By David S. Breslin, MD FACS | Urology
Prostatitis refers to a series of conditions associated with infection or inflammation of the prostate or the tissues and muscles that surround the prostate. There are numerous symptoms, many of which occur during urination or ejaculation, but can also include debilitating pain in the pelvic or pubic areas. Treatments vary according to the cause and may include a variety of options.
The prostate is usually described as a walnut-sized gland that is situated below the bladder, surrounding and comprising the upper portion of the urethra, and responsible for producing the seminal fluid, in which the sperm are suspended during ejaculation. Physicians can examine the prostate manually only by performing a digital rectal examination, where the size, consistency, and symmetry of the prostate is assessed, as well as the presence of suspicious masses.
Acute bacterial prostatitis refers to a true bacterial infection of the prostate and may include any or all of the following: high fevers, shakes, chills, fatigue, muscle aches, painful and frequent urination, cloudy urine. Treatment with antibiotics is mandatory, either orally at home, or in severe cases, with intravenous antibiotics in an inpatient setting. There are usually no long-term consequences, except chronic bacterial prostatitis may follow infrequently. If the common prostate blood test PSA is performed during this period it may very well be falsely elevated, and might incorrectly cause concern about prostate cancer.
Chronic bacterial prostatitis is the result of recurring bacterial infections from a source deep within the prostate. The symptoms are usually not as severe as those of acute prostatitis, and may resolve temporarily after a course of antibiotics, only to recur. The diagnosis is made by a characteristic history, and by the presence of positive urine cultures demonstrating the same bacterium time after time. Antibiotics are the treatment of choice with duration of perhaps 4-12 weeks, or by chronic, low-dose suppressive antibiotic therapy.
Chronic nonbacterial prostatitis/chronic pelvic pain syndrome is perhaps the most controversial, and is definitely the most common, accounting for approximately 90% of cases. It is not associated with bacteria and is not an infection. At the time of presentation, the symptoms may have been present for 6-12 months; frustrated patients may have visited multiple physicians, and have been offered multiple trials of antibiotics in the mistaken assumption that this is a bacterial infection. A patient’s quality of life is usually diminished by the time he seeks care.
Symptoms are usually associated with pelvic or perineal (the area behind the scrotum) discomfort or pain; frequent or painful urination or ejaculation. The source of the symptoms is unclear, and may include inflammation of the nerves and tissues within and surrounding the prostate. Treating this entity may be challenging and usually includes a multi-modal approach, such as over the counter anti-inflammatories like ibuprofen or naproxen. Prescription medications of a variety of types are used: alpha blockers relax the smooth muscle in the prostate and bladder neck and will increase urinary flow; certain neurologic drugs like gabapentin may help in reducing the pelvic pain; bladder antispasmodics are helpful in decreasing the urinary frequency and urgency. Biofeedback or pelvic muscle rehabilitation may also be helpful. Many patients turn to herbal or homeopathic remedies.
Asymptomatic inflammatory prostatitis is a diagnosis established in patients without symptoms, usually by an examination of prostatic tissue during a prostate biopsy; or by detecting inflammatory cells in urine or semen. It is thought that this condition might falsely elevate the PSA, hence the need for a prostate biopsy. Usually no treatment is required if there are no other symptoms.
The diagnosis of these conditions requires a careful history and physical examination, as well as a thorough investigation of laboratory studies and x-rays when indicated. In many chronic cases, relief may be incomplete or fleeting. Deliberate physician-patient communication is required to help patients understand the array of options and controversies that exist, and to reassure patients who remain symptomatic even after long-term therapy.