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Prostatitis Review

Prostatitis is an inflammation of the prostate. How common is it? In the US, over one million patients visits per year are for prostatitis. The following information will answer some of your questions on prostatitis, as well as those about the prostate itself--where it is, what is 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.

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.

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TYPES OF PROSTATITIS

There are three types of prostatitis-type presentations:

bacterial prostatitis (acute or chronic) five percent
non-bacterial prostatitis ~ 65%
prostatdynia 30%

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. 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).

Nonbacterial prostatitis is not caused by bacteria--its cause is not known. However the prostate is inflamed and prostate massage specimens semen and urine may have increased numbers of white blood cells (pus cells) when studied under the microscope. Antimicrobial medications are not effective for this type of prostatitis. Treatments, described later, may be helpful in some cases.

Prostadynia has all the symptoms of prostatitis. However, no bacteria are found on cultures and urine, 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. Antibiotics are not effective for prostadynia.

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.

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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
have abnormal urinary tract anatomy (congenital defect)
have had a recent bladder infection
have an enlarged prostate

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WHAT ARE THE SYMPTOMS OF PROSTATITIS?

The symptoms of prostatitis depend on the type of disease 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.

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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.

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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. For this urine specimen we do not want the middle of the stream, but the first few teaspoons that are urinated. The prostatic fluid is then analyzed under a microscope for signs of inflammation and infection.

When the diagnosis of prostatitis is not clear we will do a three glass urine collection with prostate massage. The three-glass urine collection method with prostate massage is used to separately measure the presence of white blood cells and bacteria in the urine and prostatic fluid. You will be asked to collect two urine samples separately: the first ounce of the urine you void (urine from your urethra) and then another sample of flowing, midstream urine (urine from your bladder). You will then almost empty your bladder by urinating into the toilet. At this point, your doctor will massage your prostate (prostatic fluid) and collect on a slide any secretions that appear. If no fluid is retrieved from the massage (about 50% of the time) you will then collect in a third container the first ounce of urine that remains in your bladder. All of these specimens will be examined and cultured separately.

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.

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HOW ABOUT INFECTIONS CAUSED BY VIRUSES?

Unfortunately, many types 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.

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HOW DO I KNOW WHICH TYPE OF PROSTATITIS I HAVE?

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 visible 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.

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 perineal and low-back pain. Microscopic examination of the urine specimen will be loaded with white blood cells and bacteria.

Nonbacterial prostatitis is more common than 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 develop an "exhaustive" or "overuse" prostatitis. A sexual history is an integral part of each man's evaluation.

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WHY IS CORRECT DIAGNOSIS SO IMPORTANT?

Because the treatment is different for the three types of prostatitis, the correct diagnosis is very important. Nonbacterial prostatitis will not 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.

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HOW IS PROSTATITIS TREATED?

Your treatment depends on the type of prostatitis you have.

If you have acute bacterial prostatitis, you will usually need to take antibiotics for seven to 14 days. 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.

If you have chronic bacterial prostatitis, you will require antibiotics for a longer period of time--usually four to 12 weeks. About 60 % 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 anti-microbial therapy may be recommended to relieve the symptoms. In some cases, surgical removal of the infected portions of the prostate may be advised.

The biggest difficulty with treatment is with the nonbacterial prostatitis and prostadynia groups. Since we have no real explanation of why these diseases exist, the treatments are aimed towards lessening symptoms rather than curing the disease. We do know however, that if you have nonbacterial prostatitis, you do not need antibiotics. Most patients when presenting with non bacterial 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. 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 doctors and hundreds of dollars on 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 moderate the symptoms of the disease.

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.

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).

For those patients with difficulty urinating or a slow stream, we can use drugs 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".

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". If the patient ingests large amount of irritating foods, we might modulate his diet. Major culprits are acidic foods such as cranberry, cola, and coffee. Alcohol and spicy foods are also irritating to the prostate.

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.

Stress management may also be helpful in those men who feel that their symptoms are worsened at times of stress. Relaxation, quiet and a peaceful meal can often help when "stressed out".

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 possibly 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.

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 placing 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.

You may find that tub baths or changes in your diet may help to alleviate your 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.

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WILL 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.
Treatment should be followed even if you have no symptoms.

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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 ultrasound. 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 1-800-242-2383.

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