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.
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.
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.
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 .
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 . 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 . Such findings could further affirm bacterial CP, but are particularly important for diagnosing non-bacterial CP.
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  . 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:
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.
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 . CP may have consequences to mental and physical health that are comparable to those of congestive heart failure or diabetes mellitus .
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 . 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 .
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 . 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 .
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.
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.
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.
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 . A comprehensive classification system comprising the categories acute prostatitis, bacterial CP, non-bacterial CP and asymptomatic inflammatory prostatitis has been established .
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.
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.
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:
While acute cases of prostatitis may be accompanied by fever, this is usually not the case in CP.
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.
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.