Prostatitis: The Four Types, Symptoms, Causes and Treatment

What prostatitis is

Prostatitis is inflammation of the prostate gland, with or without infection. Unlike enlargement and cancer, which are conditions of older men, prostatitis affects men of all ages and is the most common urological diagnosis in men under 50. About one man in six will be given the diagnosis at some point.

The term covers four quite different conditions, and getting the type right matters because treatment differs completely.

The four types

Acute bacterial prostatitis

A sudden bacterial infection of the gland, usually by bacteria that have travelled up the urethra or spread from a urinary infection. It is the least common type and the only one that is an emergency.

Symptoms come on over hours to a day or two: fever, chills, feeling very unwell, pain in the lower back, perineum (between the scrotum and anus) or genitals, painful and frequent urination, difficulty passing urine, and sometimes complete retention. The gland is exquisitely tender on examination. Untreated, it can lead to a prostatic abscess or blood infection.

Chronic bacterial prostatitis

A persistent, low-grade bacterial infection within the gland, often following an acute episode or repeated urinary infections. It causes recurrent urinary tract infections with the same organism, with milder pelvic discomfort and urinary symptoms between episodes. It accounts for perhaps 5–10% of chronic cases.

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

The common one — roughly 90% of men diagnosed with chronic prostatitis. There is no demonstrable infection, and the name reflects uncertainty about whether the prostate is even the source. Symptoms last at least three months and include:

• pain in the perineum, lower abdomen, testicles, penis or lower back
• pain or burning on urination, and sometimes during or after ejaculation
• urgency, frequency, hesitancy and a weak stream
• erectile difficulty and reduced libido in some men
• fatigue, low mood and anxiety, which are common and worsen the pain

Symptoms often wax and wane, and may flare with stress, prolonged sitting, cycling or cold. The cause is thought to involve some combination of a past infection or injury that has resolved, chronic tension and trigger points in the pelvic floor muscles, sensitisation of pelvic nerves, and inflammation. It overlaps with irritable bowel syndrome, fibromyalgia and other chronic pain conditions.

Asymptomatic inflammatory prostatitis

Inflammation found incidentally in prostate tissue or semen examined for another reason. No symptoms, no treatment.

How doctors diagnose it

• History and examination, including a rectal examination of the gland (gentle in suspected acute infection).
• Urine tests for infection, sometimes before and after prostate massage to detect bacteria from the gland itself.
• Blood tests in acute cases for infection markers; blood cultures if very unwell.
• The NIH Chronic Prostatitis Symptom Index questionnaire to measure pain, urinary symptoms and their impact.
• Tests for sexually transmitted infections when appropriate.
• Imaging (ultrasound) if an abscess is suspected or symptoms are unusual.
• A PSA test is not useful for diagnosing prostatitis and is usually deferred, because inflammation raises it.

Treatment

Acute bacterial prostatitis

Antibiotics, started promptly and continued for two to four weeks; severe cases need hospital admission for intravenous antibiotics and, if there is retention, a catheter. Pain relief, fluids and rest. An abscess may need drainage.

Chronic bacterial prostatitis

A prolonged course of an antibiotic that penetrates prostate tissue (typically a fluoroquinolone or trimethoprim-sulfamethoxazole) for four to twelve weeks. Relapses are common, and some men need low-dose long-term antibiotics.

Chronic pelvic pain syndrome

No single treatment works for everyone, and the current approach is to match treatment to each man's pattern of symptoms — a framework clinicians call UPOINT (urinary, psychosocial, organ-specific, infection, neurological, tenderness). Options with evidence include:

• Alpha-blockers for urinary symptoms, particularly in men who have not tried them before
• Anti-inflammatory medication for short periods
• A single course of antibiotics in newly diagnosed men, since some respond, but repeated courses are avoided
• Pelvic floor physical therapy — for the many men with tender, tight pelvic muscles, this is often the most effective treatment
• Pain-modulating medication (amitriptyline, gabapentin, pregabalin) for neuropathic-type pain
• Psychological approaches — cognitive behavioural therapy and stress management reduce pain and improve function
• Warm baths, avoiding prolonged sitting and cycling, regular ejaculation, and managing constipation
• Quercetin and pollen extract have shown benefit in small trials and are sometimes tried

Most men improve substantially over months to a couple of years, though some have long-term symptoms.

When to contact a doctor

See a doctor promptly for pelvic or genital pain lasting more than a few days, painful urination, or blood in urine or semen. Seek urgent care for fever and chills with urinary symptoms or pelvic pain, or inability to pass urine — acute bacterial prostatitis can become serious quickly.

Frequently asked questions

References