What Causes Prostatitis?
(This information is from Dr. Patrick Walsh's Guide to Surviving Prostate Cancer)

Sometimes we know, sometimes we don't. As one urologist commented in a review of this disorder, "Prostatitis is one of the most difficult clinical problems for men who suffer from it, as well as for the families of those men and their physicians. It is a particularly perplexing problem for urologists, who see many men with prostatitis and have difficulties with diagnosis and treatment." Fewer than 8 percent of men with prostatitis actually have a urinary tract infection (symptoms caused by bacteria, which can be helped by antibiotics). What about the rest of these men? There are actually four conditions lumped under the umbrella of prostatitis. Each one has distinct characteristics and responds differently to treatment. That's why getting the right diagnosis is so important.

The two least common forms of prostatitis are caused by bacterial infection. Note: Although these are sometimes referred to as "infectious" prostatitis, neither form is contagious and neither form can be transmitted to your sex partner. Acute bacterial prostatitis is a severe, debilitating condition that hits with all the subtlety of a Mack truck. No mystery here; men who have it know something is wrong, and they require immediate treatment. In addition to the symptoms described above, acute bacterial prostatitis is usually distinguished by chills and fever and extreme pain. It’s difficult for a man to be stoic and try to “ride out” this condition. It’s also a big mistake: if not treated, acute bacterial prostatitis can lead to more serious problems such as urinary retention (the inability to urinate), a life-threatening infection in the bloodstream (this is called sepsis), and development of an abscess (an accumulation of pus under pressure, like a pimple) within the prostate.

Acute bacterial prostatitis is really an acute urinary tract infection (UTI). Fortunately, because the inflammation is so intense, this enables certain antibiotics—which normally wouldn't be able to penetrate the blood-prostate barrier, a shield designed to protect prostatic fluid—to reach the prostate. (Usually, in keeping out bad things like infection, this barrier also blocks helpful agents.) Acute bacterial prostatitis responds dramatically to antibiotics. However, many men are undermedicated—they either don't think they need (and therefore don't take) or aren't prescribed enough antibiotics to hit the infection hard and knock it out for good. A week to ten days of treatment may ease all signs of infection, and a man may even feel back to normal within a few days. But doctors have learned the hard way—from watching acute bacterial prostatitis return as a chronic infection—that it takes much longer, about six weeks of antibiotics, to get rid of the infection. In this sense, bacterial prostatitis is a lot like another stealthy infection, tuberculosis. The prostate is like a sponge, and if any trace of bacteria is not obliterated right away, acute bacterial prostatitis becomes much more difficult to cure. Eradicating acute bacterial prostatitis the first time around by relentless treatment with antibiotics is the best way to avoid developing chronic bacterial prostatitis.

Chronic bacterial prostatitis is also caused by bacteria and is also treated with antibiotics. It can be a recurring illness, coming back periodically for years after an initial episode of acute bacterial prostatitis. Its symptoms are usually milder versions of those seen in the acute form. Here, too, treatment with antibiotics should continue for six weeks. In many cases, the infection goes away every time with treatment; if, a few months later, it returns, it will vanish again after another round of antibiotics.

Both acute and chronic bacterial prostatitis are associated with UTIs, positive urine cultures that pinpoint the bacteria's location to the prostate, and the presence of inflammatory cells in prostatic secretions. (The hallmark of chronic bacterial prostatitis is that, when the infection returns, it's caused by the same type of bacteria that caused the previous infection.)

Chronic bacterial prostatitis, in fact, is so closely tied to UTIs that many doctors believe that if you don't have a UTI, and if you've never had one, you probably don't have chronic bacterial prostatitis. One explanation for persistent bacterial prostatitis may be lingering infection in tiny stones, called calculi, in the prostate. Prostatic calculi (the prostate’s version of gallstones or kidney stones) are harmless and very common; about 75 percent of middle-aged men and 100 percent of elderly men have them.

The next category is called chronic prostatitis/chronic pelvic pain syndrome, and the cause here is a diagnostic puzzler: Nobody knows what causes the two forms of prostatitis in this group (which used to be named by what it was not, nonbacterial prostatitis), and antibiotics don't help at all. Men with chronic prostatitis/chronic pelvic pain syndrome may have many of the same symptoms as those with chronic bacterial prostatitis. However, in some men, the prostate may not even be the problem. The pain and other symptoms may be a result of spasms elsewhere in the pelvis, rectum, or lower back. This category has two subgroups: inflammatory and noninflammatory, based on whether any white blood cells (also called inflammatory cells) can be found in the prostatic fluid.

Treatment here is largely symptomatic. Your doctor may prescribe one or several medications, including antibiotics, alphablockers, 5-alpha reductase inhibitors, anti-inflammatory agents, and Elmiron (pentosan polysulfate sodium). All of these have been shown to help some men with these forms of prostatitis; the problem is determining which men will be helped by which drug or drugs. This may take a while—and plenty of patience—for you and your doctor to figure out. This is the "art" of medicine—your doctor thinking creatively, juggling and fine-tuning various treatments to find the best ones for you. Some doctors recommend anti-inflammatory drugs and sitz baths to ease muscle discomfort and make urination easier, and many men have been helped by changing their diet. Some foods—particularly spicy dishes, red wine, and caffeine—seem to make symptoms worse.

Then there's the mysterious "bonus" category known as asymptomatic inflammatory prostatitis. This condition produces no symptoms and is usually found by chance during a biopsy or when prostate tissue is removed for other reasons (for example, surgery for BPH or cancer). If it produces no symptoms, is this inflammation something we should even worry about? Maybe. We're still learning about this form of prostatitis, and, although it is not cancer, it may be linked with the formation of cancer. In other words, whatever causes the inflammation may eventually cause cancer as well. (This will be discussed at length in the next chapter.)