Prostate Infections (Prostatitis)

The prostate gland is located right below the bladder.

• Prostate infections comprise only small percentage of all men with prostatitis. This small percentage is comprised of acute and chronic prostatic infections.
• E. coli and other Gram-negative bacteria cause most acute and chronic prostatic infections.
  • Prostatic infection symptoms include groin pain, dysuria, pain with ejaculation, reduced urine output; and may include fever, malaise, and periodic recurrence of symptoms even after treatment.
  • Seek medical care if symptoms develop, emergency care if fever or inability to urinate occurs.
  • Diagnosis of prostate infections or prostatitis is made by identifying the agent (vast majority are bacteria) infecting the prostate.
  • Treatment of prostate infections or prostatitis is usually antibiotics; chronic infectious prostatitis may require long-term antibiotic treatment, and severe infections may require hospitalization with IV antibiotics.
  • Home care is limited to pain reduction. Men with a prostate infection or prostatitis need medical care.
  • Follow-up is important to confirm adequate treatment results or to plan additional treatment if the infection reoccurs.
  • Some prostate infections cannot be prevented, but reducing the risk of groin trauma or injury, avoiding sexually transmitted diseases, and staying well hydrated are ways to reduce the chance of getting infectious prostatitis.
  • The prognosis of acute infectious prostatitis is usually good, but chronic infectious prostatitis is only fair because it is difficult to cure.

The prostate gland is a part of a man's reproductive system, secreting fluids that help transport sperm. The gland lies just below the bladder and surrounds the urethra (the tube that drains the bladder).

Prostate infections may irritate the prostate and cause inflammation and swelling of the gland. Prostate infections occur most often in men aged 30-50 years but can occur in older men. Unfortunately, many people equate the terms prostate infection and prostatitis, but prostate infections comprise only two of the four major classifications of the term "prostatitis," and infectious types comprise only a few of the total number of prostatitis diagnosed patients.

The National Institutes of Health consensus panel has designated four types of prostatitis classifications.

1. Acute bacterial prostatitis
2. Chronic bacterial prostatitis
3. Chronic (nonbacterial) prostatitis/chronic pelvic pain syndrome (CPPS; sometimes termed prostatodynia) with subtypes of CPPS termed inflammatory and noninflammatory
4. Asymptomatic inflammatory prostatitis

Chronic nonbacterial prostatitis may also be occasionally caused by infection; the infectious agent may be at a low level and not found on culture of prostatic secretions. Needle biopsy has also found some patients with difficult to cultivate anaerobic organisms likely causing the infection and may explain why long term-term antibiotic therapy may help some patients with this diagnosis. If an infectious agent is identified by needle biopsy or other tests, the diagnosis should be changed to acute or chronic prostatitis. Chronic nonbacterial prostatitis/CPPS has not been scientifically demonstrated to be primarily either a disease of the prostate or the result of an inflammatory process.

The NIH has established extensive criteria for chronic pelvic pain syndrome that excludes infection and other problems and is as follows:

Inclusion Criteria

• male, at least age 18
• pain or discomfort in the pelvic area (penis, scrotum, perineum, or thereabouts) for at least 3 months

Exclusion Criteria

• the presence of cancer of the genitourinary tract
• active urinary stone disease
• herpes of the genitourinary system
• bacteriuria (100,000 colonies in a midstream urine) within the past 3 months
• antibiotic therapy within the past 3 months
• perirectal inflammatory disorders
• inflammatory bowel disease
• history of pelvic radiation or systemic chemotherapy
• history of intravesical chemotherapy
• documented gonorrhea, chlamydia, mycoplasma, or trichomonas infection of the urinary tract within the past 3 months
• clinical epididymitis within the past 3 months
• urethral stricture of 12 French or smaller
• neurological disease or disorder affecting the bladder
• prostate surgery (not including cystoscopy) within the past 3 months

This classification system is important to understand because about 90% of men with prostatitis symptoms are diagnosed with chronic pelvic pain syndrome and, by definition, do not have infectious prostatitis.

The fourth category, asymptomatic inflammatory prostatitis, by definition, does not have an identified infectious cause, nor do the affected men have pain like chronic pelvic pain syndrome diagnosed patients. These patients are discovered when the prostate is biopsied for other situations such as a reason (possible cancer) for elevated PSA (prostate specific antigen) tests, or infertility. However, if the biopsy shows only inflammatory tissue changes and no cancer or other likely cause (infectious agents) for the asymptomatic inflammatory changes, then the patient is diagnosed with asymptomatic inflammatory prostatitis. Chronic pelvic pain syndrome and asymptomatic inflammatory prostatitis are undergoing research to better define their causes and treatments.

Consequently, a diagnosis of prostatitis should be further defined by describing the classification that fits the patient. Clearly, infectious prostatitis fits only the acute or chronic classifications. The aim of this article is to describe prostate infections and not all four prostatitis classifications.

Bacterial infections cause only a small percentage of cases of prostatitis. In the remaining percent, due to chronic pelvic pain syndrome or asymptomatic inflammatory prostatitis described above, the cause is not known. Prostate infectious agents are as follows for both acute and chronic infectious prostatitis:

• Escherichia coli (E coli) is the bacterium most often the cause of prostate infections and approximately 80% of the bacterial pathogens are gram-negative organisms (for example, Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species).
• Sexually transmitted disease-causing organisms also may cause infectious prostatitis especially in sexually active men under 35 years of age; the most usually identified organisms are Chlamydia, Neisseria, Trichomonas, and Ureaplasma.
• Rarely staphylococcal and streptococcal organisms have been found to be the cause, and infrequently different organisms such as fungi, genital viruses, and parasites have been implicated.
• The infectious agent (usually bacteria) may invade the prostate in two main ways.
  • The bacteria from a previous urethral infection move through prostatic ducts into the prostate (occasionally termed retrograde infection).
  • Movement of infected urine into the glandular prostate tissue can infect via ejaculatory ducts (occasionally termed antegrade infection).

Infectious organisms, as previously stated, cause two of the four main types of prostatitis; acute infectious prostatitis and chronic infectious prostatitis.

Prostate infections can be classified as acute or chronic; the following describes their symptoms.

Acute bacterial prostatitis: Because acute prostate infection often is associated with infections in other parts of the urinary tract, symptoms may include the following:

• Increased urinary frequency
• Urgency to pass urine
• Pain with urination
• Difficulty producing a normal stream
• Pain in the genital area
• Pain with ejaculation
• Generalized symptoms that may occur and should be investigated by a caregiver immediately include the following:
  • High fever and chills
  • Generalized malaise and fatigue

Examination usually reveals an enlarged, tender, warm, firm, and irregular prostate. (The doctor should not perform a vigorous digital exam of the prostate to prevent possible spread of the infection to the bloodstream.)

Chronic bacterial prostatitis is defined by NIH as recurrent infection of the prostate. This disease is a common cause of recurrent urinary tract infections (UTIs) in men. Typically, the same strain of bacteria in prostatic fluid or urine will cause the same infection to persist or recur.

Symptoms of chronic bacterial prostatitis may be similar to acute bacterial prostatitis, but are usually less intense. They include the following:

• Increased urinary frequency along with pain and difficulty urinating
• Pain in the lower back, testes, epididymis, or penis
• Sexual dysfunction
• Low-grade fever, joint pains, and muscle aches
• Examination may reveal urethral discharge and tender testes, or epididymis.

Stress and depression are common in men with chronic infectious prostatitis.

Contact a doctor for any of the following symptoms. These symptoms are even more significant if accompanied with high fever and chills:

• Urinary burning or pain
• Difficulty passing urine
• Difficulty or pain when starting urination
• Pain in the genital area
• Pain with ejaculation

Doctors usually diagnose and treat prostate infections on an outpatient basis. If a person develops high fever with chills or a new onset of difficulty in urinating, seek medical care immediately or go to a hospital's emergency department because the infection may be spreading to other areas of the body.

The diagnosis of both acute and chronic prostate infections begins with the history of the symptoms described above, the physical exam, including the digital exam of the prostate and often confirmed by culture and identification of the infecting organism.

Acute bacterial prostatitis diagnosis

• Usually an enlarged, firm, and tender prostate is enough to make a presumptive diagnosis and start treatment (prostatic massage is not done for acute bacterial prostatitis).
• Because there is usually a low level of bacteria in urine, the doctor will perform a urinalysis to quantitate and identify infecting bacteria by urine culture.
• If the person has symptoms suggesting the infection has spread outside the prostate (high fever, chills, urine retention), blood cultures and other blood tests are likely to be ordered.
• If a spread of the infection is suspected, a doctor will often perform an ultrasound to help confirm the diagnosis and to rule out an abscess. If this ultrasound is not available, the doctor may perform a CT scan or MRI of the pelvis.

Chronic bacterial prostatitis diagnosis

One of two tests are sometimes performed to help with the diagnosis:

The classic test is a Meares-Stamey 3-glass test. Three separate urine samples are collected and examined during this test. The last sample is taken after prostatic massage.

Premassage and postmassage test (PPMT)

• In this test, urine samples are obtained before (pre-M) and after (post-M) prostatic massage and are sent for microscopic exam and culture.
• Patients will be diagnosed with chronic bacterial prostatitis if both bacteria and white blood cells are present in their post-M sample.
• In healthy men, the number of white blood cells in prostatic fluid could be as high for up to 2 days after ejaculation, so this may affect test results.

Men with recurrent urinary tract infections should have ultrasound imaging of their upper urinary tract and a plain abdominal X-ray or an intravenous urography (IVU) to exclude a possible structural problem or a kidney stone.

Certain other disorders that are very common display symptoms similar to chronic bacterial prostatitis, for example, pelvic area pain, decreased sex drive, and impotence. No one knows what causes them. Men who have these disorders often become depressed. Symptoms may be worsened by a number of factors, for example, diet, posture, or alcohol.

• Doctors use the same tests, premassage and postmassage test (PPMT) or Meares-Stamey test, to diagnose these disorders. Doctors also use similar treatment methods.
• General home care measures include hot baths, regular ejaculations, increasing fluids, and avoiding factors that worsen the condition.

The role of antibiotics is unclear in chronic bacterial prostatitis, but because prostate infections often go unnoticed, doctors may often try antibiotics to help stop the infection. Antibiotics reported to be helpful include erythromycin (E-Mycin, Erythrocin), doxycycline (Atridox, Vibramycin), or a fluoroquinolone (ciprofloxacin [Cipro, Cipro XR, Proquin XR]).

Other possible diagnostic tests/treatments for chronic bacterial prostatitis may include the following:

• Frequent prostatic massage
• Transurethral microwave thermotherapy
• Biofeedback
• Relaxation techniques
• Muscle relaxants
• Cystoscopy

Prostate infections have no therapy that could provide relief at home, except for over-the-counter pain medicine such as acetaminophen (Tylenol), ibuprofen (Motrin), or naproxen (Aleve). This will only help to temporarily relieve the discomfort until the person is seen by a doctor. Some health care practitioners suggest using a warm bath (sitz bath) or sitting on a pillow or cushion to reduce symptoms; others suggest avoiding certain activities (for example, avoiding bicycling, horseback riding, or other activities that puts pressure on the groin).

Treatment is based on the type of infection and the susceptibility of the infecting organism to antimicrobial therapy as follows:

Acute bacterial prostatitis medical treatment

Antibiotics: Patients likely will be given trimethoprim-sulfamethoxazole (Bactrim, Septra) or fluoroquinolones (ciprofloxacin [Cipro, Cipro XR, Proquin XR], norfloxacin [Noroxin]) for at least a week, and frequently longer time periods for the common infectious agents (Gram-negative bacteria). Infrequent infectious agents (listed above) may require other antimicrobials; the best treatment is to determine the antimicrobial susceptibility of the infecting agent and use the most effective antimicrobial. This information may be supplied to the treating doctor by the laboratory personnel.

• If high fever or symptoms of a severe bacterial infection are present, the patient may be hospitalized.
• At the hospital, patients may be given antibiotics such as cephalosporins or ampicillin (Principen) plus an aminoglycoside (gentamicin, amikacin [Amikin]) intravenously.
• Sometimes the patient may need a catheter (a small tube inserted through the urethra) for relief from severe obstructions that stop urine flow.

Chronic bacterial prostatitis medical treatment

The effectiveness of antibiotics is limited because most antibiotics cannot penetrate the prostate tissue when it is not inflamed.

• Patients likely will receive sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS) initially. Other potentially effective antibiotics include ciprofloxacin (Cipro) or norfloxacin (Noroxin). Patients often take antibiotics for 6 weeks; some may require antibiotics for a longer time period. Isolated organisms may show resistance to antibiotics over time, so alternate antimicrobials or alternate therapy may need to be addressed by the health care practitioner.
• Many men have a reoccurrence of the infection; however, after they stop taking antibiotics. These men may need a longer course of antibiotics or other treatments.

If a patient has a relapse or prostatic disease resistant to therapy, the doctor may continue antibiotics with prostatic massage or drainage (2 or 3 times per week). Although many clinicians may not take this approach, those that do suggest the following:

• The involved ducts and glands may be blocked, creating tiny pockets almost like abscesses.
• It is believed that prostate massage unblocks these ducts, allowing them to drain more normally, thus permitting better penetration of antibiotics.

Patients rarely need surgery, which may be considered if medication has been effective.

Other treatments may include alpha blockers (for example, tamsulosin [Flomax] or terazosin [Hytrin]) that can relax the bladder neck and muscles to help reduce the symptoms of painful urination.

Follow-up is very important to make sure the infection has cleared up. For example, in chronic bacterial prostatitis, follow-up tests after antibiotic treatment has ceased may indicate that an additional time period is needed to stop or control the infection. Some patients may benefit from additional follow-up studies if urinary tract abnormalities are found.

There are some risk factors that cannot be prevented that increase the chance of developing acute and chronic prostate infection. Such risk factors include:

• being a young or middle aged man,
• experiencing pelvic trauma,
• previous prostate infections,
•  and possibly stress and genetics.

Prevention methods or more accurately, reducing the chances of any prostate infections, is to stay well hydrated, avoid sexually transmitted diseases, and avoid any mild or undetected injury by bicycling horseback riding, or other activity that may cause groin injury.

The prognosis for acute bacterial prostatic infections is usually good if treated appropriately with effective antibiotics. The prognosis for chronic bacterial prostatic infections is less or only fair because the recurrent disease is difficult to cure, and the cure rate is less than the acute type.

• No evidence suggests that any prostate infections increase the risk of urinalysis.
• Only a few men with acute bacterial prostatitis develop chronic bacterial prostatitis. After patients recover, their doctor should evaluate their upper urinary tract.
• Only half of the men with chronic bacterial prostatitis will be cured (70% in some studies). Relapses are common and may lead to psychological problems, especially depression.