Prostatitis

Alternative names

Inflammation of the prostate.

What is prostatitis?

Prostatitis means “inflammation of the prostate”, and is one of the most common reasons men visit the doctor in the western world. It is most common in men over the age of 30, and particularly in men over the age of 60. While prostatitis is treatable, diagnosis can be lengthy and not all treatments are successful. This is partly because the various causes of prostatitis are not fully understood.

There are three main types of prostatitis:

• Acute prostatitis, which develops suddenly and may not be permanent
• Non-bacterial prostatitis, which may develop suddenly or follow a slower or variable course. It is now more commonly called chronic male pelvic pain syndrome because it cannot be proved to be “non-bacterial”, though a bacterial cause cannot be identified.
• Chronic (bacterial) prostatitis, which develops gradually and may only have subtle symptoms, though it often continues for a prolonged period.

A fourth type of prostatitis – asymptomatic inflammatory prostatitis – which has no symptoms at all but results in an inflamed prostate, is sometimes mentioned. It has been discovered when biopsies are conducted on the prostate to rule out cancer, and no cancer is found. This is an histological and not a clinical diagnosis. Prostatitis is often reported on the histological analysis of TURP specimens when the prostate resection was performed for symptoms of BPH. If the patient is asymptomatic this histological finding does not warrant any treatment.

What causes prostatitis?

The causes of prostatitis are not very well understood, although the three main types of prostatitis are based on generally accepted causes.

These range from bacterial infection to neuromuscular causes. Other less proven but possible causes include viruses, food allergies and so on. Some believe all types of prostatitis may have a combination of causes, or that the condition is a result of a few different diseases affecting the patient simultaneously.

Causes of acute bacterial prostatitis

Acute bacterial prostatitis is believed to be caused by a bacterial infection of the prostate gland. Types of bacterial infections that can cause this condition include:

• Escherichia coli (E. coli), found in the colon and resulting in infection following urinary tract infections, urethritis, or epididymitis
• sexually transmitted diseases such as gonorrhoea, chlamydia, trichomonas, and U. urealyticum

Urethral instrumentation such as a catheter or cytoscope, trauma, obstruction of the bladder outlet, or infection elsewhere in the body can also cause bacterial infections that lead to acute bacterial prostatitis.

Causes of non-bacterial prostatitis or chronic pelvic pain syndrome

In chronic non bacterial prostatitis inflammatory cells are found in the prostatic secretions but that no organisms are identified. It is presumed that chlamydia and ureaplasma may be responsible, however as these bacteria are very difficult to culture and identify, the condition is still called “non-bacterial”. As soon as an organism is identified as the cause of prostatitis, it is called chronic bacterial prostatitis.

Non-bacterial prostatitis or chronic pelvic pain syndrome often develops in men who have suffered from:

• urinary tract infection
• urethritis
• epididymitis (inflammation or infection of a duct on the posterior surface of the testicle)

Other suspected (non-bacterial) causes include spasms of the pelvic floor muscles.

Causes of chronic prostatitis

Chronic prostatitis is caused by bacterial infection, and may occur in men who have recently had

• a urinary tract infection
• urethritis
• acute prostatitis

Who gets prostatitis and who is at risk?

Acute bacterial prostatitis affects about two in every 10 000 men. Genetics do play a role. Black men are more at risk, as are men with a family history of prostatitis.

Other risks include:

• multiple sexual partners
• not using protection
• anal intercourse, particularly when not using a condom

Non-bacterial prostatitis or chronic male pelvic pain syndrome is the most common type. It affects about five in every 10 000 men. As with other types of prostatitis, risk may be increased by having many sexual partners, or risky sexual practices, including anal sex however these risks are difficult to prove.

Chronic prostatitis is more common in men over 30 years old, and it is believed that more than a third of men over the age of 65 may have some degree of chronic prostatitis. Some experts believe the following factors, which may cause congestion of the prostate gland, could result in the breeding of bacteria leading to chronic prostatitis:

• excessive alcohol intake
• perineal injury
• risky sexual practices

Symptoms and signs of prostititis

General symptoms common to all forms of prostatitis are:

• lower back pain
• pain when moving bowels
• pain in the area of the genitals (perineal or pelvic floor pain)

Symptoms and signs of acute bacterial prostatitis include:

• fever and chills
• abdominal pain
• pain when ejaculating

Blood in the urine, increased need to urinate, pain in the testicles and blood in semen are also possible symptoms.

Symptoms and signs of non-bacterial prostatitis and Chronic pelvic pain syndrome include:

• frequent urination
• pain or burning when urinating
• pain in the testicles
• tension in the urinary sphincter

Symptoms and signs of chronic prostatitis include the following, though sometimes they can be very mild, or not present at all:

• a tendency to recurrent urinary tract infections
• pain in the testicles
• pain or a burning sensation when urinating
• pain when ejaculating

Urine is sometimes bloody, or abnormal in colour, and some patients also suffer from incontinence.

How is prostatitis diagnosed?

Triple void urine specimens are collected – in other words the doctor will collect samples of initial stream, midstream, and post-stream urine (gathered through massage of the prostate).

Acute prostatitis is an acute febrile illness caused by bacterial infection of the prostate gland. The diagnosis is usually quite obvious based on the patient’s symptoms.

Acute bacterial prostatitis is diagnosed if:

• prostate is swollen, warm and firm
• urinalysis shows increased white blood cell count
• bacterial growth is found on a culture of the post-urination sample or on prostatic secretions
• initial symptoms are consistent with acute prostatitis

The syndromes of chronic bacterial prostatitis, chronic non-bacterial prostatitis and chronic pelvic pain syndrome are quite similar to one another. The difference depends on the findings of the microscopy and culture of the urine and prostate secretions.

If an organism is isolated it is called chronic bacterial prostatitis.

“Non-bacterial chronic prostatitis” is diagnosed if:

• leukocytes suggesting infection are present in the prostatic secretions
• no organism is isolated

A diagnosis of a diagnosis of chronic pelvic pain syndrome or prostatodynia is made if:

• symptoms of chronic prostatitis are present
• urine and prostate secretions are completely normal

Initial diagnosis may be proven wrong if treatments fail. As the different types of prostatitis are difficult to diagnose and treat, patients must expect that diagnosis will be a process rather than an event.

Can prostatitis be prevented?

Prostatitis cannot reliably be prevented, however lifestyle precautions – such as remaining fit and healthy – will be of benefit. Also helpful in preventing prostatitis are:

• good hygiene
• safe sex practices
• avoiding trauma
• avoiding stress

How is prostatitis treated?

Treatments specific to acute prostatitis

Acute prostatitis is completely different to chronic prostatitis or prostatodynia. It is a sudden, acute, severe febrile illness caused by bacterial infection of the prostate gland. It is treated with antibiotics. Unlike chronic prostatitis, antibiotic treatment is almost invariable successful. If patients are very ill at presentation then they are treated with intravenous antibiotics. The quinolones, such as ciprofloxacin or ofloxacin, are the most effective at penetrating the prostatic tissue. Treatment is usually for two weeks.

Acute prostatitis may occasionally be complicated by the development of a prostatic abscess. In this instance the patient’s temperature will not settle despite antibiotic treatment. The prostatic abscess is usually exquisitely tender to palpation via a rectal examination. A prostatic abscess is usually drained via a trans-urethral resection.

Some treatments or therapies are common to all types of prostatitis:

• Antibiotics are used in most treatments, even for non-bacterial prostatitis.
• Quinolones such as ciprofloxacin are the most widely used antibiotics
• Stool softeners might be prescribed to reduce the discomfort of bowel movements.
• Doctors will recommend that patients urinate frequently and completely, and may insert a catheter if the swollen prostate results in blockage.
• Increasing fluid intake to two or more litres per day to decrease constipation can help flush the bacteria from the body.
• Avoiding alcohol, caffeine, hot spicy foods, foods and drinks high in acid, and stopping smoking will help reduce irritation of the bladder.
• Warm baths may provide some relief from pain, particularly lower back pain and pain in the genital area.
• In all treatment of prostatitis, it is essential to monitor the patient after antibiotic therapy is complete, to ensure there is no lingering infection.

Treatments specific to chronic prostatitis

Chronic bacterial prostatitis is treated with a trial of antibiotics. The quinolones are the most effective. These drugs have a broad spectrum of anti-bacterial activity and penetrate the prostatic tissue well. Treatment is usually for as long as six to eight weeks. Surgery has no role.

Treatments specific to non-bacterial prostatitis / chronic male pelvic pain syndrome

Chronic non-bacterial prostatitis is also treated with a trial of antibiotics in the hope that there may be an underlying infectious cause. The quinolones are the most effective. These drugs have a broad spectrum of anti-bacterial activity and penetrate the prostatic tissue well. Treatment is usually for as long as six to eight weeks.

Treating non-bacterial prostatitis is a long process usually aimed at relieving symptoms. Pelvic floor exercises are sometimes helpful since spasms of the pelvic floor muscles are thought to be responsible for some symptoms.

Alpha-blockers, muscle relaxants and anti-inflammatory agents, as well as complementary medicine alternatives may be used.

Surgery has no role in the treatment of chronic non-bacterial prostatitis or prostatodynia.

What is the outcome of treatment?

Cases of acute prostatitis are usually completely resolved by appropriate antibiotic treatment. A two-week course of antibiotics is usually sufficient. Recurrence or persistent infection is rare.

On the other hand all forms of chronic prostatitis are difficult to treat. Standard antibiotics penetrate the prostate poorly. Quinolones and trimethoprim-sulphametoxazole penetrate the prostate fairly well. Resistance to trimethoprim-sulphametoxazole is, however, fairly common.

Chronic prostatitis is likely to recur despite treatment, but symptoms are milder and can be reduced by changes in lifestyle. Treatment lasts between six and eight weeks.

When to call the doctor

The sooner treatment is received, the better, particularly for acute forms of prostatitis. Contact your doctor as soon as you notice any symptoms.

Routine prostate checks are recommended for men over 50, and those who are at high risk of prostate cancer should start at 40.

Once prostatitis is suspected, patients need to see their doctor regularly to monitor and possibly continue treatment, or change treatment if initial treatment is unsuccessful.

Prostatitis is a complex condition, and research into it continues. More info on prostatitis as well as support from medical experts and others dealing with the condition is available from www.prostatitis.org

Reviewed by Dr Pieter J le Roux MBChB, FRCS(Eng), FRCSI, FCS(SA)Urol.