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Prostatitis: Medical Enigma

Inflammation of the prostate gland is known as prostatitis. The disorder is quite complex and poorly understood. It presents with a wide range of symptoms which may mimic other disorders. Prostatitis is a medical term used to denote disorders of the perianal (close to the anus) and symptoms of a urinary tract infection in men. The disorder is very unusual in males below the age of 30 and is a common problem in males older than 50 Prostatitis is a common condition in older men. Medical surveys indicate that about 9-12% of males will develop the condition at some point in their lives. The disorder is seen in the older males after the 3rd decade of life. Those who have developed a single episode of prostatitis are at a higher risk to develop subsequent episodes in future. In North America, about 1.5-2 million males visit physicians with a presumed diagnosis of prostatitis. Despite its widespread prevalence, prostatitis remains a poorly understood condition both for the patient and the physician. Pathophysiology of Prostatitis The reason why prostatitis occurs is not well understood. Normally the prostate has some substance which can kill bacteria by maintaining an acidic pH. However, sometimes these chemicals are decreased and then the bacteria tend to grow in the prostate. In patients with prostatitis, the activities of prostatic anti bacterial factor are decreased and the pH is very alkaline. Normally there are no bacteria present in the prostate or urine. The introduction of bacteria into the prostate is multifactorial and includes an ascending urethral infection, reflux of infected urine into prostatic ducts which empty into the posterior urethra, invasion of rectal bacteria by direct extension into the prostate or by lymphatic spread, and hematogenous spread. It is postulated that intraprostatic urinary reflux, either with infected urine or sterile urine, may be the primary etiology of most bacterial and nonbacterial prostatitis cases. Classification of Prostatitis Traditionally, prostatitis has been divided into four subtypes based on the duration of symptoms, the presence of white blood cells in the prostatic fluid and the presence of bacteria in the urine. These subtypes are acute bacterial prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis and non bacterial prostatitis. This classification is only academic and not used for the purpose of treatment. Acute Bacterial Prostatitis Acute bacterial prostatitis (ABP) is not a very common prostate infection. The individual usually present with sudden onset of fevers, chills and low back pain. He may also complain of exquisite pain near the rectal area. Other associated symptoms are painful urination, urination at night, increased frequency of urination and a very weak urinary stream. Most individual tend to be quite sick and ill looking. Most individuals will not allow the physician to examine the prostate because of the pain associated with the rectal exam. The prostate is always warm, indurated and swollen. The diagnosis of ABP is generally made on the presenting features and signs. The majority of these individuals have the presence of bacteria in their urine. In addition, secretions from the prostate are also positive for bacteria. A wide range of bacteria has been found in patients with acute prostatitis. In some rare cases, no bacteria are seen in the urine. In such cases, massaging the prostate will release secretions which usually contain the bacteria. However, massage of the prostate is not a recommended technique because the maneuver can lead to spread of bacteria into the body. The treatment of ABP is antibiotic therapy. The antibiotics are geared to treat the bacteria found in the urine. Sulphonomides (septra or Bactrim) are the most common antibiotics prescribed for acute bacterial prostatitis. Those who have allergies or reactions to sulphonomides can be treated with the fluoroquinolones (Cipro). They are just as effective as the sulphonomides. Rarely, some men are very sick and require admission to the hospital for intravenous antibiotics. These individuals may also have difficulty passing urine and moderate degree of pain. Some urologists place suprapubic catheters (a catheter placed from the pubis into the bladder) in patients who have severe obstructive symptoms from an acutely inflamed prostate gland. Some males do develop an abscess (pus) in the prostate and may not respond to therapy. The abscess is often detected as a fluctuant mass on rectal examination. Computed tomography, magnetic resonance imaging or transrectal ultrasonography usually provides an adequate image of the prostate to evaluate for abscess. The pus usually requires drainage-either via a small incision through the rectum of a via the urethra. The duration of treatment for acute bacterial prostatitis is uncertain; however, most authorities suggest 4–6 weeks of therapy. Short-course therapy is not recommended due to the risk of relapse or progression to chronic bacterial prostatitis. Chronic Bacterial Prostatitis There are some individuals who develop a chronic inflammatory disorder of the prostate. This occurs when acute bacterial prostatitis has been inadequately treated, or there is bacterial resistance to the antibiotics or because the duration of antibiotic therapy was not adequate. Others may have anatomical problems in the prostate making them more prone to prostatitis. Rarely, there is an occasional patient who may have developed chronic prostatitis without any evidence of having a prior acute illness of the prostate. These individuals are not acutely ill but do complain of malaise, lethargy, recurrent urinary tract infections, frequent urination, urgency in urination, rectal or perianal pain. The exam usually reveals a tender prostate. And then there are some rare individuals who present with long duration symptoms but the prostate is normal on exam. Diagnosis of chronic prostatitis is a little trickier than the acute form. Urine samples are collected during different times following voiding-this will represent urine from the urethra, bladder and prostate. The patient is asked to void urine and samples are collected during different intervals. The prostate fluid is collected by massaging the prostate. This massage of the prostate is very unpleasant and quite uncomfortable. The test is also expensive and most physicians do not do it regularly. There are other variations along the theme of prostate massage- all of them designed to get fluid from the prostate to check for infection. The different specimens are then analyzed for bacteria and the presence of white cells. The same bacteria that have been implicated in the acute condition have been implicated in the chronic form. Treatment Like the acute condition, the same antibiotics are used to treat the chronic disorder. Fluoroquinolones and sulphonomides (Bactrim) are first- and second-line therapy in the management of chronic prostatitis, respectively. There are a whole host of other antibiotics that can be used to treat the condition. Unlike the acute form, the chronic variety needs to be treated for 10-14 weeks of continuous therapy. Despite the long term use of the antibiotics, resistance development is unusual. However, the results of treatment are not adequate and many individuals remain unsatisfied with the therapy. Many feel that the poor response is due to the lack of the ability of the antibiotic to get inside the enlarged prostate. Rarely, surgery may be required if the cause of the prostatitis is due to infected stones or other anatomical problems. Surgery may require removal of the infected prostatic tissues. The amount of prostate removed is dependent on degree of infection. The surgery may provide a cure, but its associated complications are even worse than the original disease. Thus, surgery is a last resort therapy for chronic prostatitis. Nonbacterial Prostatitis Today, it is recognized that there are many cases of prostatitis which are not due to the bacteria and this disorder is at least 8-10 times more common than the bacterial variety. Non bacterial prostatitis presents with identical signs and symptoms as bacterial prostatitis. All cultures are negative in this condition. The prostate is usually inflamed, tender and boggy; and the prostatic fluid shows a high white cell count (indication of an infection). The cause of non bacterial prostatitis has been postulated to be due to an infection by Chlamydia trachomatis, Ureaplasma urealyticum, and Trichomonas vaginalis. The condition is best treated with either the tetracyclines or erythromycin. Unlike the bacterial variety, non bacterial prostatitis is treated for at least 2-4 weeks. Prolonged therapy is not indicated, since nonbacterial prostatitis is generally self-limiting. Additional therapy may include sitz baths, normal sexual activity and analgesics for painful urinary symptoms. Non bacterial prostatitis can be worsened by various situations. Thus it is recommended that Spicy foods, caffeine, and alcohol be avoided. These substances can irritate the bladder and induce spasms which can worsen the symptoms of non bacterial prostatitis. For those in whom the condition continues, a referral to a urologist is necessary to ensure that there is no bladder or ureteral cancer. Chronic Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome There are numerous men who have chronic prostatitis with no growth of any bacteria. This has been characterized as chronic non bacterial prostatitis. The majority of these males are older and present with chronic pain in the lower abdomen and pelvic area. Patients usually have symptoms consistent with a prostate problem. The typical symptoms include painful ejaculation and pain in the genitalia which may radiate to the penis, testes and scrotum. The majority of these individuals have an odd ache or pain of the lower abdomen and pelvis. The pain is common around the rectal area and may radiate to the inner thighs. Urinary symptoms of urgency, frequency and a weak urinary stream are also present. The majority of them have diminished libido. The physical exam is unremarkable but a rectal exam will reveal a tender prostate. Why some individuals develop chronic prostatitis is not known. It is believed that there may be multiple factors involved in the etiology. Various hypotheses have been put forward including depression, psychosomatic disorder, fibromyalgia, existence of occult benign prostate hypertrophy or some anatomical defect in the pelvic floor. Most of these hypotheses have not been validated and, in general, have not resulted in clinically useful therapies. The condition remains poorly understood today and the treatment is frustrating. Asymptomatic Prostatitis Over the last decade, there have been a few individuals who have been found to have prostatitis but no symptoms. The prostatitis is discovered on biopsy which was being done for some other prostate disorder. The condition remains an enigma and its natural course remains unknown. Some reports have indicated that antibiotics for 1-2 weeks results in a decrease in the prostate specific antigen levels. The current recommendations are that in patients with chronic asymptomatic prostatitis with elevated PSA levels, antibiotics be used to treat the condition. Other therapies Besides antibiotics, a number of other therapies have been used in the treatment of prostatitis Some physicians recommend prostate massage at least 2-3 times a week. There are no controlled trials and so the benefit of this therapy remains unknown. Acute prostatitis is a painful condition and it is quite obvious that the physicians advocating this therapy have never had a finger placed in their arse and their prostrate massaged. Another fancy therapy recommended is transurethral microwave thermotherapy. A few reports do indicate that most men did respond well but there are no long term results. Since most individual develop anxiety and stress, the use of the benzodiazepines has been found to decrease the anxiety and even minimize the pain. Like every disorder in medicine, there are also other untested therapies ranging from herbs nutrients acupressure, yoga, biofeed back, relaxations and touch therapy to help treat the disorder. None of these have any science behind it. However, since many individuals want immediate results and are dis-satisfied with conventional medical therapy, these alternative therapies have been flourshing. Other supportive treatment Warm sitz baths and nonsteroidal anti-inflammatory drugs (NSAIDs) may provide some symptom relief. Sitz baths may be done 3- 4 times a day. Some individuals do complain of worsening of their disorder with the intake of alcohol or spicy food is increased. Thus, it is highly recommended that both alcohol and flavory foods be decreased or stopped during treatment of the condition. Many men do complain of the urge to urinate frequently and may even develop bladder spasm. These irritative symptoms can be decreased by medications such as oxybutynin (Ditropan) or doxazosin (Cardura), prazosin (Minipress), tamsulosin (Flomax) or terazosin (Hytrin). A very important component of the treatment plan is to reassure the men that the condition is treatable and not contagious or cancerous. In some males with chronic prostatitis, psychological therapy or even treatment with some anti depressants may be beneficial. Recommendations for a General Approach The treatment of prostate is very empirical and thus to make the management more uniform, the following are some recommendations • If prostate is suspected based on the individuals history and physical examination, a diagnostic test must be consideredthe best choice of antibiotics include either a sulphonomides, tetracycline or a fluoroquinolones • The duration of treatment must be at least 4-6 weeks • Pain must be controlled with medication • Follow-up should be obtained to ensure that the symptoms are decreasing Conclusion The term prostatitis describes a wide spectrum of conditions with variable etiologies, prognoses and treatments. Unfortunately, this condition has not been well understood, and most recommendations for treatment are based primarily on case series and anecdotal experience. For these reasons, many men and their physicians find prostatitis to be a challenging condition to treat. Treatment of prostatitis is associated with high failure rates; therefore it is paramount that patients understand the importance of compliance. For those who fail therapy, a diligent search must be made to discover any underlying condition that may be responsible.