Dr. P. GEORGIADIS

Surgeon Urologist - Andrologist
Greek English




The condition

What is chronic prostatitis?

  • Chronic prostatitis is a series of inflammatory reactions that take place at the prostate gland and in turn affect the whole genitourinary system of a man.

  • The causative agents are various germs, the most common of which are: coliforms, enterococci, staphylococci, the proteus and a series of other specific microorganisms like chlamydia mainly but also others such as ureaplasma and mycoplasma. At this point, I must stress that all of the aforementioned are those that currently the science of microbiology with the modern means at its disposal can recognize (through special cultivations of the prostatic fluid and sperm).

  • In addition, it seems that the inflammation of the prostate tissue may be caused by other microorganisms which are not recognized by the usual means of daily practice typically employed in microbiology. These microorganisms can only be identified by the use of special examination by electron microscopy in the cultures of the prostate gland tissue.

  • This is practically why chronic prostatitis is recognized as microbial and non-microbial.

  • The above distinction essentially has to do with whether the cultures of prostatic fluid / semen have a microbial agent or not. However, what is common in both cases is the existence of leukocytes in the prostatic fluid or semen (indicative of inflammation), and that both can be controlled by use of antibiotics (regardless of course if the antibiotic alone does not lead to a radical result).

Percentage of the affected male population
  • Based on recent studies, male population rates approaching 65%-70% have chronic inflammation lesions at the prostate tissue. This has been demonstrated by histological tests done after surgeries for hyperplasia / hypertrophy of the prostate and prostate cancer.
     
  • The particularly high rate of finding chronic inflammatory lesions in surgical specimens of hypertrophy or prostate cancer, indicates the causal relationship of chronic inflammation with the hyperplasia of prostate tissue and the potential cancerous transformation of it.

  • The aforementioned information is of utmost importance since it indicates the relationship of the chronic inflammation in the prostate with swelling or even prostate cancer, and necessitates the rapid and radical treatment of the disease. It is extremely important to halt the evolutionary path of these complications, which plague especially the older part of the male population.


Figure 1. A man’s genitourinary system

Why do some show symptoms and others do not?

  • As mentioned above the percentage of the male population that is affected by the disease approximately ranges between 65% and 70%.
  • A percentage of approximately 50% will sooner or later show symptoms related to chronic inflammation.
  • Usually a large percentage of young men between the ages 20-35 will show symptoms of irritative type (e.g. pelvic pain, burning sensation on urination, sense of weight in testicles etc.). A large proportion of men between the ages 35-55 will show symptoms mainly of obstructive nature (e.g. varying degrees of dysuria with almost guaranteed evolution of chronic prostatitis and enlarged prostate gland). In both of the two aforementioned age groups there is likely existence of complications which paint quite a complex clinical picture (e.g. erectile dysfunction, subfertile sperm etc.).
  • The type of symptoms depends on how quickly the inflammatory lesions evolve and spread in the prostate tissue as well as the type and quantity of the microbes in the prostate. Symptoms also depend on the prostate area which is affected more strongly and the effectiveness of the protective mechanisms in the tissue gland.
  • Practically we are dealing with three large groups of patients.
    The first group are those who experience very early various intense and persistent symptoms of the chronic prostate inflammation and typically attempt to find immediate treatment. They are the ones who are looking desperately for a radical solution because the problem they face has changed their quality of life to a large extent.

    The second group are those whose symptoms are periodic and moderate, but annoying enough to eventually visit their urologists for help. However, the insufficient and often incorrect assessment of the disease has led them to poor or rough treatments without (long-term) effect. Eventually these patients compromise as they are typically persuaded that nothing serious can be done and that somehow their situation is a normal course of events. Usually these patients begin to look for radical treatment when the development of the disease begins to be quite difficult in everyday life and the medication they used to contain the problem is no longer effective.

    The third group are those who do not recognize or do not want to pay special attention and importance to the various small or moderate symptoms which begin to occur progressively and somehow learn to live with them. In this group, belong those who will undergo surgery sooner or later, either for hyperplasia or prostate cancer, because the course of the disease was not treated properly and early and nothing was done to even halt its evolution. At this point we must emphasize the irresponsibility of many urologists who have the misconception that chronic prostatitis or even swelling / hyperplasia of the prostate are not immediate problems to be solved. Instead, they regard these as problems as a 'natural' course of events that in some way affect the prostate gland and should only be addressed when the situation has reached an impasse (in practice that is when the patient is unable to urinate or has difficulty in urination due to an excessive swelling of the gland or if cancer is present).

What changes occur in the prostate tissue and why do the treatments with antibiotics not work?

  • The main microbial input port is the urethra.
  • The first areas to be infected are the prostate glands near the urethra and then the microbial infection spreads to the peripheral glands.
  • Clogging will follow as well as the hardening of prostatic glandular tubes and the spread of the condition around the glands due to stromal inflammation and fibrosis. As a second phase follows the hardening of the stromal tissue with strangulation of blood vessels, edema and degeneration of nerves, resulting in further lack of oxygenation and increase in tissue oxidative stress. A protective wall is progressively generated for the microbes, which then multiply uncontrollably and expand slowly throughout the prostate tissue. The consequence of this is that they can no longer be combated by the body itself or antibiotics due to impossibility of access to the necessary concentrations to be able to inhibit their development or cause their destruction.



    Figure 2. Swelling of the periurethral area; obstruction with purulent secretion from prostate tubes. 
     
    In the region of the urethra two events are progressing:
     
  • a) Small Inflammatory lesions with simultaneous formation of scar tissue, which is either converted into intraluminal narrowing at the level of the bladder’s neck or at the prostate part of the urethra (before the sphincter mechanism).
  • b) The effect of periurethral hardening along the urethra prostatic part.
  • A consequence of this is the effect of intraurethral / intraprostatic reflux of urine into the prostatic tubules, resulting in their calcification and the further worsening of the phenomenon and chronicity of the inflammation.
  • As such, in most cases in which the inflammation has caused a non-trivial amount of chronic tissue damage, the antimicrobial treatment fails to address the problem effectively and at best reduces subjective complaints or covers them for some time. This by no way means that the progress of the inflammation is inhibited; to the contrary, we could say that it is a temporary reduction of tissue edema in the prostate and nothing more (antibiotics have anti-inflammatory properties to some extent). Many patients end up reaching a second stage, with many more problems or disease complications once the masking effect of the antibiotics stops.


Figure 3. Prostatitis complications such as narrowing of the urethra, incomplete bladder emptying, prostate enlargement, intraprostatic urinary reflux.
 

Side effects and complications of chronic prostate inflammation.

Nearly 70% of chronic prostate inflammation cases, when presented in urological surgeries are accompanied by side effects such as:

  • Functional or organic urethral stricture: This entails varying degrees of difficulty in urinating and usually the severity of their stage is not be perceived by the patients themselves.
  • Problems related to sperm fertility: Due to the toxic effect of the inflammation, problems in the production and quality of sperm (reduced sperm amount or low mobility) are caused.
  • Erectile dysfunction problems: The spread of the inflammation in the erectile nerve area creates problems in inducing and maintaining the erection mechanism.
  • Increased prostate size: Due to the continuous inflammation, hyperplasia and hypertrophy of the prostate gland cells is induced, which in turn leads to further increasing difficulties in urinating and erection.
  • Increased likelihood of tumor tissue: The combination of the continuous inflammation with the simultaneous weakening of the immunological mechanism (which usually occurs after the age of 60-65 years) leads to increased likelihood for the creation of tumor cells.