By Sergey Kravchick, M.D.
Chronic prostatitis is very common in men aged 36 to 50 and is the most common urologic problem in men younger than 50 years of age — and the third most common urologic problem in older men.
According to the National Institutes of Health, the prevalence of prostatitis was 10 percent in a population of men aged 20-74 and accounted for approximately 6 – 8 percent of all urological visits in the United States.
The predominant symptom of chronic prostatitis is pain, which is most commonly localized to the perineum, suprapubic area, and penis, but can also occur in the testes, groin or low back. Patients also suffer from urgency, frequency, hesitancy, and poor interrupted flow, while some men also experience pain during or after ejaculation.
Diagnosis
Chronic prostatitis is subdivided into two groups: chronic bacterial prostatitis (CBP) and chronic pelvic pain syndrome (CPPS). The former accounts for only 5 –10 percent of men with symptoms of prostatitis and is most often caused by Escherichia coli or other gram-negative Enterobacteriaceae. Analysis of urine specimens and prostatic fluid was used to confirm the diagnosis. Currently this test was substituted for a more cost-effective “two-glass test,” in which urine is sent for culture before and after prostatic massage. Positive bacterial cultures in the post-massage sample is the main diagnostic criterion for CBP.
The diagnosis of chronic pelvic pain syndrome (CPPS) assumes no proven infection or other obvious local pathology that can cause pain. Careful examination and palpation of external genitalia, groin, perineum, coccyx, external anal sphincter (tone), internal pelvic floor and side walls may pinpoint prominent areas of spastic myofascial pains. These painful trigger points help make the diagnosis and develop treatment plans.
Treatment
Antibiotics are still the most commonly prescribed treatment for the chronic prostatitis, including bacterial and non-bacterial forms. In patients with bacterial prostatitis antimicrobial therapy helps to eradicated infection, while it may benefit CPPS patients by a strong placebo effect, the eradication or suppression of microorganisms that failed to be cultured, or the independent anti-inflammatory effect of some antibiotics. Thus, antibiotics could be considered empirical treatment for CPPS, but their benefits should be appraised after a minimum of 2 to 4 weeks of therapy.
Treatment with alpha-blockers (terazosin, alfuzosin, doxazosin and tamsulosin) has shown significant improvement in pain and voiding symptoms. In addition, treatment with anti-inflammatory drugs can further decrease pain, including pain during and after ejaculation. Although the role of phytotherapy in patients with chronic prostatitis is still controversial, recent systematic review and meta-analysis found that this treatment can significantly decrease pain scores.
For patients with chronic prostatitis and dysfunction of the pelvic floor muscles, it is very helpful to learn how to relax the muscles when the pain starts.
Physical therapy helps patients with pelvic floor pains to stretch the muscle and interrupt the circle of pain-spasm-pain. This can be combined with manual facial trigger point release and low-energy extracorporeal shock wave therapy. Upstate Urology offers these treatment modalities to patients with chronic prostatitis.
Physician Sergey Kravchick specializes in general urology, endourology, male health: chronic prostatitis/chronic pelvic pain syndrome and testicular pain and practices at Upstate Urology at UHS and Wilson Hospital in Binghamton, NY.