Prostatitis: a common cause of pelvic pain in men

By Joseph Marzucco, MS, PA-C

According to the US National Center for Health, approximately 25% of all men who visit a doctor because of urologic problems have a condition called prostatitis, or inflammation of the prostate, that is most commonly associated with pelvic or perineal pain. About 50% of all men in the United States will experience symptoms of prostatitis sometime in their lives.

What is the prostate?

The prostate is a walnut-sized gland that is situated under the bladder and is responsible for a man’s semen.

The prostate

The prostate’s primary function is to produce and store semen: 96% of a man’s ejaculate is made up of semen from the prostate and only 4% is sperm from the testicles. When a man has orgasm, the semen is deposited from the prostate into the urethra, the long canal that conveys either urine or semen to the tip of the penis.

What is prostatitis?

Prostatitis means inflammation of the prostate. Prostatitis can manifest in four different forms, or types. Knowing which type of prostatitis you have is significant, because it will suggest to your doctor what type of treatment is appropriate.

The four types of prostatitis

Type 1: Acute bacterial prostatitis
Type 2: Chronic bacterial prostatitis
Type 3: Chronic pelvic pain syndrome/Chronic prostatitis
Type 4: Asymptomatic prostatitis

Bacterial prostatitis

About 5% to 10% of prostatitis cases are caused by bacterial infection, resulting in acute or chronic bacterial prostatitis (Types 1 and 2). The two types are caused by bacteria, which cause infection, much like infection in other parts of the body. Symptoms of bacterial prostatitis usually include fever, chills, muscle or pelvic pain, fatigue, low back pain, frequent urination, burning on urination, and difficulty urinating.If you have any of these symptoms, this may suggest to your doctor the presence of bacterial prostatitis. In such a case your doctor your doctor will order a urine sample, which will show if the infection is caused by bacteria. If the urine test is positive (that is, if bacteria is found in your urine), you doctor will probably prescribe antibiotics, the first treatment choice for any bacterial (but not viral) infection.

Chronic pelvic pain syndrome/chronic prostatitis

Chronic pelvic pain syndrome (Type 3) is the most common form of prostatitis, affecting 90% (or more) of all men with prostatitis. This type occurs from puberty to old age, with the majority of cases occurring around age 43. Unfortunately, unlike in bacterial prostatitis, the cause of other types of inflammation in the prostate is unknown and a urine sample does not help in the diagnosis. Because the cause is not yet known, treatment of chronic pelvic pain is directed at reducing the pain and other symptoms, but a cure is not available.Chronic pelvic pain syndrome has a wide range of symptoms and accounts for over 2 million doctor visits annually. The typical feature of this condition is generalized pain or discomfort in the pelvic region, especially in the perineum (the area between the anus and the scrotum). The symptoms, which wax and wane, are usually present for 2 to 3 months, and are usually less severe than the symptoms of bacterial prostatitis.

Common symptoms of chronic pelvic pain

Difficulty starting your stream Pain in the head or shaft of the penis
Back pain Urethral discharge
Burning on urination Urinary frequency
Pelvic pain Urinary tract infection
Painful urination Urinary urgency
Painful ejaculation Weak stream

Asymptomatic prostatitis

A large number of men never have symptoms of prostatitis. However, often when a biopsy of the prostate is done to check for prostate cancer, the biopsy shows the presence of acute or chronic prostatitis. This suggests that many men suffer from inflammation of the prostate at some point in their lives, even if they have no sign of it. It is not known what causes some men to have symptoms but not others.

What is the treatment for prostatitis?

When a urine test confirms that a bacterial infection is the cause of prostatitis, treatment with antibiotics is usually successful. However, because 90% or more of men with this condition do not have bacterial prostatitis, treatment becomes confusing. This can be very frustrating for the patient and the physician. Your physician will often prescribe antibiotics even when there is no bacteria showing in the urine, hoping it will nevertheless be helpful. However, this is often not helpful.

Antibiotics are not always the answer to this problem

Antibiotics are useful in both acute and chronic bacterial prostatitis, and most physicians prescribe antibiotics for 2 to 3 weeks in such cases. However, antibiotics cannot treat conditions that are not caused by bacteria. Because the cause of chronic pelvic pain is unclear, many patients diagnosed with chronicprostatitis will be given antibiotics repeatedly, with uncertain benefits.
Many doctors believe that antibiotics exert some antiinflammatory benefit, which means that about one third of patients will improve even in the absence of infection. If the pain or other symptoms resolve, it is common to assume that this is the result of the antibiotics. This encourages both the patient and the doctor to use antibiotics repeatedly for long periods of time, whenever vague pelvic pain symptoms occur. However, the resolution of symptoms is not necessarily related to the use of antibiotics, and overuse of antibiotics can cause other problems.
If your symptoms persist despite antibiotic treatment, this suggests that your condition (prostatitis) is not caused by bacteria and, therefore, further use of antibiotics would not be appropriate.

In addition to antibiotics, other drugs are used to relieve symptoms of prostatitis. These include antiinflammatory drugs, such as Motrin, or drugs that control urinary frequency or incontinence, such as Detrol, Ditropan, Hytrin, or Flomax.

Are there non-drug treatments?

Other treatments that may sometimes be helpful include hot baths, frequent ejaculation (if it does not cause pain), and restricting intake of caffeine, alcohol, and spicy foods. These may help to reduce the pain but do not offer a cure to the problem. Smoking causes irritation to the prostate and can aggravate prostatitis; men with prostate problems should therefore stop smoking.Recently, tension of the muscles of the pelvic floor has been proposed as a possible cause for symptoms of chronic prostatitis. Therefore, pelvic floor relaxation exercises have become a popular way to deal with this condition. Again, this may offer relief of symptoms (pain), but will not necessarily cure the problem.

Is prostatitis linked to prostate cancer?

Prostatitis does not increase the risk for prostate cancer. However, the irritation caused by prostatitis can raise your prostate-specific antigen (PSA) level. PSA testing is a common blood test used to check for the possibility of prostate cancer. An elevated PSA may indicate the presence of prostate cancer when not associated with prostatitis. Therefore, measuring the PSA during a flare-up of prostatitis is not recommended. If a PSA test is done and the PSA level does not return to normal after prostatitis has been treated, a biopsy may be necessary. You should discuss this or any other questions about this condition with your primary care physician who should be able to answer your questions or refer you to a urologist.