Prostatitis, or...?

[Brian H.]

Hello, I am 27 and having a number of symptoms that I believe are related to prostatitis. However, I am not positive of this diagnosis and am looking for feedback. My symptoms include:

1) discomfort during ejaculation; a slight burning pain. Sometimes I have very little ejaculate. Never any blood.

2) Very occasionally, after ejaculating, my next urination is extremely painful, and the urine, especially towards the end of the stream, is very cloudy. This symptom is what sent me to the doctor. The pain lingers, and I feel a strong urge to urinate though nothing comes out, but the occasional few drops. I usually drink a big glass of water and take a shower and by the time I urinate again, the pain is gone. I have had this symptom once every couple of months for at least 5 years, and only recently was the pain so unbearable that I thought there might be something wrong.

3) Urinary symptoms: hesitancy, reduced stream, split stream, urgency, and frequency. All classic prostate symptoms. I usually have to get up once after about 6 hours of sleep to urinate.

4) general pains: lower back, hips (either, and infrequently) testicular (very infrequently), general 'bloated' feeling not related to gas. Occasional 'tickly' or sometimes slightly painful itch at the tip of the penis.

I went to my doctor with only symptom number 2 at first as it was the only one I noticed. I had been living with the others for so long I came to think they were normal, as they only slowly increased in severity and I never associated them. The doctor indicated that due to correlation with ejaculation I should keep a journal. In keeping the journal and researching prostate issues I realized the range of symptoms I was having. A urine test was clean. The DRE felt normal, according to the Doc, and I did not have any signs of acute infection.

My first treatment was 4 weeks of Cipro. At the end I felt absolutely fantastic. The doctor asked what percentage of 100 I felt, and I said  95%. All urinary symptoms were gone, orgasms felt better than they had in years, and other than the tendon pain I was having in my knees, and the tinnitis, (both Cipro side effects) all of my pain was gone. 3 weeks after the Cipro I started noticing urinary symptoms again. It started while traveling, spending 11 hours sitting in airports / on planes, I noticed the urgency and reduced stream were noticeable. By the time I got back, I knew there was still something wrong. The doctor wanted to send me to the urologist but I can't really afford it right now; we compromised and decided to do 6 weeks of Bactrim (due to the Cipro side effects and the length of my infection, if that's the case).

I'm currently 3 weeks into the Bactrim and feeling worse than I have yet. My stream quality is very poor (although it may very well still be better than what it was when I first went to the doctor; without paying attention to the symptoms before, I can't say just how bad they were). Ejaculation decreases my stream quality considerably further. The pain is not too bad, but I'm feeling intense anxiety and I think the tension in my muscles isn't helping. Hot baths provide mild relief, but not for long.

My question is mostly this: Why did the ciprofloxacin help, but the sulfamethoxazole is not? These are my own conjectures, and I'd love if others would chime in:

1) Cipro is more strongly anti-inflammatory than bactrim, and hence whatever non-bacterial issues I have were better treated by the anti-inflammatory properties of the cipro. (non-bacterial CP)

2) the bactrim is simply not effective on the organisms that are in my prostate, but the cipro was.

I have a slight worry of cancer, as I think all men with prostatitis probably go through, but my symptoms started around age 20-21 (as best as I can remember), and I'm 27 .... prostate cancers in men my age are usually more aggressive so the odds are very against this option, aren't they? 

I should say lastly that my wife has a history of yeast infections, and has been treated for a cervical infection once about 5 years ago. I believe I did a short term of general antibiotics at the time. Her recent tests came up clean.

[Concerned_male]

An detailed and articulate post.  I tried a natural remedy before conventional medicine:  saw palmetto (320mg capsules) and a tincture of Echinacea and Goldenseal daily.  One week into this regimen and my symptoms have alleviated, if not almost disappeared.  The symptoms I suffered from included urinary frequency, nocturnal urination, scrotal discomfort, and occasional discomfort post-ejaculation.  That said, I cannot establish a causal connection.  I cannot separate the effect of the saw palmetto etc  from a change of diet that I began a couple of weeks previously.  The only fluid I drink is water and I have made a concerted effort to eat unprocessed foods.   It remains possible of course that the prostatitis also just naturally came to an end.  

[Brian H.]

Thanks for the response. I'm reluctant to throw too many different methods at my prostate all at once, as then I will have no idea which one is actually working. I do believe that sitting all day at a desk, both at home and at work, is part of my issue. I think this is why the hot bath is effective, in that it relaxes the muscles around the prostate, which seems to be providing me with some relief from the frequency and urgency symptoms.

I still don't know the answer as to why the Cipro was so excellent on it's own, with no home remedies and no reduced sexual activity, while the Bactrim is not providing much relief at all. I am trying to figure out what questions I should be asking when returning to the doctor, in order to take the appropriate next step. There don't seem to be any prostatitis specialists in my area, or at least no doctors who claim expertise in the area, that I have found so far. I think it will be important for me as the patient to understand the results of the antibiotic runs as best as I can prior to seeing the doctor. For instance, I asked him if the anti-inflammatory qualities of Cipro were strong enough to see such a drastic improvement in all of my symptoms, and he simply told me that Cipro is an antibiotic, not an anti-inflammatory. Well duh, I knew that; the question is how strong of an anti-inflammatory is it? The studies are there, antibiotics DO have anti-inflammatory properties. Is this why men see improvement while on Cipro but then have recurrences of prostatitis?

What is the experience of prostatitis people around here, with respect to this question?

[Dave]

Hello Brian, people say that abx have anti-inflammatory effects and use this to explain why some people are seemingly "fixed" (albeit often temporarily) even when no bacteria can be cultured.  However, I have also read that whilst *some* do indeed have some level of anti-inflammatory action, it is insignificant in comparison with a standard NSAID like ibuprofen.  If that is true, then the whole idea that the severe symptoms might clear up due to an anti-inflammatory side-effect of the abx seems a bit iffy to me. For me, if I take ibuprofen then sure the pain lessens  but when I stop taking them, it comes back; if I take abx then all the symptoms may disappear and stay away when I stop.  This is clearly not an anti-inflammatory fix, though note I am not a doctor.

Bactrim and Cipro are different medicines and so may hit different types of bacteria, or may have different effects on the body.  I find it works the other way round for me....  never had any benefit of Cipro but Bactrim worked well, to start with. Urologists can't even agree if particular bacteria are likely to cause issues.... some say this is because prostatitis may be the body wrongly turning against some of the naturally occurring bacteria.

As to your other symptoms....  well you need to understand that unless some nasty bacteria is cultured e.g. in prostatic fluid pressed out by the doctor, then the diagnosis of "prostatitis" is frequently along the lines of 'if it looks like a duck and quacks like a duck, then it probably is a duck'.  i.e. they can't pin it down as anything else, and the symptoms are roughly right.  If you haven't already, you need to get cultures done of urine, semen and expressed prostatic fluid, though preferably after a period without abx ; if they are positive for something then great - if nothing then that doesn't mean that there is nothing. Tricky eh?

Your symptom no.2 - cloudy urination - is interesting.... does this ONLY happen after an ejaculation? Or could it be coincidence?  Sometimes I find similar though there is no link with ejaculation ... towards the end the urine turns cloudy, sometimes almost white with a sweet-chalky smell. The discoloured flow is highly irritant to the urethra and has to be washed through, after which it is fine. If the cloudy bit is last out then it can cause days of irritation remarkably like the "prostatitis" irritation.  For me I find eating Kellogg's Frosties is a surefire trigger for this though other things do too... I'm not sure what; I think it is the body dumping excess chemicals (phosphates?) and that probably changes the pH of the urine or something.  In my case I don't know if there is any link whatsoever to the "prostatitis".   However, if yours always follows ejaculation, or whatever the case,  the only thing you can do is try to capture some of the cloudy urine and get it tested as it could indicate infection  (I've never done this by the way, though one doc about 20 years ago said collect some and see if the cloudiness sinks to the bottom and then pour white vinegar into it and if it is just particles of excess chemicals, then it will just disappear).

If the Bactrim is not working at all then you need to go back to your doctor.  Some say 4 weeks of Cipro is not enough, though here is the UK the standard approach is currently 4 weeks of Oflaxacin, which is similarish, followed by 'see what works'.  I used to find 8 weeks was required, though I would experience improvement after 2.

Good luck, Dave.

[Brian H.]

The painful urination is tightly correlated with ejaculation. The cloudiness, on several occasions, has been directly associated with that painful urination. I Have had intermittent cloudiness in my urination but never really consistently, and not usually accompanied by any pain. One theory I have seen is that urine that includes highly alkaline prostatic fluid can burn quite painfully and obviously could be cloudy. 

I am still debating on whether or not to continue the Bactrim. On the one hand if it seemed like the Cipro helped much more, then I shouldn't keep taking the Bactrim. On the other hand, I am only 3 weeks into the Bactrim. After ~1 week of Cipro I was noticing improvement in all symptoms. The last thing to consider is that I've been on antibiotics for 7 of the last 10 weeks, and I am nervous about finishing this run of Bactrim only to find out I should just have been on cipro again, or nothing at all.

From the research that I have done, the relationship between Cipro and symptom improvement is maddeningly not very well understood. It seems to be the first thing that doctors throw at us, and it makes alot of us feel better while we're on it, but the long term cure rate for repeated runs of cipro is not very good. It's estimated that something like 80-90% of prostatitis is non-bacterial (i.e. the CPPS, non-bacterial form). A number of these patients DO see improvement from Cipro, which, frankly, makes no sense to the medical community. 

Another issue to raise is that my symptoms really took off during a period where I was sitting uncomfortably in airports for an entire day, then standing around on hard concrete floors for several days at a conference, and I experienced a very high amount of back pain. The recurrence of my symptoms became most noticeable around this time. The back pain was almost indistinguishable from the types of pain I'm having when I have my worst prostatitis symptoms. I had noticed some slight urinary symptoms returning BEFORE the trip though, so it may have just been a natural progression. Unfortunately with no real prostatitis specialists in my area, my guess is that most doctors here will write that off as coincidence.

However the fact that hot baths provide relief, back strain has on at least one occasion correlated with a flare-up, and other little signs Ive noticed (i.e. if I am having symptoms of urinary urgency and I consciously try to relax myself and relieve tension in my lower body, I feel less urgency), sitting for long periods of time, as I do every day for work, seems to increase discomfort.... all of these things to me seem like muscular issues.

I carry alot of tension with me about this and I worry that I am actually making it worse, which I think I am.

[Dennis Taylor]

Cipro did nothing for me. I was on it for a month and a half.

[Dave]

@ Brian - hmm, I'm no microbiologist or doctor, but the whole idea that someone who is suffering from this, with no bacteria cultured yet they get big improvement from abx, where the conclusion derived that it must be some mysterious unexplained cause that just happens to react to the abx, and not bacterial, well that seems almost arrogant/nonsensical to me.  i.e. just maybe the docs should consider that their failure to detect a bacteria might not actually mean there isn't one. Surely it would seem more likely that there is some pocket of bacterial nastiness going on that is tucked away, and locked away, and thus the tests just haven't detected it.  But what do we know....  Those that don't react to abx could still be bacterial... just the wrong abx. On the other hand I suspect there are a million and one causes of this type of discomfort and problem, many of which won't be bacterial, which is why they struggle to pin down this stuff.

I once took Bactrim for 4 weeks and it cleared my symptoms 100%  for 18 months... yet then stupidly squeezing my pelvic floor during an unusually large bowel movement, thus squeezing out a large amount of prostatic fluid out of the urethra,  well that triggered the return of the problem.  Now I can't possibly understand the cause precisely, but it doesn't look a far fetched possibility to me that whatever was going on before was still lurking down there somewhere, despite the previous apparent resolution, and the squeezing out of the prostatic fluid (or whatever came out) released it again.   I bet I would have had clear cultures during that good period. 

The back and spine can indeed cause similar pain issues.... when I had a pudendal nerve latency check and they found asymmetry, they wanted to do an MRI of the base of my spine as they said they had seen that before  where these symptoms resulted. A friend's dad had suffered from severe testicular pain to the extent that they concluded they should chop them off to see if it helped, and it was only after a date had been set that another doctor investigating his onset of epilepsy fortunately realised he had a broken neck and a bone was rubbing into the spinal cord.... and that was the cause.

I live near London and I've seen the consultants/their teams that are , quote - "the experts in prostatitis".  Experts...? - unfortunately they just come out with  the same old sh1t about this that every other uro I have seen has ever said ... "it's difficult, so use antibiotics for up to 8 weeks, and if they don't work, try some others [and now get out of my office asap]".  I don't mean to be mean to them.... its just that not a single uro i've seen has ever shown  the slightest bit of interest and the quicker they can find a way to get rid of you the better. This contrasts with physiotherapists, GU consultants, uro-neurologists (wtf?!) and GPs/MDs who have all shown real desire to understand and analyse symptoms, but lack the knowledge of how to join the dots made by the symptoms.

One key thing to remember with the prostate is that antibiotics do struggle to penetrate it - hence why Cipro and Trimethoprim (bactrim) are used as these do penetrate reasonably well, but sometimes the response can be quite slow - weeks instead of days. But as I say, best to discuss with your doc.

 Dave

[Dennis Taylor]

From what I've heard, this is a common complaint of men with CP, that their urologists just shrug it off. Even my urologist said, well if you still have this in 6 months, come back to see me.

6 months??? What about now? So I have to live with my life in ruins for 6 more months?

After I had my prostatectomy, I was talking to a GP about it and he said, "Well, we have a pretty good health care system in Canada and if removal of the prostate was an effective treatmen, more people would be doing them."
Again, more arrogance.

I wanted to say to him, "Ok, so your point is, for men with CP, they should just suck it up and suffer?"

You have no treatment for a large portion of men that have this condition and all you have to offer is indifference?

I would go further and say it's absolutely inhumane.

However, I think you could extend this to chronic pain sufferers in general.

[Brian H.]

Thanks for the replies gentlemen. I should say that I am not yet complaining about the doctors who are treating me. I am still early in this process of understanding the cause of my symptoms and starting out with antibiotics is understandable as a first guess. I will NOT continue to be prescribed antibiotics if they don't work, or if the recurrence rate seems high.

I should also mention that it wasn't my doctor who suggested that it was some other response to the antibiotics, that was my own conjecture. I am a research scientist in a non-medical field; I have seen many studies indicating that antibiotics provide temporary relief for men where no bacteria can be found. The recurrence of symptoms is very high, however. There have also been studies that antibiotics greatly improve symptoms of inflammatory diseases such as Crohn's disease and irritable bowel syndrome. I just wanted to know if anyone has seen research on the anti-inflammatory role of antibiotics in the prostate. I couldn't find any mention of it.

[Rick Hall]

I have discussed my symptoms with many doctors and urologists.  Thus far, I have received different opinions on what are the cause of my symptoms.  The opinions that believe my prostate is not the cause are based on the fact that my symptoms are not reproduced when my prostate is massaged.  I have learned that many times those that benefited from prostatectomy surgery did not experience pain when their prostate was massaged.  Those that think I do have prostate issues have no solution that has been proven to work. To make a very long story short, very little is known about CP.  I can relate to your frustration.  I have been told to "man up", "do nothing" because surgery is just too risky, "its all in your head", "take a pain pill".  Dr Krongrad is the only doctor who seemed to understand and care about my problem.  I admit, this typed of surgery is scary.  Im currently having alot of tests run in an attempt to rule out other problems that could cause these same symptoms.  I would hate to have a prostatectomy and it not rid me of my symptoms.  So far nothing else has shown up.  However the attitudes of some of these doctors has been unreal. 

[Dave]

Hi Rick, just out of interest, have antibiotics ever had any effect on it for you? - i.e. noticeable yet temporary improvement?   Your experience in general sounds very like mine ... nothing to point at the prostate, yet nothing to point anywhere else either, yet this big nasty problem sitting right across that area. My prostate has never hurt on massage either, though once I had it done and had the worst 2 weeks of my life following on from that.

[Rick Hall]

Hi Dave. I have been on cipro and doxycycl at different time periods.  At best I did notice some symptom relief as long as I was taking them.  When I stopped, my symptoms returned.  I went to a very highly regarded medical facility and was told it was not my prostate and they didnt know what was causing my symptoms. This was based on my lack of pain during the massage. This just added to the frustration.  So far Ive had an MRI, CT scan, endoscopy, colonoscopy, and a small bowel series.  Nothing else has shown up.  I DO believe my prostate is the problem according to my symptoms and so does Dr. K.  Most likely Im going to have the surgery when Im done testing.

[Dennis Taylor]

I went for one massage and the pain was through the roof. I did not enjoy that experience, at all.