CHRONIC PROSTATITIS AFFECTS EVERYONE:
What every man needs to know about chronic prostatitis & prostate cancer
by Ronald E. Wheeler M.D.


INTRODUCTION:
Chronic prostatitis (inflammation or infection of the prostate) is common to all adult men. It's associated with virtually all cases of prostate cancer and present in every prostate biopsy regardless of other findings. Chronic prostatitis may not cause significant symptoms in many men, but in others it can be a devastating disease that severely affects the quality of life of those afflicted. It's difficult to diagnose and even more difficult to treat. A wide variety of therapies are available but few actually work in more than a small percentage of cases. None of the standard treatments is able to improve the health and wellness of the prostate but a promising new approach may accomplish this. We'll review the current knowledge about chronic prostatitis, it's treatment and a possible connec-tion to prostate cancer.
THE PROSTATE
The prostate gland is a walnut sized mucus producing organ that lies just below the urinary bladder. All men are born with a prostate that grows and enlarges throughout life. There is a channel through the prostate which carries urine from the from the bladder to the outside. This is why prostate problems often cause diffi-culties in urination. The only known function of the prostate is to produce a secretion that nourishes and protects the sperm during reproduction. It has no other known purpose.
THE DEFINITION
Prostatitis is defined as inflammation or infection of the prostate. While prostatitis may be acute, associated with systemic findings of fever, chills and rigors, most cases of prostatitis are chronic and tend to be incurable with relatively frequent recurrences despite optimal standard therapy.
THE CLINICAL PRESENTATION:
The most common symptom of chronic prostatitis is pelvic pain, followed by various voiding symptoms, impotence and infertility. Pain from prostatitis is usually located in the groin, testicles, penis, just above the rectum or in the suprapubic area over the bladder. Pain is frequently associated with ejaculation. Typical voiding symptoms produced by prostatitis include getting up at night to void (nocturia), frequency, urgency of urination, incomplete voiding, decreased force of the urinary stream, intermittency of the stream and a need to push or strain to void. Impotence or erection difficulties and male infertility are also associated with prostatitis. (Please refer to Figure 1 for a list of clinical presentation models and Figure 2 for all the signs and symptoms of prostatitis.)
Prostatitis is a troubling disease that remains a health risk to most of the adult male population. John Krieger, M.D. and Richard Berger, M.D., [Urologists at the University of Washington], believe that all men will acquire prostatitis in their lifetimes. Historically, men under 50 y/o with voiding symptoms or pelvic pain had prostatitis until proven otherwise. Men over 50 y/o with the same symptoms were assumed to have enlarged prostates. A recent study has shown that most men with voiding symptoms regardless of age actually have prostatitis when properly tested. In a trial of 121 consecutive men who exhibited voiding symptoms, 80% were found to have chronic prostatitis regardless of their age.
THE DIAGNOSIS:
Prostatitis has been termed "the waste basket of clinical ignorance" by prominent Stanford University Urologist Dr. Thomas Stamey because of the difficulty it presents in diagnosis and treatment. Prostatitis is usually indicated or suggested by the symptoms it produces and the findings of a sore or tender prostate when a digital rectal examination is performed. Prostate Specific Antigen (PSA), a blood test designed to identify patients at risk for prostate cancer, will also be increased in cases of prostatitis. The presence of a specific urinary infection together with pelvic pain, voiding symptoms and a sore or tender prostate on rectal examination will identify those 5% of patients with bacterial prostatitis, a true infection.
But the only truly accurate and reliable way to diagnose prostatitis is from a microscopic examination of the prostatic fluid or expressed prostatic secretion (EPS). The prostatic fluid is obtained by gentle massage of the prostate during the digital rectal examination. When the fluid is examined under the microscope, a finding of more than 10 white blood cells per microscopic field is considered definitive proof of inflammation and prostatitis. Histological examination of a prostatic biopsy can also show definitive signs of inflammation and diagnose prostatitis. Despite the fact that examination of the prostatic fluid or EPS makes the definitive diagnosis, few family physicians and only about 33% of all urologists perform it because of difficulty in obtaining a proper sample, inadequate testing equipment or just lack of knowledge.
In prostatitis, any combination of pelvic and urinary symptoms are possible, as well as the rare individual who is without pain, discomfort or urinary problems yet still has prostatitis based on an abnormal examination of the prostatic fluid or EPS.
THE ETIOLOGY (i.e. possible causes):
- Virus - Idiopathic (Unknown)
- Bacteria - Stress and Psychological Factors
- Yeast - Immune System Based
- Dietary - A Combination of Above
> - Crystal Deposition - Social, Geneticc or Environmental
TREATMENT OPTIONS:
Treatment of prostatitis has been anything but a sure proposition. According to noted prostatitis expert Dr.Curtis Nickel of Kingston, Ontario, "there is wide-spread frustration, discomfort, and lack of knowledge in both primary care physicians and urologists' ability to manage prostatitis."
Those patients who truly have an identifiable infection of the prostate will certainly benefit from antibiotics. These need to be continued for at least 6-12 weeks and in some cases long-term or indefinite antibiotic suppression therapy is necessary. We don't have any data that looks at recurrent disease over many years. Campbell's Urology, the urologist's most authoritative reference text, identifies only about 5% of all patients with prostatitis as having bacterial prostatitis which can be "cured" at least in the short term by antibiotics. In other words, 95% of men with prostatitis have little hope for a cure with antibiotics alone since they don't actually have any identifiable bacterial infection.
In the treatment of prostatitis, physicians have traditionally recommended everything from doing nothing to multiple and extended courses of antibiotics, other drugs and lifestyle changes. Alpha blockers (Hytrin, Cardura and Flomax) are designed to relax the muscle tension in the prostate and improve urinary flow. They do tend to improve voiding difficulties and relax tension in the prostate but they are expensive, need to be taken indefinitely in high doses, may often have significant side effects and don't cure the underlying problem or prevent recurrences.
Finasteride (Proscar) can shrink prostate tissue but there is no proof it helps in the treatment of prostatitis. Allopurinol, a drug which reduces uric acid levels in the body, has been used to treat prostatitis based on the theory that uric acid crystals may form in the prostate and cause inflammation. Most clinicians who have tried Allopurinol for prostatitis report disappointing results from this therapy. Anti-inflammatory agents (Motrin or Advil) and hot sitz baths have been helpful in treating the discomfort caused by prostatitis in many patients, but neither of these treatments actually cures the disease and the benefits wear off rapidly. Irritative voiding symptoms may be relieved by bladder relaxing agents such as oxybutynin (Ditropan) while antidepressants such as amitriptyline (Elavil) have been helpful in various chronic pain conditions such as prostatitis associated with depression. Biofeedback, behavioral therapy, referral to a pain clinic and psychological treatment have all been recommended for patients with prostatitis and occasionally offer some relief to selected individuals. For the most part, current treat-ment methods for prostatitis are generally rather disappointing. (For a more detailed description of options for chronic prostatitis, please refer to Figure 3.)
Prostatic massage plus antibiotics deserves further review. Proponents of prostatic massage (championed in the Philippines) have little reproducible data to support their methods. Other drawbacks include intense discomfort/pain at the time of massage, the need for accurate cultures of the prostatic fluid and a dependence on antibiotics to ultimately effect the cure. Dr. John Krieger appropriately points out that the following multiple factors preclude accuracy of the culture technique involving urine, semen or prostatic secretion for diagnosing or treating prostatitis.
1. The presence of inhibitory substances.
2. The unknown effects of many previous courses of antibiotics.
3. The fact that most bacteria from the prostate do not readily grow on conventional culture media.
4. The high number of uncharacterized bacteria that infect human prostate tissue.
5. The difficulty in obtaining a pure specimen from the prostate which has not been contaminated by possible infections organisms of the urethra or urinary passage.
6. The fact that most cases of prostatitits are not infections in the first place.
PROSTATE SPECIFIC ANTIGEN (PSA) AND PROSTATITIS:
As mentioned earlier, Prostate Specific Antigen or PSA was originally designed as a blood test for prostate cancer screening. PSA blood levels of 0-4 were designated as "normal", but this range was arbitrarily selected as a guide for possible prostate cancer screening and does not necessarily indicate a healthy prostate. We now know that up to 30% of all prostate cancers occur in patients with PSA levels less than 4. Since prostate cancer obviously cannot be considered normal, this suggests that the original "normal" PSA range of 0-4 is much too high. It's been suggested that any PSA level greater than one indicates an unhealthy prostate with active prostatitis.
It's well known that prostatitis increases the PSA level. In fact, it is much more likely that any unexplained increase in PSA level is due to prostatitis than to prostate cancer. Many urologists will currently treat their high PSA patients with one month of antibiotics and repeat the PSA level before recommending a biopsy. Only if the second PSA level remains elevated will a biopsy be ordered.
We believe that a significant percentage of any elevation of PSA level in the blood should be considered prostatitis until proven otherwise. While prostate cancer is certainly a concern and should be considered carefully and appropriately, prostatitis is much more likely. PSA can serve as a very useful marker or indicator of the degree of prostatic inflammation present and help determine the effectiveness of prostatitis therapy.
THE LINK BETWEEN CHRONIC PROSTATITIS AND PROSTATE CANCER:
All men develop prostatitis. This has been shown in several studies including one done in 1979 by Drs. Kohnen and Drach who found 98.1% of 162 prostates removed surgically had evidence of inflammation. Dr. Timothy Moon, urologist at the University of Wisconsin, and many others report that virtually 100% of the biopsy and surgical prostate specimens they examine show evidence of prostatitis.
We also know that all men eventually get prostate cancer if they live long enough. In 1996, 40,000 men died from prostate cancer while over 300,000 new cases were diagnosed. Prostate cancer is the most common cancer to affect men and the second leading cause of cancer death in men (lung cancer is first). In the United States, one in four men who undergo prostate biopsy will be found to have prostate cancer, but all of them will have prostatitis. These findings have led Dr. Timothy Moon and others to suggest that prostate cancer is always associated with prostatitis.
Young men in their thirties typically are quite prone to prostatitis and are not generally thought to be at risk for prostate cancer. But a study from Memorial Sloan Kettering Cancer Center in New York found that 30% of 525 American men aged 30-39 actually had microscopic prostate cancer. Is it possible that chronic prostatitis may increase the risk or promote the growth of prostate cancer? There is evidence that suggests this may be so.
It's well known that chronic inflammation of several other organs is associated with various cancers. Examples include the inflammation of the lower esophagus (Barrett's esophagitis) which leads to esophageal cancer, hepatitis that eventually becomes hepatic cancer and ulcerative colitis which develops into colon cancer. Since chronic inflammation causes cancer in other organs, it is reasonable to suggest that chronic prostate inflammation (prostatitis) if left unattended may ultimately lead to prostate cancer.
Prostate cancer is always found together with prostatitis and all men will probably get both diseases if they live long enough. Both prostate cancer and prostatitis raise Prostate Specific Antigen (PSA) levels and occur most often in older men. Both conditions are currently at epidemic levels. Zinc levels are low or absent in both prostate cancer and chronic prostatitis. While prostate cancer and chronic prostatitis are clearly associated in some way, further research and epidemiologic studies are required to determine the exact nature of the relationship as well as the cause and effect mechanism.
THE RESEARCH:
Present research dollars in prostatitis are so few, that at our present pace a millennium will pass with countless innocent men suffering and possibly dying needlessly before the true answers are know. At the 1998 National Convention of the American Urological Association, (attended by American and International urology experts), 51% of all the papers and studies presented involved prostate cancer while only 3% addressed prostatitis. While a few studies of various antibiotics for the treatment of prostatitis are underway (funded largely by the pharmaceutical industry that makes the antibiotics), there is virtually no other significant research currently being done in the United States on this disease.
Practically every man alive has prostatitis, making it one of the world's most common diseases. Diagnosis is difficult and current treatments are frequently inadequate. The association between prostatitis and prostate cancer is irrefutable. With all this in mind, it is particularly disturbing that prostatitis research has been so seriously underfunded for years. Leroy Nyberg, M.D., Head of Urology Research for the National Institutes of Health (NIH) has stated: "It's amazing to me that we can't reliably treat the majority of men with prostatitis". The NIH has organized a research arm that expects to bring a fresh look to chronic prostatitis, but the results of this research is not expected for several years. Today, chronic prostatitis remains the single most underdiagnosed, misunderstood and undertreated medical disease in the world.
THE PROSTATE MERRY-GO-ROUND:
A classic example of a typical patient's experience involves a 65 year old man from Lubbock, Texas who had noted a PSA of 18. His urologist appropriately performed an ultrasound examination and prostate biopsy. The result was chronic prostatitis with no evidence of cancer. Antibiotics were given, but no other therapy was offered. (Remember that only 5% of cases of prostatitis are actually caused by bacteria which are potentially curable with antibiotics.) His PSA was repeated after 6 months and found to be unchanged. The patient underwent a second prostate biopsy which again showed only chronic prostatitis. When the patient asked his doctor what he could do, the urologist offered to repeat the PSA in another 6 months and consider an additional biopsy then.

FINAL THOUGHTS AND SUMMARY:
A PSA of >1 may indicate an unhealthy prostate. It's obvious that the lower the PSA the lower the risk of prostate cancer. Anything you can do to lower your PSA level will probably reduce your risk of eventually getting prostate cancer.
Keep track of your PSA level yourself. If the level is rising even it if remains below "4", make sure your physician is aware of it.
Have your PSA and rectal examination performed regularly, usually at least every year for men 50 or over. Men at higher than average risk for prostate cancer, such as Blacks and men with a positive family history of prostate cancer, should be checked starting at age 40. Men with known elevations in their PSA levels and those with inconclusive or "suspicious" previous biopsies may need to be checked more often. (Figure 6)
Don't be afraid to ask questions of your physician or get a second opinion about your health. A true professional will take the time to answer your questions and be open to suggestions about alternative therapies.
There may be a link between prostatitis and prostate cancer. Practically all men eventually are expected to get both and they are often found together.
Find out all you can about prostatitis and treat it as aggressively and effectively as you can. It may delay or even prevent the development of prostate cancer.
Be aware that your physician may not be an expert on the treatment of prostatitis. Ask him about the various diagnostic tests and therapies available and which ones are appropriate for you.