Table of Contents
Introduction to Prostatitis
Prostatitis is an inflammation of the prostate gland, a walnut-sized organ present in men. Its secretions form an integral part of seminal fluid, performing the function of nourishment and protection of sperm. It is located just below the bladder in males, surrounding the urethra, so that it can add its secretion to the urethra when semen passes through it. Inflammation is the body’s immune response to any pathogen that attacks it. The body recruits the immune cells at the site of invasion through the bloodstream and starts a destructive process to clear out the pathogen. This may also cause harm to surrounding normal body tissues.
Prostatitis is a very common condition in males. This is because the size of the prostate increases with age. The enlarged prostate is accompanied by many clinical symptoms and medical complications. One is obstruction of the part of the urethra that passes through the prostate. This allows bacteria to grow and cause inflammation. There are also non-bacterial causes of prostatitis.
Prevalence and Key Statistics
- Prostatitis is one of the most commonly encountered medical conditions in clinics. It is estimated that every year, physicians diagnose 4.9 individuals with prostatitis per 1000 cases presenting with the symptoms of infection. 1
- Symptomatic presentation of prostatitis is quite common too. The overall prevalence of symptoms of prostatitis is 2.2 to 9.7%, which is more than that of ischemic heart disease and diabetes. 1
- Most of these patients also have an increased risk of prostate hyperplasia, urinary tract infections, and prostate cancers. One-third of these cases resolve in a period of a year. 1
- Patients with one previous episode of prostatitis are at high risk of developing chronic lower abdominal pain.1
Types of Prostatitis
Prostatitis has multiple causes and various clinical presentations. It may have an indolent and self-limiting course or a chronically diseased state lasting for months with significant adverse outcomes. Based on the symptoms, duration, and causes, the National Institute of Health (NIH) has divided prostatitis into four major classes. 2 These are:
- Acute Bacterial Prostatitis: An acute inflammation of the prostate, due to invasion of bacteria, usually occurring in association with urinary tract infections. The bacteria find their way to the prostate through the urinary tract. It is a benign disease with no significant consequences. The condition usually lasts a few weeks, even if left untreated.
- Chronic Bacterial Prostatitis: A chronic inflammation of the prostate because of either an incompletely treated infection that relapses or recurrence of infection. This condition is associated with mild to moderate pain in the lower abdominal region. There are also intermittent episodes of urinary tract infections.
- Chronic Prostatitis: It is also known as chronic pain syndrome and chronic non-bacterial prostatitis. It is further classified as an inflammatory and non-inflammatory disease. The most important feature of this disease is the presence of persistent pain in perineal, suprapubic, testicular, or the penile region. Other crucial features are multiple urinary symptoms and sexual dysfunction.
- Asymptomatic Inflammatory Prostatitis: it is usually found through laboratory testing done for diagnosis of another disease. It remains in the body without producing any clinical symptoms.
Symptoms of Prostatitis
The symptoms of prostatitis vary for each subdivision. The different types of prostatitis may present as:
Acute Bacterial Prostatitis:
It is quite a benign condition compared to other types. The symptoms may be intense initially but regress soon with the commencement of treatment. The disease may resolve spontaneously, but it is best to seek your doctor’s advice if you notice these symptoms:
- High-grade fever
- Difficulty in voiding
- Pain during urination
- Pain around the base of the penis or behind the scrotum
- Cloudy urine
- Blood in urine
- Slow urinary stream
- Offensive smelling urine
Chronic Bacterial Prostatitis:
This condition usually depicts a poorly treated previous infection or recurrent infection. It is a more severe clinical presentation than acute bacterial prostatitis. The symptoms may last for a few months to several years with fluctuating levels of severity. This is because of the on and off inflammatory and continuous infectious state of the prostate. If you have chronic bacterial prostatitis, you may experience the following: 4
- Pain during urination
- Pain after ejaculation
- Lower back pain
- Pain in the perineal area (the region between scrotum and rectum)
- Rectum pain
- Urgency – a sudden desire to void
- A sudden desire to void in the middle of the night
- Blood in semen
- Weak urinary stream depicting obstruction
- A feeling of heaviness behind the scrotum
This is a chronic inflammation of the prostate, but bacteria are not a cause of it. The exact cause is also unknown, but certain factors can act as triggers. These triggers include stress, nerve damage, or physical injury. The most important clinical feature is pain. You may experience pain in one of the following regions, lasting for three or more months:
- Tip of the penis or maybe in the whole penis
- The perineal region
- Lower abdominal area
Pain is often accompanied by symptoms of obstruction such as urgency, frequency, weak stream urine, and dribbling, etc.
This condition is asymptomatic, as the name indicates. However, the inflammation is going on and can cause harm to functional capability. The long-term effect of asymptomatic prostatitis could be infertility.
Causes and Risk Factors
The cause of acute and chronic bacterial prostatitis is the infection with gram-negative bacteria. The most common specie involved is Escherichia coli (E. coli). 4 E. coli is a common inhabitant of the gastrointestinal tract and anal area 5, which explains its easy migration to nearby organs. There are certain conditions that increase the risk of acquiring the infection. These are 4
- Catheterization or instrumentation of urethra
- Condom drainage
- Dysfunctional urination (voiding with high pressure)
- Unprotected anal intercourse
The cause of chronic non-bacterial prostatitis is not an infection, as no pathogen can be obtained in the laboratory. However, evidence suggests it may be due to undocumented infection from Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, and Trichomonas vaginalis. Certain viruses and parasites are also involved in its etiology.
The non-infectious factors, however, play a more significant role in the pathogenesis of chronic non-bacterial prostatitis. These include: 4
- Autoimmunity – the body mistakenly recognizes its own cells as pathogens and starts reacting against them.
- Hormonal imbalances
- Pelvic floor muscles tension
- Urine refluxing into the prostate
- Psychological ill-being
The diagnosis of prostatitis is made using numerous lab investigations. For different types of prostatitis, your doctor may order different types of tests after taking history and performing a relevant clinical examination. 3
Acute Bacterial Prostatitis :
If your doctor suspects acute bacterial prostatitis, he may order the following tests:
- Urine analysis: This is a complete physical and biochemical detail of urine in order to exclude infection. In this test, the doctor looks for urine color, an unusual smell, and changes in the composition. The presence of a large number of nitrites in urine is a clue to bacterial infection.
- Urine culture: This is a gold standard test to rule out infection. In this test, the bacteria are given favorable conditions to grow, termed as media of growth. Each medium represents a particular type of bacteria. The medium in which bacteria obtained from the urine sample grows marks the presence of that certain type of bacteria.
- Imaging: Your doctor may order transrectal prostate ultrasonography or computed tomography to look for pus in the prostate. These tests also help your doctor look for any gross pathology in the prostate. If you have severe obstructive symptoms such as urgency, frequency, weak stream urine, and dribbling, etc., your doctor may order a pelvic ultrasound, specifically bladder scan. This may help in establishing the diagnosis of bladder pathology, causing secondary prostatitis.
- Serum prostate-specific antigen (PSA): This usually is not a recommended test; however, your doctor may order this test to look for cancer if there are other supporting symptoms.
Chronic Bacterial Prostatitis:
To diagnose this, the following tests may help:
- Glass test: In this, test sample of urine is collected in four phases. This helps in microbiological localization of cultures of the lower urinary tract. The first sample collected is when you start voiding, and it represents your urethral specimen. It is about 10 mL of total urine. Then next 100-150 mL of urine is labeled as a bladder sample. The third specimen is obtained while massaging the prostate. It represents expressed prostate specimen (EPS). The last specimen is 10 mL of urine that comes after EPS and depicts any remaining EPS in the prostatic urethra (part of the urethra that is within the prostate).
- Semen culture: The semen is cultured in the laboratory to allow bacterial growth and confirm the diagnosis. This is of considerable significance if bacteria obtained from your urine are the same as in your semen.
- Imaging: Your doctor may order an ultrasound of the prostate to look for gross changes that may be involved in the recurrence of infection.
- Urodynamics: These tests evaluate the obstruction in the urinary tract. They help exclude obstructive causes that may exacerbate the rate of recurrence.
The following tests are helpful in the diagnosis of chronic prostatitis:
- Glass test: This is a standard test that helps your doctor in confirming chronic prostatitis.
- Cystoscopy: This test helps your doctor to exclude bladder pathologies that may be an important cause of pelvic pain and other symptoms of chronic prostatitis.
- Transrectal ultrasound: This test is performed by your doctor to look for pathologies of the prostate.
- Urodynamics: This test is done to help your doctor exclude obstructive pathologies.
- Serum PSA levels: Suspecting prostatic cancer, your doctor may order this test.
- Psychological assessment: This test is offered by your doctor to assess the wellbeing of your psychological health, which is an important trigger in chronic prostatitis.
The treatment options are variable depending upon the types and clinical presentations of prostatitis. These include:
Acute Bacterial Prostatitis:
Before commencing treatment, your doctor will evaluate the severity of your infection, most importantly, the involvement of blood, which is a medical emergency. The treatment options for acute bacterial prostatitis are:
- Antimicrobial therapy: It usually depends on the severity of symptoms and the type of bacteria. The symptoms may resolve within a few days of therapy, but the course should be completed to avoid recurrences and relapses. The recommended treatment duration is 2-4 weeks. 6
- Urinary drainage: if an obstruction is there increasing the risk of infection, then urinary drainage via catheterization is essential.
- Hospitalization: This is done when you have a very high-grade fever that cannot be managed at home. The other symptoms supporting hospital admission are vomiting and dehydration. If you have concurrent medical conditions like diabetes or are old or have a prostatic abscess, your doctor may advise admission in the hospital.
- Prostatic abscess drainage: It is crucial to drain pus from the prostate to lessen the damage.
Chronic Bacterial Prostatitis
- Antimicrobial therapy: The fluoroquinolones are usually offered to dampen the microbial activity. 6 They are the drugs of choice because of their broad antibacterial spectrum. The recommended duration is usually 4-6 weeks.
- Alpha-blockers: The combination of antimicrobials and alpha-blockers may be prescribed by your doctor to reduce the rate of recurrent infection. 7
- For refractory cases: If you are taking medicines for a long time and there is no response, your doctor may switch to alternative therapy to treat the refractory infection. After confirming the presence of the pathogen in the prostate, your doctor will prescribe intermittent low dose antibiotic therapy. If this also fails, you will be advised to have surgery. The surgical options include radical transurethral resection of the prostate or open prostatectomy.
- Antimicrobials and alpha-blockers: These do not constitute first-line therapy but may have some positive effects when used by the patients of chronic prostatitis.
- Anti-inflammatory: These drugs may be suggested by your doctor to reduce the inflammation of the prostate of unknown cause.
- Psychotherapy: It may be recommended by your doctor considering some issues with your mental well-being. 8
- Krieger, J. N., Lee, S. W., Jeon, J., Cheah, P. Y., Liong, M. L., & Riley, D. E. (2008). Epidemiology of prostatitis. International journal of antimicrobial agents, 31 Suppl 1(Suppl 1), S85–S90.
- Krieger, J. N., Nyberg, L., Jr, & Nickel, J. C. (1999). NIH consensus definition and classification of prostatitis. JAMA, 282(3), 236–237.
- Nickel J. C. (2011). Prostatitis. Canadian Urological Association journal = Journal de l’Association des urologues du Canada, 5(5), 306–315.
- Bowen, D. K., Dielubanza, E., & Schaeffer, A. J. (2015). Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ clinical evidence, 2015, 1802.
- Kaper, J. B., Nataro, J. P., & Mobley, H. L. (2004). Pathogenic Escherichia coli. Nature reviews. Microbiology, 2(2), 123–140.
- Bjerklund Johansen, T. E., Grüneberg, R. N., Guibert, J., Hofstetter, A., Lobel, B., Naber, K. G., Palou Redorta, J., & van Cangh, P. J. (1998). The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. European urology, 34(6), 457–466.
- Barbalias, G. A., Nikiforidis, G., & Liatsikos, E. N. (1998). Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. The Journal of urology, 159(3), 883–887.
- Nickel, J. C., Mullins, C., & Tripp, D. A. (2008). Development of an evidence-based cognitive behavioral treatment program for men with chronic prostatitis/chronic pelvic pain syndrome. World journal of urology, 26(2), 167–172.