Also known as inflammation of the prostate, prostatitis is a common and often frustrating problem, particularly when the cause is not obvious. Prostatitis can cause pain in the lower back and in the area between the scrotum and rectum (the perineum) and may be accompanied by chills, fever, and a general feeling of malaise when caused by bacteria. The most common type is known as nonbacterial prostatitis, and the cause is not known. It can lead to chronic symptoms, including perineal discomfort, postejaculatory pain, and urination symptoms, and is characterized by periods of improvement and worsening.
Prostatitis is often difficult to treat, in part because several forms of the disease exist and the cause of the most common form is unknown. Some men experience acute flare-ups caused by a bacterial infection of the prostate. This acute bacterial prostatitis is associated with a sudden and continuous pain that lasts for several days. Some men have signs of inflammation, such as white blood cells in their semen, but not the painful symptoms of prostatitis.
More common, however, is chronic prostatitis, which can arise from a bacterial infection or an unidentified nonbacterial source (for example, trauma or prior infection). Nearly 95 percent of men with prostatitis are believed to have the chronic nonbacterial form (also known as chronic prostatitis/chronic pelvic pain syndrome, or CP/CPPS). Chronic nonbacterial prostatitis may last for several weeks or longer, only to disappear and then flare up again.
What causes prostatitis
The cause of bacterial prostatitis is obvious and easy to detect—infection with some type of bacteria. But researchers are not sure why some men develop the more common, nonbacterial form.
Some evidence suggests that an initial triggering event, either within the prostate or the pelvis where the prostate is located, promotes inflammation. Then the nerves that are affected by this inflammation are sensitized and inappropriately send pain messages that persist long after the trigger has disappeared. Trigger events could be anything causing inflammation in or around the prostate, such as an infection within the prostate, trauma to the perineal area (for example, from riding a bicycle) or a prostate biopsy.
Others suggest that chronic prostatitis is not a prostate problem at all. They attribute flare-ups to a pelvic muscle spasm or some other factor that mimics symptoms originating in the prostate. Another theory is that prostatitis may be an autoimmune disorder in which the immune system mistakenly attacks healthy prostate tissue and promotes inflammation.
Recent evidence suggests that any of these problems or a combination of them can trigger chronic prostatitis. Once the chronic pain syndrome is initiated, flare-ups could be triggered by a number of things such as stress, emotional problems, or certain foods or beverages, like coffee.
Other possible culprits include urinary tract abnormalities, infrequent ejaculation, dysfunctional urination and lower urinary tract infection. It is important to note, however, that none of these potential causes of nonbacterial prostatitis has been confirmed by solid research.
How to diagnose prostatitis
As part of the initial evaluation for prostatitis, a urine sample is evaluated to determine whether the disease stems from a bacterial infection. If chronic prostatitis is suspected, a urine sample may be taken from a man’s normal urine flow and then from urine voided after a prostate massage (in which the doctor strokes the prostate until fluid is pushed into the urethra). However, the value of these pre- and post-massage urine cultures has been questioned. When the diagnosis is not clear-cut—which is often the case—other diagnostic tests will need to be performed.
How to treat prostatitis
Treatment of bacterial prostatitis is straightforward: antibiotics for one to four weeks. Appropriate antibiotics include trimethoprim/sulfamethoxazole (Bactrim), doxycycline (Doryx), and fluoroquinolones such as ciprofloxacin (Cipro). Bacterial prostatitis is the most curable form of the disease. That said, some men do not respond to treatment and symptoms sometimes reappear once the antibiotics are stopped.
Treatment of nonbacterial prostatitis is more difficult. Some experts now believe that there are six CPPS subtypes, which are based on the presence of certain symptoms or characteristics. They propose that treatment or treatments (combination therapy is often required to obtain sufficient relief) be individualized based on the man’s particular subtype(s). These include:
Urinary symptoms. Pain on urination as well as a bothersome increase in urinary frequency and urgency and/or nighttime urination. Possible treatments include anticholinergic medications such as tolterodine (Detrol) and oxybutynin (Ditropan); alpha-blockers such as tamsulosin (Flomax) and alfuzosin (Uroxatral); and dietary changes such as cutting down on caffeine, spicy foods, and alcohol.
Psychosocial symptoms. A history of anxiety, depression, stress and/or a history of sexual abuse. Counseling, cognitive behavioral therapy, stress reduction techniques, and an antidepressant may be effective in this setting.
Organ-specific symptoms. Pain localized to the prostate or pain that is associated with filling and emptying the bladder. Therapies to address these symptoms include pentosan polysulfate (Elmiron), dimethyl sulfoxide (DMSO), and botulinum toxin (Botox) administered directly into the bladder.
Alternative therapies such as quercetin, bee pollen, bromelain/papain, and saw palmetto (Permixon), as well as neuromodulation, also may be helpful.
Infection, caused by organisms not typically associated with bacterial prostatitis. Ideally, the urine should be cultured to identify a causative organism and the infection treated with an antibiotic that the infectious organism is known to be sensitive to. If an antibiotic is prescribed before specific culture results are obtained and the patient does not respond to adequate therapy, an additional course of antimicrobial therapy is not warranted.
Neurological conditions. The presence of other pain-related neurologic or systemic conditions, such as irritable bowel syndrome or low back and leg pain. Neuroleptic drugs, such as pregabalin (Lyrica), nortriptyline (Aventyl, Pamelor), and amitriptyline, and acupuncture are potential therapies. Referral to a pain management clinic and stress reduction techniques also may be beneficial.
Skeletal muscle tenderness. The presence of spasms or trigger points in the abdomen or pelvis on examination by the doctor. Potential treatments for skeletal muscle tenderness include pelvic floor physical therapy, stress reduction, behavior modification (for example, sitting on a cushion when seated for a long period), oral antispasmodics, and neuromodulation.