Signs, Symptoms, Diagnosis and Treatment For Asymptomatic Inflammatory Prostatitis

The fourth category of prostatitis is Asymptomatic inflammatory prostatitis. It is a symptomless microscopic condition of the prostate gland. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis, acute bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

Signs and Symptoms

These patients have no history of genitourinary pain complaints, but leukocytosis is noted, usually during evaluation for other conditions.

Diagnosis

Diagnosis is through tests of semen, EPS or prostate tissue that reveal inflammation in the absence of symptoms.

Prostate Treatment

No treatment required. It is standard practice for men with infertility and category IV prostatitis to be given a trial of antibiotics and/or anti-inflammatories however evidence for efficacy are weak. Since signs of asymptomatic prostatic inflammation may sometimes be associated with prostate cancer, this can be addressed by tests that assess the ratio of free-to-total PSA. The results of these tests were significantly different in prostate cancer and category IV prostatitis in one study.

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Treatments For Chronic Prostatitis or CPPS

Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states that:

"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."

CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"), has recently been published. This is a combination of:

• medication using tricyclic antidepressants and benzodiazepines
• psychological therapy which uses paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century, and
  
• physical therapy - trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles.

While these studies are encouraging, definitive proof of efficacy would require a randomized, sham controlled study, which is not as easy to do with physical therapy as with drug therapy.

Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress. Biofeedback physical therapy to relearn how to control pelvic floor muscles may be useful.

Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise. Acupuncture has reportedly benefited some patients.

Pharmacological treatment

There is a substantial list of medications used to treat this disorder.

• The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta analysis found that they are moderately beneficial when the duration of therapy was at least 3 months. However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.
• Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks. Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.
• Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.
  
• Commonly used therapies that have not been properly evaluated in clinical trials are dietary modification, gabapentin, and amitriptyline.
• Therapies shown to be ineffective by randomized placebo/sham controlled trials: levaquin (antibiotics), alpha blockers for 6 weeks or less, transurethral needle ablation of the prostate (TUNA).
• At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.
• Antibiotics are generally not recommended. Any improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.
  

Surgery

Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.

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What Are The Diagnosis Of Chronic Prostatitis or CPPS?

There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90%-95% of prostatitis diagnoses. It is found in men of any age, with the peak onset in the early 30s.

CP/CPPS is subcategorized as:

• Category IIIa or inflammatory - urine, semen, and other fluids from the prostate contain pus cells (dead white blood cells or WBCs)
• Category IIIb or non-inflammatory - no pus cells are present

Based on levels of pus cells in expressed prostatic secretions, these subcategories are of limited use clinically.

Recent studies have questioned the distinction between categories IIIa and IIIb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.

In 2006, Chinese researchers found that men with categories IIIa and IIIb both had significantly and similarly raised levels of anti-inflammatory cytokine TGFβ1 and pro-inflammatory cytokine IFN-γ in their expressed prostatic secretions when compared with controls; therefore measurement of these cytokines could be used to diagnose category III prostatitis.

For CP/CPPS patients, analysis of urine and expressed prostatic secretions for leukocytes is debatable, especially due to the fact that the differentiation between patients with inflammatory and non-inflammatory subgroups of CP/CPPS may not be useful. Serum PSA tests, routine imaging of the prostate, and tests for Chlamydia trachomatis and Ureaplasma are not really proven to provide benefit for the patient.

Extraprostatic abdominal/pelvic tenderness is present in half of the patients with chronic pelvic pain syndrome but only 7% of controls.

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What Are Signs And symptoms Of Chronic Prostatitis?

The third category of prostatitis is Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS). It is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis.

Signs and Symptoms

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised by pelvic or perineal pain without evidence of urinary tract infection, lasting longer than 3 months, as the key symptom.

Symptoms may wax and wane. Pain can range from mild discomfort to debilitating. Pain may radiate to back and rectum, making sitting difficult. Dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in the penis, and frequency may all be present. Frequent urination and increased urgency may suggest interstitial cystitis (inflammation centred in bladder rather than prostate). Ejaculation may be painful, as the prostate contracts during emission of semen, although nerve- and muscle-mediated post-ejaculatory pain is more common, and a classic sign of CP/CPPS. Some patients report low libido, sexual dysfunction and erectile difficulties. Pain after ejaculation is a very specific complaint that distinguishes CP/CPPS from men with BPH or normal men.

In 2008, a literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine, finding that the symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

Theories behind the disease include stress-driven hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone (endocrine) abnormalities, neurogenic inflammation, and myofascial pain syndrome. In the latter two categories, dysregulation of the local nervous system due to past trauma, infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to inflammation that is mediated by substances released by nerve cells (such as substance P). The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the nerve pathways.

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What Are The Common Treatment Of Chronic Bacterial Prostatitis?

Chronic Bactrial Prostatitis treatment requires prolonged courses, usually takes 4–8 weeks, of antibiotics that penetrate the prostate well. Take note that β-lactams and nitrofurantoin are ineffective. These include quinolones (ciprofloxacin, levofloxacin), sulfas (Bactrim, Septra) and macrolides (erythromycin, clarithromycin). Persistent infections may be helped in 80% of patients by the use of alpha blockers (tamsulosin (Flomax), alfuzosin), or long term low dose antibiotic therapy.

Recurrent infections may be caused by inefficient urination, a benign prostatic hypertrophy, neurogenic bladder, prostatic stones or a structural abnormality that acts as a reservoir for infection.

The addition of prostate massage to courses of antibiotics was previously proposed as being beneficial. However, in more recent trials, this was not shown to improve outcome compared to antibiotics alone.

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What Are The Signs, Symptoms And Diagnosis Of Chronic Bacterial Prostatitis?

The second category of prostatitis is Chronic bacterial prostatitis. It is a bacterial infection of the prostate gland. It should be distinguished from other forms of prostatitis such as acute bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

Signs and Symptoms

Chronic bacterial prostatitis is a relatively rare condition — occurs in less than 5% of patients with prostate-related non-BPH lower urinary tract symptoms (LUTS) — that usually presents with an intermittent UTI-type picture and that is defined as recurrent urinary tract infections in men originating from a chronic infection in the prostate.

Dr. Weidner, Professor of Medicine, Department of Urology, University of Gießen, has stated: "In studies of 656 men, we seldom found chronic bacterial prostatitis. It is truly a rare disease. Most of those were E-coli." Symptoms may be completely absent until there is also bladder infection, and the most troublesome problem is usually recurrent cystitis.

Diagnosis

In chronic bacterial prostatitis there are bacteria in the prostate but usually no symptoms. The prostate infection is diagnosed by culturing urine as well as prostate fluid (expressed prostatic secretions or EPS) which are obtained by the doctor doing a rectal exam and putting pressure on the prostate. If no fluid is recovered after this prostatic massage, a post massage urine should also contain any prostatic bacteria. Prostate specific antigen levels may be elevated, although there is no malignancy. Semen analysis is a useful diagnostic tool.

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What Is The Common Treatment Of Acute Prostatitis?

Antibiotics are the first line of treatment in acute prostatitis. Antibiotics usually resolve acute prostatitis infections in a very short time. Appropriate antibiotics should be used, based on the microbe causing the infection.

Some antibiotics have very poor penetration of the prostatic capsule, others, such as Ciprofloxacin, Co-trimoxazole and tetracyclines penetrate well.

In acute prostatitis, penetration of the prostate is not as important as for category II because the intense inflammation disrupts the prostate-blood barrier. It is more important to choose a bacteriocidal antibiotic (kills bacteria, eg quinolone) rather than a bacteriostatic antibiotic (slows bacterial growth, eg. tetracycline) for acute potentially life threatening infections.

Severely ill patients may need hospitalization, while nontoxic patients can be treated at home with bed rest, analgesics, stool softeners, and hydration. Patients in urinary retention are best managed with a suprapubic catheter or intermittent catheterization.

Lack of clinical response to antibiotics should raise the suspicion of an abscess and prompt an imaging study such as a transrectal ultrasound (TRUS). E. coli is able to form a biofilm that may allow the pathogen to persist in the prostate.

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Learn The Signs And Symptoms And Diagnosis Of Acute Prostatitis

As i have mentioned in my last post that Acute Prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

Signs and Symptoms

Men with this disease often have chills, fever, pain in the lower back and genital area, urinary frequency and urgency often at night, burning or painful urination, body aches, and a demonstrable infection of the urinary tract, as evidenced by white blood cells and bacteria in the urine. Acute prostatitis may be a complication of prostate biopsy.

Diagnosis

Acute prostatitis is relatively easy to diagnose due to its symptoms that suggest infection. The organism may be found in blood or urine, and some times in both.

Common bacteria are Escherichia coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Serratia, and Staphylococcus aureus.

This can be a medical emergency in some patients and hospitalization with intravenous antibiotics may be required. A complete blood count reveals increased white blood cells. Sepsis from prostatitis is very rare, but may occur in immunocompromised patients; high fever and malaise generally prompt blood cultures, which are often positive in sepsis.

A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis. Since bacteria causing the prostatitis is easily recoverable from the urine, prostate massage is not required to make the diagnosis. Rectal palpation usually reveals an enlarged, exquisitely tender, swollen prostate gland, which is firm, warm, and, occasionally, irregular to the touch. C-reactive protein is elevated in most cases.

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What Is Prostatitis And Its Categories?

Prostatitis is an inflammation of the prostate gland, in men. A prostatitis diagnosis comprised about 8% of all urologist and 1% of which go which visits primary care physician in the United States.

The term prostatitis refers, in its strictest sense, to histological (microscopic) inflammation of the tissue of the prostate gland, although it is loosely (and confusingly) used to describe several completely different conditions. To remedy this, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) devised a new classification system in 1999, comprising four categories of prostatitis:

1. Acute prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).
2. Chronic bacterial prostatitis is a bacterial infection of the prostate gland. It should be distinguished from other forms of prostatitis such as acute bacterial prostatitis and chronic pelvic pain syndrome (CPPS).
3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis.
4. Asymptomatic inflammatory prostatitis is a symptomless microscopic condition of the prostate gland. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis, acute bacterial prostatitis and chronic pelvic pain syndrome (CPPS)

Each of these categories will be explained further in my next posting.

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3 Major Prostate Disorders

There are 3 major prostate disorders:

Prostatitis
Prostatitis is inflammation of the prostate gland. There are different forms of prostatitis, each with different causes and outcomes. Acute prostatitis and chronic bacterial prostatitis are treated with antibiotics; chronic non-bacterial prostatitis or male chronic pelvic pain syndrome, which comprises about 95% of prostatitis diagnoses, is treated by a large variety of modalities including alpha blockers, phytotherapy, physical therapy, psychotherapy, antihistamines, anxiolytics, nerve modulators and more. More recently, a combination of trigger point and psychological therapy has proved effective as well.

Benign prostatic hyperplasia
Benign prostatic hyperplasia or (BPH) occurs in older men; the prostate often enlarges to the point where urination becomes difficult.

Symptoms of "enlarged prostate" include needing to go to the toilet often (frequency) or taking a while to get started (hesitancy). If the prostate grows too large it may constrict the urethra and impede the flow of urine, making urination difficult and painful and in extreme cases completely impossible.

BPH can be treated with medication, a minimally invasive procedure or, in extreme cases, surgery that removes the prostate. Minimally invasive procedures include Transurethral needle ablation of the prostate (TUNA) and Transurethral microwave thermotherapy (TUMT). These outpatient procedures may be followed by the insertion of a temporary Prostatic stent, to allow normal voluntary urination, without exacerbating irritative symptoms.

The surgery most often used in such cases is called transurethral resection of the prostate (TURP or TUR). In TURP, an instrument is inserted through the urethra to remove prostate tissue that is pressing against the upper part of the urethra and restricting the flow of urine. Older men often have corpora amylacea (amyloid), dense accumulations of calcified proteinaceous material, in the ducts of their prostates. The corpora amylacea may obstruct the lumens of the prostatic ducts, and may underlie some cases of BPH.

Urinary frequency due to bladder spasm, common in older men, may be confused with prostatic hyperplasia. Statistical observations suggest that a diet low in fat and red meat and high in protein and vegetables, as well as regular alcohol consumption, could protect against BPH.

Prostate Cancer

Prostate cancer is one of the most common cancers affecting older men in developed countries and a significant cause of death for elderly men (estimated by some specialists at 3%). Regular rectal exams, as well as measurement of Prostate Specific Antigen are recommended for older men, usually ages 50 and up to detect prostate cancer early.

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How Does Prostate Looks Like?

A healthy human prostate is slightly larger than a walnut. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam.

The ducts are lined with transitional epithelium.

Within the prostate, the urethra coming from the bladder is called the prostatic urethra and merges with the two ejaculatory ducts. (The male urethra has two functions: to carry urine from the bladder during urination and to carry semen during ejaculation.) The prostate is sheathed in the muscles of the pelvic floor, which contract during the ejaculatory process.

The prostate can be divided in two different ways: by zone, or by lobe.

Prostate with a large median lobe bulging upwards. A metal instrument is placed in the urethra which passes through the prostate. This specimen was almost 7 centimeters long with a volume of about 60 cubic centimetres on transrectal ultrasound and was removed during a Hryntschak procedure or transvesical prostatectomy (removal of the prostate through the bladder) for benign prostatic hyperplasia.

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What Is Prostate And Its Function To Our Body?

The prostate is the from the Greek word προστάτης means "one who stands before", "protector", "guardian".

Prostate is a compound tubuloalveolar exocrine gland of the male mammalian reproductive system. Females also have prostate glands, previously called paraurethral or Skene's glands, connected to the distal third of the urethra in the prevaginal space.

Function:
The function of the prostate is to store and secrete a slightly alkaline (pH 7.29) fluid, milky or white in appearance, that usually constitutes 25-30% of the volume of the semen along with spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm. The alkalinization of semen is primarily accomplished through secretion from the seminal vesicles. The prostatic fluid is expelled in the first ejaculate fractions together with most of the spermatozoa. In comparison with the few spermatozoa expelled together with mainly seminal vesicular fluid those expelled in prostatic fluid have better motility, longer survival and better protection of the genetic material (DNA). The prostate also contains some smooth muscles that help expel semen during ejaculation.

Regulation:

To work properly, the prostate needs male hormones (androgens), which are responsible for male sex characteristics. The main male hormone is testosterone, which is produced mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands. However, it is dihydrotestosterone that regulates the prostate.

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