The problem with diagnosing and treating prostatitis

  • Wellness
  • Sunday, 20 Sep 2020

The prostate gland, which only males have, is located below the bladder and in front of the rectum. — Filepic

Prostatitis is a difficult topic and seldom discussed in public forums for good reason.

There is not much known about this condition, even among healthcare professionals.

It is at most times, a pathological diagnosis derived from examining a patient’s prostate tissue after surgical removal.

Therefore, some degree of prostatitis may co-exist with benign prostate hyperplasia (BPH), benign prostate enlargement (BPE), or even prostate cancer.

In these situations, the prostatitis element does not cause symptoms.

A StarHealth article quoted that “Around 80% of men walking around with urinary problem and sexual dysfunction actually have prostatitis and don’t know it.”

The assertion that 80% of patients with voiding issues have prostatitis is not substantiated.

The most common cause of voiding issues in older men is BPH or BPE.

However, any patient with voiding problems will need clinical assessment as there are also other known causes that are not related to prostate problems.

The term “prostatitis” in the article is also oversimplified.

Clinical prostatitis is often divided into various types.

One type is acute or bacterial prostatitis, which occurs in patients in their 40s, presenting with a very painful prostate with or without prostatic abscess and proven infection.

These patients will require antibiotics.

Occasionally, large prostate abscesses (filled with pus) will also need to be surgically drained.

The second type is chronic prostatitis where the patient might have bacterial infection (sometimes recurrent) and long-standing urinary symptoms.

This can often be seen in BPE patients and may require medical or surgical treatment, e.g. transurethral resection of the prostate (TURP) or laser surgery.

It needs to be highlighted that prostate surgery is the standard of care in appropriately selected cases of BPE and the overall risk of complications is less than 1%.

The third type of prostatitis is difficult to treat and is often referred to as chronic prostatitis (CP) or chronic pelvic pain syndrome, where there is no infection.

CP patients often present with pelvic pain, urinary symptoms and sexual dysfunction, which has lasted for more than three months.

Most Western journals report the frequency of this condition as 5%.

It is however important to understand that the problem in this group may not necessarily be related to the prostate.

These patients often require neurological, psychological and physical evaluation of the anus/rectum, and are frequently difficult to treat.

Some currently-available treatments are neuromodulation drugs, anti-inflammatory drugs, pelvic floor exercises, alpha-blockers and PDE5 inhibitors.

It is in this particular group of patients that the use of low intensity shockwave therapy (LISWT) has been tried and has shown benefit in some small studies.

In urology, LISWT was initially tried on patients with erectile dysfunction (ED). However, not all patients benefited.

Those with ED related to vascular disorders (which can be determined by a penile Doppler ultrasound) benefited more, but the success rate was inconsistent.

Therefore, LISWT for ED is still listed as an investigational treatment in most international guidelines.

However, since the treatment is low risk and non-invasive, it is now provided as an option to treat ED in some centres.

It is imperative that patients are informed that it is not yet the standard of care in ED management and that they may not see any durable benefit.

Some of the benefit seen may even be a placebo effect.

Furthermore, patients may still have to continue with their medication (PDE5 inhibitors) after LISWT.

The use of LISWT was then extended to prostatitis, but it is important to note that most studies focused on CP patients.

Most of these studies were short-term studies with low to moderate levels of evidence.

Therefore, the statement in the article that LISWT has a 90% cure rate for prostatitis is not in keeping with current scientific evidence.

This is why all the international guidelines consider LISWT for CP as investigational.

LISWT is not recommended in the treatment of BPH or BPE.

The article also made a reference to cycling as a risk for prostatitis.

Again, there has been conflicting evidence on this.

In a 2018 cross-sectional study published in the Journal of Urology that involved 3,932 male cyclists, the cyclists were found to have no worse sexual or urinary functions than swimmers and runners.

However, they may be more prone to urethral strictures, and therefore, would still need to take necessary precautions.

It has also been shown in some studies that vigorous cycling may lead to chronic pelvic pain from pudendal nerve irritation, rather than prostatitis.

The pudendal nerve is an important nerve coming from the lower spine.

The Malaysian Urological Association is open to new procedures in the treatment of urological disorders; however, the public must be adequately informed on the current status of these new treatments against the available treatment options that are already the standard of care.

Treatment offered to patients should always be evidence-based to minimise risk and optimise treatment efficacy and durability.

Brigadier-General (Rtd) Datuk Dr Selvalingam Sothilingam is the president of the Malaysian Urological Association. For more information, email The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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