Prostatitis

Prostatitis is an inflammation of the prostate.  It affects many men and can become a chronic problem with debilitating recurrent symptoms. The prostate is a gland of the male reproductive system that is located in front of the rectum and just below the bladder.  The prostate is small and weighs about 15-25gm - about the same size and shape as a walnut.  The prostate is wrapped around a tube called the urethra, which carries urine from the bladder out through the tip of the penis.

The prostate is made up mainly 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 at this time.

Prostatitis, in many ways, is a mystery to health care practitioners.  It is known that prostatitis starts with a bacterial infection: Bacteria take up residence in the prostate and as it proliferates, the patient becomes aware of a problem.  He very quickly appears at the general practitioner's surgery demanding treatment, and is given antibiotics to kill the bacteria.

It is at this point that things become mysterious.  Even after the bacteria have been killed, or should have been killed, the sensations and discomfort continue.  Course after course of antibiotic are used and still there is a constant desire to urinate and a long list of unpleasant sensations issue from below the belt.  Some health care practitioners feel that the problem is that the antibiotics cannot get into the prostate and completely clear the infection.  Other practitioners feel that the bacteria are actually gone but the nerves have been affected so that the sensations remain.  No one really has an answer to this riddle, but the fact remains many people, despite having been treated with many courses of antibiotics, continue to suffer with prostatitis.

Causes and Development; Contributing Risk Factors

There are three types of prostatitis:

• Acute infectious prostatitis is usually caused by bacteria and is treated with antimicrobial medication or antibiotic.  Acute infectious prostatitis comes on suddenly, and its symptoms such as urinary frequency and urgency, lower abdominal pain and pressure, burning on urination, chills and fever can be severe and life-threatening.  In these situations, a visit to your doctor's office or the emergency room is essential, and hospitalization is frequently required.
  
  Acute infectious prostatitis is the easiest of the three types 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, frequently, blood in your urine.
• Chronic infectious prostatitis is also caused by bacteria and also requires antimicrobial medication or antibiotics.  Unlike an acute prostate infection, the only symptoms of chronic infectious prostatitis may be recurring infectious cystitis (bladder infection).  While its chronic symptoms may not be as severe as acute infectious prostatis, it is as potentially debilitating due to its chronic recurrent nature, and it can impact on one's quality of life significantly.
  
  Chronic infectious prostatitis is associated with repeated urinary tract infections, while noninfectious 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 infectious 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 perineal and low-back pain.
• Noninfectious prostatitis is the term reserved for prostatitis that after a thorough evaluation to eliminate infectious causes are found to be not caused by bacteria.  This class of prostatitis - chronic noninfectious prostatitis - has been the subject of much research and had been a problem that has been most difficult to treat successfully.  It is generally a chronic recurrent process that can wax and wane in severity.  In addition, its cause is not well-known, and this type of prostatitis represents a majority of chronic prostatitis patients.  Antimicrobial medications or antibiotics are not effective for this type of prostatitis.  These patients probably have underlying or coexisting urologic problems that predispose them to prostatitis.  If you have noninfectious prostatitis, it is unlikely that you have a urinary tract infection.

Acute and chronic infectious prostatitis are not usually considered sexually-transmitted diseases.  The way in which the prostate becomes infected is not well understood and is the subject of many research endeavors.  Bacteria that cause prostatitis probably 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 or tube, inserted during a medical procedure, engage in rectal intercourse or oral sex, have an abnormal urinary tract, have had a recent bladder infection, have an enlarged prostate or have a voiding dysfunction.

Signs and Symptoms

The symptoms of prostatitis are nonspecific and mimic many other urologic and nonurologic diseases.  You may experience no symptoms, or symptoms so sudden and severe that 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) and low-back pain, joint or muscle pain, tender or swollen prostate, blood in the urine, or painful ejaculation.

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.  Often, lower urinary tract symptoms (LUTS) are generally attributed to BPH, but this chronic condition can be misdiagnosed as chronic noninfectious 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.

Another condition that mimics the symptoms of prostatitis - when prostatitis is not present (no inflammation) - is prostatodynia (painful prostate).  This problem is not well understood, but may be related to a voiding dysfunction involving the spasm of muscles involved with the voiding process.  Patients with prostatodynia 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 from other musculoskeletal conditions.

Because of the connections between the urethra, the bladder, and the prostate, conditions affecting one or the other organ have similar or overlapping symptoms.  In addition, these conditions may occur concurrently in the same patient, thus complicating diagnosis and treatment.  A thorough evaluation and accurate diagnosis is important in establishing treatment in these situations.

Diagnosis and Tests

To help make an accurate diagnosis, several types of examinations are useful.  Since the prostate is an internal organ, the physician cannot look at it directly.  However, the prostate lies in front of the rectum and the doctor can feel it by inserting a gloved, lubricated finger into the rectum.  This simple procedure, called a digital rectal examination.  The physician can estimate whether the prostate is enlarged or has lumps or other areas of abnormal texture and tenderness.  This examination can provide an accurate diagnosis in acute and chronic bacterial prostatitis that are responsive to antibiotics.

This examination is also 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.  This examination is also utilized in the assessment of men with BPH.

One test that may be performed when chronic prostatitis is suspected is prostate massage, during which prostatic fluid is collected.  While performing the digital rectal examination, your doctor may vigorously massage the prostate to force prostatic fluid out of the gland and into the urethra.  One may feel some discomfort depending on the sensitivity of your prostate.

The prostatic fluid is then analyzed under a microscope for signs of inflammation and infection.  The three-glass urine collection method is used to 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 and collect on a slide any secretions that appear.  You will then collect in a third container the first ounce of urine that remains in your bladder.

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 antimicrobial medication can be prescribed.

Treatment and Prevention

Treatment depends on the type of prostatitis.

If you have acute infectious prostatitis, you will usually need to take antimicrobial medication for 7 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 infectious prostatitis, you will require antimicrobial medication for a longer period of time - usually 4 to 12 weeks.  About 60% of all cases of chronic infectious 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.

If you have noninfectious prostatitis, you do not need antimicrobial medication.  Depending on your symptoms, you may receive one of a variety of treatments.  These may range from medication to surgery, and may even involve behavioral therapies such as biofeedback to correct certain voiding dysfunctions associated with prostatitis.

In addition, it is common to find patients who have recurrent episodes of infectious and noninfectious prostatitis over a long period of time.  These patients may actually be suffering from an underlying voiding abnormality that may be functional or structural that predisposes them to these episodes of prostatitis.  Correcting these abnormalities may cure or at least decrease the episodes of these recurrent events. 

You may find that tub baths or changes in your diet may help to alleviate your 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.

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 contagious: you can live your life normally and continue sexual relations without passing it on.