Chronic prostatitis

Chronic prostatitis symptoms

The symptoms of chronic prostatitis/chronic pelvic pain syndrome include:

Pain

This is usually around the base of the penis, around the anus, in the lower tummy (abdomen) and in the lower back. Sometimes the pain spreads down to the tip of the penis and/or into the testicles (testes). Pain is the main symptom in chronic prostatitis. The pain may vary in severity from day to day.

Urinary symptoms

These may include mild pain when you pass urine, an urgent desire to pass urine at times, some hesitancy when trying to pass urine or a poor urinary stream.

Sexual problems

You may experience difficulty in getting an erection (impotence), ejaculation may sometimes be painful, or be premature, and some men have worse pain (as described above) after having sex.

Other symptoms

You may feel tired and have general aches and pains. You may feel anxious, stressed or depressed and your quality of life may feel worse.

Men with chronic bacterial prostatitis tend to have symptoms that wax and wane:

• During a flare-up, you can have pain and discomfort. You feel this mainly at the base of your penis, around your anus, just above your pubic bone and/or in your lower back. Pain may spread to your penis and testicles (testes). Passing stools (faeces) can be painful.

• You may also have symptoms from a urine infection, such as pain when you pass urine, passing urine frequently or an urgent desire to pass urine.

• These symptoms are similar to the symptoms of acute bacterial prostatitis. However, men with a flare-up of chronic bacterial prostatitis tend to be less ill than those with acute prostatitis. For example, a high temperature (fever) is less likely and you are less likely to have general aches and pains.

• If you have chronic bacterial prostatitis, your symptoms will generally ease when treated with antibiotics. However, unless the antibiotics completely clear the infection from the prostate gland, you are at risk of the infection coming back (flaring up) again.

• In between flare-ups, you may have some mild residual pain and some mild urinary symptoms (such as passing urine frequently or an urgent desire to pass urine).

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Acute prostatitis

When the prostate gland becomes infected with a germ (a bacterial infection), the condition is known as acute prostatitis. 'itis' means inflammation, so prostatitis is inflammation of the prostate - not all forms of prostatitis are bacterial, but this leaflet will mainly cover bacterial prostatitis. Symptoms include pain, mainly at the base of the penis and around the anus. A bladder infection commonly occurs at the same time. Treatment includes a four-week course of antibiotic medication.

by Dr Toni Hazell

How common is chronic prostatitis?

Up to 8% of men will be affected by symptoms of prostatitis at some point in their lives, however it is difficult to know how many truly have chronic prostatitis as the symptoms may sometimes be due to another condition. The risk of having chronic prostatitis goes up with age, being three times more common in men aged 50 - 59 than in those aged 20 - 39.

How do you get chronic prostatitis?

The exact cause is often unknown and there may be several different causes or types of prostatitis. Chronic bacterial prostatitis is one possibility - caused by a persistent (chronic) infection with a germ (a bacterial infection). A man with chronic bacterial prostatitis will usually have had recurring urine infections. Chronic bacterial prostatitis is more common in men who have an immune system that doesn't work properly (are immunocompromised) - this may be due to a disease, such as untreated HIV, or because they have a condition such as arthritis which needs to be treated with drugs that suppress the immune system.

Chronic bacterial prostatitis is usually caused by the same type of germs (bacteria) that causes the urine infections. The prostate gland can harbour infection and therefore recurring infections can occur. Chronic bacterial prostatitis is not a sexually transmitted infection, but it can sometimes be caused by sexually transmitted bacteria.

What causes chronic pelvic pain syndrome (CPPS)?

CPPS is a type of chronic prostatitis that causes discomfort or pain in your lower pelvic region - mainly at the base of your penis and around your anus. It is usually diagnosed if you have had pain for at least three months within the previous six months. The cause of this type of chronic prostatitis is not fully understood.

How is chronic prostatitis diagnosed?

Examination of your prostate gland

Your doctor may examine your prostate gland. The doctor inserts a gloved finger in your back passage (rectum). Your prostate gland may be tender on examination in chronic prostatitis. However, this is not so in every case.

A urine sample

A urine sample is usually taken to rule out urine infection. This is especially important for chronic bacterial prostatitis although, in between flare-ups, there may be no signs of infection.

Further tests of your kidneys and urinary tract

If your doctor suspects that you have chronic bacterial prostatitis, they may suggest that you have further tests to rule out any problem with your urinary tract that may have contributed to (or caused) the infection. For example, an ultrasound scan of your kidneys to look for any abnormalities.

Tests to exclude other causes for your symptoms

This includes:

• Swab or urine tests.

• Blood tests.

• Fluid sample from the prostate.

Swab or urine tests are done to exclude a sexually transmitted infection (STI) which can produce similar symptoms to chronic prostatitis.

Sometimes your doctor may suggest a blood test to exclude other problems with your prostate gland. These are done to rule out other conditions of your prostate or nearby organs if your symptoms are not typical.

If you are referred to a urologist, a sample of fluid ('secretions') from the prostate may be collected to rule out infection in your prostate. This is sometimes done in cases of chronic prostatitis.

To do this, a doctor can gently massage your prostate, with a gloved finger in your rectum. By doing this, fluid from the prostate is pushed out into the urethra and comes out from the penis to be collected and tested for germs (bacteria). If you have CPPS, no bacteria are found in the prostate fluid or urine.

What is the prostate gland?

Cross-section diagram of the prostate and nearby organs

The prostate gland is only found in men and is part of the male reproductive system. It lies just beneath the bladder. It is normally about the size of a chestnut.

The urethra is the tube that passes urine from the bladder and it runs through the middle of the prostate. The prostate helps to make semen and seminal fluid but most semen is made by another gland (the seminal vesicle).

Chronic prostatitis treatment

The treatment of chronic prostatitis can be difficult. However, in most people, symptoms improve over months or years.

If your GP suspects that you have chronic prostatitis, as mentioned above, they will usually refer you to a specialist for further assessment. In the meantime, your GP may suggest one or more of the following whilst you are waiting for your appointment with a specialist:

• Painkillers such as paracetamol or ibuprofen may ease the pain.

• Laxatives may be helpful if it is painful or difficult to pass stools.

• Antibiotics are recommended if your doctor thinks you have chronic bacterial prostatitis. The antibiotic course should last for 2-4 weeks. Antibiotics are usually advised if you have had a urinary tract infection or an episode of acute prostatitis within the previous year. This is to be absolutely sure that no infection is present.

Treatments that a specialist may suggest

Various treatments have been tried for chronic prostatitis. They may benefit some people but so far there are few research studies to confirm whether they help in most cases. They are not 'standard' or routine treatments but a specialist may advise that you try one.

Possible treatments for chronic bacterial prostatitis include the following:

• A longer course of antibiotics. If the specialist suspects that you have chronic bacterial prostatitis and your symptoms have not cleared after a four-week course of antibiotics, they may suggest a longer course. Sometimes a course of up to three months is used.

• Removal of the prostate (prostatectomy) may very occasionally be considered if you have small stones (calculi) in the prostate. It is not clear how much this may help but it has been suggested that these small stones may be a reason why some people have recurrent infections in chronic bacterial prostatitis. However, this is not a common type of treatment and is not suitable in everyone. Your specialist will advise.

For chronic prostatitis/CPPS, possible treatments may include the following:

• Antibiotics - these may be tried initially, although the evidence for their effectiveness is limited. It may be that some antibiotics have anti-inflammatory properties as well or that they may clear some germs (bacteria) that are difficult to find when your urine is tested.

• Alpha-blockers - are medicines that are used to treat prostate gland enlargement. They relax the muscle tissue of the prostate and the outlet of the bladder. There are several different brands. There is some evidence that they help in CPPS and one may be worth a try.

• Other medicines - for example, bioflavonoids (such as quercetin) and finasteride (a medicine which may 'shrink' the prostate).

• Stress management - this and other pain-relieving techniques are sometimes tried to help cope with the persistent pain.

What is the outlook?

It is difficult to give an outlook (prognosis). Your symptoms may last a long time, although they may 'come and go' or vary in severity. Painkillers can keep discomfort to a minimum.

Some people worry that they may have a serious disease such as prostate cancer. However, worry and anxiety can make symptoms of chronic prostatitis worse so seeking a formal diagnosis is advised.

Most men diagnosed with chronic prostatitis/CPPS tend to have an improvement in their symptoms over the following six months. In one study, about a third of men had no further symptoms one year later. In another large study, one third of men showed moderate to marked improvement over two years.

Can chronic prostatitis cause infertility?

It is though that chronic prostatitis may reduce the amount and quality of sperm, which may have an effect on fertility.