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Chronic Prostatitis

The term prostatitis refers to an inflammation of the prostate gland. A prostatitis is considered chronic, if inflammation and accompanying symptoms persist for more than a few weeks.


Presentation

Bacterial CP

Symptoms associated with bacterial CP include pain at the penis' base, around the anus, in close proximity to the pubic bone and in the lower back. In some cases, pain is also experienced in penis and testes. Defecation may be slightly painful, too. Additionally, symptoms rather related to an infection of the urinary tract may be present. These include pollakiuria, dysuria and stranguria. Often, patients report that symptoms appear and diminish intermittently.

When compared with cases of acute prostatitis, symptoms of CP are generally less intense. High fever is not observed in CP.

Although an infection of the prostate gland may not be eliminated during the initial phase of antibiotic treatment, symptoms usually diminish under therapy. They are, however, likely to return if the antibiotic treatment is terminated while the infection persists. First signs of a relapse are dysuria and mild pain.

Non-bacterial CP

The non-bacterial CP is also known as chronic pelvic pain syndrome, a term referring to a symptom complex persisting for more than 3 months. Pain and urinary symptoms are similar to those observed in cases of bacterial CP, but additional symptoms are also present. These comprise possible impotence, pain upon or after ejaculation, pain after sexual intercourse as well as general aches and fatigue [9].

Fatigue
  • Five cross-sectional themes: (1) Need for repeated confirmation - disease not life-threatening nor leading inexorably towards cancer; (2) Disturbed sleep and fatigue; (3) Concealing pain and problems - 'normalizing'; (4) Enduring pain by performing activities[ncbi.nlm.nih.gov]
  • Data from 6824 male twins in the Vietnam Era Twin Registry were examined to evaluate the association between self-reported lifetime physician diagnosis of CP with COPCs including fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular[ncbi.nlm.nih.gov]
  • In this chronic prostatitis video, he discusses prostate pain, fatigue, antibiotics, and surgery. A Florida man had chronic prostitis for 8 years.[prostatitissurgery.com]
  • Prostatitis can cause great discomfort which varies but can include pelvic pain, pelvic pressure, a vague sense of discomfort, a feeling of malaise and fatigue, fever, burning on urination, pain on reaching orgasm, and bleeding.[clinicaltrials.gov]
  • Alpha blockers (nonselective) doxazosin (Cardura) terazosin (Hytrin) Dizziness, headache, and fatigue are most common . Nasal congestion, dry mouth, and swelling in the ankles can also occur .[askdoctork.com]
Perineal Pain
  • Symptoms (sudden onset) Irritative urinary symptoms (Mild to Moderate) Dysuria Urinary Frequency Urinary urgency Ejaculatory pain Hematospermia Referred pain Low pack pain Perineal pain Lower Abdominal Pain Scrotal Pain Pain in penis Pain in inner thighs[fpnotebook.com]
  • Presentation is usually with chronic, low grade perineal pain, usually varying in severity and frequency. The pain may be exacerbated by sitting on a hard chair.[gpnotebook.co.uk]
Turkish
  • It has been determined that although there is a strong and significant correlation between UPOINT classification and NIH-CPSI score in Turkish patients with chronic prostatitis or chronic pelvic pain syndrome, the inclusion of ED as an independent subdomain[ncbi.nlm.nih.gov]
Abdominal Pain
  • Symptoms (sudden onset) Irritative urinary symptoms (Mild to Moderate) Dysuria Urinary Frequency Urinary urgency Ejaculatory pain Hematospermia Referred pain Low pack pain Perineal pain Lower Abdominal Pain Scrotal Pain Pain in penis Pain in inner thighs[fpnotebook.com]
  • The symptoms of a food intolerance or allergy may include vomiting, diarrhea, nausea, or abdominal pain. If you have a food intolerance you may also experience gas, bloating, headache, cramps, irritability, and nervousness.[prostatitis.net]
  • The following are signs and symptoms that may be present with prostatitis: Painful, difficult and/or frequent urinating Blood in the urine Groin pain , rectal pain , abdominal pain and/or low back pain Fever and chills Malaise and body aches Urethral[medicinenet.com]
Suprapubic Pain
  • Lower abdominal tenderness or suprapubic pain may be present if there is concomitant bladder infection or obstruction. Costovertebral tenderness should be sought.[clinicaladvisor.com]
Back Pain
  • Other features may include low back pain, which may extend down the leg, mild bouts of fever and dysuria. Rectal examination usually reveals an enlarged, firm, and irregular prostate. Massage exudes a purulent urethral discharge.[gpnotebook.co.uk]
  • Some symptoms patients with chronic abacterial prostatitis present with are: Urinary urgency painful urination burning upon urination, urinary frequency difficulty starting urination, weak urinary stream frequent need to urinate at night low back pain[pelvicrehabilitation.com]
  • Common symptoms include pain and discomfort around the genitals, anus and/or lower back, pain while passing stool or urinating, and frequent urination or urinary urgency.[melbourneurologist.com.au]
  • I have been suffering from bladder and lower back pain for about six months now. I have been to the doctor several times and each time the test was negative for infection.[icliniq.com]
  • Prostate pain, lower back pain and discomfort in the genital area are just some of the common signs that Chronic Prostatitis might be the issue.[chronicbodypain.net]
Low Back Pain
  • Other features may include low back pain, which may extend down the leg, mild bouts of fever and dysuria. Rectal examination usually reveals an enlarged, firm, and irregular prostate. Massage exudes a purulent urethral discharge.[gpnotebook.co.uk]
  • Some symptoms patients with chronic abacterial prostatitis present with are: Urinary urgency painful urination burning upon urination, urinary frequency difficulty starting urination, weak urinary stream frequent need to urinate at night low back pain[pelvicrehabilitation.com]
  • back pain, dysuria, perineal and suprapubic discomfort Often have history of urinary tract infection by same organism May have NO symptoms Granulomatous prostatitis: Necrotizing or non-necrotizing granulomas may be seen in men who have undergone BCG[pathologyoutlines.com]
  • Prostatitis symptoms and signs like low back pain, fever, and chills do not occur with BPH. BPH symptoms and signs that do not occur in prostatitis include a weak stream of urine and a sense of not fully emptying the bladder.[medicinenet.com]
Pelvic Pain
  • The 653 participants with NIH-CPSI pain scores 8 or greater who first experienced symptoms after 1986 were considered incident chronic prostatitis/chronic pelvic pain syndrome cases and the 19,138 who completed chronic prostatitis/chronic pelvic pain[ncbi.nlm.nih.gov]
  • Mean age was similar (chronic pelvic pain syndrome 52.3 vs control 57.0 years, p 0.27).[ncbi.nlm.nih.gov]
  • This article is about one kind of chronic pelvic pain in males. For females, see pelvic pain .[en.wikipedia.org]
  • CBP and CNP/CPPS both lead to pelvic pain and lower urinary tract symptoms.[ncbi.nlm.nih.gov]
  • These are the cornerstones for empowerment and self-care required in the management of chronic pelvic pain.[ncbi.nlm.nih.gov]
Dysuria
  • […] prostatitis must be differentiated from other causes of chronic pelvic pain, such as interstitial cystitis/bladder pain syndrome and pelvic floor dysfunction; prostate and bladder cancers; benign prostatic hyperplasia; urolithiasis; and other causes of dysuria[ncbi.nlm.nih.gov]
  • Symptoms (sudden onset) Irritative urinary symptoms (Mild to Moderate) Dysuria Urinary Frequency Urinary urgency Ejaculatory pain Hematospermia Referred pain Low pack pain Perineal pain Lower Abdominal Pain Scrotal Pain Pain in penis Pain in inner thighs[fpnotebook.com]
  • A 38-year-old man reports pelvic pain, dysuria, and urinary urgency for the past 4 weeks. He has had several similar episodes over the past 2 years; urine cultures were not performed.[nejm.org]
Painful Ejaculation
  • ejaculation pain in the perineum ( the area between anus and scrotum) pain in the testicles pain in the penis pain in the groin We at Pelvic Rehabilitation Medicine work hand in hand with the best urologists and urogynecologists in the tri-state area[pelvicrehabilitation.com]
  • ejaculations; lower abdominal pain .[health.ccm.net]
  • Chronic prostatitis may also cause pain during sex, painful ejaculation, burning on urination, and flu-like fatigue, fever, and mental impairment. Treatments for chronic prostatitis are not always effective.[prostatitissurgery.com]
  • Other symptoms include burning on urination, frequency of urination, increases sexual desires, lack of or reduced sexual desires, slight discharge from urethra, premature ejaculation, painful ejaculation, backache following intercourse.[finetreatment.com]
  • When to See a Doctor If you feel pelvic pain, painful or difficult urination and painful ejaculation (orgasm), it is wise to pay your doctor a visit.[newhealthguide.org]
Urinary Urgency
  • Symptoms (sudden onset) Irritative urinary symptoms (Mild to Moderate) Dysuria Urinary Frequency Urinary urgency Ejaculatory pain Hematospermia Referred pain Low pack pain Perineal pain Lower Abdominal Pain Scrotal Pain Pain in penis Pain in inner thighs[fpnotebook.com]
  • A 38-year-old man reports pelvic pain, dysuria, and urinary urgency for the past 4 weeks. He has had several similar episodes over the past 2 years; urine cultures were not performed.[nejm.org]
  • Some symptoms patients with chronic abacterial prostatitis present with are: Urinary urgency painful urination burning upon urination, urinary frequency difficulty starting urination, weak urinary stream frequent need to urinate at night low back pain[pelvicrehabilitation.com]
Urinary Retention
  • Catheter drainage, whether urethral or suprapubic may be used to treat acute urinary retention.[craneherb.com]
  • Fever, chills, and urinary retention (the inability to pass urine) may occur. Patients may need hospitalization. Category II (formerly termed "chronic bacterial prostatitis").[smithinstituteforurology.com]
  • Hospital treatment may be needed if you're very ill or unable to pass urine ( acute urinary retention ). Chronic prostatitis Treatment for chronic prostatitis (where symptoms come and go over several months) usually aims to control the symptoms.[nhs.uk]
  • Men with acute prostatitis complicated by urinary retention are best managed with a suprapubic catheter or intermittent catheterization .[en.wikipedia.org]

Workup

Diagnosis of CP is based on medical history, clinical examination, a digital rectal examination to confirm prostate enlargement and possibly additional diagnostic measures to rule out differential diagnostics.

The patient's medical history should give indications towards CP. If an acute bacterial prostatitis had been diagnosed before and an antibiotic treatment had been administered without achieving complete freedom of symptoms, CP poses a probable differential diagnosis. This suspicion may be corroborated if the patient describes typical symptoms or shows prostate enlargement.

In cases of bacterial CP, bacteria can usually be detected in urine or semen samples [10]. In order to confirm that bacteria originate from the prostate gland, urine samples may be taken before, during and after massaging the prostate. The apparent absence of bacteria from urine and/or semen does not rule out bacterial CP.

Since urine reflux is one of the main causes of prostatitis and prostatitis may affect micturition, urodynamic tests may be indicated to revise the functionality of the bladder and to detect possible voiding disorders [11]. Such findings could further affirm bacterial CP, but are particularly important for diagnosing non-bacterial CP.

Pyuria
  • […] obstruction) lower back pain Physical exam fever chills digital rectal exam enlarged prostate very tender on exam may indicate acute prostatitis less tender on exam may indicate chronic prostatitis Studies Urine studies for bacterial infection urinalysis pyuria[step2.medbullets.com]
  • […] resection Otherwise, most cases are idiopathic and do not require acid-fast stain Laboratory Bacterial: prostatic secretion cultures should have bacterial counts 10x urethral / bladder cultures Non-bacterial: 10 WBC / HPF in prostatic secretions without pyuria[pathologyoutlines.com]
  • Benign prostatic hypertrophy and overactive bladder may also present with lower urinary tract symptoms, but are generally without signs of infection like fever or pyuria. D. Physical Examination Findings.[clinicaladvisor.com]
Occult Blood Positive
  • Daytime and night-time frequency, storage symptoms, post-micturition symptoms, and urine occult blood positivity also significantly improved.[ncbi.nlm.nih.gov]

Treatment

In order to treat bacterial CP, antibiotics are administered for extended periods of time, usually for 4 or more weeks. This regimen may also be indicated if no bacteria can be detected in urine and/or semen, since such an outcome does not rule out bacterial CP. Trimethoprim-sulfamethoxazole and fluorquinolones are most frequently used [12] [13]. They need to be administered in high doses to assure sufficiently high levels of active compounds in the prostate gland.

If the bacterial infection persists, it is recommended to continue administering low, suppressive doses of antibiotics. Trimethoprim-sulfamethoxazole (at single strength qhs), trimethoprim (100 mg qhs), ciprofloxacin (250 mg qhs) and ofloxacin (200 mg qhs) are options to be considered.

Antibiotics alone generally do not suffice to relieve the patient from all symptoms and to eliminate the CP. Antibiotic therapy may thus be complemented with the following drugs: 

  • Anti-inflammatory drugs and analgesics.
  • Alpha-receptor antagonists such as tamsulosin or terazosin may be indicated to relax muscles of prostate and bladder.
  • Muscle relaxants.
  • 5α-reductase inhibitor finasteride to diminish the size of the prostate gland.

It has occasionally been recommended to relief prostate pressure by ejaculating more frequently or by massaging the prostate gland. Furthermore, the patient should be advised to reduce consumption of caffeine and alcohol. The patient may also benefit from warm baths or relaxation techniques.

Few scientific evidence is available that proves the effectiveness of these drugs and accompanying treatments. The variety of factors contributing to CP further complicates an adequate treatment. Thus, therapy has to be adapted to each single patient.

Prognosis

CP requires a prolonged and consequent treatment that generally includes antibiotics. While success rates of only 30% to 40% have been reported for trimethoprim-sulfamethoxazole, fluoroquinolones are effective in 60% to 90% of CP cases.

A lack of effect is not necessarily caused by resistant bacteria. It has to be taken into account that antibiotics hardly penetrate the prostate, since no active transport systems are available and pH differences between blood and prostatic fluid further complicate diffusion of acidic antibiotics into the inflamed tissue. These circumstances are the main cause for persisting infections and CP.

Continued therapy is indicated since CP does severely reduce the patient's quality of life. There is an apparent relation between CP and erectile dysfunction. To date, it is not known whether this relation is of organic or psychological nature [7]. CP may have consequences to mental and physical health that are comparable to those of congestive heart failure or diabetes mellitus [8].

Etiology

CP results from an acute inflammation of the prostate gland that did not heal. Acute prostatitis, in turn, may be caused by ascending infections with bacteria. Prostatitis may also be non-bacterial - but even though this form occurs more often, little is known about its causes. Any enlargement of the gland may finally lead to an obstruction of its ducts and CP.

Bacteria most often reach the prostate by ascending through the urethra. Other, less probable sources of infection may be bladder, bowel, blood and lymph. Gram-negative bacteria such as Escherichia coli (E. coli), Klebsiella, Proteus and Pseudomonas may trigger prostatitis, but gram-positive bacteria such as Enterococcus have also been isolated [3]. E. coli are by far the most common causative agents. In contrast to E. coli strains responsible for uncomplicated urinary infections, it has been proposed that E. coli strains provoking CP are more virulent and tend to produce biofilms. This would explain why they are rather difficult to eliminate and why the corresponding acute cases of prostatitis become often chronic.

Any condition facilitating bacterial colonization of the prostate gland does predispose for prostatitis. Such circumstances include the presence of the foreskin, sexual activity as well as previous instrumentation or catheterization but also pathologic conditions such as an urethral stricture, a bladder neck hypertrophy or an anatomic predisposition for retrograde spread from intraprostatic ducts [4].

Epidemiology

Prostatitis is a very common disease and accounts for a large share of cases presented in urology; it is even considered the most common urologic disease in men younger than 50 years [5]. It has been estimated that up to half of all men suffer from prostatitis at least once in their life, most likely when aged 35 to 50 years. Thus, it does not come as a surprise that millions of cases are diagnosed each year [6].

Only 5% to 10% of prostatitis cases can be classified as bacterial CP. The remaining cases are termed non-bacterial and may be provoked by different conditions.

Sex distribution
Age distribution

Pathophysiology

While ascending infections with different species of bacteria are clearly responsible for bacterial CP, there are still considerable knowledge gaps regarding the etiology and pathophysiology of non-bacterial CP.

Presumably, one of the most common noxious agents causing irritation and finally inflammation of the prostate gland in cases of non-bacterial CP is urine. Urine reflux to the prostate occurs in patients suffering from urethral stricture or other voiding dysfunctions. Any enlargement of the prostate (e.g. benign prostatic hyperplasia, a very common, non-cancerous condition), may also provoke non-bacterial CP due to obstruction of the poorly drained ducts composing the gland. Both conditions, an irritation due to urine reflux as well as obstructed ducts, lead to tubule fibrosis and aggravate the initial obstruction. Consequently, secretion diminishes and prostatic stones develop, a process that triggers an even stronger inflammatory response and CP.

On the other hand, bacterial CP is caused by rather virulent bacteria that ascend to the prostate gland, cause an infection and the corresponding inflammation. The consequences brought on by this inflammation are very similar to those observed in non-bacterial CP.

Of note, it has been observed that certain allergies are associated with an increased risk for prostatitis. It is therefore tempting to speculate that autoimmune-mediated inflammation could possibly also trigger prostatitis.

Prevention

Men can take several preventive measures to avoid prostatitis. Most of these measures include reducing irritation of the prostate and decreasing pressure inside the gland. These aims can be reached by avoiding consumption of caffeine and alcohol, but also of very spicy food. It is recommended to avoid long, uninterrupted times of sitting and to cushion the surface by using a pillow. When riding a bicycle, it is advised to adjust the saddle accordingly and wear appropriate shorts. Warm sit baths may also prove beneficial.

Summary

Chronic prostatitis (CP) describes a prolonged inflammation of the prostate gland that results from an acute prostatitis that has not been cured. Bacterial and non-bacterial prostatitis are distinguished, while the latter may also be referred to by chronic pelvic pain syndrome. Of note, an asymptomatic inflammatory prostatitis may also be diagnosed and treated [1]. A comprehensive classification system comprising the categories acute prostatitis, bacterial CP, non-bacterial CP and asymptomatic inflammatory prostatitis has been established [2].

Patients present with pain and urinary problems, sometimes also with impotence and overall weakness. In the majority of cases of CP, it is not possible to identify a clear cause. While antibiotics are prescribed to eliminate possibly existing bacteria, other drugs are used for symptomatic treatment and include analgesics, antiphlogistics, alpha-receptor antagonists and muscle relaxants. Therapy of CP is often a major challenge requiring long-term treatment.

Patient Information

Pain in the pelvic area, problems upon urinating and during sexual activity are typical symptoms for an inflammation of the prostate gland, a prostatitis. If this inflammation persists for more than a few weeks, it is termed CP.

Causes

While a smaller share of CP cases are caused by ascending infections with bacteria, the majority of CP is of non-bacterial origin. Causes may be voiding problems of the bladder, benign prostate hyperplasia or even conditions affecting the immune system. Prostatitis may dispose for prostate cancer and people affected by prostate cancer tend to develop prostatitis.

Signs and symptoms

Patients may note the following symptoms:

  • Pain in the pubic region, in close proximity to the penis' base and anus, and in the lower back.
  • Symptoms compatible with an urinary infection such as an urgent need to urinate and pain upon urinating.
  • Recurrent urinary infections.
  • Sexual problems, e.g. impotence or pain when ejaculating.
  • Blood in urine or semen.

While acute cases of prostatitis may be accompanied by fever, this is usually not the case in CP.

Diagnosis

After getting the patient's medical history, the physician needs to conduct a digital rectal examination of the prostate gland. To do so, a gloved finger is introduced into the rectum to palpate the prostate. This way, the physician checks for possible enlargement of the gland. This examination may be unpleasant, but is generally not painful.

Urine samples are taken to evaluate the possible presence of bacteria in urine. Although positive findings do indicate a prostatitis or urinary infection, negative findings do not rule out the presence of microorganisms.

Blood tests can also provide valuable information as to the origin of health problems.

If no cause can be identified, further diagnostic measures may be undertaken, e.g. to evaluate bladder function and to check for sexually transmitted diseases. Whereas any problem affecting the urinary tract that leads to urine reflux may eventually cause CP, symptoms of sexually transmitted disease may be confounded with those of CP.

Treatment

CP is potentially curable, but usually requires a prolonged and consequent treatment. It is particularly complicated to reach sufficiently high concentrations of drugs in the prostate gland or to treat cases of unknown cause. The therapy should thus be adapted to every single patient who is, in turn, required to provide feedback.

CP is generally treated with antibiotics, even if no bacteria could be found in the urine. Antibiotics may be administered for 4 weeks or even longer periods of time.  Other drugs may be prescribed to reduce pain and inflammation, to provide relief to muscle spasms and to relax the muscles of prostate and bladder. Since an enlargement of the prostate gland often contributes to CP, drugs causing a reduction of its size may also be administered.

A certain adaption of the patient's live style may serve to reduce symptoms. Avoiding long times of sitting, particularly on non-cushioned surfaces, reducing the consumption of irritating substances such as caffeine and alcohol as well as warm baths may bring relief.

If pharmacological treatment of CP does not suffice to eliminate the inflammation, the prostate may be removed in a procedure called prostatectomy. This surgical intervention may be especially indicated if the patient suffers from recurrent prostatitis caused by small stones obstructing the ducts composing the prostate gland.

References

Article

  1. Sandhu JS. Use of empiric antibiotics in the setting of an increased prostate specific antigen: con. J Urol. 2011 Jul. 186(1):18-9.
  2. Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999 Jul 21. 282(3):236-7.
  3. Nickel JC, Costerton JW. Coagulase-negative staphylococcus in chronic prostatitis. J Urol. 1992;147(2):398–400.
  4. Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE. Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis. Br J Urol. 1982;54(6):729–731.
  5. Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. 1998 Apr. 159(4):1224-8.
  6. Weidner W, Diemer T, Huwe P, Rainer H, Ludwig M. The role of Chlamydia trachomatis in prostatitis. Int J Antimicrob Agents. 2002 Jun. 19(6):466-70.
  7. Magri V, Perletti G, Montanari E, Marras E, Chiaffarino F, Parazzini F. Chronic prostatitis and erectile dysfunction: results from a cross-sectional study. Arch Ital Urol Androl. 2008 Dec. 80(4):172-5.
  8. McNaughton Collins M, Pontari MA, O'Leary MP, Calhoun EA, Santanna J, Landis JR, et al. Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network. J Gen Intern Med. Oct/2001. 16(10):656-62.
  9. Tran CN, Shoskes DA. Sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome. World J Urol. 2013 Apr 12.
  10. Budía A, Luis Palmero J, Broseta E, et al. Value of semen culture in the diagnosis of chronic bacterial prostatitis: a simplified method. Scand J Urol Nephrol. 2006;40(4):326–331.
  11. Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J, Bushman W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology. 2000;56(6):951–955.
  12. Lipsky BA. Prostatitis and urinary tract infection in men: what's new; what's true? Am J Med. 1999;106(3):327–334.
  13. Alexander RB, Propert KJ, Schaeffer AJ, et al. Chronic Prostatitis Collaborative Research Network. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med. 2004;141(8):581–589.

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Last updated: 2018-06-22 04:12