Prostatitis

SYMPTOMS OF NON-BACTERIAL PROSTATITIS

(represents 90%-95% of prostatitis)

(Men with this condition typically have 2 or more symptoms)

Urinary frequency & Urinary urgency (frequent urination and hard to hold once urge occurs)

For patients, urinary frequency can range from being annoying to debilitating
There is typically a feeling of something always nagging in your bladder/urethra/genitals and typically after someone urinates, they don’t feel ‘emptied’ and have the feeling of having to urinate again even though there is no urine there
The normal relaxation you feel after urination when you have no pelvic pain is not there
Always a nagging feeling, and sometimes patients push on the bladder to see if it there is any reason to urinate
Frequency/urgency means you have to always be near a bathroom and sometimes can hardly hold in the urge to urinate
If you are in a movie theatre, sports event etc. you usually look to sit in the aisle seat because when the urge comes, you have to go
Some patients feel that their life revolves around being near a toilet
Urinary urgency and frequency can deprive people of sleep because of how often they wake up during the night

Perineal pain (pain between the anus and scrotum)

Perineum is one of the most common sites of pelvic pain, is intimate, can hurt 24/7 and can be very distressing
The perineum is the place where most muscles of the pelvic floor attach and therefore has many sources of referred pain
Perineum is often the site of bicycle riding pain
Perineum pain can be made worse by sitting or standing
In a 2009 Stanford study of our work published in the Journal of Urology, it was documented that 79% of subjects complained of pain in the perineum
We documented key abdominal and pelvic muscles that all refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus)
The perineum and the anal sphincter is one of the parts of the body where the patients feel the feeling of “sitting on a golf ball”
Perineal pain is intimate pain and when it doesn’t stop, it is very distressing

Discomfort or pain during or hours after ejaculation

Increased discomfort hours or the day after sexual activity is common
Our explanation about why there is often an increase in discomfort during or after sexual activity in men and women with chronic pelvic pain syndromes is as follows:
- Orgasm causes strong contractions of the pelvic, prostate and seminal vesicle muscles lasting about once a second during orgasm.
- There is a significant increase in nervous system arousal during sexual activity.
- The pleasure spasm of orgasm in the form of the increased series of contractions during orgasm will tighten the pelvic muscles further.
- This increased tightening temporarily contracts an already contracted area which doesn’t relax well and it tends to throw the patient further above the symptom threshold
- When our patients learn to release the muscles inside the pelvic floor, they usually can feel this increased muscle contraction
- After a certain time frame (from hours to days), the pelvic muscles relax and return to their baseline level, the normal tightened state of the pelvic floor reasserts itself (which is back to some degree of pain or discomfort when a person has chronic pelvic pain syndrome).
- For this reason we do not recommend increasing sexual activity (as has often been suggested by physicians our male patients have seen) when a person has an increase in symptoms after sex

Sitting pain

Sitting can trigger or exacerbate discomfort/pain/symptoms
Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
Sitting pain makes one acutely aware of how sitting is the center of social and work life
Sitting pain usually starts out milder at the morning but after sitting through the day, there is increased discomfort that can last into the night
Patients often are looking for the padded seats in a restaurant because sitting is so uncomfortable
Difficult to sit with friends or family and socialize
Difficult to fly or drive for any distance without pain
Sometimes patients have to go on disability because they can’t work because their job is a sitting job
Sitting pain is one of the symptoms that raises the fear that you might not be able to work or function
Some patients go on disability because they can’t sit
Most endure the pain and deal with the buildup of pain during the day

Genital pain (penile pain)

In men, pain at the tip and shaft of the penis is a common symptom
In men, penile pain is sometimes accompanied with a redness at the tip
In men, sometimes there is an irritation on the tip so that rubbing against underwear is uncomfortable
Genital pain usually referred from the anterior levator ani and one of the easier symptoms to resolve

Dysuria (pain or burning during urination)

Burning or pain with urination is always disconcerting
It is often associated with pelvic floor dysfunction
When the chronic spasm and myofascial contraction of the pelvic muscles is resolved, in many of our patients, dysuria is also resolved
Sometimes people feel no pain during urination but only after
Dysuria can be so painful that urination becomes a large ordeal and sets off further pain

Nocturia (frequent urination at night)

Often this is a major problem in that someone’s sleep is so disturbed they are exhausted all the time
Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain protective guarding and anxiety

Reduced urinary stream and hesitancy of urination

In men this is an important symptom to medically evaluate as to whether the source of the reduced stream from prostate enlargement or other other issues
Hesitancy of initiating urination can be worsened when urine is held in longer than comfortable (because we speculate the tightening of the muscles to hold in the urine puts the muscles in a kind of spasm that is slow to release upon urination)
A contributing symptom to low self-esteem and hypochondriasis especially in younger men
When urinary symptoms are muscular in origin, after loosening the pelvic floor, the flow of urine can improve
Some people with muscle based pelvic pain have to wait for a while to get a stream of urine going

Testicle pain or discomfort

Testicular pain/discomfort is particularly miserable and scary
Pain/discomfort is felt in one testicle or another
Sometimes the cremaster muscles pull up the testicles or penis especially when the anal sphincter is sore and this can be very disconcerting
Patients have come to see us who had their testicle removed and their pain remained unchanged

Suprapubic pain (pain above the pubic bone)

It is common symptom
Suprapubic pain is common with patients who have urinary frequency, urgency, hesitancy and anterior symptoms
Sometimes pressing on this area can refer into the anorectal (anus and rectal) area and sometimes bladder pain is experienced here
Pain can be on one side or another or in the middle

Coccyx (tailbone) pain or Coccygodynia/coccydynia

Tailbone pain is common
It is typically referred pain from the pelvic floor and not from the tailbone itself
Patients` 1 who had their tailbone removed typically felt no relief
Coccyx pain is often related to post bowel movement pain

Low back pain (on one side or both)

This is common and often confuses patients and practitioners because the symptoms are referred from the muscles of the pelvic floor, not the low back
Discomfort can be on one side or another or migrate from one side to another

Groin pain (on one side or both)

Groin pain often is confused with a hernia
We have seen patients who have had hernia repair for their pain that did not resolve their groin pain

Discomfort or relief after a bowel movement

Relief after a bowel movement occurs when the tight pelvic muscles relax
Discomfort after a bowel movement is a very disconcerting experience because when people have post bowel movement pain, symptoms often begin more strongly for the rest of the day
Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes.
When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close.’
That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
Resolving post bowel movement pain in our patients tends to occur as their entire pelvic muscle tension releases

Symptoms can migrate or change location

It is not uncommon for symptoms to change location or ‘migrate’
Sometimes pain or sensation will appear in one part of the pelvis or abdomen and then the next day it is elsewhere

Heat (hot bath or shower, heating pad) helps temporarily

Hot water or heat often helps temporarily
Cold weather flares up symptoms in some patients

Benzodiazepines temporarily reduce symptoms when first used

The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
Benzodiazepines are addictive and when used regularly for pelvic pain, they tend to lose their effectiveness when used regularly over time and can cause addiction
Benzodiazepines typically make the user tired and should not be used when driving or having to be alert

Reduced libido (reduced interest in sex)

Reduced interest in sex is common with pelvic pain
In pelvic muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido

Anxiety about having sex and ‘erectile dysfunction’ in men

Because sex and be painful or painful afterward, there is often a conditioned withdrawal from having sex to avoid pain
This anxiety and the often resultant difficult in men can result in difficulty in maintaining an erection which adds to relationship difficulties, courting difficulties particularly in younger patients,
Anxiety with having sex, in our view is the major reason for performance anxiety and what is ‘medicalized’ as erectile dysfunction
In our experience when pain goes away, so does the anxiety and what is called erectile dysfunction connected to it

Anxiety and catastrophic thinking

The scariest part of pelvic pain is the catastrophic thought that it will never go away
Most patients attention is on their pain most of the time at some level and this focus is most disconcerting
It is a focus that distract your attention away from your life and with many patients, paints an unacceptable future

Depression

When you are in the throes of pelvic pain, the thought that it will never go away prompts depression in many patients
Where the doctors cannot help you and you see no light at the end of the tunnel, depression or and anxious depression is the rule rather than the except
Depression involves the feeling of helplessness about doing anything about what you feel is critically wrong in your life

Social withdrawal and difficulty in intimate relations

The withdrawal that comes from chronic pain and it distracting any enjoyment of the moment
There is a major toll that chronic pelvic pain takes on relationships on partners of those in pain
The difficult issues that arise from partners involve the problems arising from the patient’s withdrawal from sex, withdrawal from going out and doing things with others, planning trips, parenting, socializing and doing the things of partnership or marriage
In the pelvic pain patient’s suffering and preoccupation with pain, the much needed experience of a partner for the other to be present is often lost

Impairment of self-esteem

Self-esteem almost always goes down
Men and women with chronic pelvic pain almost always worry that no one will want to be with them

Sleep disturbance

Sleep disturbance is very common
Patients either to wake up to urinate or because of pain and anxiety
Patients typically wake up anxious
We wrote a paper about precipitous rise in cortisol in the morning amongst pelvic pain patients
Many patients wake up anxious, wondering if the pain has gone, disappointed every day that it isn’t

Stress increases pain

ordinary stresses as well as extraordinary stress tend to increase symptoms
when stress has triggered pelvic pain, the stress tends to triggers the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone

Helplessness and hopelessness

Helplessness and hopelessness is the real suffering with chronic pelvic pain
Helplessness comes from a patient’s inability to stop pain/discomfort that is draining and scary
The hopelessness and helplessness of pelvic pain steals away your ability to rest or enjoy anything
Hopelessness in pelvic pain patients arises when they can’t see anything on the horizon anything that might help them

SYMPTOMS OF LESS PREVALENT CATEGORIES OF PROSTATITIS ACCORDING TO NIH CATEGORIES

The National Institutes of Health categorized prostatitis in 4 types. By far the most prevalent type is called Category III non bacterial prostatitis (with our without inflammation). Non-bacterial prostatitis is the most common form of up 90%-95% of cases of men diagnosed with prostatitis that we described above.

Below is a description of symptoms related to the more uncommon forms of prostatitis.

FOUR CATEGORIES OF PROSTATITS (NIH)

Type I: Acute bacterial prostatitis

Type II: Chronic bacterial prostatitis

Type III: Non-bacterial prostatitis: (most prevalent form

Subtype IIIA CPPS nonbacterial inflammatory prostatitis

Subtype IIIB CPPS nonbacterial non-inflammatory prostatitis

Type IV: Asymptomatic inflammatory prostatitis

Category I – Acute Bacterial Prostatitis

Description

Acute Bacterial Prostatitis is quite clear both in its diagnosis and in its treatment. Infection and inflammation are evident and traditional treatments work well. We do offer the idea that chronic pelvic tension may be its initiating cause.

It can occur at any age and manifest with symptoms such as fever, chills, pain, and urinary dysfunction. Positive findings involving the presence of white blood cells in the urine as well as pathogenic bacteria confirm this diagnosis. Acute bacterial prostatitis develops relatively quickly and is often associated with a feeling of being sick. Newer antibiotics produce good results. It is important to have this condition treated quickly because of the risk of the spread of bacteria into the bloodstream, retention of urine, and potential abscess formation. Chronic bacterial prostatitis can develop from acute bacterial prostatitis that is poorly treated. Antibiotic therapy should be extended to 28 days to assure eradication of the infection.

Symptoms

Fever and chills

Prostate pain

Dysuria

Lower back pain

Perineal pain (pain between the anus and scrotum)

Difficulty urinating

Urinary retention

Because of retention of urine due to swelling of the prostate gland, a catheter may be inserted into the penis to allow for proper flow of urine. While this catheter may increase the risk of prostatic abscess or infection in the gland, catheterization is an important part of therapy when there is urinary retention. Some men with acute urinary retention may be better served with a small plastic catheter inserted directly into the bladder through the skin of the suprapubic area.

Factors associated with onset

Migration of bacteria up the urethra

Unprotected anal intercourse

Immune disorders

Urinary retention or instrumentation

Prevalence

Relatively rare (approximately 5% of reported diagnoses of prostatitis)

Tests for Diagnosis

Urinalysis (microscopic inspection)

Culture of urine (important and often neglected by physicians)

Traditional treatments used

Antibiotics (muscle injection of aminoglycosides or penicillin, oral fluoroquinolones)

Success of traditional treatment

The most successfully treated type of prostatitis

Category II – Chronic Bacterial Prostatitis

Description

Chronic Bacterial Prostatitis represents a more difficult condition than acute bacterial prostatitis. Most chronic bacterial prostatitis develops because of inadequately treated acute prostatitis. Men who have recurrent bacterial colonization of the urethra because of poor hygiene, poor sexual practices, or a need to instrument the urethra may have bacterial colonization and infection. Men who have strictures or scar tissue in the urethra that narrow the tube restricting urinary flow may be prone to developing recurrent bacterial infection. Often there is no bacterial growth in the bladder and one can be completely asymptomatic between episodes of acute flare-up, at which time the bacteria grow, spread, and begin to infect the bladder. This is a hallmark of chronic bacterial prostatitis. Men are usually free of symptoms between episodes.

Symptoms (may be intermittent or constant)

Urinary frequency (need to urinate more than every two hours)

Dysuria (pain or burning during urination)

Recurring urinary tract dysfunction with poor flow, hesitancy, and nocturia (frequent voiding at night). These symptoms also mimic enlargement of the prostate gland.

Symptoms are intermittent depending on the bacterial burden. In an individual, repeated episodes tend to be associated with the same bacteria.

Factors associated with onset

Inadequately treated acute bacterial prostatitis

Calculi or stones in the prostate

Uncircumcised, with poor hygiene

Partial urinary retention

Prevalence

Relatively rare (approximately 5% of all men who have prostatitis)

Tests for diagnosis

Localized urinary and prostate fluid cultures are very important but often neglected by physicians

Positive bacterial localization from prostate during periods with no symptoms

Traditional treatments used

Fluoroquinolone antibiotics have proven to be the most effective, usually requiring a minimum of six weeks of therapy

Nitrofurantoin can suppress flare-ups of infection but does not eradicate the organism

Occasionally, because of enlargement of the prostate with age and the occurrence of multiple stones in the prostate, a patient may benefit from transurethral resection of the recurrently infected tissue

Success of traditional treatment

Antibiotics are usually effective for acute flare-ups

Eradicating recurrent episodes is difficult. Antibiotics used for this condition may become less effective over time because the bacteria may mutate and become resistant

Category III Non bacterial prostatitis a. with inflammation or without inflammation (see top)

Category IV– Asymptomatic Prostatitis

Description

Asymptomatic Prostatitis can be thought of as a ‘sleeper condition’ in that a man will not recognize he has it because there are no subjective symptoms. Usually it is discovered when a man sees a doctor who finds evidence of inflammation through either a biopsy or examination of prostatic fluid under a microscope. This is a significant condition because there is evidence that inflammation of the prostatic fluid or semen may cause a rise in the PSA level (prostate specific antigen), which is routinely screened now in men over 50 and thought to be an indicator of possible prostate cancer. When men eliminate infection through antibiotic treatment, the PSA level returns to normal, and the concern about cancer is removed. Diagnosing this condition therefore eliminates the need for further testing for prostate cancer including prostate biopsy. PSA also usually rises in proportion to enlargement of the prostate gland.

Symptoms (may be intermittent or constant)

No subjective symptoms for patient

Increased level of white cells in prostatic fluid or semen

PSA often elevated (prostate specific antigen that sometimes indicates prostate cancer when elevated)

Factors associated with onset

Unknown

Prevalence (number of people)

Number unknown. This condition is poorly understood, and is usually only detectable through PSA screening or prostatic fluid analysis

Tests for diagnosis

Elevated PSA

Indications of inflammation in the prostatic fluid/semen

Traditional treatments used

Four weeks of antibiotics

Success of traditional treatment

Unknown