Prostatitis

 

Types and Clinical Course of Prostatitis

Prostatitis is classified into several categories based on the NIH consensus classification system, reflecting different underlying causes and clinical presentations:

 

Acute Bacterial Prostatitis (NIH Category I)

This is a severe bacterial infection of the prostate gland, characterized by sudden onset and significant systemic symptoms. The body temperature often rises to 39-40°C (102.2-104°F), and the patient may experience fever alternating with chills. Urination becomes difficult and painful (dysuria). The developing edema (swelling) of the prostate gland in acute prostatitis can compress the urethra, potentially leading to acute urinary retention (inability to urinate).

 

Chronic Bacterial Prostatitis (NIH Category II)

This involves a persistent or recurrent bacterial infection of the prostate. The clinical course is often more indolent or characterized by intermittent flare-ups. Symptoms may be milder than in acute prostatitis but can be long-lasting and bothersome.

 

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) (NIH Category III)

This is the most common type of prostatitis. It is characterized by chronic pelvic pain and urinary symptoms in the absence of a demonstrable bacterial infection (though inflammation may be present in some subtypes - Category IIIA, inflammatory CPPS; or absent - Category IIIB, non-inflammatory CPPS). The clinical course is often more variable and symptoms can be more subtle initially, but can become significant and impact quality of life. Exacerbations can occur at any time due to unfavorable factors.

 

Asymptomatic Inflammatory Prostatitis (NIH Category IV)

In this condition, inflammation of the prostate is found incidentally (e.g., during evaluation for other conditions like infertility or elevated PSA), but the patient has no symptoms of prostatitis.

 

Associated Conditions

Prostatitis, particularly if chronic or inadequately treated, can lead to the development of associated conditions, such as:

• Vesiculitis: Inflammation of the seminal vesicles.
• Epididymo-orchitis: Inflammation of the epididymis and testicles.

 

Symptoms of Prostatitis

The symptoms of prostatitis can be varied and depend on the type and severity of the inflammation. Common symptom domains include pain, urinary problems, and sexual dysfunction.

 

Pain and Discomfort

Pain sensations with prostatitis are often localized to:

• The perineum (area between the scrotum and anus).
• The suprapubic region (lower abdomen).
• The testicles (orchialgia).
• The lower back or sacrum.
• The penis (tip or shaft).

Pain during or after urination (dysuria) affects more than half of patients with prostatitis. Pain during or after sexual intercourse or ejaculation occurs in approximately 5-12% of patients. The pain associated with prostatitis is often described as aching, persistent, or throbbing.

 

Urinary Disorders (Lower Urinary Tract Symptoms - LUTS)

With prostatitis, patients often experience various urination disorders:

• Urinary Frequency: Needing to urinate more often than usual.
• Urinary Urgency: A sudden, strong need to urinate.
• Dysuria: Pain or burning during urination.
• Pain at the end of urination.
• Nocturia: Waking up at night to urinate.
• Weak or Interrupted Urine Stream: A thin and sluggish stream of urine.
• Hesitancy: Difficulty starting urination.
• Incomplete Bladder Emptying: Sensation that the bladder is not fully empty after urinating.
• Acute Urinary Retention (in severe acute prostatitis).

 

Sexual Dysfunction

Sexual dysfunction is a common complaint in prostatitis and can manifest as:

• Pain during or after ejaculation (odynorgasmia).
• "Erased" or diminished sensation of orgasm.
• Premature ejaculation or, conversely, delayed ejaculation.
• Erectile dysfunction: Weakening of erection, its incompleteness, or short duration.
• Decreased libido (sexual desire).

 

Impact on Fertility

Prostatitis can affect sperm quality and male fertility. Inflammation of the prostate gland can lead to:

• Changes in the composition of prostatic fluid, which is a major component of semen.
• Reduced sperm motility.
• Abnormal sperm morphology.
• Decreased sperm count (oligospermia).

As a result, the fertilizing ability of sperm can be significantly impaired in men with prostatitis, potentially contributing to male infertility.

 

Diagnosis of Prostatitis

Diagnosing prostatitis involves a comprehensive evaluation including medical history, physical examination, and laboratory tests:

1. Medical History: Detailed history of symptoms (pain location and character, urinary symptoms, sexual dysfunction), duration, previous UTIs or STIs, sexual history, and any risk factors. Validated symptom scores (e.g., NIH Chronic Prostatitis Symptom Index - NIH-CPSI) may be used.
2. Physical Examination: Including a digital rectal examination (DRE) to assess the prostate gland for tenderness, swelling, bogginess (in acute), or firmness/nodularity.
3. Laboratory Tests:
   • Urinalysis and Urine Culture: To detect infection (pyuria, bacteriuria). The "two-glass" or "four-glass" test (Meares-Stamey test) was historically used to localize infection to the urethra, bladder, or prostate by collecting sequential urine and expressed prostatic secretion (EPS) samples. Pre- and post-prostatic massage urine samples are often used today.
   • Expressed Prostatic Secretions (EPS) Examination: Microscopic examination of EPS (obtained after prostatic massage) for white blood cells and bacteria. Culture of EPS.
   • Semen Analysis and Culture: May be performed if fertility is a concern or infection of seminal vesicles is suspected.
   • Urethral Swab/Testing for STIs: To rule out sexually transmitted infections like gonorrhea or chlamydia, often using PCR diagnostics.
   • Blood Tests: Complete blood count (CBC) may show leukocytosis in acute bacterial prostatitis. Prostate-Specific Antigen (PSA) may be temporarily elevated during acute inflammation but is not a specific marker for prostatitis.
4. Imaging Studies (Not routinely needed for uncomplicated prostatitis):
   • Transrectal Ultrasound (TRUS): May be used to visualize the prostate, look for abscesses, calcifications, or signs of BPH.
   • CT Scan or MRI: Rarely indicated, primarily if complications like a prostatic abscess are suspected or to rule out other pelvic pathology.
5. Urodynamic Studies: May be considered if significant voiding dysfunction is present to assess bladder and urethral function.
6. Cystoscopy (Urethrocystoscopy): May be used to evaluate the urethra and bladder for other potential causes of symptoms, such as strictures or bladder pathology, especially in chronic cases.

Treatment of Prostatitis

The treatment of prostatitis depends significantly on its specific type (acute bacterial, chronic bacterial, CP/CPPS), the severity of symptoms, and the patient's individual tolerance to various medications. A competently and qualitatively selected comprehensive treatment plan, tailored to the individual, allows, in most cases, for complete resolution of prostatitis or at least significant relief from its unpleasant manifestations.

 

General Principles

A comprehensive approach is key. Only treatment supervised by a physician (urologist) can yield the desired result. If prostatitis is not treated in a timely and appropriate manner, it can become chronic and lead to complications.

 

Therapeutic Modalities

Treatment for prostatitis can include a combination of the following:

• Antibiotic Therapy:
  • Acute Bacterial Prostatitis: Requires prompt treatment with antibiotics that penetrate well into prostatic tissue (e.g., fluoroquinolones, trimethoprim-sulfamethoxazole, or parenteral antibiotics like cephalosporins or aminoglycosides in severe cases). Treatment duration is typically 2-4 weeks or longer. Hospitalization may be needed for severe infections.
  • Chronic Bacterial Prostatitis: Requires a longer course of antibiotics (typically 4-12 weeks) with agents that have good prostatic penetration. Choice of antibiotic should ideally be guided by culture and sensitivity testing of urine or EPS.
  • Antibiotic therapy should always be conducted under the control of appropriate diagnostic tests (e.g., follow-up cultures if indicated).
• Alpha-Blockers: Medications like tamsulosin, alfuzosin, or silodosin can relax the smooth muscles at the bladder neck and in the prostate, improving urinary flow and reducing voiding symptoms. Often used for CP/CPPS and chronic bacterial prostatitis.
• Anti-inflammatory Drugs: Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help reduce pain and inflammation.
• Pain Management: Other analgesics may be used. For chronic pain, neuromodulators like amitriptyline or gabapentin are sometimes considered.
• Immunostimulating Therapy / Immune Modulators: May be considered in some cases, particularly if recurrent infections or underlying immune issues are suspected, but their role is not universally established.
• Physiotherapy: Various physical therapy modalities can be beneficial:
  • Pelvic floor muscle relaxation exercises and biofeedback (for CP/CPPS with pelvic floor muscle tension).
  • Local heat therapy.
  • Transrectal hyperthermia, laser-magnetic therapy, or UHF (Ultra-High Frequency) therapy have been used in some settings to reduce inflammation and pain. The use of physiotherapy can accelerate the elimination of swelling, inflammation, and pain in the perineum in acute or chronic prostatitis.
• Reflexology (Acupuncture): Can be very effective as part of a comprehensive treatment plan for acute or chronic prostatitis, helping to alleviate pain and improve symptoms.
• Local Treatment:
  • Prostate Massage: Historically used to drain prostatic ducts, especially in chronic bacterial prostatitis or to obtain EPS for diagnosis. Its therapeutic efficacy is debated and it should be avoided in acute bacterial prostatitis.
  • Microclysters: Medicated enemas (e.g., with anti-inflammatory agents) have been used in some traditional protocols.
• Symptomatic Treatment: Addressing specific symptoms like urinary urgency or frequency.
• Lifestyle Modifications and Supportive Care:
  • Diet: Avoiding bladder irritants like caffeine, alcohol, and spicy foods. Ensuring adequate hydration.
  • Regular Bowel Habits: Preventing constipation.
  • Stress Management.
  • Physiotherapy Exercises (General): Regular physical activity can be beneficial.
• Phytotherapy (Herbal Remedies): Some herbal supplements like saw palmetto or quercetin have been explored, particularly for CP/CPPS, but evidence is often limited.
• Psychological Support/Counseling: Important for managing chronic pain and the psychological impact of chronic prostatitis.
• Surgical Treatment (Rare): Surgery (e.g., transurethral resection of the prostate - TURP) is rarely indicated for prostatitis itself but may be considered for complications like prostatic abscess drainage or to relieve bladder outlet obstruction due to BPH that might be contributing to recurrent prostatitis.

 

Potential Complications and Long-Term Consequences

If prostatitis is not treated in a timely or effective manner, it can become chronic and lead to several significant and often "formidable" complications that can impact a man's quality of life:

• Chronic Pelvic Pain Syndrome (CP/CPPS): Persistent pain in the pelvic region, perineum, or genitalia.
• Recurrent Urinary Tract Infections (UTIs).
• Epididymitis and/or Orchitis: Inflammation can spread to the epididymis and testicles (testicular inflammation, epididymitis).
• Vesiculitis: Inflammation of the seminal vesicles.
• Prostatic Abscess: A collection of pus within the prostate, more common with acute bacterial prostatitis, requiring drainage.
• Sepsis/Bacteremia: In severe acute bacterial prostatitis, infection can spread into the bloodstream.
• Sexual Dysfunction:
  • Decreased libido (sexual desire).
  • Erectile dysfunction, potentially progressing to impotence.
  • Painful ejaculation.
• Infertility: Chronic inflammation can affect sperm production, motility, and the quality of seminal fluid.
• Urinary Disorders: Chronic urinary symptoms, bladder outlet obstruction, or even acute urinary retention.
• Spread to Other Organs of the Genitourinary System: Such as pyelonephritis (kidney infection).
• Impact on Mental Health: Chronic pain and sexual dysfunction can lead to anxiety, depression, and reduced quality of life.

While prostatitis itself is an inflammatory condition, and chronic inflammation is a risk factor for some cancers, the direct progression of typical prostatitis to **prostate adenoma (Benign Prostatic Hyperplasia - BPH)** or **prostate cancer** is not a direct causal pathway. However, chronic inflammation might create an environment that could influence the development of these conditions, or symptoms might overlap, necessitating careful diagnosis. BPH is a separate aging-related condition, and prostate cancer has distinct risk factors.

 

Prevention of Prostatitis

While not all cases of prostatitis can be prevented, certain measures may help reduce the risk or frequency of episodes:

• Avoid Prolonged Hypothermia: Particularly of the pelvic region.
• Maintain a Healthy Lifestyle:
  • Regular physical activity to avoid a sedentary lifestyle.
  • Balanced diet, avoiding excessive intake of irritants like alcohol, spicy foods, fried, and heavily processed/canned foods.
  • Adequate hydration.
• Practice Safe Sex: To reduce the risk of STIs that can lead to prostatitis.
• Good Personal Hygiene.
• Manage Constipation: Ensure regular bowel movements.
• Regular Sex Life: Avoiding prolonged periods of sexual abstinence or, conversely, overly traumatic sexual activity (though evidence for this is varied).
• Prompt Treatment of UTIs: To prevent ascending infection.
• Regular Urological Check-ups: For men, especially those over 40 or with risk factors, a compulsory examination for the condition of the prostate 1-2 times a year can help in early detection of issues.
• Post-Treatment Prophylaxis: After an episode of prostatitis, conducting preventive outpatient treatment courses (e.g., at least 2 times a year for a month) and possibly one course of spa treatment (balneotherapy) may be recommended by some physicians to reduce recurrence risk, though evidence for specific spa treatments varies.

 

Differential Diagnosis of Prostatitis-Like Symptoms

Symptoms often attributed to prostatitis can also be caused by other conditions affecting the male lower urinary tract and pelvic region. A thorough differential diagnosis is important:

Condition	Key Differentiating Features
Prostatitis (Acute/Chronic Bacterial, CP/CPPS)	Pelvic/perineal pain, LUTS, sexual dysfunction. DRE findings vary. Positive cultures in bacterial forms. NIH-CPSI for CP/CPPS.
Benign Prostatic Hyperplasia (BPH)	Primarily obstructive and irritative LUTS (weak stream, hesitancy, frequency, urgency, nocturia). Prostate often enlarged on DRE/US. More common in older men.
Urinary Tract Infection (Cystitis, Urethritis)	Dysuria, frequency, urgency. Urethral discharge in urethritis. Urinalysis shows pyuria/bacteriuria. Prostate may not be primarily involved.
Sexually Transmitted Infections (STIs)	Urethral discharge, dysuria. Can cause epididymitis. Specific tests for gonorrhea, chlamydia, etc.
Urethral Stricture	Weak urine stream, straining, incomplete emptying. History of trauma or infection. Diagnosed by urethrography or cystoscopy.
Bladder Cancer / Prostate Cancer	Can cause LUTS, hematuria. PSA may be elevated in prostate cancer. Diagnosed by cystoscopy/biopsy, imaging. Prostatitis can also elevate PSA.
Interstitial Cystitis/Bladder Pain Syndrome (in males)	Suprapubic pain related to bladder filling, frequency, urgency. Urine cultures negative. Diagnosis of exclusion.
Neurological Conditions (e.g., Neurogenic Bladder)	Variety of LUTS depending on the neurological lesion. Urodynamic studies helpful.
Musculoskeletal Pain (e.g., Piriformis Syndrome, Pelvic Floor Myalgia)	Pain may mimic prostatic pain but related to muscle trigger points or nerve entrapment. Physical therapy assessment.

 

When to Consult a Urologist

When the first signs or symptoms suggestive of prostatitis appear, it is crucial to **consult a urologist immediately.** Self-treatment or delaying medical attention can lead to the condition becoming chronic or developing complications. Only a qualified physician (urologist) will be able to:

• Perform a correct and thorough diagnosis to determine the type of prostatitis.
• Identify the underlying cause(s) and contributing factors.
• Prescribe an effective, individualized, and comprehensive treatment plan for prostatitis.
• Monitor progress and adjust treatment as needed.
• Rule out other serious conditions that may mimic prostatitis.