The prostate is a walnut-shaped gland which is part of the male reproductive system. Prostate fluid is crucial to fertility as it nourishes and transports sperm.
The prostate gland is located just underneath the bladder. The water pipe (urethra) passes through the prostate and carries urine from the bladder or, during orgasm, carries the ejaculate.
The last section of the large bowel is called rectum and this lies behind the prostate gland.
The prostate gland has a role in hormone production. It changes testosterone into a biologically active form called dihydrotestosterone (DHT) which is ten times more potent.
The prostate gland tends to enlarge as men age.
1. In young Men, the prostate is about the size of a walnut.
2. As Men Age, it grows the size of a Ping-Pong ball.
3. Old Men; it grows to the size of an orange or tennis ball.
Prostatitis is an inflammatory process that leads to swelling of the prostate gland. Not all prostatitis is an infection of the prostate tissue.
There are four types of prostatitis.
1. Acute Bacterial Prostatitis. Acute prostatitis is the result of a bacterial infection that enters the prostate gland through the urinary tract system or genital tract system.
2. Chronic Bacterial Prostatitis. It is characterised by a longer duration and crescendo of symptoms like pain in the pelvis accompanied by urinary and ejaculatory issues.
3. Nonbacterial Prostatitis is prostate inflammation from stress, nerve irritation, injuries or past urinary infections. This form of prostatitis has no signs of bacteria in the urine or semen.
4. Chronic prostatitis/chronic pelvic pain syndrome, inflammation of the prostate with pain lasting from weeks to years leading to poor quality of life.
Prostatitis is a common urinary tract issue among men over 50.
Prostatitis causes nearly one million hospital visits annually.
· Acute prostatitis – affects 1 in 10,000 men.
· Chronic prostatitis – will affect 1 in 10 men (age group between 30 and 50). Men in their 50s are three times more likely to get it compared to men less than 40s
Acute prostatitis risk factors
· urinary tract infection (bacterial infections)
· sexually transmitted infection (STI)
· recent intervention (prostate biopsy, urinary catheter insertion)
· recent trauma like a pelvic injury
· Immunosuppression (certain medications or medical conditions)
· Lower urinary tract voiding issues, incomplete emptying of the bladder
Chronic prostatitis risk factors
Symptoms will last at least three months and vary in severity
· history of prostatitis
· presence of abdominal conditions, like irritable bowel syndrome
· possible link with sexual abuse
Acute prostatitis symptoms
· pain in the genital or lower abdomen or anal area.
· pressure sensation in the perineal area that worsens when one sits down
· urination pain, frequent urination, inability to hold urine (urgency), urine flow can change (stop and start), failure to empty the bladder (urine retention), blood in the urine
· chills and rigors, feeling weak and unwell, high temperature
· painful ejaculation
Chronic prostatitis symptoms
· non-specific pain in the genital or anal or lower abdomen or lower back
· frequent urination, especially at night, inability to hold urine (urgency), difficulty urinating, inability to empty the bladder completely
· painful ejaculation
· in recurrent chronic prostatitis, anxiety, distress and poor quality of life are common feelings experienced
If you have symptoms of prostatitis, seek medical attention.
If you have acute prostatitis, this needs to be treated promptly because, if not addressed, it may lead to an inability to empty the bladder (urine retention) or sepsis.
If you have constant symptoms of chronic prostatitis, your family doctor will refer you to an NHS urology consultant or private urologist.
Chronic pelvic pain syndrome is not life-threatening. This is chronic nonbacterial prostatitis.
Men with prostatitis chronic pelvic pain can live a normal life, although it is often challenging. The main focus is on developing coping strategies as the fluctuating symptoms of chronic pelvic pain syndrome can severely impair quality of life.
Distress, anxiety, lack of sleep, balancing work life and pressures on relationships can be overwhelming for men with chronic pelvic pain syndrome (cp cpps).
One must accept that managing prostatitis chronic pelvic pain (cp cpps) is not straightforward. Be prepared; there will be failures. The expectations have to be adjusted accordingly.
Your NHS consultant or private urologist will guide you and provide all the necessary support to tackle chronic prostatitis.
No prevention can be taken. However;
If you feel that you are not emptying well, address this with your doctor as soon as possible. Not emptying your bladder well can lead to retention. This predisposes to urine or urine infections that may lead to prostate infection.
If you have diabetes, keep your sugar levels well controlled. High sugar levels mean your immune system is suppressed, exposing you to a urine infection or recurrent infections.
Scientists are working hard on a new treatment method to help reduce chronic prostatitis, but there is no upcoming solution around the corner.
To diagnose prostatitis, your doctor will take a detailed history of your symptoms, urine flow and urine voiding and perform a physical exam which includes a digital rectal exam to feel the prostate gland.
Additional investigations include;
· urine test (dipstick and urine for culture and sensitivity)
· blood tests
· if, on examination, the prostate felt very inflamed and painful, you may be asked to do a transrectal ultrasound or MRI (magnetic resonance imaging) scan to rule out any abscess (collection of pus).
Prostate specific antigen (PSA) is a protein produced by the prostate that can be measured by taking a blood sample. Slight traces of PSA are commonly found in men.
Prostatitis can cause a raised PSA level. Other causes can lead to an increased PSA blood level, such as enlarged prostate, incomplete emptying of the bladder, prostate cancer and more. As a Urologist, unless clinically indicated from a clinical examination, I do not recommend you take a PSA blood level during an episode of prostatitis.
If your PSA level is taken during an attack of prostatitis, your PSA levels can come very high, raising concerns. The first step is to repeat the PSA in four to six weeks to ensure that the levels have returned. If the PSA is still high after prostatitis has settled, you may need more tests to find out why. The tests ordered are MRI prostate and if there is anything suspicious a prostate biopsy may be offered.
Am I at risk of getting prostate cancer if I have chronic prostatitis?
Specific scientific investigations have alluded that chronic prostatitis may increase the risk of prostate cancer. Not all men with prostatitis develop inflammation in their prostate gland.
The link between prostate cancer and chronic prostatitis needs to be explored in more detail. We need more research to understand if there is a connection between the two.
If you are worried about developing prostate cancer, discuss it with your NHS consultant, private urologist or family doctor.
There is no best or fast treatment/s for prostatitis. Accurate diagnosis is the key, as treatment depends on the type of prostatitis you suffer from.
Acute bacterial prostatitis
Four to six weeks of antibiotic treatment. Typically Ciprofloxacin or trimethoprim are prescribed. These oral antibiotics have good penetration of the prostate gland.
Suppose the prostatitis infection is severe or you are not improving on oral antibiotic tablets. In that case, you will be asked to go to the hospital to be given antibiotics via a drip.
A severe prostate infection can develop a prostate abscess, which will need to be drained, as well as a course of intravenous or oral antibiotics.
Keep well hydrated.
Avoid fizzy drinks, caffeinated beverages (tea, coffee, cola), artificial sweeteners, juices and alcohol, as they irritate the inner lining of the bladder worsening your urinary symptoms.
Pain relief medication like paracetamol or ibuprofen is typically recommended. They help in calming inflammation. Natural anti-inflammatories can be taken like Quercetin.
To help with emptying the bladder well, alpha-blockers like tamsulosin, alfuzosin and others are prescribed. In addition, to help with the waterworks, they may play a part in decreasing prostate pressure.
Chronic bacterial prostatitis cases
Oral antibiotic treatment, with the most effective medications being fluoroquinolones (ciprofloxacin) and trimethoprim. These are given for four to six weeks.
Medication like tamsulosin addresses urinary tract emptying issues.
Pain relief medication like paracetamol or non-steroidal like ibuprofen is prescribed.
Asymptomatic inflammatory prostatitis
Asymptomatic inflammatory prostatitis doesn't usually need any treatment.
There are specific situations when antibiotics for four to six weeks may be prescribed. These are;
· Very high PSA blood test levels
· Very high levels of white cells in urine or semen
After completion of treatment, the PSA blood test levels are checked to ensure resolution. If not, then you will be asked to undergo further tests.
Chronic prostatitis or chronic pelvic pain syndrome
Chronic pelvic pain conditions are debilitating for some men. The main challenges are getting on top of the flare-ups and finding a strategy to cope with the psychological stress.
Many will be anxious and feel lost and cornered. Finding a solution takes work. Expectations have to be adjusted accordingly. Stress management should be part of the treatment plan. Having an open, honest conversation with your NHS consultant or private urologist is the first step to establishing an action plan.
Oral antibiotics or low-dose antibiotics do not have a role.
The European Association of Urology (EAU) guidelines encourage a multimodal approach to achieve the best outcomes. Even though hard as each flare-up is a setback, keep hope. The majority do resolve with time.
What can one try?
1. Alpha-blockers (tamsulosin, alfuzosin, doxazocin and others).
Improve bladder emptying and urine flow. Relief of the intraprostatic pressure may help speed the recovery of inflammatory episodes.
2. Anti-inflammatory Agents (ibuprofen, diclofenac, and others)
By addressing the inflammation, they alleviate pain, aches and discomfort symptoms.
3. Prostatic Massage
The doctor inserts a finger from the back passage, and the prostate is massaged until excess seminal fluid is released from the prostate gland's ducts easing inflammation and providing relief for chronic non bacterial prostatitis.
This technique was a standard therapy around the 1980s. Its value in addressing chronic pelvic pain syndrome is uncertain. Many studies involved regular prostate massages, not a one-off.
4. Pelvic Floor Exercises
Pelvic muscle training may be an option for select men with chronic pelvic pain syndrome.
Pelvic muscle rehabilitation can lead to increased blood flow, the release of natural endorphins, lower urinary tract symptoms and stretch of the pelvic floor muscles. These mechanisms are thought to help with chronic pain.
More studies are needed to validate the role of pelvic floor exercises in men with chronic prostatitis and predict those men who will respond to pelvic floor rehabilitation
5. Hot baths (Sitz bath) and hot water bottles
The soothing relief is commonly experienced by many men who take regular hot baths. The warm water surrounding the pelvis increases blood circulation. Varying temperatures may help drain the prostate gland ducts.
Those that do not have access to a bath can use a hot water bottle as an alternative.
6. Lifestyle Changes: weight loss, exercise, relaxation techniques and change in diet
There are no studies that prove that eating certain foods can prevent prostatitis.
Spicy foods, caffeine (tea, coffee), alcohol, fizzy drinks, and certain juices inflame and irritate the bladder. Avoiding or limiting their intake can provide relief.
7. Quercetin and sunflower seeds or omega supplements
These are natural anti-inflammatory. Their role is not proven, but some men find it helpful to address chronic pain.
Acupuncture is used for a wide range of chronic conditions.
Traditional Chinese medicine postulate that sensory nerve stimulation combined with augmenting pain perception is the mechanism behind the regulation and redistribution of Qi in the body. Ultimately this improves any neuromuscular dysfunction.
The western theory believes that acupuncture stimulates tissue healing, leads to local pain relief by altering the pain reflex and encourages the release of endorphins.
The data is not solid, and more research needs to be done to determine if acupuncture has a role or whether a particular group of men with chronic pelvic pain syndrome may benefit.
Since it does not cause harm and some patients get relief, one can explore this option.
9. Shockwave treatment
Shockwave treatment is safe and effective. The sound waves increase blood circulation and aid in the healing process.
The non-invasive shockwave treatment typically consists of four 20-minute sessions planned once a week or two sessions per week.
The therapeutic benefit effect is usually felt at four weeks.
Written By Mr E Calleja
NHS Consultant, Private Urologist, Robotic Surgery