In this blog, PCRI presents an article from guest contributor, J. Curtis Nickel, MD, FRCSC. 

Prostatitis is associated with inflammation (and or neural upregulation or sensitization), and in a few cases, infection of the prostate, causing pain in the prostate and pelvic area along with variable urinary symptoms. Acute bacterial prostatitis is rare, quite severe, relatively simple to diagnose, and quite easy to cure with antibiotics. Chronic bacterial prostatitis is a little more difficult to diagnose, but is typically associated with a chronic bacterial infection of the prostate characterized by recurrent urinary tract infections. Again, antibiotics are the primary treatment. The majority of men with prostate and pelvic pain and urinary symptoms (over 90% of prostatitis diagnoses) do not have a bacterial infection and remain somewhat of a medical enigma. Diagnosis is made by ruling out bacterial infection (and/or no benefit with antibiotics) and any other urological condition that could produce pelvic or prostate pain. This condition is now known as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Worldwide, approximately 6-8% of men have experienced prostatitis like symptoms, and for at least a third of these men, it is a very significant health concern. It is the most common urology diagnosis in men less than 50 years of age and the third most common urology diagnosis in men over 50 years. The impact on a patients’ quality of life is significant because of the constant chronic pain and its effect on life’s activities. The treatment is not very effective and must be individualized for each patient, usually using a multimodal treatment approach. The goal of treatment of CP/CPPS is not necessarily cure but rather relief from symptoms, increase in activities, and general improvement in quality of life.

Prostate Cancer Concerns in Men with Prostatitis

Men with a diagnosis of prostatitis appear to be diagnosed with prostate cancer more than men without prostatitis. While this might seem concerning, there is absolutely no concrete evidence that a prostatitis diagnosis actually increases the risk of developing or eventually dying from prostate cancer. It does increase the risk of being diagnosed with prostate cancer, presumably because of over utilization of urology care, higher worry about prostate disease including cancer, increased PSA testing, and thus increased likelihood of a prostate biopsy.

Inflammation of the prostate gland can have an impact on PSA screening for prostate cancer. While bacterial infection of the prostate gland (acute or chronic) can elevate the PSA levels 10 or even 100 fold, appropriate treatment usually brings down the level to baseline but takes at least 6 months after effective antibiotic treatment. Nonbacterial CP/CPPS can cause very minor increases in PSA in some individuals, however, an elevated PSA should never be attributable to CP/CPPS unless the patient and/or urologist is looking for an excuse to not perform a biopsy. 

Men Who Have Both Prostatitis and Prostate Cancer

Many times, prostatitis symptoms bring patients to the urologist’s office only to be diagnosed with prostate cancer. Other times, men are referred with an elevated PSA, and the urologist determines the patient has a prostatitis syndrome. Once prostate cancer is diagnosed, it can be followed by active surveillance or treatment according to best contemporary standards. However, a diagnosis of prostatitis should be taken into account when deciding upon the treatment modality, as it can impact, not necessarily the cancer prognosis, but rather the prostatitis symptoms. Radiation therapy can significantly aggravate the pain and urinary symptoms, while it is a fact that pelvic pain can persist after radical prostatectomy. Hormone therapy either has no impact or, in some patients, the prostatitis symptoms improve.

Radiation for Prostate Cancer can Aggravate or Cause Prostatiti

As noted in the previous section, men with a diagnosis of prostatitis, particularly those with an inflammatory subtype, can experience a temporary or even long term deterioration or exacerbation of symptoms. While some men have no change in the state of their prostatitis symptoms during or following radiation, it is impossible to predict the symptomatic outcome.

Men with no history of prostatitis can develop a radiation prostatitis, indistinguishable from CP/CPPS. This can occur with external beam radiotherapy or brachytherapy (radioactive seeds implanted into the prostate). The symptoms could include dysuria (burning during urination), poor, intermittent, obstructive stream, pain on ejaculation, and pain in the prostate, pelvic and/or bladder area. It can be quite severe, with poor bladder emptying (even urinary retention), inflammation of the prostate and bladder neck, and even dystropic (abnormal) calcification of the prostate gland. While it can be temporary (typically at least several months), the severe symptoms can become a chronic condition. Antibiotics rarely help and treatment is only supportive (alpha blockers, anti-inflammatories, etc) and not curative.

Prostatitis in Men with No Prostate

Many men with severe prostatitis insist on having a prostatectomy, even when they do not have cancer, in a desperate attempt to alleviate symptoms. In many cases, the surgery is futile and symptoms persist after the prostate is removed. For those patients with both prostatitis and prostate cancer, a radical prostatectomy cannot be guaranteed to cure the prostatitis symptoms. The pelvic pain, in many cases, persists. If one is lucky enough and the prostatitis pain resolves, it unfortunately can return once the local pelvic nerve “shock” stage has passed. Although difficult to predict, about one third of patients with prostatitis symptoms undergoing a radical prostatectomy for prostate cancer will see some resolution of their prostatitis symptoms. One of the most difficult aspects of CP/CPPS, or rather just CPPS, since we are discussing men who do not have a prostate, are those men who have never had prostatitis but develop symptoms of severe prostatitis following a radical prostatectomy. Patients report a pelvic pain described as burning, stabbing, sharp, knife-like and/or spasm-like. It is likely caused by some form of pelvic nerve damage during surgery, such that the nervous system (even beyond the pelvic area) becomes sensitized, resulting in a neuropathic pelvic pain syndrome. The treatment is both conservative (physiotherapy, heat treatment, muscle relaxants) and targeted stimulus. While this condition can persist in men for months and even years, it usually slowly improves with time.

Prostatitis and Prostate Cancer

The lesson for men with prostate cancer is that prostatitis can occur and impact their prostate cancer journey. Less is known about prostatitis than is known about prostate cancer, but it can significantly change a prostate cancer survivor’s life. Treatment of prostatitis symptoms in men with prostate cancer can be difficult, and is usually supportive rather than curative. But directed management is beneficial in improving symptoms when the correct diagnosis is established.

About Dr. Nickel:

Dr. Nickel’s research covers inflammatory, benign prostate and pain diseases of the urinary tract. He has over 550 publications, is on the editorial board of eight Urology journals, editor of the AUA Update Series, presented in 45 countries, funded by US NIH and Canadian CIHR and was awarded a CIHR Tier I Canada Research Chair (until 2021), AUA Distinguished Contribution Award and SIU Academy Award. He is currently Immediate Past-President of the Canadian Urological Association.