Learn about the symptoms and treatment options for prostatitis, including chronic prostatitis, physical therapy, medication, and radiology.

Prostatitis

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Overview

Prostatitis is defined as a painful inflammation of the prostate gland. 
&nbsp;

The prostate is a walnut-shaped gland in males found in front of the rectum and below the bladder. It is wrapped around the urethra and produces the fluid part of the semen. Thus, playing a role in male fertility. Furthermore, the contraction of the prostate muscles also helps in the ejaculation of semen into the urethra.

With advancing age, disorders of the prostate, such as infections, neoplasia, inflammation, and benign enlargement become more common. They are a common cause of lower urinary tract symptoms, such as nocturia, urgency, frequency, and poor flow.

Prostatitis is the third most common urinary tract disease in men older than 50 years<a href="#accordion">[1]</a> [<a href="#accordion">3]</a>. Whereas, it is the most common urologic diagnosis in men under 50 years<a href="#accordion">[3]</a>. In the United States, prostatitis is responsible for 25% of men presenting with genitourinary symptoms<a href="#accordion">[2]</a>. Prostatitis is also associated with other prostate diseases, such as prostate cancer and benign prostatic hyperplasia (BPH)<a href="#accordion">[1]</a>. The prevalence of prostatitis was found to be between 2%-10% among men in Europe, Asia, and North America<a href="#accordion">[2]</a>.

A study conducted in a subset of the Karachi population found an increase in the number of prostatic disease cases each year<a href="#accordion">[1]</a>. The incidence of BPH associated with prostatitis increased from 1.2% in 2015 to 9.2% in 2018<a href="#accordion">[1]</a>. 
&nbsp;

The National Institutes of Health (NIH) classifies prostatitis into four types<a href="#accordion">[2]</a> <a href="#accordion">[4]</a>.

<ul>
	<li>Acute Bacterial Prostatitis - This is the least common type and can occur at any age. It has a sudden onset with symptoms like high fever, chills, urgency, painful urination, and pain in the genital area. It can be caused by bacteria traveling from the urethra into the prostate, reflux of urine into the prostate ducts, or lymphatic spread from the rectum. 
	&nbsp;</li>
	<li>Chronic Bacterial Prostatitis - Also rare, chronic bacterial prostatitis is difficult to treat, and the infection frequently recurs again and again. While fever may be absent, other symptoms are similar to acute bacterial prostatitis, but milder. Approximately 70-80% of cases are due to E. coli. Chronic bacterial prostatitis tends to last longer, often for years. It is more common in older men and symptoms include painful urination, nocturia, blood in semen, rectum pain, pain after ejaculation, and lower back pain. 
	&nbsp;</li>
	<li>Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) -&nbsp; This is the most common type and is characterized by perineal or pelvic pain without any evidence of infection. The pain can last longer than 3 months, ranging from mild to severely debilitating<a href="#accordion">[3].</a> Inflammation of the prostate or the nerves in the area is likely to blame but the exact cause remains unknown. 
	&nbsp;</li>
	<li>Asymptomatic Inflammatory Prostatitis - &nbsp;Approximately one-third of all patients who present with prostatitis have asymptomatic inflammatory prostatitis. The inflammation of the prostate is not associated with any symptoms. It is mostly discovered incidentally while evaluating people for BPH. Treatment is not needed; however, it can lead to infertility.&nbsp; 
	&nbsp;</li>
</ul>

Signs and Symptoms

The signs and symptoms of prostatitis vary based on the type of prostatitis<a href="#accordion">[5</a>] <a href="#accordion">[6]</a>. 
&nbsp;

<h5>Acute Bacterial Prostatitis (ABP)</h5>

ABP is the least common type of prostatitis, characterized by a sudden and severe onset of symptoms resulting from a bacterial infection in the prostate gland. Key signs and symptoms of ABP include:

<ul>
	<li>High fever accompanied by chills and sweating</li>
	<li>Nausea and vomiting</li>
	<li>Body aches</li>
	<li>Severe pelvic pain, often radiating to the lower back or rectum</li>
	<li>Painful and frequent urination</li>
	<li>Nocturia</li>
	<li>Blood in the urine (hematuria)</li>
	<li>Urinary retention (difficulty in completely emptying the bladder)</li>
	<li>Painful ejaculation 
	&nbsp;</li>
</ul>

<h5>Chronic Bacterial Prostatitis (CBP)</h5>

CBP involves recurrent urinary tract infections (UTIs) caused by persistent bacterial infections in the prostate gland. The signs and symptoms of CBP may include:

<ul>
	<li>Recurring episodes of UTIs</li>
	<li>Pelvic pain or discomfort that lasts for at least three months</li>
	<li>Frequent urination</li>
	<li>Nocturia</li>
	<li>Poor urine stream</li>
	<li>Painful ejaculation</li>
	<li>Blood in the semen (hematospermia)</li>
	<li>Erectile dysfunction</li>
</ul>

&nbsp;

<h5>Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)</h5>

CP/CPPS is the most prevalent form of prostatitis, accounting for approximately 90-95% of cases. It is characterized by persistent or recurrent pelvic pain, discomfort, and urinary symptoms. Common signs and symptoms of CP/CPPS include:

<ul>
	<li>Persistent or recurring pelvic pain (in the perineum, testicles, or penis) lasting for at least three months</li>
	<li>Urinary urgency and frequency</li>
	<li>Painful urination (dysuria)</li>
	<li>Painful ejaculation</li>
	<li>Erectile dysfunction</li>
	<li>Lower back pain</li>
	<li>Psychological distress, such as anxiety and depression</li>
</ul>

&nbsp;

<h5>Asymptomatic Inflammatory Prostatitis (AIP)</h5>

AIP is diagnosed incidentally during the evaluation of other conditions, as it typically lacks noticeable symptoms. However, when symptoms do occur, they may include:

<ul>
	<li>Nocturia (frequent urination at night)</li>
	<li>Mild urinary symptoms, such as urgency or weak urine flow 
	&nbsp;</li>
</ul>

Causes

The causes of different types of prostatitis vary, ranging from bacterial infections to non-infectious factors. 
&nbsp;

Acute Bacterial Prostatitis (ABP) - ABP is primarily caused by bacterial pathogens, such as Escherichia coli (E. coli) and other gram-negative bacteria. The infection typically arises from the urinary tract and spreads to the prostate gland. Bacterial prostatitis may occur due to ascending urethral infection, urinary catheterization, or systemic bacteremia. 
&nbsp;

Chronic Bacterial Prostatitis (CBP) - CBP is characterized by recurrent urinary tract infections (<a href="https://merisehat.pk/disease/uti">UTIs</a>) caused by a persistent bacterial infection in the prostate gland. The bacteria responsible for CBP are often the same as those found in ABP. They may reside in the prostate gland or enter it through the urinary tract. The infection can be perpetuated by the presence of biofilms or other factors that hinder the effectiveness of antibiotic treatment. 
&nbsp;

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) - The exact causes of CP/CPPS remain uncertain, and the condition is thought to result from a combination of multiple factors. These may include inflammation, neuromuscular dysfunction, autoimmune responses, hormonal imbalances, psychological stress, and pelvic floor muscle abnormalities. In some cases, previous episodes of bacterial prostatitis may contribute to the development of CP/CPPS. 
&nbsp;

Asymptomatic Inflammatory Prostatitis (AIP) - The causes of AIP are not well understood. It is believed to be associated with subclinical inflammation in the prostate gland, where inflammatory cells are present without noticeable symptoms. The underlying mechanisms and triggers for the inflammation in AIP are still under investigation. 
&nbsp;

Currently, there are no specific screening tests available for prostatitis. Prostatitis is typically diagnosed based on the presence of characteristic symptoms, medical history, physical examination, and laboratory tests, such as urine and prostate fluid analyses. 
&nbsp;

Diagnosis

Doctors diagnose prostatitis by considering a combination of factors, including a thorough medical history, physical examination, evaluation of symptoms, and specific diagnostic tests. The common diagnostic tests used for diagnosing prostatitis include[6]:

&nbsp;

Medical History - The doctor will inquire about the patient&#39;s symptoms, their duration and severity, and any previous episodes of prostatitis or urinary tract infections. A detailed medical history helps in assessing the nature and progression of the condition.

&nbsp;

Physical Examination - During a physical examination, doctors will assess for any discharge from the urethra, enlarged or tender lymph nodes in the groin, or a swollen or tender scrotum. They will also perform a digital rectal examination (DRE).

&nbsp;

Digital Rectal Examination (DRE) - During a DRE, the doctor inserts a gloved, lubricated finger into the rectum to assess the prostate gland&#39;s size, shape, and texture. This examination can help identify tenderness, enlargement, or irregularities that may indicate prostatitis.

&nbsp;

Urine Tests - A urine sample is collected to perform various laboratory tests, such as:

<ul>
	<li>Urinalysis: This test checks for the presence of white blood cells, red blood cells, bacteria, and other abnormalities in the urine, which may indicate infection or inflammation.</li>
	<li>Urine Culture: A urine sample is cultured to identify the specific bacteria causing the infection, particularly in cases of bacterial prostatitis.</li>
</ul>

&nbsp;

Prostate Fluid Analysis - A prostate massage or a voided urine specimen after a prostate massage can be used to collect prostate fluid for analysis. The fluid is examined for white blood cells, bacteria, and other inflammatory markers. This test can help distinguish between different types of prostatitis.

&nbsp;

Urodynamic Tests - These tests assess how effectively the bladder and urethra store and release urine. It includes:

<ul>
	<li>Uroflowmetry: This test evaluates how rapidly urine is released from the bladder.</li>
	<li>Post Void residual measurement - This evaluates the amount of urine remaining in the bladder after emptying. 
	&nbsp;</li>
</ul>

Blood Tests - Blood tests may be conducted to assess markers of inflammation, such as C-reactive protein (CRP) and prostate-specific antigen (PSA). Elevated levels of these markers may indicate infection or inflammation in the prostate gland. 
&nbsp;

Imaging Studies - In some cases, imaging studies, such as transrectal ultrasound (TRUS), may be recommended to evaluate the prostate gland&#39;s size, and structure, and detect any abnormalities. TRUS can help identify conditions that may mimic prostatitis, such as prostate abscess or stones. 
&nbsp;

Cystoscopy - A cystoscope helps visualize the urethra and bladder. It is inserted through the tip of the penis under local anesthesia. Cystoscopy can help assess for urinary tract stones, and narrowing or blockage of the urinary tract. 
&nbsp;

Biopsy - A small piece of the prostate tissue is extracted and examined for any abnormality. Doctors often use biopsies for detecting prostate cancer. 
&nbsp;

Semen Analysis - A semen sample is assessed for the presence of blood and signs of infection. 
&nbsp;

Prostatitis, if left untreated or inadequately managed, can lead to several potential complications. These include:

<ul>
	<li>Abscess Formation - In severe cases of acute bacterial prostatitis (ABP) or chronic bacterial prostatitis (CBP), the infection can progress to the formation of an abscess within the prostate gland. An abscess is a localized collection of pus that requires prompt medical attention and may necessitate drainage or surgical intervention. 
	&nbsp;</li>
	<li>Prostate Enlargement -&nbsp;Chronic inflammation of the prostate gland, as seen in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), can contribute to prostate enlargement, a condition known as benign prostatic hyperplasia (BPH). BPH can cause urinary symptoms, such as increased frequency, urgency, weak urine flow, and difficulty in emptying the bladder. 
	&nbsp;</li>
	<li>Urinary Complications -&nbsp;Prostatitis can lead to various urinary complications, including recurrent urinary tract infections (UTIs), bladder infections, and urethral strictures. These conditions can cause symptoms such as pain or discomfort during urination, blood in the urine (hematuria), and urinary frequency. 
	&nbsp;</li>
	<li>Sexual Dysfunction -&nbsp;Prostatitis can impact sexual function and lead to sexual dysfunction. Symptoms may include erectile dysfunction, painful ejaculation (dyspareunia), decreased libido, and difficulty achieving or maintaining an erection. 
	&nbsp;</li>
	<li>Psychological Distress -&nbsp;Chronic prostatitis, particularly chronic pelvic pain syndrome (CP/CPPS), can significantly impact a person&#39;s quality of life and emotional well-being. The persistent pain, discomfort, and associated symptoms can lead to psychological distress, including anxiety, depression, and reduced overall quality of life. 
	&nbsp;</li>
</ul>

Treatment

The treatment strategies for prostatitis depend on the specific type of prostatitis and may involve a combination of approaches, including medication, lifestyle modifications, and other supportive measures<a href="#accordion">[2]</a> <a href="#accordion">[5]</a> <a href="#accordion">[6]</a>. 
&nbsp;

Acute Bacterial Prostatitis (ABP)

ABP is typically treated with a course of antibiotics to target the underlying bacterial infection. The choice of antibiotic is based on the suspected bacteria and its sensitivity profile. Oral antibiotics are typically recommended for 6 to 8 weeks to prevent recurrence. In severe cases, hospitalization may be required for intravenous antibiotics and supportive care. Pain management with analgesics and anti-inflammatory medications may also be prescribed. Patients are advised to increase fluid intake and avoid substances, such as caffeinated beverages, alcohol, and spicy foods. 
&nbsp;

Chronic Bacterial Prostatitis (CBP)

CBP requires prolonged antibiotic treatment, often for several weeks or 6 months, to effectively eliminate the persistent bacterial infection. The choice of antibiotics is guided by the results of urine and prostate fluid cultures. In some cases, the use of alpha-blockers may be considered to relax the muscles around the prostate and improve urinary symptoms. Pain management and anti-inflammatory medications may also be prescribed. 
&nbsp;

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

The treatment of CP/CPPS is often challenging and focuses on managing symptoms and improving quality of life. It may include a combination of approaches, such as:

<ul>
	<li>Medications: Alpha-blockers, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, or low-dose anti-depressants may be prescribed to relieve pain, relax the pelvic muscles, and improve urinary symptoms.</li>
	<li>Physical Therapy: Pelvic floor physical therapy, including relaxation techniques, stretching exercises, and biofeedback, may help relieve pelvic pain and muscle tension.</li>
	<li>Lifestyle Modifications: Avoiding triggers, such as caffeine, alcohol, spicy foods, and prolonged sitting, and adopting stress management techniques may help alleviate symptoms.</li>
	<li>Psychological Support: Counseling, cognitive-behavioral therapy, or relaxation techniques can help manage the psychological distress associated with CP/CPPS. 
	&nbsp;</li>
</ul>

Asymptomatic Inflammatory Prostatitis (AIP)

As AIP typically lacks noticeable symptoms, treatment is generally not necessary. However, if symptoms develop or worsen, the approach may be similar to that of CP/CPPS, focusing on symptom management and lifestyle modifications. 
&nbsp;

Prostatitis is a complex condition influenced by various factors. While the exact causes and risk factors are not fully understood, certain factors have been identified as potential risk factors for developing prostatitis<a href="#accordion">[5]</a>. 
&nbsp;

<ul>
	<li>Age: Prostatitis can occur at any age, but it is more commonly observed in men between the ages of 30 and 50. The risk may increase with advancing age.</li>
	<li>History of Prostatitis: Individuals who have previously experienced prostatitis are at a higher risk of developing recurrent episodes or chronic prostatitis.</li>
	<li>Urinary Tract Infections (UTIs): A history of urinary tract infections, particularly recurrent UTIs, can increase the risk of developing prostatitis.</li>
	<li>Recent Urinary Procedures: Certain urological procedures, such as urinary catheterization, cystoscopy, or prostate biopsy, can introduce bacteria into the urinary tract and increase the risk of prostatitis.</li>
	<li>Sexual Factors: Engaging in unprotected sexual intercourse, having multiple sexual partners, or practicing anal intercourse may increase the risk of bacterial prostatitis.</li>
	<li>Urinary Tract Abnormalities: Structural abnormalities in the urinary tract, such as urethral strictures or bladder outlet obstruction, can predispose individuals to prostatitis.</li>
	<li>Immune System Factors: Conditions that weaken the immune system, such as HIV/AIDS or immunosuppressive therapy, may increase the susceptibility to prostatitis.</li>
	<li>Stress and Psychological Factors: Chronic stress and psychological factors, including anxiety and depression, may contribute to the development or exacerbation of prostatitis symptoms.</li>
	<li>Sedentary Lifestyle: Leading a sedentary lifestyle with prolonged periods of sitting or immobility may increase the risk of prostatitis, particularly chronic pelvic pain syndrome (CP/CPPS). 
	&nbsp;</li>
</ul>

While it may not be possible to completely prevent prostatitis, certain measures can be taken to reduce the risk of developing the condition or minimize the chances of recurrent episodes. 
&nbsp;

<ul>
	<li>Good Hygiene: Practicing good hygiene habits, including regular washing of the genital area and proper cleaning of the anal area after bowel movements. This helps reduce the risk of bacterial contamination and potential infection.</li>
	<li>Safe Sexual Habits: Using condoms during sexual intercourse reduces the risk of sexually transmitted infections (STIs) that can lead to prostatitis. It is also advisable to limit the number of sexual partners and communicate openly about sexual health.</li>
	<li>Staying Hydrated: Drinking an adequate amount of water to maintain proper hydration. Sufficient hydration helps flush out bacteria and promotes urinary tract health.</li>
	<li>Avoiding Prolonged Sitting: Avoiding prolonged periods of sitting, especially on hard surfaces, as this can potentially lead to pelvic congestion and discomfort. It is advised to take breaks, stretch, and move around regularly, especially if one has a sedentary job or lifestyle.</li>
	<li>Maintaining Regular Bowel Movements: Preventing constipation by consuming a fiber-rich diet, staying physically active, and maintaining regular bowel movements. Straining during bowel movements can put pressure on the prostate gland and potentially contribute to prostatitis.</li>
	<li>Managing Stress: Stress management techniques, such as relaxation exercises, deep breathing, meditation, or engaging in joyful activities can help reduce stress levels. Chronic stress can weaken the immune system and potentially increase the risk of prostatitis.</li>
	<li>Seeking Prompt Treatment: If one experiences symptoms suggestive of prostatitis or has a history of recurrent episodes, they should seek medical attention promptly. Early diagnosis and appropriate treatment can help prevent the progression of prostatitis and minimize complications. 
	&nbsp;</li>
</ul>

There are currently no defined treatment protocols for chronic pelvic pain syndrome (CPPS). Recently, researchers explored the impact of manual therapy intervention in the treatment of CPPS<a href="#accordion">[7]</a>.

Patients were administered six sessions for nine weeks. Manual therapy not only reduced their pain but also their urinary symptoms and improved their quality of life. 
&nbsp;

Key Points

<ul>
	<li>Prostatitis refers to inflammation or infection of the prostate gland, which can cause a variety of symptoms and discomfort.</li>
	<li>There are four main types of prostatitis: acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and asymptomatic inflammatory prostatitis (AIP).</li>
	<li>The symptoms of prostatitis can vary but commonly include pelvic pain or discomfort, urinary symptoms (such as increased frequency or urgency), pain during urination or ejaculation, and sexual dysfunction.</li>
	<li>Prostatitis can have multiple causes, including bacterial infections, non-bacterial inflammation, pelvic muscle tension, or unknown factors.</li>
	<li>Diagnosing prostatitis involves a combination of medical history evaluation, physical examination (including digital rectal examination), urine and prostate fluid analysis, and sometimes imaging studies.</li>
	<li>Treatment for prostatitis depends on the type and severity of the condition. It may involve antibiotics for bacterial prostatitis, pain management medications, alpha-blockers, physical therapy, lifestyle modifications, and psychological support.</li>
	<li>Complications of prostatitis can include abscess formation, prostate enlargement (benign prostatic hyperplasia), urinary complications, sexual dysfunction, and psychological distress.</li>
	<li>Risk factors for prostatitis include age, history of prostatitis or urinary tract infections, recent urinary procedures, sexual factors, urinary tract abnormalities, immune system factors, stress, sedentary lifestyle, and certain occupations.</li>
	<li>Preventive measures for prostatitis include maintaining good hygiene, practicing safe sexual habits, staying hydrated, avoiding prolonged sitting, managing stress, practicing safe medical procedures, and seeking prompt treatment when symptoms arise. 
	&nbsp;</li>
</ul>

[1] Frequency and trends of prostatic diseases in a subset of Karachi population: A retrospective study. Pakistan Journal of Medicine and Dentistry. Published online 2021. doi:10.36283/pjmd10-1/004.

[2] Prostatitis. Medscape.

[3] Shah AA, Mannan A, Ayub M, Shafi N, Ali A, Raza ZA, Farooq M. Anwar MS. Questionnaire Survey of Urologists Concerning Chronic Prostatitis and Chronic Pelvic Pain Syndrome. Esculapio - JSIMS 2022;18(02):214-218.

[4] Prostatitis: Prevalence, classification and treatment. AMA Journal of Ethics. 2006;8(11):748-751. doi:10.1001/virtualmentor.2006.8.11.cprl1-0611.

[5] Prostatitis. NHS.

[6] Prostatitis: Inflammation of the Prostate. National Institute of Diabetes and Digestive and Kidney Diseases.

[7] Rabal Conesa C, Cao Avellaneda E, López Cubillana P, et al. Manual therapy intervention in men with chronic pelvic pain syndrome or chronic prostatitis: An exploratory prospective case-series. Cureus. Published online 2022. doi:10.7759/cureus.24481.