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Prostatitis

Definition

Prostatitis is an inflammation of the prostate gland, a common condition in adult males. Often caused by infection, prostatitis may develop rapidly (acute) or slowly (chronic).

Description

Prostatitis may be the symptom-producing disease of the genitourinary tract for which men most often seek medical help. About 40% of visits to a specialist in genitourinary problems (urologist) are for prostatitis. Forms of prostate inflammation include acute and chronic bacterial prostatitis and inflammation not caused by bacterial infection. A painful condition called prostatodynia, which may be caused by abnormal nerves or muscles in the region, is also thought to be a form of prostatitis. The chronic bacterial form is sometimes experienced by men whose sex partners have a bacterial infection of the vagina, making this a sexually transmitted disease. Other cases occur when small stones form within the prostate and become infected. Sometimes infection is caused by poor hygiene, surgical procedures, or even swimming in polluted water.

The sexually transmitted disease gonorrhea may sometimes cause prostatitis, and tuberculosis may spread to the prostate. Parasites and fungi may infect the prostate gland. Some men whose prostatitis is not caused by any microorganism have microscopic collections of cells called granulomas in their prostate tissue. Whether viruses also may cause prostatitis is debatable.

Causes and symptoms

However the inflammation may begin, it causes blockages in the tiny glands within the prostate so that secretions build up, and the prostate swells. In acute cases, this swelling can occur very suddenly and cause considerable pain. When prostatitis develops gradually, trouble with the flow of urine may be the first symptom. Small stones may form, because the body attempts to neutralize bacteria by coating them with calcium. These stones may become infected themselves and make the condition worse.

Symptoms and signs that are typically experienced by men with prostatitis include:

  • Difficulties in urinating. Most urinary problems are caused when the swollen prostate blocks the tube that carries urine from the bladder to the outside of the body (urethra). Patients feel the need to urinate more often than usual, often urgently. Urination is sometimes painful. It is hard to start the flow of urine and difficult to totally empty the bladder. Patients wake up at night to urinate. The stream may be weak or split. Dribbling after attempts to urinate may leave embarrassing wet spots on clothing. In severe prostatitis blood or sand-like particles (small calcium collections) may be passed in the urine.
  • Pain. Besides pain when urinating, caused by prostate swelling, stimulation of nerves in the prostate gland may cause pain in the penis, one or both testicles, the lower stomach, the low back, and the area between the scrotum and the anus (perineum). Some patients experience pain during or after ejaculation, whenever they sit down or walk, or during bowel movements.
  • Sex and fertility. The pain of prostatitis can make it impossible to enjoy sex. Men with prostatitis may be troubled by early release of sperm (premature ejaculation). Occasionally there is blood in the semen. Some of the drugs prescribed to ease the flow of the urine can dampen the desire to have sex. Because the normal prostate secretions make up part of the semen, prostatitis may lower fertility by severely lowering the number of sperm and making them less mobile.
  • Psychological problems. A man with prostatitis who feels that nothing can be done and he "just has to live with it" may experience serious depression. Low sexual desire certainly contributes to depression.

A person with acute prostatitis may suddenly develop fever and chills, along with rapidly developing urinary symptoms and pain in the perineum or low back. This state is a medical emergency that demands immediate medical help.

Diagnosis

Most often the symptoms and physical findings are enough to form a diagnosis of prostatitis. When the examiner inserts a finger in the rectum, the swollen prostate can be felt; it may be extremely tender when probed. Squeezing the gland slightly will produce a few drops of fluid that may be cultured to learn whether bacteria are present. The fluid typically contains a large number of white blood cells, especially the cells used to fight off infection (macrophages). Note: too much pressure on the prostate can force bacteria into the blood and cause a serious general infection. Many patients with chronic bacterial prostatitis also have recurring urinary tract infections (diagnosed by examining and culturing urine samples). These infections can be an important clue to the diagnosis. If doubt remains, the urologist may insert a special instrument called a cystoscope through the penis to directly view the prostate from inside and see whether it looks inflamed.

Treatment

Acute prostatitis is first treated with antibiotics. Even though it may be difficult for drugs to actually get into the inflamed prostate, most patients do quickly get better. If intravenous antibiotics are needed or the bladder is retaining urine, a hospital stay may be necessary. Broad-spectrum antibiotics that work against most bacteria are used first. At the same time tests are done with samples of prostatic fluid to determine which bacterium is causing the infection, so that drugs can be prescribed to fight the specific germ. In chronic cases, the best results are obtained with a combination of the antibiotics trimethoprim and sulfamethoxazole. Oral antibiotics should be given for 1–3 months; longer, if necessary. If a fungus or some other organism is causing infection, special drugs are available. If chronic prostatitis continues despite all medical efforts and is seriously affecting the patient's life, the prostate may be removed surgically.

Nonbacterial prostatitis requires other measures to relieve urinary symptoms. These measures include drugs that fight inflammation (steroids or nonsteroids) and a type of drug called an alpha-blocker that reduces muscle tension. Reduced muscle tension eases urine flow, allowing the bladder to empty. A narrowed urethra may be widened by placing a collapsed balloon at the site of obstruction and expanding it. This procedure is called balloon dilation. The effects of such dilation are usually temporary. Some physicians believe that stress is an important factor in prostatitis, and therefore prescribe diazepam (Valium) or another tranquilizer. The type of prostatitis known as prostatodynia is usually treated with a combination of muscle relaxing drugs, heat, special exercises, and sometimes a tranquilizer.

There are a number of "tips" for relieving symptoms of prostatitis. They are especially helpful early on, before antibiotics have a chance to cure infection, or for patients with chronic or non-bacterial prostatitis:

  • Hot sitz baths. Exposing the perineum to very hot water for 20 minutes or longer often relieves pain.
  • Ice. When heat does not help, ice packs, or simply placing a small ice cube in the rectum, may relieve pain for hours.
  • Water. A patient who has to urinate very often may want to cut back on his fluid intake but this will cause dehydration and increase the risk of bladder infection. Instead, it is best to drink plenty of water.
  • Diet. Most doctors recommend cutting out—or cutting down on—caffeine (as in coffee or tea), alcohol, and spicy or acid foods. Constipation should be avoided because large, hard bowel movements may press on the swollen prostate and cause great pain. Bran cereals and whole-grain breads are helpful.
  • Exercise. It is especially important for patients with chronic prostatitis to keep up their activity level. Simply walking often will help (unless walking happens to make the pain worse).
  • Frequent ejaculation. Ejaculating two or three times a week often is recommended, especially when taking antibiotics.

Alternative treatment

A treatment popularized in the Philippines is called "prostate drainage." At regular intervals, a finger is inserted into the rectum, to exert pressure on the prostate at the same time that an antibiotic treatment is given. Acupuncture and Chinese herbal medicine also can be effective in treating prostatitis. Nutritional supplements that support the prostate, including zinc, omega-3 fatty acids, several amino acids, and anti-inflammatory nutrients and herbs, can help reduce pain and promote healing. Western herbal medicine recommends saw palmetto (Serenoa repens) to support the prostate gland. Hot and cold contrast sitz baths can help reduce inflammation.

Prognosis

Most patients with acute bacterial prostatitis are cured if they receive proper antibiotic treatment. Every effort should be made to get a cure at the acute stage because chronic prostatitis can be much more difficult to eliminate. If the acute illness is not controlled, complications such as a localized infection (prostatic abscess), kidney infection, or infection of the blood (septicemia) may develop. When chronic prostatitis cannot be cured, it still is possible to keep urinary symptoms under control and keep the patient active by using low doses of antibiotics and other measures. If a man with any form of prostatitis develops serious psychological problems, he should be referred to a psychiatric specialist.

Prevention

Potential sources of infection should be avoided. Good perineal hygiene should be maintained and sex should be avoided when one's partner has an active bacterial vaginal infection. If the kidneys, bladder, or other genitourinary organs are infected, prompt treatment may prevent the development of prostatitis. By far the best way of preventing chronic prostatitis is to treat an initial acute episode promptly and effectively.

BOOKS

Rous, Stephen N. The Prostate Book: Sound Advice on Symptoms and Treatment. 2nd ed. New York: W. W. Norton, 1995.

Walsh, Patrick C., and Janet F. Worthington. The Prostate: A Guide for Men and the Women Who Love Them. New York: Warner Books, 1997.

ORGANIZATIONS

Prostate Health Council, American Foundation for Urologic Disease. 1128 N. Charles St., Baltimore, MD 21201.(800) 242-AFUD.

The Prostatitis Foundation, Information Distribution Center. 2029 Ireland Grove Park, Bloomington, IL 61704. (309) 664-6222. <http://www.prostate.org>.

David A. Cramer, MD

KEY TERMS

Culture—A test in which a sample of body fluid, such as prostatic fluid, is placed on materials specially formulated to grow microorganisms. A culture is used to learn what type of bacterium is causing infection.

Cystoscope—A viewing instrument that is passed up the urethra into the region of the prostate to get a good look at the organ "from the inside."

Ejaculation—The process by which semen (made up in part of prostatic fluid) is ejected by the erect penis.

Granuloma—A cluster of cells that form in tissue that has been inflamed for some time.

Perineum—An area close to the prostate, between the scrotum and anus.