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ATLANTA UROLOGY ASSOCIATES, P.C.
Bruce Stein, M.D.
Stephen B. Siegel, M.D.
478 Peachtree Street, NJ?., Suite 909-A
Atlanta, GA 30308
Tel (404) 525-5567 FAX (404) 880-0192
www.lJrology-Atlanta.com
PROSTATITIS - REVIEW
Prostatitis is an inflammation of the prostate. How common is it? In the US, over 2 million patientvisits per year are a result of prostatitis. It is the most common urologic problem in men less than 50
years old. Between 64% of all men will develop prostatitis in their lifetime. If a man has an episode of
prostatitis, he has a 50% chance of having another episode in his lifetime. The following information
will answer some of your questions on prostatitis, as well as those about the prostate itself--where it is
and what it does.
WHAT IS THE PROSTATE AND WHAT DOES IT DO?
The prostate is a gland of the male reproductive system. It is located in front of the rectum and just
below the bladder, the organ that stores urine. The prostate is quite small--it weighs only about an
ounce--and is nearly the same size and shape as a walnut. As shown below, the prostate wraps around a
tube called the urethra, which carries urine from the bladder out through the tip of the penis.
1 Ureter
thra through prostate
The prostate is made up largely of muscular and glandular tissues. Its main function is to produce fluid
for semen, which transports sperm. During the male orgasm (climax), muscular contractions squeeze
the prostate’s fluid into the urethra. Sperm, which are produced in the testicles, are also propelled into
the urethra during orgasm. The sperm-containing semen leaves the penis during ejaculation.
TYPES OF PROSTATITIS
Historically three types of prostatitis were recognized:
l bacterial prostatitis (acute or chronic) - 5%
(new categories I and II)
l non-bacterial prostatitis
- 65% (new category Bra)
l prostatdynia 30% (new category IIIb)
This older classification unfortunately did not take into account newer information about prostatitis.
Mislabeling a patient’s problem often led to treatments that might not have been warranted.
A new classification of prostatitis by the US Nation Institute of Health (NIH) was recently introduced.
Category I
Technical Name
Acute bacterial prostatitis
Category II
Chronic bacterial prostatitis
Category III
Chronic abacterial prostatitis
Also known as ‘chronic pelvic
pain syndrome or CPPS’
No demonstrable infection
Category IIIa
Infllammatory chronic pelvic
pain syndrome
Non-inflammatory chronic
pelvic pain syndrome
White blood cells
Category IIIb
Category IV
Asymptomatic inflammatory
prostatitis
Descrintion
A&e infection of the prostate gland
Recurrent infection of the prostate
in prostaticjluids
No white blood cells in prostaticjluids
No symptoms but inflammation seen on
biopsy or white blood cells seen in prostate fluids
Category I or acute bacterial prostatitis is caused by bacteria and is treated with antibiotics. Acute
bacterial prostatitis comes on suddenly, and its symptoms--including chills and fever--are severe.
Therefore, a visit to your doctor’s office or the emergency room is essential, and hospitalization is
frequently required.
Category II or chronic bacterial prostatitis is also caused by bacteria and requires antibiotics. Unlike an
acute prostate infection, the only symptoms of chronic bacterial prostatitis may be recurring bacterial
cystitis (bladder infection).
Category IIIa or nonbacterial prostatitis is not, to our current knowledge, caused by a bacteria or virus-its cause is not known. In fact. we are not sure that chronic nonbacterial orostatitis is even a disease of
the orostate! However, the prostate is probably inflammed and prostate massage specimens, semen and
urine may have increased numbers of white blood cells (pus cells) when studied under the microscope.
Although no bacteria is isolated, antibiotics may be effective for this type of prostatitis. This category is
the most problematic for urologists in terms of its cause and treatment. Normally, when pus cells are
identified, we hope to find a causative agent, usually a bacteria or virus. To date we have not
consistently found any cause. Many urologists suspect that the inflammation is caused by a bacteria or
virus not usually associated with diseases, of which there are countless. On the other hand, many
diseases exist where inflammation is not associated with a bacteria or virus, such as arthritis or colitis.
Category IlIb or prostadynia has all the symptoms of prostatitis. However, no bacteria are found on
cultures and mine, prostate massage specimens and semen have no white blood cells when examined
under the microscope. We have no idea why prostadynia exists, nor do we have an effective cure.
Antibtiotics are not effective for prostadynia. Many feel that Type IIIb is some form of nerve-muscle
problem with the pelvic region.
Note: The ‘itis’ at the end of prostatitis denotes inflammation. Inflammation usually denotes white blood
cells or pus cells. Therefore, technically speaking, prostadynia is not truly prostatitis. We add it to the
list because the symptoms and treatment are identical to nonbacterial prostatitis.
HOW DOES BACTERIAL PROSTATITIS DEVELOP?
Despite their names, acute and chronic bacterial prostatitis are not contagious and are not considered to
be sexually transmitted diseases. Your sexual partner cannot catch this infection from you.
How then did you get it? The way in which the prostate becomes infected is not clearly understood.
The bacteria that cause prostatitis may get into the prostate from the urethra by backward flow of
infected urine into the prostate ducts or from rectal bacteria.
Certain conditions or medical procedures increase the risk of contracting prostatitis. You are at higher
risk for getting prostatitis if you:
. recently have had a medical instrument, such as a urinary catheter (a soft, lubricated tube used to drain
urine from the bladder) inserted during a medical procedure
. engage in rectal intercourse
l
have abnormal urinary tract anatomy (congenital defect)
l
have had a recent bladder infection
l
have an enlarged prostate
WHAT ARE THE SYMPTOMS OF PROSTATITIS?
The symptoms of prostatitis depend on the type of prostatitis you have. You may experience no
symptoms or symptoms so sudden and severe that they cause you to seek emergency medical care.
Symptoms, when present, can include any of the following: fever, chills, urinary frequency, frequent
urination at night, difficulty urinating, burning or painful urination, perineal (referring to the perineum,
the area between the scrotum and the anus) and low-back pain, joint or muscle pain, tender or swollen
prostate, blood in the urine, or painful ejaculation.
ARE THE SYMPTOMS OF PROSTATITIS UNIQUE?
The symptoms of prostatitis resemble those of other infections or prostate diseases. Thus, even if the
symptoms disappear, you should have your prostate checked. For example, benign prostatic hyperplasia
(BPH), a noncancerous enlargement of the prostate that is common in men over age 40, may produce
urinary tract symptoms similar to those experienced with prostatitis.
Similarly, urethritis, an inflammation of the urethra (often caused by an infection), may also give rise to
many of the symptoms associated with prostatitis.
Still another condition that mimics the symptoms of prostatitis--when prostatitis is not present--is
prostadynia (painful prostate). Patients with prostadynia have pain in the pelvis or in the perineum.
Such pain may result from a prostate problem, but the pain can have a variety of different causes
including muscle spasms or other musculoskeletal conditions.
Yet another term we may mention in discussing your prostate problem is prostatosis, a more vague
word, which simply means “a condition of the prostate.” It might be interchangeable with prostadynia.
Because of the connections between the urethra, the bladder, and the prostate, conditions affecting one
or the other often have similar or overlapping symptoms. These include the following:
Depression
Fibromyalgia
Interstitial Cystitis
Hernia
Urethral Stricture
Drug/Food Reaction
Stress
Spinal Stenosis
Ureteral Stone
Bladder Cancer
Seminal Vesicle Cyst
Prostate Cyst
Ejaculatory Duct Cyst
Benign Prostate Hyperplasia
Urethritis
Radiation Cystitis
Allergic Reaction
HOW IS PROSTATITIS DIAGNOSED?
To help make an accurate diagnosis, several types of examinations are useful.
The prostate is an internal organ, so the physician cannot look at it directly. Because the prostate lies in
front of the rectum, just inside the anus, the doctor can feel it by inserting a gloved, lubricated finger
into the rectum.
This simple procedure, called a digital rectal examination ( or just ‘rectal’), allows the physician to
estimate whether the prostate is enlarged or has lumps or other areas of abnormal texture. While this
examination may produce momentary discomfort, it causes neither damage nor significant pain.
Because this examination is essential in detecting early prostate cancer, which is often without
symptoms, the American Urological Association recommends a yearly prostate examination for every
man over age 40 and an immediate examination for any man who develops persistent urinary symptoms.
The test that must be performed when prostatitis is suspected is prostate massaging, during which
prostatic fluid is collected. While performing the digital rectal examination, your doctor may vigorously
massage the prostate to force prostatic fluid out of the gland and into the urethra. Although prostate
massage is not comfortable, we need to be able to examine the fluid to accurately diagnose your
condition. If no fluid is expressed after massage, we may ask you to give us another urine specimen so
that we might be able to examine the washout of the prostate channel from the first part of urination.
The most used diagnostic testing is as follows:
Pre-massaee urine. You need to provide a specimen from the middle ofyour stream offreeflowing
urine. This represents the urinefi-om your bladder (Called midstream urine or VBZ). Urination
should be stopped after this specimen is collected so that additional specimens can be obtained a
few minutes later. You will then go back to the examination room to see the doctor. Note: Some
physicians will use the initialfirstfew teaspoons of urination to look at the urethra (Calledfirst
glass or VBI)
Prostate massage. The physician will examine the prostate with a digital rectal exam. He or she will
then vigorously massage the prostate gland to force theprostatefluid into the urethra (channel
through the penis). This discharge is called expressedprostatic secrtions or Eps. At least 50% of
the time, prostate fluid will be found at the tip of the penis. This fluid, tffound, is examined under
the microscope and also sent to the laboratory for culture (identtfication of type of bacterial
growth) and sensitivity (fbacterial growth is found, which antibiotics are most effective against
the bacteria).
Post massage urine. Another urine specimen is obtained. This time only thejrst two teaspoons of
urine that is passed is collected. This represents thefluidforced into the penis by the massage.
This is referred to as post ntassaee urine or VB3. This urine is examined under the microscope
and also sent to the laboratory for culture and sensitiviq. If cultures from the post massage urine
arepositivefor bacteria and the concentration of bacteria in the post massage specimen is greater
than thepre massage specimen, a diagnosis of bacterial prostatitis is made. If the cultures are
positivefrom both urine specimens, but in equal concentrations, the most likely diagnosis is
urinary tract infection (bladder or kidney infection, also known as cystitis orpyelonephritisj
prostate
EPS
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Mldstr
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urethra
not mandatory
Jrine
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Post mar
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Examination of these samples will help your physician determine whether your problem is an
inflammation or an infection and whether the problem is in your urethra, bladder, or prostate. If an
infection is present, your doctor will also be able to identify the type of bacteria involved so that the
most effective antibiotics can be prescribed.
HOW ABOUT INFECTIONS CAUSED BY VIRUSES?
Unfortunately, many type of organisms other than bacteria can cause infections or inflammations.
Viruses are the best known agents of infections, but other types of organisms also exist that may be
linked to infections of various parts of the body. Organisms that we have tried to link to prostatitis
include chlamydia, ureaplasma, mycoplasma, herpes simplex, cytomegalovirus, adenovirus, and
trachoma. None of the studies done on prostatitis have shown these agents, some of which are viruses, to
be present any more in patients with prostatitis than those without prostatitis. We do not have any
effective treatment for viral infections.
HOW DO I KNOW WHICH TYPE OF PROSTATITIS 1 HAVE?
Category I or acute bacterial prostatitis is the easiest of the three conditions to diagnose because it comes
on suddenly and the symptoms require quick medical attention. Not only will you have urinary
problems, but you may also have a fever and pain and, occasionally visable blood in your urine. Your
urine may be cloudy and microscopic examination of the urine specimen will be loaded with white
blood cells and bacteria.
Category II or chronic bacterial prostatitis is associated with repeated urinary tract infections, while
nonbacterial prostatitis is not. In fact, if you do not have a urinary tract infection or a history of one, you
probably do not have chronic bacterial prostatitis. Other symptoms, if any, may include urinary
problems such as the need to urinate Frequently, a sense of urgency, burning or painful urination, and
possibly groin, perineal(area where one sits under the scrotum and in front of the anus) and low-back
pain. Microscopic examination of the urine specimen will be loaded with white blood cells and bacteria.
Category III or ‘chronic pelvic pain syndrome’ with (type IIIa) pus cells or without (type IIIb) white cells
in prostate massage specimens are more common than Category I and II or acute and chronic bacterial
prostatitis. It may cause no symptoms, or its symptoms may mimic those of chronic bacterial prostatitis.
If you have nonbacterial prostatitis, however, it is unlikely that you will have urinary tract infections.
On occasion we will find patients developing prostatitis from lack of sexual activity. This is called
‘congestive prostatitis’ and suggests that lack of ejaculation causes the semen to stay in the prostate too
long and cause inflammation. Conversely, men who ejaculate too frequently can deveiop an ‘exhaustive’
or ‘overuse’ prostatitis. A sexual history is an integral part of each man’s evaluation.
Category IV are patients who have no infection or symptoms but are found to have pus cells in their
prostate massage specimen. These patients, without symptoms, might be found after a routine
examination of the urine showed white blood cells and additional evaluation revealed these white blood
cells (or pus cells) to be coming from the prostate. Some patients, also without symptoms, might also be
found after an elevated prostate specific antigen blood test, a test used to screen for prostate cancer.
Prostate inflammation can cause an elevation in the PSA. A prostatebiopsy to test for cancer might
show no cancer but inflammation of the prostate.
WHY IS CORRECT DIAGNOSIS SO IMPORTANT?
Because the treatment is different for the three types ofprostatitis, the correct diagnosis is very
important. Nonbacterial prostatitis will not usually clear up with antibiotics, and bacterial prostatitis will
not go away without such treatment.
In addition, it is important to make sure that your symptoms are not caused by urethritis or some other
condition that may lead to permanent bladder or kidney damage.
HOW IS PROSTATITIS TREATED?
Your treatment depends on the type of prostatitis you have.
Category I - acute bacterial prostatitis
If you have acute bacterial prostatitis, you will usually need to take antibiotics for 7 to 14 days. In some
cases, intravenous antibiotics are required in the early stages of treatment, Almost all acute infections
can be cured with this treatment. Analgesic drugs to relieve pain or discomfort and, at times,
hospitalization may also be required.
Category II - chronic bacterial prostatitis
If you have chronic bacterial prostatitis, you will require antibiotics for a longer period,of time--usually
4 to 12 weeks. In most cases we use antibiotics in the ‘quinolone’ or ‘sulfa/trimethoprim’ groups. About
60 percent of all cases of chronic bacterial prostatitis clear up with this treatment. For cases that don’t
respond to this treatment, long-term, low-dose antibiotic therapy may be recommended to relieve the
symptoms. In some cases, surgical removal of the infected portions of the prostate may be advised.
Category III - chronic pelvic pain syndrome (CPPS)
The biggest difficulty with treatment is with the nonbactrial prostatitis and prostadynia groups. Since
we have no real explanation of why these diseases exist, the treatments are more aimed at lessening
symptoms rather than curing the disease.
Antibiotics
We do know however, that if you truly have nonbacterial prostatitis, you do not need antibiotics. The
major problem with this statement is that proving that bacteria were not present prior to any treatments.
Most patients when presented with nonbacterial prostatitis will have already had several courses of
antibiotics before they get to a urologist. These drugs have usually been given before the cultures have
returned. Since bacterial prostatitis is curable with antibiotics, and technically the cultures could miss an
infection, a trial of drugs, even if the culture shows no growth, may be warranted. In patients with IIIa,
when pus cells are present, a course of therapy Tom 2 to as long as 12 weeks may be appropriate. In
patients with II@, when no pus cells are seen, a trial course of antibiotics for 1 to as long as 4 weeks
seems reasonable. In some studies as many as 40% of men will improve with antibiotics. One major
problem that arises is the variability of nonbacterial prostatitis to cause symptoms. As the disease waxes
and wanes normally, patients can be misled to believe that the antibiotics are really helping their
problem. When the drug doesn’t work, the patient then believes that they have become resistant and
want to try yet another drug. Sometimes after countless visits to the doctors and hundreds of dollars of
medication, the problem still exists and the cultures, done over and over, still show no growth of any
bacteria.
What does help? Again the treatment is aimed more at reducing symptoms rather than curing them. The
non-bacterial prostatitis will come and go - good months and bad months. All we can do is try to lessen
the symptoms of the disease.
Hot baths
Hot baths are helpful for almost all men with prostatitis of any kind. These are often referred to as sitz
baths and the warm water and relaxation of the bath soothe the prostate and relieves symptoms. While
there is no scientific evidence proving that these “home remedies” are effective, they are not harmful and
some people experience relief from symptoms while using them.
Alpha blockers
For those patients with difficulty starting urination or a slow stream, we can use dmgs to relax the
muscles of the sphincter area (sphincters are the muscular valves that hold the urine in the bladder -that’s why we are not wet all the time!!). These drugs are called ‘alpha blockers’.
Anti-spasmodic drugs
For those patients who have urgency and frequency of urination, we can use medications to relax the
muscles that surround the bladder to make it less sensitive. These drugs are referred to as
‘parasympathetic blockers’ or anti-spasmodics.
Fluids and Diet
Drinking plenty of water helps. This dilutes the acidity and salt in the urine and dilutes any irritants that
you might eat (caffeine, cranberry, citrus acid, peppers and spices, etc).
If the patient ingests large amounts of irritating foods, we might modulate his diet. Major culprits are
acidy foods such as cranberry, cola, and coffee. Alcohol and spicy foods are also irritating to the
prostate. Some patients have specific food items that are bothersome, such as onions or tomatoes. If you
can identify an increase in symptoms with any food group - reduce your intake.
Anti-inflammatories
Non-steroidal anti-inflammatory medications may also be helpful. Ibuprofen and naproxen, both
available over-the-counter now, along with stronger prescription anti-inflammatories may be of some
benefit. Muscle relaxants are also helpful in some men. New categories of anti-inflammatories are
being produced and some of these may have some beneficial effects against ‘inflammations’ of the
prostate.
Finasteride (Proscar)
Finasteride, a drug that shrinks the prostate gland by blocking certain hormones, it can be helpful in
some cases, particularly in men with larger prostates. Herbal remedies, including zinc and saw palmetto,
have helped some men. The mechanism of action of various herbal remedies is poorly understood.
Psychological support
Stress management and biofeedback may also be helpful in those men who feels that their symptoms are
worsened at times of stress. Life style changes may help, including massage, relaxation, coping
mechanisms, psychological support, diet changes and exercise. For some a quiet and a peaceful meal
can often help when ‘stressed out’. Psychotherapy and coping skills may also help.
Sexual Frequency
Many men with prostatitis stop having sexual relations because of fear of transmitting disease to their
partner. Some men stop having sex because they are depressed. Prostatitis cannot be transmitted. We
encourage men to maintain a normal sex life. The amount of sex we recommend is based on one’s usual
sexual patterns. If you are ejaculating rarely and we feel that congestive prostatitis is possible present,
we would recommend ejaculating perhaps one to three times a week. Masturbation is OK. In those
men who might have overuse prostatitis, we sometimes recommend less sexual activity.
Prostate Massage
Regular prostate massages can also be helpful. The physician will forcibly press the prostate gland
firmly in an attempt to break up or release areas of inflammation from the gland. Technically,
ejaculation will do the same thing, but some feel that the forcible (and painful) massage is more
effective.
Microwave treatments
Experimental use of microwave therapy has been reported as an effective treatment for non-bacterial
prostatitis. This technology is referred to as transurethral microwave therapy or TUMT. In one
technique, a microwave probe is placed into the prostate channel through the penis using a catheter or
soft rubber tube. Another technique is place the microwave probe next to the prostate through the
rectum. The prostate is heated gently at various intervals. The probe placed though the penis has been
approved by the FDA for the treatment of enlarged prostates, but not yet for the treatment of prostatitis.
Acupuncture
Acupuncture is the Chinese originated medical therapy using fine needles into certain ‘nerve sites’ for
each body part. Its use in prostatitis is not supported by Western medical literature but some patients do
respond and it seems to cause little harm or risk.
Phytotherapy
Herbal therapy is the use of naturally occurring plants or plant extracts for the treatment of various
diseases. Herbal treatments supporters make no differentiation between prostate enlargement (BPH) or
prostatitis. The American Food and Drug Administration (FDA) views these as food additives and
makes little or no effort to control the use or content of herbal therapy. No American studies have been
done to establish the safety or usefulness any herbal treatment for prostate enlargement or symptoms.
In the last few years a number of European studies have been done that suggest that herbal therapy can
help relieve prostate symptoms. These studies do not give any answers as to why herbal therapy works
and none have the safety investigations so necessary for American drug studies. Another problem is the
different amount of herbal extract in each product. This means that the amount of herb in each
preparation may be different. Many of the preparations come with multiple herbs so that it may be
impossible to determine which herb is helping reduce prostate symptoms. Nevertheless many men in the
United States have used herbal therapy purchased through drug and health food stores with some
success. These drugs do not require prescriptions and are rarely covered by insurance.
of
The most popular of these extracts is saw palmetto. Saw palmetto is sold under a variety of names and
often with a variety of other herbs or extracts. Saw palmetto was originally thought to be similar to
finasteride (Proscar). We now believe this not to be true as saw palmetto doesn’t lower the prostate
specific antigen and prostate volume like finasteride does. Some researchers feel that saw palmetto may
reduce prostate inflammation. As of now we do not know why saw palmetto works. It does seem to be
safe, without significant side effects.
Other less well know extracts include Pygeum Africanum, beta-sitosterol, pollen extract, pumpkin seeds,
South African star grass and stinging nettles, meparticin, and radix mticae. These extracts all appear to
be safe and well tolerated. Their effectiveness has not been established with any American studies.
Category IV
Treatment of patients with no symptoms and no definite evidence ofinfection may be difficult to justify.
However, if the patient has an elevated prostate specific antigen (PSA) blood test and has required one
or more biopsies of the prostate to rule out cancer, a case for antibiotic treatments followed by additional
PSA tests could be made. A discussion with your physician of your options is needed.
WlLL PROSTATITIS AFFECT ME OR MY LIFESTYLE?
Prostatitis is a treatable disease. Even if the problem cannot be cured, you can usually get relief from
your symptoms by following the recommended treatment.
Prostatitis is not a contagious disease. You can live your life normally and continue sexual relations
without passing it on.
You should keep in mind the following ideas:
* Correct diagnosis is key to management of prostatitis.
l
Treatment should be followed even if you have no symptoms.
WILL I GET PROSTATE CANCER FROM HAVING PROSTATITIS?
No association between prostatitis and prostate cancer has been established. However, the screening
tests that we now use for prostate cancer include the prostate specific antigen (PSA), digital rectal
examinations and prostatic ultrtisound. All three can be skewed by the presence of prostatitis.
The PSA levels can be falsely elevated by prostatitis. If a patient has an elevated PSA, along with
finding of prostatitis, we encourage treatment and a repeat of the blood tests. Many patients with
chronic prostatitis will undergo prostate biopsies because their PSA values are too high. The biopsy is
necessary as we cannot tell prostatitis from prostate cancer in many cases.
Having prostatitis does not increase your risk of getting any other prostate disease. But remember, even
if your prostatitis is cured, there are other prostate conditions, such as prostate cancer, that require
prostate checkups at least once a year after age 40.
This information is modified from information ‘provided by the Prostate Health Council c/o American
Foundation for Urologic Disease, Inc. For more information call I-800-242-2383.