Type I: The main treatment is broad-spectrum antibiotics, symptomatic treatment and supportive therapy. In cases with urinary retention, fine catheterization or suprapubic cystostomy can be used to drain urine, and in cases with prostate abscess, surgical drainage can be used.
Type II: Treatment is based on oral antibiotics, with sensitive drugs chosen for a course of 4-6 weeks, during which the patient should be evaluated for efficacy in stages. If the efficacy is not satisfactory, other sensitive antibiotics can be used instead. Alpha-blockers can be used to improve urinary symptoms and pain. Botanicals, NSAIDs, and M-blockers can also improve the 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: alpha-blockers, NSAIDs, botanicals, and M-blockers are available for treatment.
Type IV: No treatment is generally required.
Treatment
Type I
Antibiotic treatment of type I prostatitis is necessary and urgent. Once the clinical diagnosis or blood or urine culture results are obtained, antibiotics should be applied immediately. The treatment can be started by applying antibiotics such as broad-spectrum penicillin, triple cephalosporins, aminoglycosides or fluoroquinolones via the intravenous route. After the patient’s fever and other symptoms improve, the patient can be switched to oral medications (e.g., fluoroquinolones) for at least 4 weeks. Patients with milder symptoms should also be treated with antibiotics for 2 to 4 weeks.
For acute bacterial prostatitis with urinary retention, suprapubic cystostomy can be used to drain urine, or fine catheterization can be used, but the catheter should not be left in place for more than 12 hours. In cases with abscess formation, transrectal ultrasound-guided fine needle aspiration drainage, transurethral resection prostatic abscess drainage or perineal aspiration drainage can be used.
Types II and III
The clinical progressiveness of chronic prostatitis is not clear enough to threaten the life and vital organ function of patients, and not all patients require treatment. The goal of treatment for chronic prostatitis is to relieve pain, improve urinary symptoms and improve quality of life, and the evaluation of efficacy should be based on symptom improvement.
1. General Treatment
The actual health education, psychological and behavioral counseling has a positive effect. The patient should abstain from alcohol, 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.
（The most common first-line drug used in clinical practice for the treatment of prostatitis is antibiotics, but only about 5% of patients with chronic prostatitis have a clear bacterial infection.
Type II: Antibiotics are chosen based on the results of bacterial cultures and the ability of the drug to penetrate the prostate. The ability of the drug to penetrate the prostate depends on the degree of ionization, lipolysis, protein binding, relative molecular mass, and molecular structure. The choice of antibiotics includes fluoroquinolones (e.g., ciprofloxacin, levofloxacin, lomefloxacin, and moxifloxacin), tetracyclines (e.g., minocycline), and sulfonamides (e.g., cotrimoxazole).
After the diagnosis of prostatitis, the course of antibiotic treatment is 4-6 weeks, during which the patient should be evaluated in stages of efficacy. If the results are not satisfactory, other sensitive antibiotics can be used. The treatment of intraprostatic injection of antibiotics is not recommended.
Type IIIA: Antibiotic therapy is mostly empirical and is based on the theory that certain pathogens that are routinely culture-negative are presumed to be responsible for this type of inflammation. Therefore, oral antibiotics such as fluoroquinolones are recommended for 2 to 4 weeks, followed by a decision to continue antibiotic therapy based on feedback on efficacy. Continuation of antibiotics is recommended only if the patient’s clinical symptoms do decrease. The recommended total course of treatment is 4 to 6 weeks. Some patients with this type may have intracellular pathogens such as Chlamydia trachomatis, Ureaplasma lysis or Mycoplasma humanum, and may be treated with oral antibiotics such as tetracyclines or macrolides.
Type IIIB: Antibiotic treatment is not recommended.
(2) Alpha-blockers Alpha-blockers can relax the smooth muscles of 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 in the treatment.
The current meta-analysis of studies suggests that alpha-blockers may be more effective in patients with untreated or newly diagnosed prostatitis than in chronic, refractory patients, that longer courses (12 to 24 weeks) may be more effective than shorter courses, and that less selective agents may be more effective than more selective agents.
Alpha-blockers should be used for at least 12 weeks. alpha-blockers can be used in combination with antibiotics for the treatment of type IIIA prostatitis and the combination should be used for at least 6 weeks.
(3) Non-steroidal anti-inflammatory analgesics Non-steroidal anti-inflammatory analgesics are used empirically to treat the symptoms associated with type III prostatitis. Their primary purpose is to relieve pain and discomfort. To date, only a few randomized, placebo-controlled studies have evaluated the efficacy of such drugs. Controlled clinical studies have demonstrated the effectiveness of celecoxib in improving pain and other symptoms in patients with type IIIA prostatitis.
(4) Botanicals The role of botanicals in the treatment of type II and type III prostatitis is gaining attention as an optional treatment. The main botanicals are 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.
Commonly used botanical preparations include: Pulsatilla, sabal palm and its infusion. Due to the variety, the dosage depends on the patient’s specific condition, and the course of treatment is usually measured in months. Adverse effects are minor.
A recently completed multicenter controlled study showed that the combination of Pulsatilla and levofloxacin was significantly more effective than levofloxacin alone in the treatment of type III prostatitis. Another randomized, double-blind, placebo-controlled study showed that prolonged (6 months) treatment with Pulsatilla significantly reduced pain and urinary symptoms in patients with type III prostatitis compared to placebo.
(5) M-blockers M-blockers (e.g., tolterodine) may be used in patients with prostatitis with overactive bladder (OAB) symptoms such as urgency, frequency, and nocturia without urinary tract obstruction.
（The patient with chronic prostatitis who has depression and anxiety can be treated with antidepressants and anxiolytics along with prostatitis. These medications can improve the patient’s mood disorder symptoms as well as relieve physical symptoms such as abnormal urination and pain. It is important to pay attention to the prescription regulations and adverse drug reactions of 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 according to the specifications of the Chinese Medicine Association or the Society of Integrative Medicine.
3.Other treatments
The prostate massage is one of the traditional treatment methods. Studies have shown that proper 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 not recommended for patients with type I prostatitis.
Biofeedback therapy requires the patient to actively participate in the treatment through the biofeedback instrument. This is a non-invasive and optional treatment.
There are reports of heat therapy using microwave, radiofrequency, laser and other physical means via urethral, transrectal and perineal routes. Although it can provide some short-term relief, there is a lack of long-term follow-up data. It is not recommended for unmarried and infertile patients.
4.Prostate injection therapy/transurethral prostate irrigation There is no evidence to confirm the efficacy and safety of this treatment.
Surgical procedures such as 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 a combination of prostate related diseases.
Type IV
The patient does not need treatment. If the patient has an elevated PSA or infertility, the differential diagnosis should be made and the patient should be treated accordingly.