There are two main types of chronic prostatitis. 'Chronic bacterial prostatitis' is caused by persistent (chronic) infection with a germ (a bacterial infection). 'Chronic prostatitis/chronic pelvic pain syndrome (CPPS)' has a cause which is not fully understood.
Chronic prostatitis typically causes pain in the lower pelvic region of men. Urinary symptoms such as frequency of passing urine and pain on passing urine may also be present. Treatment can be difficult and may include antibiotics and other medicines. Symptoms may last a long time, although they may 'come and go' or vary in severity.
What is the prostate gland?
The prostate gland is only found in men. It lies just beneath the bladder. It is normally about the size of a chestnut. The urethra is the tube that passes urine from the bladder and it runs through the middle of the prostate. The prostate helps to make semen but most semen is made by another gland (the seminal vesicle).
What is chronic prostatitis?
Prostatitis means that you have inflammation of your prostate gland. Prostatitis can be sudden-onset (acute) or persistent (chronic). It can also be caused by an infection (infective) or be non-infective. Less than 1 in 10 cases of prostatitis are due to bacterial infection.
For the diagnosis of chronic prostatitis, symptoms need to have been present for at least three months. In acute prostatitis, symptoms usually come on and go away much more quickly. There are two main types of chronic prostatitis:
- Chronic bacterial prostatitis.
- Chronic prostatitis/chronic pelvic pain syndrome (CPPS).
The rest of this leaflet is just about chronic prostatitis.
Who gets chronic prostatitis?
Chronic prostatitis is actually quite common. About 2 men in 10 will have chronic prostatitis at some point during their lives. Chronic prostatitis most commonly affects men between the ages of 30-50 but men of any age can be affected.
About 9 in 10 men with chronic prostatitis have chronic prostatitis/chronic pelvic pain syndrome (CPPS). About 1 in 10 men with chronic prostatitis have chronic bacterial prostatitis, so this is rare in comparison to chronic prostatitis/CPPS.
Chronic bacterial prostatitis
What causes chronic bacterial prostatitis?
Chronic bacterial prostatitis is a type of infective prostatitis. It is caused by a persistent (chronic) infection with a germ (a bacterial infection) of the prostate gland. A man with chronic bacterial prostatitis will usually have had recurring urine infections. Chronic bacterial prostatitis is usually caused by the same type of germs (bacteria) that causes the urine infections. The prostate gland can harbour infection and therefore recurring infections can occur. Chronic bacterial prostatitis is not a sexually transmitted infection.
What are the symptoms of chronic bacterial prostatitis?
Men with chronic bacterial prostatitis tend to have symptoms that wax and wane. During a flare-up, you can have pain and discomfort. You feel this mainly at the base of your penis, around your anus, just above your pubic bone and/or in your lower back. Pain may spread to your penis and testicles (testes). Passing stools (faeces) can be painful. You may also have symptoms from a urine infection, such as pain when you pass urine, passing urine frequently or an urgent desire to pass urine.
These symptoms are similar to the symptoms of acute bacterial prostatitis. However, men with a flare-up of chronic bacterial prostatitis tend to be less ill than those with acute prostatitis. For example, a high temperature (fever) is less likely and you are less likely to have general aches and pains.
If you have chronic bacterial prostatitis, your symptoms will generally ease when treated with antibiotics. However, unless the antibiotics completely clear the infection from the prostate gland, you are at risk of the infection coming back (flaring up) again. In between flare-ups, you may have some mild residual pain and some mild urinary symptoms (such as passing urine frequently or an urgent desire to pass urine).
Chronic prostatitis/chronic pelvic pain syndrome
What causes chronic prostatitis/chronic pelvic pain syndrome (CPPS)?
Chronic prostatitis/CPPS is a persistent (chronic) discomfort or pain that you feel in your lower pelvic region - mainly at the base of your penis and around your anus. It is usually diagnosed if you have had pain for at least three months within the previous six months.
The cause of this type of chronic prostatitis is not fully understood. Many theories have been put forward as to the cause. These include:
- Infection of the prostate with a germ that has not yet been identified.
- Nerve problems affecting the prostate.
- An autoimmune problem of the prostate gland (antibodies that we normally produce to fight infection may be attacking the cells of the prostate gland for some reason).
- Inflammation resulting from urine being forced backwards up into the prostate at the time of urination.
The term prostatitis really refers to inflammation and/or infection of the prostate gland. However, the exact cause of this form of chronic prostatitis is not known and there is a variable response to antibiotics and anti-inflammatory painkillers. For these reasons, some doctors prefer to use the term 'chronic pelvic pain syndrome' (CPPS). Using this term does not necessarily imply that the problem definitely stems from a problem with the prostate gland.
What are the symptoms of chronic prostatitis/CPPS?
Symptoms have usually been present for at least three months within the previous six months.
The symptoms include:
- Pain - this is usually around the base of the penis, around the anus, in the lower tummy (abdomen) and in the lower back. Sometimes the pain spreads down to the tip of the penis and/or into the testicles (testes). Pain is the main symptom in chronic prostatitis. The pain may vary in severity from day to day.
- Urinary symptoms - such as mild pain when you pass urine, an urgent desire to pass urine at times, some hesitancy when trying to pass urine, a poor urinary stream.
- Sexual problems - you may experience difficulty in getting an erection (impotence), ejaculation may sometimes be painful and some men have worse pain (as described above) after having sex.
- Other symptoms - you may feel tired and have general aches and pains.
Do I need any tests for chronic prostatitis?
- Examination of your prostate gland. Your doctor may examine your prostate gland, using a gloved finger in your back passage (rectum). Your prostate gland may be tender on examination in chronic prostatitis. However, this is not so in every case.
- A urine sample is usually taken to rule out urine infection. This is especially important for chronic bacterial prostatitis although, in between flare-ups, there may be no signs of infection.
- Further tests of your kidneys and urinary tract. If your doctor suspects that you have chronic bacterial prostatitis, they may suggest that you have further tests to rule out any problem with your urinary tract that may have contributed to (or caused) the infection. For example, an ultrasound scan of your kidneys to look for any abnormalities.
- Tests to exclude other causes for your symptoms, including:
- Some swab or urine tests to exclude a sexually transmitted infection which can produce similar symptoms to chronic prostatitis. Note that chronic prostatitis is not a sexually transmitted infection itself.
- Other tests may be advised to rule out other conditions of your prostate or nearby organs if your symptoms are not typical. For example, sometimes your doctor may suggest a blood test to exclude other problems with your prostate gland.
If your doctor suspects that you have chronic prostatitis, they may refer you to a specialist (usually a urologist) for further assessment. If you are referred to a specialist, a sample of fluid ('secretions') from the prostate may be collected to rule out infection in your prostate. To do this, a doctor can gently massage your prostate, with a gloved finger in your rectum. By doing this, fluid from the prostate is pushed out into the urethra and comes out from the penis to be collected and tested for germs (bacteria). If you have CPPS, no bacteria are found in the prostate fluid or urine.
What is the treatment for chronic prostatitis?
The treatment of chronic prostatitis can be difficult. However, in most people, symptoms improve over months or years.
If your GP suspects that you have chronic prostatitis, as mentioned above, they will usually refer you to a specialist for further assessment. In the meantime, your GP may suggest one or more of the following whilst you are waiting for your appointment with a specialist:
- Painkillers such as paracetamol or ibuprofen may ease the pain.
- Laxatives may be helpful if it is painful or difficult to pass stools.
- Antibiotics are recommended if your doctor thinks you have chronic bacterial prostatitis. The antibiotic course should last for 2-4 weeks. Antibiotics are usually advised if you have had a urinary tract infection or an episode of acute prostatitis within the previous year. This is to be absolutely sure that no infection is present.
Reassurance and explanation are also sometimes helpful. Some people worry that they may have a serious disease such as prostate cancer. Worry and anxiety can make symptoms worse. Therefore, it may be useful to know that you have chronic prostatitis and not some other disease. However, you will have to accept that pain or discomfort are likely to continue for some time.
Treatments that a specialist may suggest
Various treatments have been tried for chronic prostatitis. They may benefit some people but so far there are few research studies to confirm whether they help in most cases. They are not 'standard' or routine treatments but a specialist may advise that you try one.
For chronic bacterial prostatitis, possible treatments may include the following:
- A longer course of antibiotics. If the specialist suspects that you have chronic bacterial prostatitis and your symptoms have not cleared after a four-week course of antibiotics, they may suggest a longer course. Sometimes a course of up to three months is used.
- Removal of the prostate (prostatectomy) may be considered if you have small stones (calculi) in the prostate. It is not clear how much this may help but it has been suggested that these small stones may be a reason why some people have recurrent infections in chronic bacterial prostatitis. However, this is not commonly carried out and is not suitable in everyone. Your specialist will advise.
For chronic prostatitis/CPPS, possible treatments may include the following:
- Antibiotics - these may be tried initially, although the evidence for their effectiveness is limited. It may be that some antibiotics have anti-inflammatory properties as well or that they may clear some germs (bacteria) that are difficult to find when your urine is tested.
- Alpha-blockers - are medicines that are used to treat prostate gland enlargement. They relax the muscle tissue of the prostate and the outlet of the bladder. There are several different brands. There is some evidence that they help in CPPS and one may be worth a try.
- Other medicines - for example, bioflavonoids (such as quercetin) and finasteride (a medicine which may 'shrink' the prostate).
- Stress management - this and other pain-relieving techniques are sometimes tried to help cope with the persistent pain.
What is the outlook?
It is difficult to give an outlook (prognosis). Your symptoms may last a long time, although they may 'come and go' or vary in severity. Painkillers can keep discomfort to a minimum.
Most men diagnosed with chronic prostatitis/CPPS tend to have an improvement in their symptoms over the following six months. In one study, about a third of men had no further symptoms one year later. In another large study, one third of men showed moderate to marked improvement over two years.
Further reading and references
; European Association of Urology (2018).
; NICE CKS, February 2015 (UK access only)
; Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ Clin Evid. 2015 Aug 272015. pii: 1802.
; Common Questions About Chronic Prostatitis. Am Fam Physician. 2016 Feb 1593(4):290-6.
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