Prostatitis

What is prostatitis?

Prostatitis is an inflammation of the prostate.

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. 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 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.

What are the different types of prostatitis?

There are three types of prostatitis:

  • Bacterial prostatitis (acute or chronic)
    • 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 our office or the emergency room is essential and hospitalization is frequently required. 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).
  • Non-bacterial prostatitis
    • Non-bacterial prostatitis is not caused by bacteria; its cause is not known. Nevertheless, the prostate is inflamed and when prostate massage specimens are studied under the microscope, there may be evidence of increased numbers of white blood cells (pus cells) in semen and urine.. Anti-microbial medications are not effective for this type of prostatitis. Treatments, described later, may be helpful in some cases.
  • Prostadynia
    • Prostadynia has all the symptoms of prostatitis, but no bacteria are found in cultures and urine. Prostate massage specimens and semen have no white blood cells when examined under the microscope. We have no idea why prostadynia exists, nor do we have an effective cure. Antibiotics are not effective for prostadynia.

Note: The "-itis" at the end of prostatitis denotes inflammation. Inflammation usually denotes white blood cells or pus cells. Therefore, technically speaking, prostadynia is not truly prostatitis. We add it to the list because the symptoms and treatment are identical to non-bacterial prostatitis.

How does bacterial prostatitis develop?

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. The bacteria that cause prostatitis may get into the prostate from the urethra by backward flow of infected urine into the prostate ducts or from rectal bacteria.

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 had a recent bladder infection
  • Have an enlarged prostate

What are the symptoms of prostatitis?

The symptoms of prostatitis depend on the type of disease you have. You may experience no symptoms or symptoms so sudden and severe they cause you to seek emergency medical care. Symptoms, when present, can include any of the following:

  • Fever
  • Chills
  • Urinary frequency
  • Frequent urination at night
  • Difficulty urinating
  • Burning or painful urination
  • Perineal (referring to the perineum, the area between the scrotum and the anus)
  • Low-back pain
  • Joint or muscle pain
  • Tender or swollen prostate
  • Blood in the urine
  • Painful ejaculation

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 non-cancerous 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.

Still another condition that mimics the symptoms of prostatitis -- when prostatitis is not present -- is prostadynia (painful prostate). Patients with prostadynia have pain in the pelvis or in the perineum. Such pain may result from a prostate problem, but the pain can have a variety of different causes, including muscle spasms or other musculoskeletal conditions.

Yet another term we may mention in discussing your prostate problem is prostatosis, a more vague word that simply means "a condition of the prostate." It is often interchangeable with prostadynia. Because of the connections between the urethra, bladder, and prostate, conditions affecting one or the other often have similar or overlapping symptoms.

How is prostatitis diagnosed?

To help make an accurate diagnosis, several types of examinations are useful. The prostate is an internal organ, so it cannot be looked at directly. Because it 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.

The test that must be performed when prostatitis is suspected is prostate massaging, during which prostatic fluid is collected. While performing the digital rectal examination, your prostate may be vigorously massaged to force prostatic fluid out of the gland and into the urethra. Although prostate massage is not comfortable, we need to be able to examine the fluid to accurately diagnose your condition. If no fluid is expressed after massage, we may ask you for another urine specimen so that we may examine the washout of the prostate channel from the first part of urination. For this urine specimen we do not want the middle of the stream, but the first few teaspoons that are urinated. The prostatic fluid is then analyzed under a microscope for signs of inflammation and infection.

When the diagnosis of prostatitis is not clear we will do a three-glass urine collection with prostate massage. The three-glass urine collection method with prostate massage is used to separately measure the presence of white blood cells and bacteria in the urine and prostatic fluid. You will be asked to collect two urine samples separately: the first ounce of the urine you void (urine from your urethra), and then another sample of flowing midstream urine (urine from your bladder). You will then almost empty your bladder by urinating into the toilet. At this point, your doctor will massage your prostate (prostatic fluid) and collect on a slide any secretions that appear. If no fluid is retrieved from the massage (which occurs about 50 percent of the time) you will then collect in a third container; the first ounce of urine that remains in your bladder. All of these specimens will be examined and cultured separately.

Examination of these samples will help us 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, we will also be able to identify the type of bacteria involved so that the most effective antibiotics can be prescribed.

What 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 has shown these agents, some of which are viruses, to be present more frequently in patients with prostatitis than in those without prostatitis. We do not have any effective treatment for viral infections.

How do I know what type of prostatitis I have?

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, 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.

Chronic bacterial prostatitis is associated with repeated urinary tract infections, while non-bacterial 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 perineal and low-back pain. Microscopic examination of the urine specimen will be loaded with white blood cells and bacteria.

Non-bacterial prostatitis is more common than bacterial prostatitis. It may cause no symptoms or its symptoms may mimic those of chronic bacterial prostatitis. If you have non-bacterial prostatitis, however, it is unlikely that you will have urinary tract infections. On occasion we will find patients developing prostatitis from lack of sexual activity. This is called "congestive prostatitis" and suggests that lack of ejaculation causes the semen to stay in the prostate too long and cause inflammation. Conversely, men who ejaculate too frequently can develop an "exhaustive" or "overuse" prostatitis. A sexual history is an integral part of each man's evaluation.

Why is a correct diagnosis so important?

Because the treatment is different for the three types of prostatitis, the correct diagnosis is very important. Non-bacterial prostatitis will not clear up with antibiotics, and bacterial prostatitis will not go away without such treatment. In addition, it is important to make sure 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. If you have acute bacterial prostatitis, you will usually need to take antibiotics for seven to 14 days. 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.

If you have chronic bacterial prostatitis, you will require antibiotics for a longer period of time -- usually four to 12 weeks. 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 anti-microbial therapy may be recommended to relieve the symptoms. In some cases, surgical removal of the infected portions of the prostate may be advised.

Non-bacterial prostatitis and prostadynia cause the biggest difficulty with treatment.. Since we have no real explanation of why these diseases exist, the treatments are aimed at lessening symptoms more than curing the disease.

We do know, however, that if you have non-bacterial prostatitis, you do not need antibiotics. Most patients with non-bacterial prostatitis will have already had several courses of antibiotics before they get to a urologist. These drugs have usually been given before the cultures have returned. Since bacterial prostatitis is curable with antibiotics, and technically the cultures could miss an infection, a trial of drugs -- even if the culture shows no growth -- may be warranted. One major problem is the variability of non-bacterial prostatitis to cause symptoms. As the disease waxes and wanes normally, a patient can be misled to believe the antibiotics are helping his problem. When the drug doesn't work, the patient then believes that he has become resistant and wants to try yet another drug. Sometimes, after countless visits to the doctor and hundreds of dollars worth of medication, the problem still exists and the cultures, done over and over, still show no growth of any bacteria.

An appropriate treatment is aimed more at reducing symptoms rather than curing them. The nonbacterial prostatitis will come and go; there will be good months and bad months. All we can do is try to moderate the symptoms of the disease. 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 relieve symptoms. In addition, drinking plenty of water helps. This dilutes the acidity and salt in the urine and dilutes any irritants that you might eat (e.g., caffeine, cranberry, citrus acid, peppers and spices).

For those patients with difficulty urinating or who have a slow stream, we can use drugs to relax the muscles of the sphincter area. (Sphincters are the muscular valves that hold the urine in the bladder.) These drugs are called "alpha blockers."

For those patients who have urgency and frequency of urination, we can use medications to relax the muscles that surround the bladder to make it less sensitive. These drugs are referred to as "parasympathetic blockers." If the patient ingests large amount of irritating foods, we might modulate his diet. Major culprits are acidic foods, such as cranberry, cola, and coffee. Alcohol and spicy foods are also irritating to the prostate. Non-steroidal anti-inflammatory medications may be helpful. Ibuprofen and naproxen, both available over-the-counter, along with stronger prescription anti-inflammatories may be of some benefit. Stress management may be helpful in those men who feel that their symptoms are worsened at times of stress. Relaxation and quiet and a peaceful meal can often help when "stressed out."

Many men with prostatitis stop having sexual relations because of fear of transmitting disease to their partners. Some men stop having sex because they are depressed. Prostatitis cannot be transmitted, so 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 possibly present, we would recommend ejaculating perhaps one to three times a week. Masturbation is OK for this purpose. In those men who might have overuse prostatitis, we sometimes recommend less sexual activity.

Experimental use of microwave therapy has been reported as an effective treatment for non-bacterial prostatitis. This technology is referred to as "transurethral microwave therapy" or TUMT. In one technique, a microwave probe is placed into the prostate channel through the penis using a catheter. Another technique is to place the microwave probe next to the prostate through the rectum. The prostate is heated gently at various intervals. The probe placed though the penis has been approved by the FDA for the treatment of enlarged prostates, but not yet for the treatment of prostatitis.

You may find that tub baths or changes in your diet help to alleviate your symptoms. While there is no scientific evidence proving these "home remedies" are effective, they are not harmful and some people experience relief from symptoms while using them.

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 infecting your partner. 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 prostatitis?

No association between prostatitis and prostate cancer has been established. Nevertheless, the screening tests we now use for prostate cancer include the prostate specific antigen (PSA), digital rectal examinations and prostatic ultrasound. Results of all three can be skewed by the presence of prostatitis.

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.