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Other pelvic pain conditions

III. Prostate Disorders

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prostatitis
benign prostatic hyperplasia/obstruction
prostate cancer
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PROSTATITIS top

The prostate gland is a spongy, walnut-shaped organ surrounding the urethra and is located directly below the bladder neck. The main function of the prostate gland is to produce fluid which combines with semen to produce seminal fluid which is ejaculated on orgasm.

Disorders of the prostate can cause pain not only in the prostate itself but also in the bladder, urethra, genital area and pelvic floor and can affect the storage and emptying function of the bladder. The relationship between chronic prostatitis and PBS/IC is currently the subject of ongoing investigation.

The National Institutes of Health (NIH) in the United States of America has drawn up the following classification of prostatitis into four categories:

otherpain

 
Illustration courtesy of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
I   acute prostatitis (bacterial)  
II chronic bacterial prostatitis  
IIIa chronic prostatitis/pelvic pain syndrome, inflammatory  
IIIb chronic prostatitis/pelvic pain syndrome, non-inflammatory  
IV asymptomatic inflammatory prostatitis  
     

Acute bacterial prostatitis

This is the least common form of prostate infection affecting only 5% of patients with prostatitis, but is the easiest to diagnose and treat. It may have spread to the prostate from an infection in the urethra or bladder. It is characterised by sudden onset.
Symptoms:

  • urinary urgency and frequency, including at night
  • painful or burning urination
  • worsening urinary flow or urinary retention or incomplete emptying of the bladder
  • pain in lower back or genital area
  • general malaise, nausea
  • low-grade fever and chills

Urine tests show infection of the urinary tract. Treatment is an appropriate antibiotic. Risk factors include catheterisation or instrumentation, urinary tract infection, unprotected anal intercourse.

 
   

Chronic bacterial prostatitis

This is a recurrent infection of the prostate gland, affecting only a small percentage of men with chronic prostatitis. Patients experience recurrent flare-ups with exacerbation of symptoms. It is characterised by gradual onset with symptoms as above. Some patients may exhibit no symptoms at all and the condition may only be discovered by chance. Chronic bacterial prostatitis may be caused by an underlying defect in the prostate.

Fluoroquinolone is commonly given to treat this condition. However, chronic bacterial prostatitis does not always respond to antibiotics.

 
   

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

Chronic prostatitis/chronic pelvic pain syndrome is the most common form of prostatitis and it believed to affect some 95% of men with prostatitis symptoms, including very young men in their early twenties. The terms prostatodynia or abacterial prostatitis are also sometimes still used to describe this condition, but have been officially replaced by CP/CPPS. Unlike acute or chronic bacterial prostatitis, it is not caused by any identifiable infection and therefore does not respond to treatment with antibiotics. It may be inflammatory or non-inflammatory. While its cause is unknown, one possibility that has been suggested is that it could be of autoimmune or genetic origin.

CP/CPPS is a debilitating, severely painful condition, often causing great psychological and emotional stress to the patient. It can have a devastating impact on a man’s quality of life with a major effect on his social and working life. The social economic cost is consequently enormous, bearing in mind that this affects men from an early age. Like PBS/IC, it may be accompanied by other conditions such as irritable bowel syndrome, allergies etc.

Symptoms may be similar to those of bacterial prostatitis or interstitial cystitis and include:

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  • pain in the perineum, lower abdomen, penis, testicles
  • pain on ejaculation
  • bladder irritation
  • frequent/urgent need to urinate
  • bladder outlet obstruction (incomplete emptying of the bladder)
  • there may also be blood in the semen
 

There is also a form of inflammatory prostatitis which is asymptomatic (i.e. the patient feels no symptoms).

Like PBS/IC, CP/CPPS is a diagnosis based on symptoms and exclusion: all other possible identifiable causes of the symptoms have to be excluded (e.g. bacterial, virus, yeast or parasitic infection or infestation, trauma, autoimmune disorder, stones, cancer/tumour, BPH, urethral stricture or allergy).

There is no treatment that is effective for all patients; treatment is individual and may require a combination of therapies. In order to exclude the possibility of infection, a 2-4 week course of antibiotics is often first prescribed.  If this has no effect, there is in principle little point in continuing antibiotics.
Treatment may include alpha-blockers (e.g. tamsulosin, terazosin, alfuzosin), anti-inflammatory drugs (NSAIDs), alternative therapies and sitz baths (to alleviate the pain), 5 alpha-reductase inhibitors (e.g. finasteride) may help some patients, anticholinergic drugs can be used to treat bladder irritation, sedatives and muscle relaxants to relax the muscles in the pelvic floor, dietary restrictions to avoid foods that aggravate the symptoms.
The NIH Chronic Prostatitis Symptoms Index (NIH-CPSI) can be used to evaluate symptoms and impact on the quality of life and to follow the patient’s progress during treatment.

 
   
BENIGN PROSTATIC HYPERPLASIA (BPH) AND BENIGN PROSTATIC OBSTRUCTION (BPO) top
   

It is common for the prostate gland to become enlarged as a man ages. This condition, believed to be caused by hormonal changes, is known as benign prostatic hyperplasia (BPH). This can lead to benign prostatic enlargement, benign prostatic obstruction (BPO) and/or lower urinary tract symptoms (LUTS).

Cause
The cause of benign prostatic hyperplasia is as yet unknown but it may be linked to hormonal changes that occur as men age.

Symptoms
BPH rarely causes symptoms before the age of 40, but more than half of men in their sixties and as many as 90% in their seventies and eighties have some symptoms of BPH.
As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually the bladder weakens and loses the ability to empty itself. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.
Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involves changes or problems with urination, such as

 
  • a hesitant, interrupted, weak stream
  • leaking or dribbling
  • urgent, sudden need to urinate
  • pushing or straining to begin urination
  • frequent urination, especially at night (nocturia)
 
The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all, so-called acute urinary retention.
Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones and incontinence.
 
   

PROSTATE CANCER

Prostate cancer is the most common cancer affecting men and is one of the biggest medical problems with which the male population is faced. Although the cause is still unknown, risk factors are increasing age and possibly heredity. Treatment is most successful if the cancer is diagnosed at an early stage. However, early forms of prostate cancer are often without symptoms. This is why male population screening programmes are of such importance. The introduction of the Prostate-Specific Antigen (PSA) test has led to an increase in early diagnosis of prostate cancer.

As the cancer develops, symptoms may include:

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  • increased dribbling or hesitancy (stop/start flow)
  • urinary retention (inability to urinate or to fully empty the bladder)
  • frequent need to urinate (especially at night)
  • an urgent need to urinate
  • pain or burning when urinating
  • pain in the pelvic floor, lower back or upper thighs

 
It is important for men with bladder or urination disorders to seek medical advice at the earliest possible stage to ensure the right diagnosis and treatment since painful bladder syndrome/interstitial cystitis, bacterial and non-bacterial prostatitis, benign prostatic obstruction and cancer can all cause similar urination disorders, pain or irritation.
 
   
Further information on prostate disorders
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The Prostatitis Manual
by J. Curtis Nickel MD
Bladon Medical Publishing
ISBN: 1904218083

 
   

Further patient information on disorders of the urinary tract

http://www.urologyhealth.org

http://kidney.niddk.nih.gov/kudiseases/a-z.asp

Glossary of medical terms for patients

http://www.urologyhealth.org/glossary/

 
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