What is prostatitis

Prostatitis is the inflammation (swelling) of the prostate gland and sometimes the areas around the prostate. Prostatitis can be very painful and distressing, but will often get better eventually.

The prostate is a small gland found in men that lies between the penis and bladder (Figure 1). Prostate gland produces fluid that’s mixed with sperm to create semen.

Unlike other prostate conditions, such as prostate enlargement or prostate cancer, which usually affect older men, prostatitis can develop in men of all ages. However, it commonly affects men aged between 30 and 50.

Prostatitis is the most common urinary tract problem for men younger than age 50 and the third most common urinary tract problem for men older than age 50 ¹. Prostatitis accounts for about two million visits to health care providers in the United States each year ².

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing prostatitis. During treatment of bacterial prostatitis, urologists may recommend increasing intake of liquids and avoiding or reducing intake of substances that irritate the bladder. Men should talk with a health care provider or dietitian about what diet is right for them.

Scientists have identified four types of prostatitis:

1. Acute bacterial prostatitis – where the symptoms are severe and develop suddenly; it’s rare but it can be serious and requires immediate treatment; it’s always caused by an infection
2. Chronic bacterial prostatitis
3. Chronic prostatitis or chronic pelvic pain syndrome – where the symptoms come and go over a period of several months; it’s the most common type; it’s not usually caused by an infection. In chronic prostatitis, signs of infection in the prostate gland can’t usually be found. In these cases, the cause of symptoms isn’t clear.
4. Asymptomatic inflammatory prostatitis. Men with asymptomatic inflammatory prostatitis do not have symptoms. A health care provider may diagnose asymptomatic inflammatory prostatitis when testing for other urinary tract or reproductive tract disorders. This type of prostatitis does not cause complications and does not need treatment.

What is the prostate?

The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a man’s fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

Figure 1. Prostate gland

Who is more likely to develop prostatitis?

The factors that affect a man’s chances of developing prostatitis differ depending on the type.

• Chronic prostatitis or chronic pelvic pain syndrome. Men with nerve damage in the lower urinary tract due to surgery or trauma may be more likely to develop chronic prostatitis/chronic pelvic pain syndrome. Psychological stress may also increase a man’s chances of developing the condition.
• Acute and chronic bacterial prostatitis. Men with lower urinary tract infections (UTIs) may be more likely to develop bacterial prostatitis. Urinary tract infections that recur or are difficult to treat may lead to chronic bacterial prostatitis.

Acute prostatitis

Bacterial prostatitis is a bacterial infection of the prostate gland occurring in a bimodal distribution in younger and older men ³. Bacterial prostatitis can be acute bacterial prostatitis or chronic bacterial prostatitis in nature and if not treated appropriately, can result in significant morbidity ⁴.

Bacterial prostatitis is most commonly caused by infection from members of the Enterobacteriaceae family, but organisms from other families can be responsible and are more likely in certain high-risk populations ³. Escherichia coli is the most common isolate from urine cultures and is the causative agent in the majority (approximately 50% to 90%) of cases ³. Other common isolates include the species Proteus, Klebsiella, Enterobacter, Serratia, and Pseudomonas. Gram-positive organisms such as Enterococcus species and Staphylococcus species and sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum are also sometimes implicated. Prostate manipulation from procedures such as transrectal prostate biopsy, transurethral prostate biopsy, cystoscopy, and catheterization appears to increase the risk of pseudomonas, mixed organism, staphylococcal infections, and treatment failure prostatitis. Special consideration should be given to immunocompromised patients as they are at higher risk of contracting bacterial prostatitis from atypical organisms such as Salmonella species, Mycobacterium species, Staphylococcus species, among others. Though this article focuses on bacterial etiologies, fungal and viral etiologies should be strongly considered in these patient populations as well. Despite the fact that Enterobacteriaceae are the most common causative organisms in both acute bacterial prostatitis and chronic bacterial prostatitis, gram-positive organisms and atypicals are more likely in chronic bacterial prostatitis than in acute bacterial prostatitis; although, the role of gram-positive organisms in chronic bacterial prostatitis is debated despite the fact they sometimes are isolated in culture ⁵.

Acute prostatitis symptoms

Acute bacterial prostatitis. The symptoms of acute bacterial prostatitis come on suddenly and are severe. Men should seek immediate medical care. Symptoms of acute bacterial prostatitis may include:

• urinary frequency
• urinary urgency
• fever
• chills
• a burning feeling or pain during urination
• pain in the genital area, groin, lower abdomen, or lower back
• nocturia—frequent urination during periods of sleep
• nausea and vomiting
• body aches
• urinary retention—the inability to empty the bladder completely
• trouble starting a urine stream
• a weak or an interrupted urine stream
• urinary blockage—the complete inability to urinate
• a UTI—as shown by bacteria and infection-fighting cells in the urine

Chronic prostatitis

Chronic prostatitis or chronic pelvic pain syndrome is the most common and least understood form of prostatitis. Chronic prostatitis can occur in men of any age group. Chronic prostatitis affects 10 to 15 percent of the U.S. male population ⁶.

Chronic prostatitis symptoms

Chronic prostatitis or chronic pelvic pain syndrome symptoms

The main symptoms of chronic prostatitis or chronic pelvic pain syndrome can include pain or discomfort lasting 3 or more months in one or more of the following areas:

• between the scrotum and anus
• the central lower abdomen
• the penis
• the scrotum
• the lower back

Pain during or after ejaculation is another common symptom. A man with chronic prostatitis or chronic pelvic pain syndrome may have pain spread out around the pelvic area or may have pain in one or more areas at the same time. The pain may come and go and appear suddenly or gradually. Other symptoms may include:

• pain in the urethra during or after urination.
• pain in the penis during or after urination.
• urinary frequency—urination eight or more times a day. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination.
• urinary urgency—the inability to delay urination.
• a weak or an interrupted urine stream.

Chronic bacterial prostatitis symptoms

The symptoms of chronic bacterial prostatitis are similar to those of acute bacterial prostatitis, though not as severe. This type of prostatitis often develops slowly and can last 3 or more months. The symptoms may come and go, or they may be mild all the time. Chronic bacterial prostatitis may occur after previous treatment of acute bacterial prostatitis or a UTI (urinary tract infection). The symptoms of chronic bacterial prostatitis may include

• urinary frequency
• urinary urgency
• a burning feeling or pain during urination
• pain in the genital area, groin, lower abdomen, or lower back
• nocturia
• painful ejaculation
• urinary retention
• trouble starting a urine stream
• a weak or an interrupted urine stream
• urinary blockage
• a urinary tract infection (UTI)

Prostatitis causes

The causes of prostatitis differ depending on the type.

Acute prostatitis and chronic bacterial prostatitis. A bacterial infection of the prostate causes bacterial prostatitis. The acute type happens suddenly and lasts a short time, while the chronic type develops slowly and lasts a long time, often years. The infection may occur when bacteria travel from the bladder, kidneys, the tubes that connect the kidneys to the bladder (ureters), and the urethra into the prostate.

Chronic prostatitis or chronic pelvic pain syndrome. The exact cause of chronic prostatitis/chronic pelvic pain syndrome is unknown. Life stresses and emotional factors may play a part in chronic prostatitis/chronic pelvic pain syndrome. Researchers believe a microorganism, though not a bacterial infection, may cause the condition. This type of prostatitis may relate to chemicals in the urine, the immune system’s response to a previous urinary tract infection (UTI), or nerve damage in the pelvic area.

Possible causes of chronic nonbacterial prostatitis include:

• A past bacterial prostatitis infection
• Bicycle riding
• Less common types of bacteria
• Irritation caused by a backup of urine flowing into the prostate
• Irritation from chemicals
• Nerve problem involving the lower urinary tract
• Parasites
• Pelvic floor muscle problem
• Sexual abuse
• Viruses

Most men with chronic prostatitis have the nonbacterial form.

Risk factors for prostatitis

Risk factors for acute prostatitis include:

• having a urinary tract infection (UTI) in the recent past
• having an indwelling urinary catheter (a flexible tube that’s used to drain urine from the bladder)
• having a prostate biopsy
• having a sexually transmitted infection (STI)
• having HIV or AIDS
• having a problem with your urinary tract
• anal sex
• injuring your pelvis

Risk factors for chronic prostatitis include:

• being middle-aged (30-50 years of age)
• having prostatitis in the past
• having other painful abdominal conditions, such as irritable bowel syndrome (IBS)
• sexual abuse

Prostatitis symptoms

Each type of prostatitis has a range of symptoms that vary depending on the cause and may not be the same for every man. Many symptoms are similar to those of other conditions.

Acute prostatitis symptoms

Symptoms of acute prostatitis include:

• pain, which may be severe, in or around your penis, testicles, anus, lower abdomen or lower back – passing stools (feces) can be painful
• urinary symptoms, such as pain when peeing, needing to pee frequently (particularly at night), problems starting or “stop-start” peeing, an urgent need to pee and, sometimes, blood in your urine
• not being able to pee, which leads to a build-up of urine in the bladder known as acute urinary retention – this needs urgent medical attention
• generally feeling unwell, with aches, pains and possibly a fever
• a small amount of thick fluid (discharge) may come out of your penis from the urethra (the tube that carries urine out of the bladder)

See your doctor immediately if you have these symptoms so that the cause can be investigated and appropriate treatment recommended.

Chronic prostatitis symptoms

You may have chronic prostatitis if you’ve had the following symptoms for at least three months:

• pain in and around your penis, testicles, anus, lower abdomen, or lower back
• pain when peeing, a frequent or urgent need to pee, particularly at night, or “stop-start” peeing
• an enlarged or tender prostate on rectal examination, although in some cases it may be normal
• sexual problems, such as erectile dysfunction, pain when ejaculating, or pelvic pain after sex

These symptoms can have a significant impact on your quality of life. However, in most cases, they’ll gradually improve over time and with treatment.

Prostatitis complications

The complications of prostatitis may include:

• bacterial infection in the bloodstream
• prostatic abscess—a pus-filled cavity in the prostate
• sexual dysfunction
• inflammation of reproductive organs near the prostate

Prostatitis diagnosis

A health care provider diagnoses prostatitis based on:

• a personal and family medical history
• a physical exam
• medical tests

A health care provider may have to rule out other conditions that cause similar signs and symptoms before diagnosing prostatitis.

Personal and Family Medical History

Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose prostatitis.

Physical Exam

A physical exam may help diagnose prostatitis. During a physical exam, a health care provider usually

• examines a patient’s body, which can include checking for
• discharge from the urethra
• enlarged or tender lymph nodes in the groin
• a swollen or tender scrotum
• performs a digital rectal exam

A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam, the health care provider asks the man to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight, brief discomfort during the rectal exam. A health care provider usually performs a rectal exam during an office visit, and the man does not need anesthesia. The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.

Many health care providers perform a rectal exam as part of a routine physical exam for men age 40 or older, whether or not they have urinary problems.

Medical tests

A health care provider may refer men to a urologist—a doctor who specializes in the urinary tract and male reproductive system. A urologist uses medical tests to help diagnose lower urinary tract problems related to prostatitis and recommend treatment. Medical tests may include:

• urinalysis
• blood tests
• urodynamic tests
• cystoscopy
• transrectal ultrasound
• biopsy
• semen analysis

Urinalysis

Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container in a health care provider’s office or a commercial facility. A health care provider tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.

Your health care provider can diagnose the bacterial forms of prostatitis by examining the urine sample with a microscope. The health care provider may also send the sample to a lab to perform a culture. In a urine culture, a lab technician places some of the urine sample in a tube or dish with a substance that encourages any bacteria present to grow; once the bacteria have multiplied, a technician can identify them.

Blood tests

Blood tests involve a health care provider drawing blood during an office visit or in a commercial facility and sending the sample to a lab for analysis. Blood tests can show signs of infection and other prostate problems, such as prostate cancer.

Urodynamic tests

Urodynamic tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely and may include the following:

• uroflowmetry, which measures how rapidly the bladder releases urine
• postvoid residual measurement, which evaluates how much urine remains in the bladder after urination

Cystoscopy

Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. He or she performs cystoscopy during an office visit or in an outpatient center or a hospital. He or she will give the patient local anesthesia. In some cases, the patient may require sedation and regional or general anesthesia. A urologist may use cystoscopy to look for narrowing, blockage, or stones in the urinary tract.

Transrectal ultrasound

Transrectal ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The health care provider can move the transducer to different angles to make it possible to examine different organs. A specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images; the patient does not require anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the man’s rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate cancer.

Biopsy

Biopsy is a procedure that involves taking a small piece of prostate tissue for examination with a microscope. A urologist performs the biopsy in an outpatient center or a hospital. He or she will give the patient light sedation and local anesthetic; however, in some cases, the patient will require general anesthesia. The urologist uses imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to guide the biopsy needle into the prostate. A pathologist—a doctor who specializes in examining tissues to diagnose diseases—examines the prostate tissue in a lab. The test can show whether prostate cancer is present.

Semen analysis

Semen analysis is a test to measure the amount and quality of a man’s semen and sperm. The man collects a semen sample in a special container at home, a health care provider’s office, or a commercial facility. A health care provider analyzes the sample during an office visit or sends it to a lab for analysis. A semen sample can show blood and signs of infection.

Prostatitis treatment

Treatment for prostatitis will depend on whether you have acute or chronic prostatitis.

Acute prostatitis treatment

Acute prostatitis (where symptoms are sudden and severe) is usually treated with painkillers and a two to four week course of antibiotics.

Hospital treatment may be needed if you’re very ill or unable to pass urine (acute urinary retention).

The antibiotic prescribed may depend on the type of bacteria causing the infection. Urologists usually prescribe oral antibiotics for at least 2 weeks. The infection may come back; therefore, some urologists recommend taking oral antibiotics for 6 to 8 weeks. Severe cases of acute prostatitis may require a short hospital stay so men can receive fluids and antibiotics through an intravenous (IV) tube. After the IV treatment, the man will need to take oral antibiotics for 2 to 4 weeks.

Prostatitis diet

Most cases of acute bacterial prostatitis clear up completely with medication and slight changes to diet.

Your urologist may recommend:

• avoiding or reducing intake of substances that irritate the bladder, such as alcohol, caffeinated beverages, and acidic and spicy foods
• increasing intake of liquids—64 to 128 ounces per day—to urinate often and help flush bacteria from the bladder

Chronic prostatitis treatment

Chronic prostatitis or chronic pelvic pain syndrome

Treatment for chronic prostatitis or chronic pelvic pain syndrome (where symptoms come and go over several months) aims to decrease pain, discomfort, and inflammation. The aim is to reduce symptoms to a level where they interfere less with day-to-day activities, rather than getting rid of the pain completely. A wide range of symptoms exists and no single treatment works for every man. Although antibiotics will not help treat nonbacterial prostatitis, a urologist may prescribe them, at least initially, until the urologist can rule out a bacterial infection. Occasionally, a four- to six-week course of antibiotics, such as ciprofloxacin, may be prescribed even if no infection is found; this is to see if your condition improves.

A referral to your local pain clinic may also be considered.

A urologist may prescribe other medications:

• Silodosin (Rapaflo)
• 5-alpha reductase inhibitors such as finasteride (Proscar) and dutasteride (Avodart)
• Alpha-adrenergic blockers such as tamsulosin, may also be prescribed if you have problems with urination; these can help relax the muscles in the prostate gland and the base of the bladder. It often takes about 6 weeks before these medicines start working. Many people do not get relief from these medicines.
• Painkiller such as acetaminophen or paracetamol
• Nonsteroidal anti-inflammatory drugs—also called NSAIDs may help relieve pain—for example aspirin, ibuprofen, and naproxen sodium
• Glycosaminoglycans such as chondroitin sulfate
• Muscle relaxants such as cyclobenzaprine (Amrix, Flexeril), diazepam and clonazepam (Klonopin) can help to reduce spasms in the pelvic floor.
• If your symptoms are severe, stronger painkillers or neuromodulators such as amitriptyline, nortriptyline (Aventyl, Pamelor), gabapentin and pregabalin (Lyrica), may be considered

Alternative treatments may include:

• warm baths, called sitz baths
• local heat therapy with hot water bottles or heating pads
• physical therapy, such as:
  • Kegel exercises—tightening and relaxing the muscles that hold urine in the bladder and hold the bladder in its proper position. Also called pelvic muscle exercises.
  • myofascial release—pressing and stretching, sometimes with cooling and warming, of the muscles and soft tissues in the lower back, pelvic region, and upper legs. Also known as myofascial trigger point release.
• relaxation exercises
• biofeedback
• phytotherapy with plant extracts such as quercetin, bee pollen, and saw palmetto
• acupuncture

Some people have found some relief from pollen extract (Cernitin) and allopurinol. But research does not confirm their benefit. Stool softeners may help reduce discomfort with bowel movements.

To help ensure coordinated and safe care, people should discuss their use of complementary and alternative medical practices, including their use of dietary supplements, with their health care provider.

For men whose chronic prostatitis/chronic pelvic pain syndrome symptoms are affected by psychological stress, appropriate psychiatric treatment and stress reduction may reduce the recurrence of symptoms.

Surgery, called transurethral resection of the prostate, may be done in rare cases if medicine does not help. In most cases, this surgery is not done on younger men. It may cause retrograde ejaculation. This can lead to sterility, impotence, and incontinence.

Chronic bacterial prostatitis

A urologist treats chronic bacterial prostatitis with antibiotics; however, treatment requires a longer course of therapy. The urologist may prescribe a low dose of antibiotics for up to 6 months to prevent recurrent infection. The urologist may also prescribe a different antibiotic or use a combination of antibiotics if the infection keeps coming back. The urologist may recommend increasing intake of liquids and avoiding or reducing intake of substances that irritate the bladder.

A urologist may use alpha blockers that treat chronic prostatitis/chronic pelvic pain syndrome to treat urinary retention caused by chronic bacterial prostatitis. These medications help relax the bladder muscles near the prostate and lessen symptoms such as painful urination. Men may require surgery to treat urinary retention caused by chronic bacterial prostatitis. Surgically removing scar tissue in the urethra often improves urine flow and reduces urinary retention.

Prostatitis prognosis

Acute prostatitis

Acute prostatitis usually clears with a course of antibiotics. It’s important to take the full course to ensure that the infection clears completely.

Rarely, other complications of acute prostatitis can occur. These include:

• acute urinary retention – because passing urine can be very painful, urine can build up in your bladder, causing pain in your lower tummy (abdomen) and inability to pass urine at all; to relieve this, a catheter (a thin, flexible, hollow tube is needed)
• prostate abscess – if antibiotics aren’t effective in treating prostate infection, rarely an abscess can develop in your prostate gland; your doctor may suspect this if your symptoms don’t improve despite antibiotic treatment; further tests will be needed to confirm a prostate abscess, such as an ultrasound scan or CT scan of your prostate gland; if an abscess is present, you’ll need an operation to drain it

Chronic prostatitis

Chronic prostatitis can be challenging to treat because little is known about what causes it. Most men will gradually recover with treatment, but this can take several months or years.

Some men with prostatitis find their symptoms return (relapse) later on, which will require further treatment.

Prostatitis isn’t prostate cancer and there’s currently no clear evidence that it increases your chances of developing cancer of the prostate.

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