Prostatitis is 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.

 

WHAT IS THE PROSTATE AND WHAT DOES IT DO?

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 during ejaculation.

 

TYPES OF PROSTATITIS

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.

 

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 frequently required.  

 

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 infection).

 

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, and others.

 

HOW DOES BACTERIAL PROSTATITIS DEVELOP?

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 medical procedure
• engage in rectal intercourse
• have abnormal urinary tract anatomy (congenital defect)
• have an enlarged prostate

 

WHAT ARE THE SYMPTOMS OF PROSTATITIS?

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.

 

ARE THE SYMPTOMS OF PROSTATITIS UNIQUE?

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:

 

HOW IS PROSTATITIS DIAGNOSED?

To help make an accurate diagnosis, several types of examinations are useful.

 

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.

 

A common diagnostic testing protocol is as follows:

Pre-massage 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 bacteria).

 

Post massage 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 pyelonephritis)

Examination of 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.

 

HOW ABOUT INFECTIONS CAUSED BY VIRUSES?

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.

 

HOW DO I KNOW WHICH TYPE OF PROSTATITIS I HAVE?

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.

 

WHY IS CORRECT DIAGNOSIS SO IMPORTANT?

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.

 

HOW IS PROSTATITIS TREATED?

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. 

 

Antibiotics

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 tried.

Anti-depressants

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.

Physical Therapy

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

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. 

 

Anti-spasmodic drugs

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 Oxytrol.

 

Anti-inflammatories

Non-steroidal 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.  

Minimally invasive prostate treatments

Experimental use 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.

Fluids and Diet

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.

 

Psychological support

Stress management 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.

Acupuncture

Acupuncture is 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. 

Prostate Massage

Regular prostate 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

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.

 

Sexual Frequency

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.   

 

Phytotherapy

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 studies.  

 

Category IV

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.

 

WILL PROSTATITIS AFFECT ME OR MY LIFESTYLE?

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.

 

WILL I GET PROSTATE CANCER FROM HAVING PROSTATITIS?

No association 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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