Synopsis
Separate acute prostate infection from a chronic bacterial reservoir and chronic pelvic pain, then choose safe tissue-active treatment with an explicit review point.
- Acute fever, perineal pain, dysuria and obstructive symptoms suggest bacterial prostatitis; retention, sepsis or suspected abscess requires hospital assessment. If ceftriaxone is chosen, hypersensitivity to any cephalosporin or a severe reaction to another beta lactam excludes that medicine.
- Collect midstream urine for culture and examine gently when indicated; never perform vigorous prostate massage during suspected acute bacterial infection.
- For acute prostatitis, review antibiotics after fourteen days and decide whether to stop or continue for another fourteen using symptoms, examination and investigations.
Key red flags
Sepsis, inability to pass urine, severe dehydration, suspected prostate abscess or failure to improve within forty eight hours of treatment warrants hospital assessment. Do not attempt repeated traumatic catheterisation in a distressed patient.
Investigation priorities
Identify the organism before treating a suspected acute episode.
Management branches
A forty five year old has four months of recurrent dysuria and perineal discomfort.
- Three cultures have grown a similar Escherichia coli susceptibility pattern after temporary improvement with short bladder courses. He is now afebrile, voiding freely and clinically stable; urology arranges localisation testing after confirming there is no acute febrile episode.
- The assessment supports chronic bacterial prostatitis. The organism is trimethoprim-resistant, and microbiology identifies no appropriate safer oral alternative; renal function is normal, and there is no tizanidine, steroid use, previous quinolone reaction or relevant tendon disease. After discussing risks, he begins ciprofloxacin 500 mg orally twice daily for six weeks.
Key medicines
Ciprofloxacin 500 mg film coated tabletsFor acute prostatitis, NICE specifies 500 mg orally twice daily for fourteen days, then review whether to stop or continue for another fourteen days. The selected chronic bacterial regimen is 500 mg orally twice daily for four to six weeks; the worked case uses six weeks after specialist review.Reserve treatment for documented unsuitability of other commonly recommended antibiotics. The selected SmPC renal table uses creatinine clearance: above 30 to 60 ml/min/1.73 m², give 250–500 mg every twelve hours; at 30 or below, use its explicit ≤30 branch of 250–500 mg every twenty four hours. Haemodialysis doses are given after dialysis; peritoneal dialysis also uses the daily interval. Confirm the current renal estimate and infection-specific dose. Do not use with quinolone or formulation hypersensitivity or tizanidine. Avoid prior serious quinolone reactions and concurrent corticosteroids; use particular caution with older age, renal impairment or transplantation. Discuss tendon rupture, neuropathy, mood or suicidal symptoms, dysglycaemia, QT and aortic risks, and stop promptly for serious reactions. Take one to two hours before or at least four hours after iron, calcium supplements or antacids.
Trimethoprim 50 mg per 5 ml suspensionFor acute prostatitis when selected with specialist advice, give 200 mg as 20 ml orally twice daily for fourteen days, then review whether another fourteen days is needed.Use the named liquid concentration when calculating volumes. Its renal table keeps 200 mg twice daily for the first three days at eGFR 15–30 ml/min, then reduces to 100 mg as 10 ml twice daily; at eGFR below 15 the half-dose applies from the start. In dialysis, involve renal and infectious-disease specialists before prescribing. Hypersensitivity, severe hepatic insufficiency, megaloblastic anaemia and other blood dyscrasias exclude this product. A suspected severe cutaneous reaction requires immediate withdrawal and assessment; previous trimethoprim-induced SJS, TEN or DRESS rules out rechallenge. Follow potassium and renal function, particularly with ACE inhibitors, angiotensin receptor blockers or potassium-sparing drugs; avoid hazardous methotrexate use. Prolonged prostatitis treatment also requires haematological monitoring and review of folate risk.