Prostatitis: symptoms, causes, diagnosis and treatment

Prostatitis is inflammation of the prostate, and it is not always an infection. It may be caused by germs reaching the gland, but it can equally arise in the complete absence of any infecting agent, as a result of behavioural and lifestyle factors. It is one of the most common urological conditions in men, peaking between the ages of 20 and 50, and it causes not only urinary but also sexual symptoms.

Where the prostate sits, and why it becomes inflamed

The prostate is a gland located in the male perineum at a strategic point: below the bladder and in front of the rectum. It is traversed by the urethra, the channel through which urine and semen leave the body. Urologists habitually compare it to a chestnut, since that is normally its shape and size. The seminal vesicles open into it: together, the prostate and the seminal vesicles produce at least 80% of the fluid released at ejaculation.

It is precisely this anatomical position that exposes it. The prostate communicates with the outside world through the urethra and is separated from the rectum by only a thin layer of mucosa. Two routes of infection follow:

• From outside, through the urethra
• From inside, through the lymphatic vessels that drain not only the prostate but also the sigmoid colon and the rectum

Behavioural factors: the cause patients underestimate

The prostate is highly sensitive to lifestyle, much like the stomach and the bowel. Even in the absence of any specific infecting agent, a series of behavioural factors, compounding one another, contributes decisively to inflaming the gland:

• Anxiety and stress
• Smoking, alcohol and recreational drug use
• Irregular sexual activity, particularly when episodic
• A sedentary life
• Prolonged driving or riding — car, motorcycle, scooter, bicycle — continuously for many hours
• A poor diet, low in fibre
• Irregular bowel habit

This is the central point, and patients should hear it plainly: without changing these factors, the inflammation tends to become chronic and the symptoms return cyclically, despite medical treatment.

Types of prostatitis

Clinical classification

• Acute prostatitis
• Subacute prostatitis
• Chronic prostatitis: given its tendency to recur, this accounts for by far the largest share of cases

Aetiological classification

According to whether bacteria are present in the biological fluids examined (essentially semen and urine), prostatitis is divided into:

• Bacterial prostatitis
• Abacterial prostatitis, in which no organism is isolated

The abacterial form is also the one most often accompanied by chronic pelvic pain, with persistent urinary and sexual symptoms in the absence of any demonstrable infection. It is the most frustrating form for the patient, because antibiotics alone do not resolve it.

Symptoms of prostatitis

The symptom picture is highly varied and spans two domains.

Urinary symptoms

• Increased urinary frequency
• Burning on urination
• Feeling of incomplete emptying after voiding
• Heaviness in the perineal, suprapubic and testicular area

Sexual symptoms

• Burning on ejaculation
• Ejaculatory difficulty
• A tendency to premature ejaculation

These are troublesome, limiting symptoms that affect the patient's relationships. Prostatitis is one of the organic causes to look for whenever premature ejaculation appears in adulthood.

Diagnosis

Diagnosis rests on three levels.

• A detailed lifestyle assessment: diet, way of life, sexual activity, bowel function, alcohol and coffee intake, drug use. This is not a preamble: it is a substantial part of the diagnosis, because the treatment depends on it
• Digital rectal examination, for direct assessment of the prostate
• Cultures: urine culture, semen culture and, where appropriate, a urethral swab. These exclude or confirm the presence of common organisms and, above all, of sexually transmitted pathogens: Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma

In forms with more florid urinary symptoms, transrectal prostate ultrasound can be very useful in clarifying the extent of the inflammatory process.

Treatment

Patients must be told plainly: resolving the problem inevitably requires removing or reducing the negative behavioural factors. If these are not changed decisively, the inflammatory process tends to become chronic and the symptoms return periodically and cyclically, despite medical treatment.

The drugs available are:

• Targeted antibiotics, to eliminate any organisms identified on culture
• Anti-inflammatories and pelvic decongestants, to reduce pain and urinary symptoms

In abacterial forms, antibiotics alone do not resolve the condition, and lifestyle correction becomes the cornerstone of treatment.

Frequently asked questions about prostatitis

Is prostatitis always an infection?

No. Prostatitis can arise in the complete absence of any infecting agent, driven by behavioural factors: stress, a sedentary life, prolonged driving, a low-fibre diet, irregular bowel habit, alcohol, smoking. These are the abacterial forms, and they are why antibiotics alone are often not enough.

Is prostatitis contagious?

The abacterial forms are not. In bacterial forms the organism may be a common germ or a sexually transmitted pathogen (Chlamydia, Ureaplasma, Mycoplasma), in which case assessing the partner makes sense. This is one reason cultures are indispensable.

Can prostatitis cause premature ejaculation?

Yes. A tendency to premature ejaculation is one of the sexual symptoms of prostatitis, along with burning on ejaculation and ejaculatory difficulty. It is one of the organic causes always to look for when premature ejaculation appears in adulthood in a man who previously had normal control.

Can prostatitis be cured?

Yes, but not with drugs alone. If the behavioural factors that caused it are not corrected, the symptoms tend to return cyclically despite treatment. Changing lifestyle is not an optional extra: it is part of the treatment.

Is cycling bad for the prostate?

Prolonged, continuous driving or riding — car, motorcycle, scooter and bicycle — for many hours is among the factors that contribute to inflaming the gland. That does not mean giving it up, but it should be weighed within the overall picture alongside the other factors, which act cumulatively.

Does prostatitis increase the risk of prostate cancer?

Prostatitis is an inflammation, not a precancerous lesion. It can, however, raise the PSA: one of the reasons a high PSA is not a diagnosis of cancer and must always be interpreted by a specialist within the clinical picture.

Do you have persistent urinary or ejaculatory symptoms? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.