversial and suggestions have

may not be possible, but amelioration of symp­

toms, decrease in impact on daily activities and

ranged from 4 to 12 weeks.36 Because of the very

real possibility

of persistence, the physician

improvement of quality of life is achievable.

Treatment consists of conservative or supportive

should err on the side of too much antibiotic

management, drug therapy, and less frequently

rather than too little. Failure of antibiotic ther­

surgical intervention.

apy is a real possibility (likely secondary to

small foci of bacteria forming biofilms in the

prostate ducts and acini or associated with pro­

Conservative Management

static calculi) which becomes a management

problem. Switching to a more potent fluoroqui­

Some patient experience exacerbations with

nolone (if trimethoprim, norfloxacin or ofloxa­

selected food (spicy?) or drink (alcohol or

cin was used as first line therapy) or adding

acidic?) and while this is not universal, if it can

tetracycline (doxycycline) or a macrolide

be identified in an individual patient, then

(azithromycin or clarithromycin) may be of

avoidance can potentially benefit that individ­

benefit. In patients who continue to have recur­

ual. Depression, stress and anxiety have been

rent UTIs or in whom symptoms recur when

shown to be associated with increased symp­

the antibiotics are discontinued, low dose, long

toms and poorer quality of life15­17 and any

term suppressive therapy may have to be con­

maneuver that can reduce these issues in a

sidered. Repetitive prostate massage37,38 and the

patients’ life should be utilized. Some activities,

concomitant use of alpha blockers39 have been

such as high impact sports, bicycle or horse­

advocated based on low level evidence and

back riding may also exacerbate or be associ­

prostate massage might be considered for

ated with persistence of symptoms and these

patients who experience symptomatic relief

should be discontinued. Hot sitz baths, the use

during their diagnostic prostate massage or

of a donut cushion and other such options do

alpha blockers for those with obstructive void­

help patients improve or at least control their

ing symptoms. Surgery is the very last resort40

symptoms. Other potentially effective therapies