Inflammation of the prostate (prostatitis)

 | March 1, 2008

Inflammation of the prostate (prostatitis)

This condition gets little press, but its anonymity belies its prevalence. Prostatitis is probably the most common prostate disorder, responsible for almost two million visits to the doctor in the United States each year and accounting for a quarter of all urinary or genital complaints by young and middle-aged men. Despite its commonness, little is known about the disorder. In fact, the term prostatitis, which translates to inflammation of the prostate, refers to a loose assemblage of syndromes characterized by urinary trouble, like burning or painful urination, and pelvic discomfort (see "Symptoms of prostatitis," below). Although it causes some of the same symptoms, prostatitis differs from BPH (see "Prostate enlargement"). It is possible to have both prostatitis and BPH at the same time.

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What is prostatitis?

Some types of prostatitis are caused by bacterial infection. These conditions are often accompanied by the classic symptoms of infection, such as fever, chills, and muscle pain, as well as by urinary problems. As a result, they are relatively easy to diagnose and treat, usually responding well to antibiotics. However, such straightforward forms of prostatitis are rare. A study in the journal Urology suggests that bacteria are responsible for fewer than 10% of all cases of prostatitis.

Researchers are uncertain about what causes the remaining 90%. Little research has been done in this area, but potential culprits include difficult-to-detect bacteria, such as chlamydia and staphylococcus; immunological and inflammatory processes; depression and stress; and mechanical or neuromuscular problems in the pelvic muscles that irritate the general area. Indeed, as the last point illustrates, it's not even known whether the disorder necessarily involves the prostate gland itself. This uncertainty makes the treatment of prostatitis often frustrating and occasionally impossible.

Prostatitis affects men of all ages, although it seems to be rare in prepubescent boys and most common in young to middle-aged men. Some doctors are concerned that prostatitis — especially the chronic variety, characterized by long-lasting bacterial infection — could interfere with fertility, although this has not been proved. On the other hand, whatever the form, prostatitis doesn't appear to increase your risk for prostate cancer; nor is it contagious. As far as we know, it can't be transmitted sexually.

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Diagnosing prostatitis

No single test or diagnostic procedure can confirm a case of prostatitis. Instead, if you experience urinary discomfort, like painful or burning urination or pain in the pelvic area, your doctor will look for signs of inflammation and infection by performing a DRE, getting a urine sample, and perhaps testing your prostate's secretions.

An inflamed prostate feels swollen and mushy to the doctor, like an overripe piece of fruit. This finding strongly suggests prostatitis (see "Digital rectal examination"), although it's not necessary for a diagnosis. In a variant of the disease, known as prostatodynia (see "Type III: Chronic nonbacterial prostatitis/pelvic pain syndrome"), the gland feels normal.

The DRE is usually followed by a simple urine test to check for bacteria and white blood cells, which indicate an infection. If both bacteria and white blood cells are found, your condition is probably one of the bacterial forms. If only white blood cells are discovered, which is usually the case, you may have one of the nonbacterial types.

If no signs of infection or inflammation are found in your urinalysis, your doctor may want to test your prostate's secretions directly. This is accomplished through prostate "massaging" or "stripping," a procedure that causes the prostate to release some of its fluids into the urine. These fluids are then examined in the lab for the presence of bacteria or white blood cells.

The procedure is similar to the DRE, in that your doctor inserts a finger in the rectum to press on the gland. You begin the procedure by mostly emptying your bladder into the toilet. Just before you're finished, you hold the tip of your penis to stop the flow. You bend over, and your doctor presses your prostate with his finger, causing it to expel some fluid. The urge to urinate is intense, but you need to wait until your doctor gives you the go-ahead to release the urine. The first few ounces go into a standard urine test cup, and then you finish in the toilet. Doctors generally resort to this procedure only when necessary.

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Treating prostatitis

The National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, classifies prostatitis into four types, each with its own treatment approach (see Table 1).

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Type I: Acute bacterial prostatitis

This infection is caused by bacteria that travel from the urethra, and perhaps from the rectum, to the prostate. It's the least common but most dramatic form of prostatitis, beginning abruptly with high fever, chills, joint and muscle aches, and profound fatigue. In addition, you may have pain around the base of the penis and behind the scrotum, pain in the lower back, and the feeling of a full rectum. As the prostate becomes more swollen, you may find it more difficult to urinate, and the urine stream may become weak. If you can't urinate at all, it's a medical emergency; the prostate is likely so swollen that it's completely blocking urine flow.

Antibiotics are the standard treatment and are highly effective for this form of prostatitis (see Table 2). Typical choices include fluoroquinolones — such as ciprofloxacin (Cipro), levofloxacin (Levaquin), and ofloxacin (Floxin) — and trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim). It's important to continue your medication for the entire prescribed course, even if you are feeling better. This will help prevent your infection from returning. Steps that you can take at home to help relieve your discomfort include hot baths, stool softeners, and over-the-counter pain relievers, such as aspirin or ibuprofen. In addition, drinking plenty of fluids can help flush the bacteria from your system.

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Type II: Chronic bacterial prostatitis

This type of prostatitis is also caused by bacteria. It appears to be more common in older men who have BPH (see "Prostate enlargement"), and it can follow a bout of acute bacterial prostatitis. Unlike the acute form, however, chronic bacterial prostatitis is a subtle, low-grade infection that can begin insidiously and persist for weeks or even months.

Typically, an affected man does not have a fever, but is troubled by intermittent symptoms such as a sudden urge to urinate, frequent urination, painful urination, or the need to get up at night to urinate. Some men have low back pain, pain in the rectum, or a feeling of heaviness behind the scrotum. Others have pain after ejaculation, and the semen may be tinged with blood. These symptoms wax and wane, and are sometimes so understated that you might not even notice them.

Treatment requires the same antibiotics used for the acute form (see "Type I: Acute bacterial prostatitis"), usually for one to three months, but even with the prolonged treatment, the infection often recurs. If this happens, the recurrence can usually be controlled with another course of antibiotics.

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Type III: Chronic nonbacterial prostatitis/chronic pelvic pain syndrome

The most common form of prostatitis, Type III, is also called chronic pelvic pain syndrome. Its symptoms resemble those of chronic bacterial prostatitis. However, no bacteria are evident, and pinpointing a cause or causes has been difficult. Research suggests that chronic pelvic pain syndrome may result from a cascade of interconnected events. The initiating event may be an undetectable infectious agent or a physical trauma that causes inflammation or nerve damage in the genitourinary area. Over time, this may lead to heightened sensitivity of the nervous system. In other words, chronic nonbacterial prostatitis may be an overactive pain syndrome. What's more, some physicians and researchers are beginning to think that the condition may affect the entire pelvic floor, not just the prostate gland.

Type III prostatitis has two variants, distinguished by the presence or absence of inflammation. In Type IIIA prostatitis, white blood cells, a sign of infection, are found in the urine and in prostate secretions. Doctors frequently prescribe antibiotics for Type IIIA prostatitis in case there's an undetected bacterial infection, but such treatment is generally ineffective. Because there is no known cause, most other therapies aim to reduce discomfort rather than address the cause of the condition. Pain medications that reduce inflammation — such as aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs) — may be helpful, and so may hot baths. In addition, your doctor may prescribe anticholinergic drugs, such as tolterodine (Detrol) and oxybutynin (Ditropan), which reduce urinary symptoms by decreasing bladder contractions. Or you may be prescribed alpha blocker drugs, which relax the muscles at the neck of the bladder, easing the flow of urine.

Type IIIB prostatitis is often referred to as prostatodynia. This term means "pain in the prostate" and, not surprisingly, that's the main symptom of the condition. But what's causing this pain is not clear; the prostate feels normal when it's examined, the urine is free of infection, and prostate secretions don't contain white blood cells. The pain can be persistent and debilitating, and is often accompanied by depression, anxiety, or sexual dysfunction. Urine flow can also be abnormal — with an interrupted or weak stream, an urge to urinate (even when you can produce little urine), or frequent urination (often in small amounts). Although it can occur at any age, prostatodynia is most common in young to middle-aged men.

Alpha blockers are the most likely to reduce such symptoms, but they must be used with care to prevent an excessive reduction in blood pressure. One 2007 review published in Urologia Internationalis found that alpha blockers were more likely to be effective for men who were newly diagnosed with chronic pelvic pain syndrome; that an extended course of treatment (three to six months) was more effective than a shorter course; and that broader alpha blockers such as doxazosin (Cardura) and terazosin (Hytrin) were more effective than the more selective agents. But other experts have found that the selective alpha blocker alfuzosin (Uroxatral) is more effective.

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Type IV: Asymptomatic inflammatory prostatitis

This variant has no symptoms. It is diagnosed when white blood cells are found in prostate secretions or in prostate tissue during an evaluation for other prostate disorders. With no symptoms and no known cause, it's not treated.

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Review Date: 2008-03-01

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