The prostate is a walnut-shaped gland that is part of the male reproductive system, it is used to produce a liquid that goes into semen. Prostatitis while not a commonly discussed condition, is relatively common, with a lifetime prevalence of 1.8% to 8.2%. Singapore reported prevalence of prostatitis-like symptoms is 2.8% in a clinical study (Singapore Med J. 2002 Apr;43(4):189-93). Respondents who reported pain or discomfort in the perineum, testicles, tip of penis or bladder/suprapubic region were identified as having prostatitis-like symptoms. Other symptoms included lower urinary tract symptoms such as pain during urination and erectile dysfunction with affected quality of life.
Prostatitis is one of the most frustrating and challenging diagnoses in urology. Much confusion exists about the cause of symptoms attributed to prostatitis. By using a broader diagnosis formulation, physicians can better differentiate various forms of prostatitis or genital/pelvic pain syndromes. This condition occurs in men of all ages.
What is Prostatitis
The National Institutes of Health divides prostatitis into four syndromes:
- Acute bacterial prostatitis
- Chronic bacterial prostatitis (CBP)
- Chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS)
- Asymptomatic inflammatory prostatitis.
Category I: Acute bacterial prostatitis
Patients usually present with fever, and symptoms of the lower urinary tract such as burning, frequency and/ or difficulty urinating. Some may even notice blood in their urine. This type of infection can occur suddenly, without risk factors, or in men who have had recent instrumentation of the urinary tract, such as catheterization. The urinalysis is usually abnormal and subsequent culture typically grows the infective bacteria. Antibiotic therapy is highly effective in this setting.
Category II: Chronic bacterial prostatitis
This is a diagnosis usually given to men with recurrent urinary tract infections, who grow the same organism in the urine, over and over again when they are symptomatic. After excluding sources of reinfection, like abnormal urinary tract anatomy or a stone within the ureters or bladder, the organism can usually be localized to the prostate gland, by means of a special culture technique which involves urine specimens taken before and after a prostate massage. These men are usually symptom-free when microscopic analysis of their urine is normal. Sometimes it is impossible to eradicate the organism from the prostate gland despite prolonged antibiotic therapy. Depending upon the frequency or severity of re-infection, your doctor may suggest daily low-dose antibiotic therapy to prevent recurrent bouts up to 4 – 6 weeks duration of antibiotics, to adequately penetrate the prostate. . If four to six weeks of antibiotic therapy is effective but symptoms recur, another course may be prescribed, perhaps in combination with alpha-blockers or nonopioid analgesics.
Category III: Chronic abacterial prostatitis
This represents the most common form of chronic prostatitis, accounting for more than 90% of all prostatitis cases. Most men who present to their doctor with burning or pain in the pelvis or urinary tract, and lower urinary tract symptoms do not have bacteria in their urine or prostate massage specimen. They often present as prostatic pain lasting for more than 3 months without consistent culture results. Fortunately, this observation was taken into account during the classification process and includes a broader and more accurate diagnosis: Chronic Pelvic Pain Syndrome. Some men only experience pain, while some may experience urinary problems as well as changes in their sexual function. Many patients receive antibiotics or other medications which afford them no relief from their symptoms.
Often, an abnormality of the pelvic floor musculature is identified, which can also explain certain urinary symptoms such as inability to start a urinary stream or weaker flow, and certain components of sexual dysfunction, such as pain or spasm after ejaculation. Certainly, there are other causes for one or all of these symptoms, therefore, a physician must exclude the other possibilities before making a diagnosis of chronic pelvic pain syndrome. Besides muscular tension and myofascial trigger points, some men also have symptoms consistent with irritable bowel syndrome, Fibromyalgia or disorders of defecation. For this reason, a multidisciplinary treatment plan is often necessary, incorporating the expertise of urologists, physical therapists, psychologists and colorectal specialists.
Category IV: Asymptomatic inflammatory prostatitis
This happens in patients without symptoms but is incidentally, found in inflammation in semen specimens or prostate biopsies. There is no history of prostate pain, but leukocytes or bacteria have been found incidentally on workups for other conditions. This type of prostatitis may not require treatment since it is not a clinical diagnosis, which means it was not identified by the patient’s symptoms nor the findings on the clinical exam. On the other hand, treatment may be warranted if an asymptomatic man is being evaluated for infertility, since the inflammation noted in his semen may be a sign of reproductive tract infection, and in some instances when a man has an elevated PSA without evidence of prostate cancer.
What Causes Prostatitis?
Risk factors may be largely unknown but include conditions that facilitate the introduction of bacteria into the urethra and prostate (which also predispose the patient to urinary tract infections) and conditions that can lead to chronic neuropathic pain. Patients with a history of urethritis caused by sexually transmitted infections (STIs) are thought to be at risk of subsequent chronic prostatitis.
While having similar symptoms, chronic prostatitis should be differentiated from other causes of chronic pelvic pain, such as interstitial cystitis/bladder pain syndrome and pelvic floor dysfunction; prostate and bladder cancers; benign prostatic hyperplasia; urolithiasis (bladder/kidney stones); and other causes of dysuria, urinary frequency, and nocturia.
There are other theories including chemicals in the urine, the immune system’s response to previous urinary tract infections or nerve damage in the pelvic area.
Symptoms Of Prostatitis
Painful urination or frequency of urination
When Should I Seek Medical Attention?
Many doctors tend to focus on Category 2: Chronic Bacterial Prostatitis evaluation of chronic prostatitis patients. This group of patients have symptoms lasting three months or longer and consistently grows the same bacterial strain on repeated cultures (using post-prostate massage urine; midstream clean-catch urine; or prostate secretions, such as expressed secretion). Gram-negative Escherichia coli is the most common organism followed by gram-positive Enterococcus. The main thrust of treatment is 4 – 6 weeks of antibiotic therapy.
But the fact is Category 3: Chronic Non-Bacterial Prostatitis/Chronic Pelvic Pain Syndrome is much more common, comprising more than 90% of chronic prostatitis cases. It is defined as pelvic pain lasting three or more months without consistently positive bacterial cultures. Antibiotic therapy does not have any role in the alleviation of prostatic pain.
Prostatitis has similar symptoms to other urinary tract conditions; it requires adequate evidence and experience to diagnose the specific illness. Here at Singapore Paincare, our team of experienced primary care doctors and pain specialists, together with the Urologists, will conduct a thorough diagnosis by evaluating your medical history and conducting physical examinations. This may include a digital rectal exam, urinalysis or blood test.
What Treatments Are Available for Prostatitis?
In many instances, non-surgical treatment methods can provide excellent outcomes. At Singapore Paincare, our goal is to treat your pain with the least invasive option possible after accurately identifying the cause of your pain. Our pain resolution approach focuses on removing pain generators via specialised injection and minimally invasive procedures. Combined with pharmacological treatments and cognitive and physical rehabilitative therapies. We help patients to improve their functions and prevent pain from recurring.
Non-Surgical Treatments for Prostatitis
Cognitive Psychotherapy and Physiotherapy
Neurospan Radiofrequency Ablation
Spinal Cord Stimulation
Surgical Treatment for Prostatitis
A variety of medicines and non-invasive treatments can resolve prostatitis, so surgery isn’t usually considered. If none of the medications work, your option is:
Transurethral Resection of the prostate
How Can I Prevent Prostatitis?
It is important to get treatment for UTIs as soon as possible to prevent the infection from spreading to the prostate. If you are experiencing pain in your perineum when sitting, make an appointment with a doctor as soon as possible. You can resolve the problem before it leads to chronic pelvic pain.
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