Prostatitis & testicular pain

What is prostatitis and testicular/ pelvic Pain?

It’s common for men of all ages to develop a prostate infection leading to inflammation aka prostatitis; the source can be a urinary bacteria (eg E.Coli), a virus (eg flu, adeno, gastro) or sexually transmitted (eg gonorrhoea, chlamydia, herpes). Prostatitis can also develop in the absence of infection due to one’s own immune system becoming dysfunctional eg during periods of severe stress or in those with other auto-immune conditions.

Inflammation of the prostate can be:

• acute ie recent onset over a few days or weeks) and then resolve (self limiting); or

• chronic, ie persist for months or years; or

• Intermittent, ie several episodes/ relapses over many years with periods in between where symptoms completely resolve.

The reason it becomes chronic or intermittent is because either:

1) they receive no treatment or incorrect treatment in the early acute phase (eg prescribed the wrong antibiotics or given the wrong diagnosis and thus prescribed no antibiotics and anti-inflammatories)

or

2) they have dysfunction of the immune system due to severe life stress (work, relationship, poor sleep), high trait anxiety, genetics, medication etc

or

3) they have an underlying structural abnormality of the urinary/ genital tract eg a urethral stricture or diverticulum, or ejaculatory duct obstruction due to a prostate cyst etc.

What are the symptoms of prostatitis?

Men can feel any or all of the following classic symptoms:

1) Pain - this can radiate to any of the following due to the nerve supply of the prostate: tip of the penis, perineum (under the scrotum in front of the anus), the testes (testicles) or bladder (lower abdomen below the belly button).

2) urinary symptoms - urinating more frequently, more urgently, waking at night to urinate and dysuria (burning/ hot or tingling when passing urine).

3) sexual symptoms - sharp pain/ dull ache during or after ejaculation, blood or other discolouration of semen, reduced semen volume.

How is prostatitis diagnosed?

Prostatitis is a ‘clinical diagnosis’. This means there is no single test to confirm or exclude it. It is made via a careful history and examination in order to establish the initial ‘trigger’ of infection/ severe stress/ anxiety etc.

A standard urine test may show white blood cells +\- a bacteria (eg E.Coli, gonorrhoea, etc).

The best urine test is to collect the very first 5-10 mLs of urine immediately after a prostatic digital examination via the rectum by your urologist or GP.

There are 3 types of prostatitis based on the post DRE 1st void urine results:

1) In bacterial prostatitis, there will be bacteria on lab culture after 48hours;

2) In inflammatory, non-bacterial prostatitis, there are white cells on microscopy but no bacteria on culture;

3) In non-inflammatory, non-bacterial prostatitis, there are no white cells on microscopy AND no bacteria on culture. This type is usually related to nerve dysfunction.

Other tests are often normal but can sometimes find a reversible cause. These include:

• Urinary tract ultrasound - to assess post-void residual, prostate and bladder;

• MRI of the prostate and seminal vesicles - to assess for abnormalities such as abscess, utricle cyst, ejaculatory duct obstruction or cancer;

• Cystoscopy - to assess for urethral stricture, urethral diverticulum, utricle cyst of the veru, bladder neck obstruction, prostate median lobe, bladder stone or tumour, etc;

• Uro-Flow study and Uro-dynamics - to assess for functional obstruction of the prostate/ bladder neck or dysfunctional voiding;

• MRI spine, nerve conduction studies and consultation with a chronic pain/ neurology specialist - to assess and treat any neurological causes emanating from the nerves or spinal cord.

How is prostatitis treated?

The principles of treatment are:

• Establish the diagnosis

• Differentiate whether it is bacterial or not and whether it is inflammatory or not

• Search for underlying reversible anatomic causes and rule out an abscess

• identify triggers or exacerbating factors (eg severe stress, anxiety, poor sleep, poor nutrition, immune compromise or suppression, poorly controlled diabetes, high risk sexual practices leading to recurrent bacteria within the urethra

• Consider a 2-4 week course of a fluoro-quinolone antibiotic eg ciprofloxacin/ norfloxacin; 2nd line options include Bactrim DS, doxycycline or amoxicillin/ augmentin DF for certain bacteria but these may be less effective; typical antibiotics used for UTI such as cephalexin and trimethoprim which do not penetrate into the prostate for short 5-7 day courses are usually ineffective;

• Consider a 2-4 week course of a non-steroidal anti-inflammatory (NSAID); my preferred agent is meloxicam because it is long acting, once-daily and relatively gentle on the stomach but other NSAIDs are also effective.

• If there are prominent urinary symptoms, consider adding a 4 week course of an alpha-blocker such as tamsulosin (Flomaxtra).