an inflammation of the prostate. In the US, over 2 million patient-visits per
year are a result of prostatitis. It is the most common urologic problem in men
less than 50 years old. Between 6-8% of all men will develop prostatitis in
their lifetime. If a man has an episode of prostatitis, he has a 50% chance of
having another episode in his lifetime. The following information will answer
some of your questions about prostatitis, as well as those about the prostate
itself--where it is and what it does.
The prostate is a gland of the male reproductive system. It is located
in front of the rectum and just below the bladder, the organ that stores urine.
The prostate is quite small--it weighs only about an ounce--and is nearly
the same size and shape as a walnut. As shown below, the prostate wraps around a
tube called the urethra, which carries urine from the bladder out through the
tip of the penis.
The prostate is made up largely of muscular and glandular tissues. Its
main function is to produce fluid for semen, which transports sperm. During
the male orgasm (climax), muscular contractions squeeze the prostate's fluid
into the urethra. Sperm, which are produced in the testicles, are also propelled
into the urethra during orgasm. The sperm-containing semen leaves the penis
Historically three types of prostatitis were recognized:
• bacterial prostatitis (acute or chronic) ~ 5% (new
categories I and II)
• non-bacterial prostatitis ~ 65% (new category IIIa)
• prostatodynia 30% (new category IIIb)
This older classification unfortunately did not take into account newer
information about prostatitis. Mislabeling a patient's problem often led to
treatments that might not have been warranted.
A new classification of prostatitis by the US National Institute of
Health (NIH) was recently introduced.
Acute Bacterial Prostatitis
Acute infection of prostate
Chronic bacterial prostatitis
recurrent infection of
Also known as "chronic pelvic
pain syndrom of CPPS"
No demonstrable infection
inflammatory chronic pelvic pain syndrome
white blood cells in prostate fluid
non-inflammatory chronic pelvic pain syndrome
no white blood cells in prostatic fluid
asymptomatic inflammatory prostatitis
no symptoms but white blood cells seen in prostatic
Category I or acute bacterial prostatitis is caused by bacteria and is
treated with antibiotics. Acute bacterial prostatitis comes on suddenly, and its
symptoms--including chills and fever--are severe. Therefore, a visit to your
doctor's office or the emergency room is essential, and hospitalization is
Category II or chronic bacterial prostatitis is also caused by bacteria
and requires antibiotics. Unlike an acute prostate infection, the only symptoms
of chronic bacterial prostatitis may be recurring bacterial cystitis (bladder
Category III, or nonbacterial prostatitis, is not believed to be caused
by a bacteria or virus, but its cause is not known. In fact, we are not sure
that chronic nonbacterial prostatitis is even a disease of the prostate! There
is currently a large amount of research underway to determine the cause of this
type of chronic prostatitis. Possible causes include bacterial or viral
infection that cannot be detected in the usual manner, pelvic floor muscle
dysfunction, abnormal blood flow to the bladder and prostate, autoimmune
disorders, a physical manifestation of depression, pelvic floor muscle strain,
Despite their names, acute and chronic bacterial prostatitis are not
contagious and are not considered to be sexually transmitted diseases. Your
sexual partner cannot catch this infection from you. The way in which the prostate becomes infected is
not clearly understood. Certain conditions or medical procedures increase the
risk of contracting prostatitis. You are at higher risk for getting
prostatitis if you:
recently have had a medical instrument, such as a urinary catheter (a
soft, lubricated tube used to drain urine from the bladder) inserted during a
engage in rectal intercourse
have abnormal urinary tract anatomy (congenital defect)
have an enlarged prostate
The symptoms of prostatitis depend on the type of prostatitis you have.
Acute bacterial prostatitis causes fever, painful urination, and slowing of the
urinary stream. Patients may also have lower abdominal or back pain, or pain in
the rectum or perineum, which is the space between the scrotum and the
anus. There may be pain during ejaculation and blood in the semen. These
symptoms are usually sudden and severe, and will usually cause the patient to
seek out urgent medical care. The symptoms of chronic prostatitis are usually
slower in onset, and are frequently present for weeks to months before patients
seek medical help. Many patients complain of pain in the perineum, or a feeling
that they are "sitting on a golf ball." Others have pain in the testicles,
urethra, deep in the base of the penis, or in the rectum. Some patients
complain of a spasm of pain deep in the pelvis, and many patients have pain
during urination and ejaculation. Some patients complain of decreased force to
the urinary stream, burning during urination, or unusual frequency of
urination. Some patients will also report decreased rigidity of their
erections, although most men remain sexually potent.
The symptoms of
prostatitis resemble those of other infections or prostate diseases. Thus,
even if the symptoms disappear, you should have your prostate checked. For
example, benign prostatic hyperplasia (BPH), a noncancerous enlargement of the
prostate that is common in men over age 40, may produce urinary tract symptoms
similar to those experienced with prostatitis. Similarly, urethritis, an inflammation of the
urethra (often caused by an infection), may also give rise to many of the
symptoms associated with prostatitis.
Because of the
connections between the urethra, the bladder, and the prostate, conditions
affecting one or the other often have similar or overlapping symptoms. These
include the following:
Seminal Vesicle Cyst
Ejaculatory Duct Cyst
To help make an accurate diagnosis, several types of examinations are
The prostate is an internal organ, so the physician cannot look at it
directly. Because the prostate lies in front of the rectum, just inside the
anus, the doctor can feel it by inserting a gloved, lubricated finger into the
rectum. This simple procedure, called
a digital rectal examination ( or just 'rectal'), allows the physician to
estimate whether the prostate is enlarged or has lumps or other areas of
abnormal texture. While this examination may produce momentary discomfort, it
causes neither damage nor significant pain. Because this examination is essential in detecting early prostate cancer,
which is often without symptoms, the American Urological Association recommends
a yearly prostate examination for every man over age 40 and an immediate
examination for any man who develops persistent urinary symptoms.
When prostatitis is suspected the urologist will perform prostate massage
during the prostate exam, to force prostatic fluid out of the gland and into the
urethra. Although prostate massage is not comfortable, the urologist needs to be
able to examine the fluid to accurately diagnose your condition. If no fluid is
expressed after massage, you may be asked to give another urine specimen to
examine the washout of the prostate channel from the first part of urination.
diagnostic testing protocol is as follows:
urine You need to provide a specimen from the middle of your stream of
free flowing urine. This represents the urine from your bladder (Called
midstream urine or VB2). Urination should be stopped after this specimen is
collected so that additional specimens can be obtained a few minutes later.
You will then go back to the examination room to see the doctor. Note: Some
physicians will use the initial first few teaspoons of urination to look at the
urethra (Called first glass or VB1)
Prostate massage The physician will examine the prostate with a
digital rectal exam. He or she will then vigorously massage the prostate gland
to force the prostate fluid into the urethra (channel through the penis). This
discharge is called expressed prostatic secretions or EPS. At least 50% of the
time, prostate fluid will be found at the tip of the penis. This fluid, if
found, is examined under the microscope and also sent to the laboratory for
culture (identification of type of bacterial growth) and sensitivity (if
bacterial growth is found, which antibiotics are most effective against the
urine. Another urine specimen is obtained. This time only the first two
teaspoons of urine that is passed is collected. This represents the fluid
forced into the penis by the massage. This is referred to as post massage
urine or VB3. This urine is examined under the microscope and also sent to the
laboratory for culture and sensitivity. If cultures from the post massage
urine are positive for bacteria and the concentration of bacteria in the post
massage specimen is greater than the pre massage specimen, a diagnosis of
bacterial prostatitis is made. If the cultures are positive from both urine
specimens, but in equal concentrations, the most likely diagnosis is urinary
tract infection (bladder or kidney infection, also known as cystitis or
these samples will help your physician determine whether your problem is an
inflammation or an infection and whether the problem is in your urethra,
bladder, or prostate. If an infection is present, your doctor will also be able
to identify the type of bacteria involved so that the most effective antibiotics
can be prescribed.
Unfortunately, many type of organisms other than bacteria can cause
infections or inflammations. Viruses are the best known agents of infections,
but other types of organisms also exist that may be linked to infections of
various parts of the body. Organisms that we have tried to link to
prostatitis include chlamydia, ureaplasma, mycoplasma, herpes simplex,
cytomegalovirus, adenovirus, and trachoma. None of the studies done on
prostatitis have shown these agents, some of which are viruses, to be present
any more in patients with prostatitis than those without prostatitis. We do
not have any effective treatment for viral infections.
Category I or acute bacterial prostatitis is the easiest of the three
conditions to diagnose because it comes on suddenly and the symptoms require
quick medical attention. Not only will you have urinary problems, but you may
also have a fever and pain and, occasionally visible blood in your urine. Your
urine may be cloudy and microscopic examination of the urine specimen will be
loaded with white blood cells and bacteria.
Category II or chronic bacterial prostatitis is associated with repeated
urinary tract infections, while nonbacterial prostatitis is not. In fact, if you
do not have a urinary tract infection or a history of one, you probably do not
have chronic bacterial prostatitis. Other symptoms, if any, may include urinary
problems such as the need to urinate frequently, a sense of urgency, burning or
painful urination, and possibly groin, perineal(area where one sits under the
scrotum and in front of the anus) and low-back pain. Microscopic examination
of the urine specimen will be loaded with white blood cells and bacteria.
Category III or 'chronic pelvic pain syndrome' with (type IIIa) pus cells
or without (type IIIb) white cells in prostate massage specimens are more common
than Category I and II or acute and chronic bacterial prostatitis. This is the
most common type of "prostatitis" in younger men, and the most difficult type of
prostatitis to treat.
Category IV are patients who have no infection or symptoms but are found
to have pus cells in their prostate massage specimen. These patients, without
symptoms, might be found after a routine examination of the urine showed white
blood cells and additional evaluation revealed these white blood cells (or pus
cells) to be coming from the prostate. Some patients, also without symptoms,
might also be found after an elevated prostate specific antigen blood test, a
test used to screen for prostate cancer. Prostate inflammation can cause an
elevation in the PSA. A prostate biopsy to test for cancer might show no
cancer but inflammation of the prostate.
Because the treatment is different for the three types of prostatitis,
the correct diagnosis is very important. Nonbacterial prostatitis will not
usually clear up with antibiotics, and bacterial prostatitis will not go away
without such treatment. In addition, it is important to make sure that your
symptoms are not caused by urethritis or some other condition that may lead to
permanent bladder or kidney damage.
Your treatment depends on the type of prostatitis you have.
Category I - acute bacterial prostatitis
If you have acute bacterial prostatitis, you will usually need to take
antibiotics for 7 to 14 days. In some cases, intravenous antibiotics are
required in the early stages of treatment. Almost all acute infections can be
cured with this treatment. Analgesic drugs to relieve pain or discomfort and, at
times, hospitalization may also be required.
Category II - chronic bacterial prostatitis
If you have chronic bacterial prostatitis, you will require antibiotics
for a longer period of time--usually 4 to 12 weeks. In most cases we use
antibiotics in the 'quinolone' or 'sulfa/trimethoprim' groups. About 60
percent of all cases of chronic bacterial prostatitis clear up with this
treatment. For cases that don't respond to this treatment, long-term, low-dose
antibiotic therapy may be recommended to relieve the symptoms. In some cases,
surgical removal of the infected portions of the prostate may be advised.
Category III - chronic pelvic pain syndrome (CPPS)
This group of patients is the most difficult group to treat. In some
patients the symptoms will come and go for several years and then resolve
completely. In others this problem becomes a long-term, chronic condition,
similar to arthritis or back pain. There may be long periods of minimal
symptoms and then symptom flare-ups. The treatments are aimed at resolving
symptoms during flare-ups and decreasing the frequency of flare-ups.
We know that
patients who truly have nonbacterial prostatitis do not need antibiotics.
Recent studies have shown that patients without prostatitis have the same amount
of bacteria or more in their semen than patients with chronic prostatitis.
Unfortunately, it is very difficult to prove that bacteria are not present in
the prostate and causing symptoms of prostatitis. Many patients with
non-bacterial prostatitis will have already had several courses of antibiotics
before they get to a urologist, so cultures of prostate fluid or semen may not
be reliable. Since bacterial prostatitis is curable with antibiotics, a trial
of antibiotics may be warranted. In some cases antibiotics for 6 weeks has given
relief when shorter courses have failed. In some studies as many as 40% of men
will improve with antibiotics. One problem that arises with assessing the
results of antibiotic therapy is the fact that the symptoms of chronic
prostatitis wax and wane. As the disease waxes and wanes normally, patients
can be misled to believe that the antibiotics are really helping their problem.
If antibiotics don't work at a later time, the patient may believe that an
infection has become resistant and want to try another drug. Patients may make
countless visits to doctors and spend hundreds of dollars on medication, and
still have the same problem. If cultures are negative and a patient fails to
improve after a 6 week course of antibiotics then other treatments should be
There is growing evidence that certain
anti-depressants may disrupt transmission of pain signals in the spinal cord,
and give relief for patients who mainly experience pain. These medications
include Effexor, Celexa, and others. Other medications that may help with pain
include neurontin or Elavil.
Pelvic Floor Therapy
In some patients the symptoms may be caused by spasm
or chronic tightening of the pelvic floor muscles. Pelvic floor biofeedback
therapy helps teach relaxation of the pelvic floor muscles. Medications such as
Valium or Soma may also help relax the pelvic floor.
Some patients have certain places in the pelvic floor
called "trigger points" that may act as a source of pain. Daily physical
pressure with a finger in the rectum can help to resolve the pain, but requires
a therapist or family member who is able to perform the daily therapy.
Alpha-blockers are drugs that relax the muscles in the prostate and
bladder neck, and can help to improve the force of the urinary stream and
decrease pain during urination. Commonly used drugs include Flomax, Uroxatrol,
Hytrin, and Cardura.
For those patients who have urgency and frequency of urination, we can
use medications that relax the bladder muscles and help the bladder to hold more
urine. The commonly used medications include Detrol LA, Ditropan XL, and
anti-inflammatory medications may also be helpful. Ibuprofen and naproxen,
both available over-the-counter now, along with stronger prescription
anti-inflammatories may be of some benefit.
invasive prostate treatments
of minimally invasive prostate treatments has been reported as an effective
treatment for non-bacterial prostatitis. This technology is referred to as
transurethral needle ablation of the prostate, or
TUNA. This treatment is a standard treatment for prostate enlargement
but is effective in many cases of chronic prostatitis.
Drinking plenty of water helps. This dilutes the acidity and salt in
the urine and dilutes any irritants that you might eat (caffeine, cranberry,
citrus acid, peppers and spices, etc).
Some patients find that certain foods make their symptoms worse, but it
is not predictable from patient to patient. Major culprits are acidy foods such
as cranberry, cola, and coffee. Alcohol and spicy foods are also irritating to
the prostate. Some patients have specific food items that are bothersome, such
as onions or tomatoes. If you can identify an increase in symptoms with any
food group - reduce your intake.
and biofeedback may also be helpful in those men who feels that their symptoms
are worsened at times of stress. Life style changes may help, including
massage, relaxation, coping mechanisms, psychological support, diet changes and
exercise. For some a quiet and a peaceful meal can often help when 'stressed
out'. Psychotherapy and coping skills may also help.
the Chinese originated medical therapy using fine needles into certain 'nerve
sites' for each body part. Their are some reports of success with chronic
prostatitis. In addtion, there is a new treatment that uses low-voltage
stimulation of an acupuncture point in the leg that shows promise for bladder
and prostate symptoms.
massages can also be helpful. The physician will forcibly press the prostate
gland firmly in an attempt to break up or release areas of inflammation from the
gland. Technically, ejaculation will do the same thing, but some feel that the
forcible (and painful) massage is more effective.
Hot baths are helpful for almost all men with prostatitis of any kind.
These are often referred to as sitz baths and the warm water and relaxation of
the bath soothe the prostate and relieves symptoms. While there is no
scientific evidence proving that these "home remedies" are effective, they are
not harmful and some people experience relief from symptoms while using them.
Many men with prostatitis stop having sexual relations because of fear of
transmitting disease to their partner. Some men stop having sex because they
are depressed. Prostatitis cannot be transmitted. We encourage men to
maintain a normal sex life. The amount of sex we recommend is based on one's
usual sexual patterns. If you are ejaculating rarely and we feel that
congestive prostatitis is possible present, we would recommend ejaculating
perhaps one to three times a week.
Herbal therapy is the use of naturally occurring plants or plant extracts
for the treatment of various diseases. Herbal treatments supporters make no
differentiation between prostate enlargement (BPH) or prostatitis. The
American Food and Drug Administration (FDA) views these as food additives and
makes little or no effort to control the use or content of herbal therapy. No
American studies have been done to establish the safety or usefulness of any
herbal treatment for prostate enlargement or symptoms. In the last few years a
number of European studies have been done that suggest that herbal therapy can
help relieve prostate symptoms. These studies do not give any answers as to
why herbal therapy works and none have the safety investigations so necessary
for American drug studies. Another problem is the different amount of herbal
extract in each product. This means that the amount of herb in each
preparation may be different. Many of the preparations come with multiple
herbs so that it may be impossible to determine which herb is helping reduce
prostate symptoms. Nevertheless many men in the United States have used herbal
therapy purchased through drug and health food stores with some success. These
drugs do not require prescriptions and are rarely covered by insurance.
The most popular of these extracts is saw palmetto. Saw palmetto is
sold under a variety of names and often with a variety of other herbs or
extracts. Saw palmetto was originally thought to be similar to finasteride
(Proscar). We now believe this not to be true as saw palmetto doesn't lower
the prostate specific antigen and prostate volume like finasteride does. Some
researchers feel that saw palmetto may reduce prostate inflammation. As of now
we do not know why saw palmetto works. It does seem to be safe, without
significant side effects.
Other less well know extracts include Pygeum Africanum, beta-sitosterol,
pollen extract, pumpkin seeds, South African star grass and stinging nettles,
meparticin, and radix urticae. These extracts all appear to be safe and well
tolerated. Their effectiveness has not been established with any American
Treatment of patients with no symptoms and no definite evidence of
infection may be difficult to justify. However, if the patient has an elevated
prostate specific antigen (PSA) blood test and has required one or more biopsies
of the prostate to rule out cancer, a case for antibiotic treatments followed by
additional PSA tests could be made. A discussion with your physician of your
options is needed.
Prostatitis is a treatable disease. Even if the problem cannot be
cured, you can usually get relief from your symptoms by following the
recommended treatment. Prostatitis
is not a contagious disease. You can live your life normally and continue
sexual relations without passing it on.
You should keep in mind the following ideas:
• Correct diagnosis is key to management of prostatitis.
• Treatment should be followed even if you have no symptoms.
between prostatitis and prostate cancer has been established. However, the
screening tests that we now use for prostate cancer include the prostate
specific antigen (PSA), digital rectal examinations and prostatic ultrasound.
All three can be skewed by the presence of prostatitis. The PSA levels can be falsely elevated by
prostatitis. If a patient has an elevated PSA, along with finding of
prostatitis, we encourage treatment and a repeat of the blood tests. Many
patients with chronic prostatitis will undergo prostate biopsies because their
PSA values are too high. The biopsy is necessary as we cannot tell prostatitis
from prostate cancer in many cases. Having prostatitis does not increase your risk of getting any other
prostate disease. But remember, even if your prostatitis is cured, there are
other prostate conditions, such as prostate cancer, that require prostate
checkups at least once a year after age 40.
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