Before posting the standard treatment listed in the guidelines, I would like to emphasize the issue that patients often trust the so-called “experts” when they visit the clinic. However, in the standardized treatment of diseases, evidence-based medicine with META analysis, i.e., IA-level basis, is increasingly important. The actual fact is that you can find a lot of people who are not aware of the fact that they are not able to get the job done. Therefore, the individualized treatment for prostatitis is necessarily based on the group, standardized treatment, and only after level I evidence treatment, level IV evidence treatment is meaningful. IV. Treatment
(A) Treatment principles
Prostatitis should be treated in a comprehensive manner.
Type I: mainly broad-spectrum antibiotics, symptomatic treatment and supportive therapy. Those with urinary retention can use fine tube catheterization or suprapubic cystocentesis to drain urine, and those with prostate abscess can take surgical drainage.
Type II: Treatment is based on oral antibiotics, choosing sensitive drugs, and the course of treatment is 4-6 weeks, during which the patient should be evaluated in stages of efficacy. If the efficacy is unsatisfactory, other sensitive antibiotics can be used instead. Alpha-blockers can be used to improve urinary symptoms and pain. Botanical preparations, NSAIDs and M-blockers can also improve the associated symptoms.
Type IIIA: Oral antibiotics can be given for 2 to 4 weeks, and then the decision to continue antibiotic therapy is based on their efficacy feedback. Alpha-blockers are recommended to improve urinary symptoms and pain, and NSAIDs, botanicals and M-blockers are also available.
Type IIIB: medications such as alpha-blockers, NSAIDs, botanicals and M-blockers can be chosen for treatment.
Type IV: Generally no treatment is required.
(II) Treatment method
Type Ⅰ
Antibiotic treatment of type I prostatitis is necessary and urgent. Antibiotics should be applied as soon as a clinical diagnosis or blood or urine culture results are obtained. It is recommended to start with intravenous application of antibiotics, such as: broad-spectrum penicillin, triple cephalosporins, aminoglycosides or fluoroquinolones. After the patient’s fever and other symptoms improve, oral medications (e.g., fluoroquinolones) are recommended for a minimum of 4 weeks. Antibiotics should also be used for 2 to 4 weeks in patients with milder symptoms.
Acute bacterial prostatitis with urinary retention can be treated with suprapubic cystostomy to drain urine, or fine catheterization, but the catheter should not be left in place for more than 12 hours. Those with abscess formation can be drained by transrectal ultrasound-guided fine needle aspiration, transurethral resection of the prostatic abscess, or transperineal aspiration.
Types II and III
The clinical progressiveness of chronic prostatitis is not clear enough to threaten the patient’s life and vital organ function, and not all patients require treatment. The goal of treatment for chronic prostatitis is mainly to relieve pain, improve urinary symptoms and improve quality of life, and efficacy evaluation should be based on symptom improvement.
1, general treatment Health education, psychological and behavioral counseling has a positive effect. Patients should abstain from alcohol, avoid spicy and stimulating food; avoid holding urine, sedentary, pay attention to warmth, and strengthen physical exercise.
2.Medication The three most commonly used drugs are antibiotics, alpha-blockers and non-steroidal anti-inflammatory analgesics, and other drugs also have different degrees of efficacy in relieving symptoms.
(1) Antibiotics: Currently, the most commonly used first-line drugs in clinical practice for the treatment of prostatitis are antibiotics, but only about 5% of patients with chronic prostatitis have a definite bacterial infection.
Type II: Antibiotics are selected based on bacterial culture results and the ability of the drug to penetrate the prostate gland. The ability of the drug to penetrate the prostate depends on its degree of ionization, lipid solubility, protein binding rate, relative molecular mass and molecular structure. The recommended antibiotics to choose from are fluoroquinolones (such as ciprofloxacin, levofloxacin, lomefloxacin and moxifloxacin), tetracyclines (such as minocycline) and sulfonamides (such as cotrimoxazole).
After the diagnosis of prostatitis, the course of antibiotic treatment is 4-6 weeks, during which the patient should be evaluated for the efficacy of the stage. If the efficacy is not satisfactory, other sensitive antibiotics can be used instead. Intraprostatic injection of antibiotics is not recommended as a treatment method.
Type IIIA: Antibiotic therapy is mostly empirical and is based on the theory that certain pathogens that are routinely culture-negative are presumed to cause this type of inflammation. Therefore, oral antibiotics such as quinolones are recommended for 2 to 4 weeks, followed by a decision to continue antibiotic therapy based on efficacy feedback. Continuation of antibiotics is recommended only if the patient does experience a reduction in clinical symptoms. The recommended total course of treatment is 4 ~ 6 weeks. Some patients with this type may have intracellular pathogenic infections such as Chlamydia trachomatis, Ureaplasma lysis or Mycoplasma humanum, which can be treated with oral antibiotics such as tetracyclines or macrolides.
Type IIIB: Antibiotic treatment is not recommended.
(2) Alpha-blockers: Alpha-blockers can relax smooth muscle in the prostate and bladder and improve lower urinary tract symptoms and pain, making them the basic treatment for type II/III prostatitis.
The choice of alpha-blocker can vary depending on the patient’s condition. The recommended alpha-blockers are: doxazosin, naftopidil, tamsulosin and terazosin. Controlled studies have shown varying degrees of improvement in urinary symptoms, pain and quality of life index. The adverse effects of these drugs, such as vertigo and postural hypotension, should be noted during treatment. Studies suggest that alpha-blockers may be more effective in patients with untreated or newly diagnosed prostatitis than in chronic, refractory patients, and that a longer course (12 weeks to 24 weeks) of treatment may be more effective than a shorter course of treatment.
The course of alpha-blockers should be at least 12 weeks. alpha-blockers can be used in combination with antibiotics to treat type IIIA prostatitis, and the combined course of treatment should be at least 6 weeks.
(3) Botanicals: The therapeutic role of botanicals in type II and III prostatitis is gaining attention as the recommended therapeutic drugs. Botanical preparations mainly refer to pollen-based preparations and plant extracts, which have a wide range of pharmacological effects, such as non-specific anti-inflammatory, anti-edema, and promoting bladder contraction and urethral smooth muscle relaxation.
Recommended botanical preparations include: Pulsatilla, sabal palm and its infusion, etc. Due to the large number of varieties, their dosage depends on the specific condition of the patient, and the course of treatment is usually measured in months. Adverse effects are minor.
The results of a recently completed multicenter, randomized, double-blind, placebo-controlled study showed that Pulsatilla significantly reduced pain symptoms and improved quality of life in patients with IIIA prostatitis. Another study showed that prolonged (6 months) treatment with Pulsatilla significantly reduced pain and urinary symptoms in patients with type III prostatitis compared to placebo. The combination of Pulsatilla and levofloxacin was significantly more effective than levofloxacin monotherapy in the treatment of type IIIA prostatitis.
(4) Non-steroidal anti-inflammatory analgesics: Non-steroidal anti-inflammatory analgesics are empirically used to treat the symptoms associated with type III prostatitis. Their primary purpose is to relieve pain and discomfort. Several randomized, placebo-controlled studies have been conducted to date to evaluate the efficacy of such drugs. Controlled clinical studies have confirmed the effectiveness of celecoxib in improving pain and other symptoms in patients with type IIIA prostatitis.
(5) M-blockers: M-blockers (e.g., tolterodine) may be used to treat prostatitis patients with overactive bladder (OAB) manifestations such as urinary urgency, frequency, and nocturia but without urinary obstruction.
(6) Antidepressants and anxiolytics: For patients with chronic prostatitis who have a combination of depression, anxiety and other mood disorders, you can choose to use antidepressants and anxiolytics to treat the prostatitis at the same time. These drugs can improve the patient’s mood disorder symptoms as well as relieve physical symptoms such as abnormal urination and pain. It is important to be aware of the prescription regulations and adverse drug reactions to these drugs when applying them. The main antidepressants and anxiolytics available are tricyclic antidepressants, selective 5-hydroxytryptamine reuptake inhibitors and benzodiazepines.
(7) Chinese herbal medicine: It is recommended that the Chinese herbal medicine treatment of prostatitis be carried out in accordance with the relevant norms of the Society of Chinese Medicine or the Society of Integrative Medicine.
3.Other treatments
(1) prostate massage: prostate massage is one of the traditional treatments, research shows that appropriate prostate massage can promote the emptying of the prostate ducts and increase the local concentration of drugs, thus relieving the symptoms of patients with chronic prostatitis, so it is recommended as an adjuvant therapy for type III prostatitis. It is prohibited for patients with type I prostatitis.
Biofeedback combined with electrical stimulation therapy can relax and harmonize the pelvic floor muscles and relax the external sphincter, thus relieving the perineal discomfort and urinary symptoms of chronic prostatitis. Biofeedback therapy requires the patient to actively participate in the treatment through the biofeedback instrument. The therapy is non-invasive and is an optional treatment method.
(3) Heat therapy: mainly using the thermal effect produced by a variety of physical means to increase blood circulation in the prostate tissue, accelerate metabolism, which is conducive to anti-inflammatory and eliminate tissue edema, relieve pelvic floor muscle spasm, etc. Although there is some short-term relief of symptoms, there is a lack of long-term follow-up data. It is not recommended for unmarried and infertile people.
(4) Prostate injection therapy/transurethral prostate irrigation therapy: There is a lack of evidence-based medical evidence to confirm its efficacy and safety.
(5) Surgery: Transurethral cystotomy and transurethral resection of the prostate are difficult to treat for chronic prostatitis and should only be chosen when there is an indication for surgery for combined prostate related diseases.
Type IV
The treatment is usually not needed. If the patient has a combination of elevated serum PSA or infertility, attention should be paid to the differential diagnosis and treatment accordingly.