ATLANTA UROLOGY ASSOCIATES, P.C. Bruce Stein, M.D. Stephen B. Siegel, M.D. 478 Peachtree Street, NJ?., Suite 909-A Atlanta, GA 30308 Tel (404) 525-5567 FAX (404) 880-0192 www.lJrology-Atlanta.com PROSTATITIS - REVIEW Prostatitis is an inflammation of the prostate. How common is it? In the US, over 2 million patientvisits per year are a result of prostatitis. It is the most common urologic problem in men less than 50 years old. Between 64% of all men will develop prostatitis in their lifetime. If a man has an episode of prostatitis, he has a 50% chance of having another episode in his lifetime. The following information will answer some of your questions on prostatitis, as well as those about the prostate itself--where it is and what it 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. 1 Ureter thra through prostate 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. TYPES OF PROSTATITIS Historically three types of prostatitis were recognized: l bacterial prostatitis (acute or chronic) - 5% (new categories I and II) l non-bacterial prostatitis - 65% (new category Bra) l prostatdynia 30% (new category IIIb) This older classification unfortunately did not take into account newer information about prostatitis. Mislabeling a patient’s problem often led to treatments that might not have been warranted. A new classification of prostatitis by the US Nation Institute of Health (NIH) was recently introduced. Category I Technical Name Acute bacterial prostatitis Category II Chronic bacterial prostatitis Category III Chronic abacterial prostatitis Also known as ‘chronic pelvic pain syndrome or CPPS’ No demonstrable infection Category IIIa Infllammatory chronic pelvic pain syndrome Non-inflammatory chronic pelvic pain syndrome White blood cells Category IIIb Category IV Asymptomatic inflammatory prostatitis Descrintion A&e infection of the prostate gland Recurrent infection of the prostate in prostaticjluids No white blood cells in prostaticjluids No symptoms but inflammation seen on biopsy or white blood cells seen in prostate fluids Category I or 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. Category II or 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). Category IIIa or nonbacterial prostatitis is not, to our current knowledge, caused by a bacteria or virus-its cause is not known. In fact. we are not sure that chronic nonbacterial orostatitis is even a disease of the orostate! However, the prostate is probably inflammed and prostate massage specimens, semen and urine may have increased numbers of white blood cells (pus cells) when studied under the microscope. Although no bacteria is isolated, antibiotics may be effective for this type of prostatitis. This category is the most problematic for urologists in terms of its cause and treatment. Normally, when pus cells are identified, we hope to find a causative agent, usually a bacteria or virus. To date we have not consistently found any cause. Many urologists suspect that the inflammation is caused by a bacteria or virus not usually associated with diseases, of which there are countless. On the other hand, many diseases exist where inflammation is not associated with a bacteria or virus, such as arthritis or colitis. Category IlIb or prostadynia has all the symptoms of prostatitis. However, no bacteria are found on cultures and mine, 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. Antibtiotics are not effective for prostadynia. Many feel that Type IIIb is some form of nerve-muscle problem with the pelvic region. 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. 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 l have abnormal urinary tract anatomy (congenital defect) l have had a recent bladder infection l have an enlarged prostate WHAT ARE THE SYMPTOMS OF PROSTATITIS? The symptoms of prostatitis depend on the type of prostatitis 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. 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. These include the following: Depression Fibromyalgia Interstitial Cystitis Hernia Urethral Stricture Drug/Food Reaction Stress Spinal Stenosis Ureteral Stone Bladder Cancer Seminal Vesicle Cyst Prostate Cyst Ejaculatory Duct Cyst Benign Prostate Hyperplasia Urethritis Radiation Cystitis Allergic Reaction 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. The most used diagnostic testing is as follows: Pre-massaee urine. You need to provide a specimen from the middle ofyour stream offreeflowing urine. This represents the urinefi-om your bladder (Called midstream urine or VBZ). Urination should be stopped after this specimen is collected so that additional specimens can be obtained a few minutes later. You will then go back to the examination room to see the doctor. Note: Some physicians will use the initialfirstfew teaspoons of urination to look at the urethra (Calledfirst glass or VBI) Prostate massage. The physician will examine the prostate with a digital rectal exam. He or she will then vigorously massage the prostate gland to force theprostatefluid into the urethra (channel through the penis). This discharge is called expressedprostatic secrtions or Eps. At least 50% of the time, prostate fluid will be found at the tip of the penis. This fluid, tffound, is examined under the microscope and also sent to the laboratory for culture (identtfication of type of bacterial growth) and sensitivity (fbacterial growth is found, which antibiotics are most effective against the bacteria). Post massage urine. Another urine specimen is obtained. This time only thejrst two teaspoons of urine that is passed is collected. This represents thefluidforced into the penis by the massage. This is referred to as post ntassaee urine or VB3. This urine is examined under the microscope and also sent to the laboratory for culture and sensitiviq. If cultures from the post massage urine arepositivefor bacteria and the concentration of bacteria in the post massage specimen is greater than thepre massage specimen, a diagnosis of bacterial prostatitis is made. If the cultures are positivefrom both urine specimens, but in equal concentrations, the most likely diagnosis is urinary tract infection (bladder or kidney infection, also known as cystitis orpyelonephritisj prostate EPS l&void d rim IOI Mldstr !I urethra not mandatory Jrine b ladde r Post mar urine w 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. HOW ABOUT INFECTIONS CAUSED BY VIRUSES? Unfortunately, many type 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. HOW DO I KNOW WHICH TYPE OF PROSTATITIS 1 HAVE? Category I or 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 visable 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. Category II or 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 groin, perineal(area where one sits under the scrotum and in front of the anus) and low-back pain. Microscopic examination of the urine specimen will be loaded with white blood cells and bacteria. Category III or ‘chronic pelvic pain syndrome’ with (type IIIa) pus cells or without (type IIIb) white cells in prostate massage specimens are more common than Category I and II or acute and chronic 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 deveiop an ‘exhaustive’ or ‘overuse’ prostatitis. A sexual history is an integral part of each man’s evaluation. Category IV are patients who have no infection or symptoms but are found to have pus cells in their prostate massage specimen. These patients, without symptoms, might be found after a routine examination of the urine showed white blood cells and additional evaluation revealed these white blood cells (or pus cells) to be coming from the prostate. Some patients, also without symptoms, might also be found after an elevated prostate specific antigen blood test, a test used to screen for prostate cancer. Prostate inflammation can cause an elevation in the PSA. A prostatebiopsy to test for cancer might show no cancer but inflammation of the prostate. WHY IS CORRECT DIAGNOSIS SO IMPORTANT? Because the treatment is different for the three types ofprostatitis, the correct diagnosis is very important. Nonbacterial prostatitis will not usually 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. HOW IS PROSTATITIS TREATED? Your treatment depends on the type of prostatitis you have. Category I - acute bacterial prostatitis If you have acute bacterial prostatitis, you will usually need to take antibiotics for 7 to 14 days. In some cases, intravenous antibiotics are required in the early stages of treatment, 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. Category II - chronic bacterial prostatitis If you have chronic bacterial prostatitis, you will require antibiotics for a longer period,of time--usually 4 to 12 weeks. In most cases we use antibiotics in the ‘quinolone’ or ‘sulfa/trimethoprim’ groups. About 60 percent 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 antibiotic therapy may be recommended to relieve the symptoms. In some cases, surgical removal of the infected portions of the prostate may be advised. Category III - chronic pelvic pain syndrome (CPPS) The biggest difficulty with treatment is with the nonbactrial prostatitis and prostadynia groups. Since we have no real explanation of why these diseases exist, the treatments are more aimed at lessening symptoms rather than curing the disease. Antibiotics We do know however, that if you truly have nonbacterial prostatitis, you do not need antibiotics. The major problem with this statement is that proving that bacteria were not present prior to any treatments. Most patients when presented with nonbacterial 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. In patients with IIIa, when pus cells are present, a course of therapy Tom 2 to as long as 12 weeks may be appropriate. In patients with [email protected], when no pus cells are seen, a trial course of antibiotics for 1 to as long as 4 weeks seems reasonable. In some studies as many as 40% of men will improve with antibiotics. 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 the doctors and hundreds of dollars of 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 lessen the symptoms of the disease. Hot baths 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. 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. Alpha blockers For those patients with difficulty starting urination or a slow stream, we can use dmgs 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’. Anti-spasmodic drugs 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’ or anti-spasmodics. Fluids and Diet 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). If the patient ingests large amounts of irritating foods, we might modulate his diet. Major culprits are acidy foods such as cranberry, cola, and coffee. Alcohol and spicy foods are also irritating to the prostate. Some patients have specific food items that are bothersome, such as onions or tomatoes. If you can identify an increase in symptoms with any food group - reduce your intake. Anti-inflammatories 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. Muscle relaxants are also helpful in some men. New categories of anti-inflammatories are being produced and some of these may have some beneficial effects against ‘inflammations’ of the prostate. Finasteride (Proscar) Finasteride, a drug that shrinks the prostate gland by blocking certain hormones, it can be helpful in some cases, particularly in men with larger prostates. Herbal remedies, including zinc and saw palmetto, have helped some men. The mechanism of action of various herbal remedies is poorly understood. Psychological support Stress management and biofeedback may also be helpful in those men who feels that their symptoms are worsened at times of stress. Life style changes may help, including massage, relaxation, coping mechanisms, psychological support, diet changes and exercise. For some a quiet and a peaceful meal can often help when ‘stressed out’. Psychotherapy and coping skills may also help. Sexual Frequency 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 possible 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. Prostate Massage Regular prostate massages can also be helpful. The physician will forcibly press the prostate gland firmly in an attempt to break up or release areas of inflammation from the gland. Technically, ejaculation will do the same thing, but some feel that the forcible (and painful) massage is more effective. Microwave treatments 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 place 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. Acupuncture Acupuncture is the Chinese originated medical therapy using fine needles into certain ‘nerve sites’ for each body part. Its use in prostatitis is not supported by Western medical literature but some patients do respond and it seems to cause little harm or risk. Phytotherapy Herbal therapy is the use of naturally occurring plants or plant extracts for the treatment of various diseases. Herbal treatments supporters make no differentiation between prostate enlargement (BPH) or prostatitis. The American Food and Drug Administration (FDA) views these as food additives and makes little or no effort to control the use or content of herbal therapy. No American studies have been done to establish the safety or usefulness any herbal treatment for prostate enlargement or symptoms. In the last few years a number of European studies have been done that suggest that herbal therapy can help relieve prostate symptoms. These studies do not give any answers as to why herbal therapy works and none have the safety investigations so necessary for American drug studies. Another problem is the different amount of herbal extract in each product. This means that the amount of herb in each preparation may be different. Many of the preparations come with multiple herbs so that it may be impossible to determine which herb is helping reduce prostate symptoms. Nevertheless many men in the United States have used herbal therapy purchased through drug and health food stores with some success. These drugs do not require prescriptions and are rarely covered by insurance. of The most popular of these extracts is saw palmetto. Saw palmetto is sold under a variety of names and often with a variety of other herbs or extracts. Saw palmetto was originally thought to be similar to finasteride (Proscar). We now believe this not to be true as saw palmetto doesn’t lower the prostate specific antigen and prostate volume like finasteride does. Some researchers feel that saw palmetto may reduce prostate inflammation. As of now we do not know why saw palmetto works. It does seem to be safe, without significant side effects. Other less well know extracts include Pygeum Africanum, beta-sitosterol, pollen extract, pumpkin seeds, South African star grass and stinging nettles, meparticin, and radix mticae. These extracts all appear to be safe and well tolerated. Their effectiveness has not been established with any American studies. Category IV Treatment of patients with no symptoms and no definite evidence ofinfection may be difficult to justify. However, if the patient has an elevated prostate specific antigen (PSA) blood test and has required one or more biopsies of the prostate to rule out cancer, a case for antibiotic treatments followed by additional PSA tests could be made. A discussion with your physician of your options is needed. WlLL 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. l Treatment should be followed even if you have no symptoms. 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 ultrtisound. 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 I-800-242-2383.
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