(i) Principles of treatment
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: Treatment with alpha-blockers, NSAIDs, botanicals and M-blockers are available.
Type IV: No treatment is generally required.
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 mainly to relieve pain, improve urinary symptoms and improve quality of life, and efficacy evaluation should be based on symptom improvement.
(II) Treatment methods
1. Type I
Antibiotic treatment of type I prostatitis is necessary and urgent. Once the clinical diagnosis or blood and urine culture results are obtained, antibiotics should be applied immediately. At the beginning, antibiotics can be applied intravenously, such as: broad-spectrum penicillin, third-generation cephalosporins, aminoglycosides or fluoroquinolones, etc. When the patient’s fever and other symptoms improve, switch to oral medications (e.g., fluoroquinolones) for a minimum of 4 weeks. Patients with milder symptoms should also take oral antibiotics for 2 to 4 weeks.
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 prostatic abscess drainage or perineal puncture drainage.
2.Type II and III
(1) General treatment
Health education, psychological and behavioral counseling have positive effects. Patients should abstain from alcohol, avoid spicy and stimulating food; avoid holding urine and sitting for a long time, pay attention to keeping warm, and strengthen physical exercise.
(2) Drug treatment
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 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 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 commonly used antibiotics are fluoroquinolones (such as ciprofloxacin, levofloxacin and lomefloxacin), 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 in stages of efficacy. If the efficacy is not satisfactory, other sensitive antibiotics can be changed. 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 fluoroquinolones 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 to 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 muscles in the prostate and bladder and improve lower urinary tract symptoms and pain, thus becoming the basic drug for the treatment of type II/III prostatitis.
Different alpha-blockers can be selected according to the individual patient. The recommended alpha-blockers are: alfuzosin, doxazosin, naftopidil, tamsulosin and terazosin, etc. The results of controlled studies have shown that these drugs have improved urinary symptoms, pain and quality of life index in patients to varying degrees. The results of controlled studies showed that these drugs had different degrees of improvement on 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.
The duration of treatment with alpha-blockers should be at least 12 weeks. alpha-blockers can be used in combination with antibiotics for the treatment of type IIIA prostatitis, and the combined duration of treatment should be 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 confirmed the effectiveness of celecoxib in improving pain and other symptoms in patients with type IIIA prostatitis.
(4) Botanical agents: The therapeutic role of botanical agents in type II and type III prostatitis is gaining attention as an optional treatment. The botanicals 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.
Commonly used botanical preparations include: Pulcitol, quercetin, 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 controlled study showed that the combination of Pulsatilla and levofloxacin was significantly more effective than levofloxacin monotherapy in the treatment of type III prostatitis. The results of another randomized, double-blind, placebo-controlled study showed that long-term (6 months) treatment with Pulsatilla significantly reduced pain and urinary symptoms in patients with type III prostatitis compared to placebo.
(5) M-blockers: Patients with prostatitis with overactive bladder (OAB) manifestations such as urinary urgency, frequency and nocturia without urinary obstruction may be treated with the M-blocker tolterodine.
(6) Antidepressants and anxiolytics: For patients with chronic prostatitis who have combined depression and anxiety, depending on their condition, antidepressants and anxiolytics can be used along with the treatment of prostatitis. These medications can significantly improve both the patient’s mood disorder symptoms and also the physical discomfort and pain. The clinical application of these drugs must pay attention to the prescription regulations and adverse drug reactions. The main antidepressants and anxiolytics available are tricyclic antidepressants, selective 5-hydroxytryptamine reuptake inhibitors and benzodiazepines.
(7) Traditional Chinese medicine (TCM): It is recommended that TCM treatment of prostatitis be carried out in accordance with the relevant norms of the Chinese Medicine Society or the Society of Integrative Chinese and Western Medicine, and that methods such as clearing heat and dampness, activating blood circulation and draining urine and lymphatic drainage be adopted for evidence-based treatment.
(3) Other treatments
(1) Prostate massage Prostate massage is one of the traditional treatments. 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. The combination of other treatments can be effective in shortening the duration of the disease. It is prohibited for patients with type I prostatitis.
(2) Biofeedback therapy Studies have shown that patients with chronic prostatitis have a synergistic dysfunction of the pelvic floor muscles or tension in the external urethral sphincter. Biofeedback combined with electrical stimulation can cause fatigue relaxation of the pelvic floor muscles and make them coordinated, while relaxing 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. This therapy is non-invasive and is an optional treatment.
(3) Heat therapy mainly uses the heat produced by a variety of physical means to increase blood circulation in the prostate tissue and accelerate metabolism, which is conducive to anti-inflammatory and eliminate tissue edema and relieve pelvic floor muscle spasm. There are reports of heat therapy using microwave, radiofrequency, laser and other physical means via urethral, transrectal and perineal routes. Although it has a certain effect on symptom relief in the short term, long-term follow-up data are lacking. It is not recommended for unmarried and infertile people.
(4) Prostate injection therapy/transurethral prostate irrigation There is a lack of evidence-based medical evidence.
(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.
3. Type IV
The patient does not need treatment. If the patient has elevated serum PSA or infertility, the differential diagnosis should be noted and treated accordingly.