Prostate Infections

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.

Infection that irritates the prostate can inflame the gland, causing swelling. Prostate infections or prostatitis occurs most often in men aged 30-50 years but can occur in older men.

• Prostatitis is classified into 4 types. Of these, infection causes the first 2 syndromes listed. No one is sure what causes the other syndromes.

• Acute bacterial prostatitis

• Chronic bacterial prostatitis

• Chronic abacterial prostatitis

• Prostatodynia (pain in the prostate gland)

• A recent Wisconsin survey estimated the incidence of prostatitis at 6%. A population-based study found the prevalence rate to be higher than 8%.

• Half of all men are estimated to develop symptoms of prostatitis at some time in their lives. In 1985, more office visits occurred for prostatitis than for either benign prostatic hypertrophy or prostate cancer. In the early 1990s, prostatitis resulted in 2 million office visits per year in the United States. It is the most common urologic diagnosis in men younger than 50 years.
  
  
• In spite of it being a common and an important problem, prostatitis is poorly studied and not well understood.

Bacterial infections cause only 5% of cases of prostatitis. In the other 95%, the cause is not known.

• Different organisms, fungi, genital viruses, and parasites have been implicated. Some have familiar names such as Escherichia coli (E coli).

• Rarely staphylococcal and streptococcal organisms have been found to be the cause.

• The disease can reach the prostate in 2 ways.

• The bacteria from a previous urethral infection move through prostatic ducts into the prostate.

• Movement of infected urine into the glandular prostate tissue can infect via ejaculatory and prostatic ducts.

Prostate infections can be acute or chronic.

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

• Increased urinary frequency

• Urgency to pass urine

• Pain with urination

• Difficulty producing a normal stream

• Pain in your genital area

• Pain with ejaculation

• Generalized symptoms that should not be ignored include the following:
  
  
  • High fever and chills
    
    
  • Generalized malaise and fatigue

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

• Chronic bacterial prostatitis: 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 may be similar to acute bacterial prostatitis but are less intense. They include the following:
    
    
    • Increased urinary frequency along with pain and difficulty urinating
      
      
    • Pain in your 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.
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  • Stress and depression are very common in men with this condition. It is not clear whether psychological concerns cause this problem or vice versa.

Contact your 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 your genital area

• Pain with ejaculation

Doctors usually diagnose and treat prostate infections on an outpatient basis. If you develop high fever with chills or a new onset of difficulty in urinating, go to a hospital’s emergency department.

• Acute bacterial prostatitis

• Usually an enlarged, firm, and tender prostate is enough to make a diagnosis and start treatment.

• Because you always have bacteria in your urine, your doctor will perform a urinalysis and culture to determine the bacterial cause.

• If you have symptoms outside your prostate, a blood culture may be positive.

• A doctor will likely perform an ultrasound to 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 your pelvis.

• Chronic bacterial prostatitis

• 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.

• The Meares-Stamey test is difficult to perform. The prostatic secretions are not easy to obtain, and interpreting test results is controversial. Sometimes disease is present but not detected. For these reasons, doctors have proposed another test that is simpler to perform, more practical, and much less expensive.
  

• 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.

  • You will be diagnosed with chronic bacterial prostatitis if both bacteria and white blood cells are present in your 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.

• 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.

• Conditions with similar symptoms: Certain other disorders, which are very common, display symptoms similar to chronic bacterial prostatitis—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. Because prostate infections often go unnoticed, doctors may try antibiotics. Antibiotics reported to be helpful include erythromycin (E-Mycin, Erythrocin), doxycycline (Atridox, Vibramycin), or a fluoroquinolone (Ciprofloxacin, Ofloxacin).

• Other possible treatments include the following:
  • Frequent prostatic massage

  • Transurethral microwave thermotherapy

  • Biofeedback

  • Relaxation techniques

  • Muscle relaxants

|Self-Care at Home|

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 you are seen by a doctor.

|Medical Treatment|

• Acute bacterial prostatitis

• Antibiotics: You likely will be given trimethoprim-sulfamethoxazole (Bactrim, Septra) or fluoroquinolones (ciprofloxacin, norfloxacin, ofloxacin) for 4-6 weeks.
  
  
  • If you have a high fever or symptoms of a severe bacterial infection, you may be hospitalized.
    
    
  • At the hospital, you may be given cephalosporins or ampicillin plus an aminoglycoside (gentamicin, amikacin).
    
    
  • Sometimes you may need a catheter (a small tube inserted through your urethra) for severe obstructions.
    
    

• Chronic bacterial prostatitis

• The effectiveness of antibiotics is limited because most antibiotics cannot penetrate the prostate tissue when it is not inflamed.
  
  
  • You likely will receive sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS) first. Other effective antibiotics include ciprofloxacin (Cipro), norfloxacin (Noroxin), or ofloxacin (Floxin).
    
    
  • Many men have a relapse, however, after they stop taking antibiotics. These men may need a longer course of antibiotics.

• If you have a relapse or a resistant disease, your doctor may continue your antibiotics with prostatic massage or drainage (2 or 3 times per week).
  
  
  • 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.

• You rarely need surgery, which may be considered if medication has not worked.

|Follow-up|

Follow-up is very important to make sure the infection has cleared up.

|Prevention|

Activities such as bicycling, jogging, and horse riding may irritate your prostate gland. These activities should be avoided in men with a history of prostate infections.

|Outlook|

No evidence suggests that prostate infections increase the risk of prostate cancer.

• Only a few men with acute bacterial prostatitis develop chronic bacterial prostatitis. After you recover, your doctor should evaluate your 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.

Media file 1: Male urinary system and prostate: The prostate makes some of the milky fluid (semen) that carries sperm. The gland is the size of a walnut and is found just below the bladder, which stores urine. The prostate wraps around a tube (the urethra) that carries urine from the bladder out through the tip of the penis. During a man's orgasm (sexual climax), muscles squeeze the prostate's fluid into the urethra. Sperm, which are made in the testicles, also go into the urethra during orgasm. The milky fluid carries the sperm through the penis during orgasm.

Media type:  Illustration

prostate infection, prostate infections, prostatitis, sore penis, poor urination, burning urination

Author: Mamta Varshney, MD, Assistant Professor, Department of Internal Medicine, St Louis University School of Medicine.

Editors: James E Keany, MD, FACEP, Director of Emergency Medical Education, Department of Emergency Medicine, Mission Hospital Regional Medical Center and Children's Hospital at Miss; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Jeter (Jay) Pritchard Taylor III, MD, Vice-Chief, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina.