Prostatitis – acute and chronic: symptoms and treatment

Prostatitis is inflammation or irritation of the prostate gland that shows up as pain in the pelvis and problems with passing urine. It is one of the most common urological diagnoses in men under 50 and one of the most confusing, because one name covers several different conditions – from a serious bacterial infection to chronic pain without any infection.

Roughly one man in ten has complaints like these at some point in his life. Apart from the acute bacterial form, the condition is not life-threatening, but it seriously affects quality of life – sleep, work, sex life and mood. The key to successful treatment is an accurate diagnosis: an antibiotic helps only when there really are bacteria.

What is prostatitis

The prostate is a small gland below the bladder through which the urethra passes. The modern classification distinguishes four forms of prostatitis:

• Acute bacterial prostatitis – a sudden infection of the gland, most often with bowel bacteria that have entered through the urethra. It is a serious illness and needs immediate treatment.
• Chronic bacterial prostatitis – bacteria remain in the gland and cause recurring urinary tract infections for months.
• Chronic pelvic pain syndrome – the most common form, roughly nine cases in ten. The pain and urinary complaints last at least three months, but no bacteria are found.
• Inflammation without symptoms – it is found by chance during tests done for another reason and is usually not treated.

Symptoms

In acute bacterial prostatitis the symptoms develop over a few hours:

• high temperature and shivering;
• severe pain in the perineum (between the scrotum and the anus), the lower abdomen and the lower back;
• burning, frequent and difficult urination, sometimes being completely unable to pass urine;
• feeling generally unwell and aching muscles.

This is an emergency. If you have a temperature with shivering and pain in the prostate area, go to an emergency department or call 112 (the European emergency number) without waiting for an appointment – the infection can spread to the blood or form an abscess.

The chronic forms are quieter and come in waves:

• a dull ache or heaviness in the perineum, testicles, penis, groin or above the pubic bone;
• pain or discomfort on ejaculation;
• burning when passing urine, frequent urges, a weak stream;
• anxiety, poor sleep, weaker erections.

The complaints often get worse after sitting for a long time, getting cold, drinking alcohol or stress, and ease off during calm periods.

Causes and risk factors

In the bacterial forms the cause is most often a bowel bacterium that has reached the prostate through the urethra or through infected urine flowing back into the small ducts of the gland. The risk is higher with a urethral catheter, after a prostate biopsy, with a narrowing of the urethra, phimosis, an enlarged prostate with urine left in the bladder, and with unprotected anal sex.

In chronic pelvic pain syndrome no infection is found. The complaints are kept going by several mechanisms at the same time – spasm of the pelvic floor muscles, an oversensitive nervous system, inflammation without bacteria, disturbed urination and psychological and emotional stress. The combination is different in every man, so treatment is individual too.

Diagnosis

The examination with Dr Penev in Plovdiv or Karlovo starts with a detailed conversation – exactly where the pain is, when it gets worse, how you pass urine, what infections and treatments you have had. For the chronic forms you fill in a standardised questionnaire about pain, urination and quality of life, which is later used to measure the effect of treatment.

This is followed by a careful rectal examination – in acute prostatitis the gland is hot and very tender, while in the chronic forms tense, tender pelvic floor muscles can often be felt. Ultrasound of the prostate, bladder and kidneys shows the size of the gland and the urine left in the bladder, and rules out an abscess or stones. A urine test and urine culture are done and, if needed, a sample of prostate fluid, to confirm or rule out a bacterial cause. In men over 45–50, PSA is also tested, but only after the acute inflammation has settled, because inflammation raises it temporarily. If urethritis is suspected, a sample is taken to test for sexually transmitted infections.

Treatment

Acute bacterial prostatitis

Antibiotic treatment starts straight away, often intravenously in hospital at Kaspela University Hospital (UMBAL Kaspela), Plovdiv, and continues with tablets for 2–4 weeks in total. If you cannot pass urine, a temporary catheter is inserted, and an abscess is drained. After recovery a follow-up urine culture is done.

Chronic bacterial prostatitis

Based on the urine culture, antibiotics that penetrate the prostate tissue well are chosen for a long course of 4–6 weeks. At the same time, the factors that keep the infection going, such as urine left in the bladder, are treated.

Chronic pelvic pain syndrome

A single medicine is rarely enough here. Dr Penev builds a plan around your main complaints: alpha-blockers for difficulty passing urine, anti-inflammatory medicines for short periods, physiotherapy and pelvic floor relaxation, herbal preparations and acupuncture for suitable patients, warm baths, regular exercise and work on stress and sleep. Laser therapy for chronic prostatitis is an additional drug-free method that can be added to the plan if needed and at Dr Penev’s discretion, with the aim of relieving pain. The realistic goal is a lasting reduction in symptoms; improvement comes gradually, over weeks and months, so patience and regular follow-up are part of the treatment.

When to see a urologist

Book an appointment if you have pain or heaviness in the pelvis, perineum or testicles that lasts more than a few days, burning and frequent urination, pain on ejaculation or recurring urinary tract infections. The sooner the form of prostatitis is identified, the shorter and more successful the treatment. If you have a high temperature, do not wait – this is an emergency.

Prevention

The risk of a flare-up is lower if you drink enough fluids, have a regular sex life, avoid sitting for long periods and getting cold, keep alcohol and spicy food in moderation and have urinary infections treated promptly – more in our tips on preventing urinary tract infections.

Prostatitis responds well to treatment once it is clear which form it is and what keeps it going. If your symptoms continue, book an appointment with Dr Penev in Plovdiv or Karlovo for an accurate diagnosis and an individual treatment plan.