Prostate pain

There are many disorders of prostate that result in pain. Pain originating from the prostate can present with symptoms of pain in the pelvis, perineum or lower abdomen as well as back pain.

The following diseases are most common causes of pain originating from the prostate.

1. Prostatitis

2. BPH

3. Prostatic cancer

4. Prostatic calculi

5. Prostatic pain syndrome

Prostate is a walnut size reproductive organ in males. It is situated just below the urinary bladder and surrounds the urethra that passes through it into the penis.

Because of the common nerve supply, pain of prostatic origin is often felt in the rectum and perineum.

Prostatitis is an inflammatory condition of the prostate gland. It has been classified into four types.

Acute bacterial prostatitis presents with fever, perineal pain, dysuria and urinary obstruction. Chronic bacterial prostatitis occurs due to recurrent infection and presents with pain and difficulty in passing urine. Chronic abacterial prostatitis is also called chronic pelvic pain syndrome. It may be inflammatory when the fluid derived from prostatic massage contains inflammatory cells or non-inflammatory. Another variety is called asymptomatic inflammatory prostatitis that is not associated with pain and is incidentally diagnosed on biopsy.

The risk factors for prostatitis include age above 50 years, prostatic calculi, UTI, trauma during cycling or horse-riding, dehydration, bladder catheterization, HIV infection, urethral stricture, cystoscopy, transurethral resection of prostate and transrectal prostate biopsy.

The organisms responsible for such infections include aerobic gram-negative bacteria like E. coli, Pseudomonas, Klebsiella, Proteus, N. gonorrhoeae, Enterobacteriaceae and B. pseudomallei. Some gram-positive bacteria like S. faecalis and S. aureus may be responsible. Other less common causes include C. trachomatis, Ureaplasma, trichomoniasis, M. tuberculosis, blastomycosis, coccidioidomycosis, cryptococcus, histoplasmosis, paracoccidiomycosis and candidiasis.

Diagnosis requires complete blood count, urinalysis, urine or prostatic fluid culture.   General measures include adequate hydration, stool softeners, sitz or hip bath, analgesics and antipyretics. Specific treatment may require antibiotics. In some cases, surgical drainage of prostatic abscess may be required.

Prostatic pain syndrome is chronic perineal pain lasting for more than 3 months and is not due to any infection. The pain also radiates to back and rectum. It is managed with antidepressants, psychotherapy and physical therapy.

 

BPH or benign prostatic hyperplasia is a condition in which the prostate enlarges in size to produce bladder outflow obstruction. It is commonly seen in older males and affects the quality of life. Back pressure changes affect bladder, ureters and kidneys and may result in renal failure.

The symptoms can be of two types: irritative or obstructive. The irritative symptoms include frequency, urgency, dysuria and nocturia. The obstructive symptoms include poor urinary stream, hesitancy, terminal dribbling, incomplete voiding of bladder and overflow incontinence. Hematuria or blood in urine is an alarming symptom.

Evaluation of BPH includes a physical exam and a PSA (prostate specific antigen) test. Other tests including  ultrasonography of the prostate and prostatic biopsy to exclude cancer may be needed in some men. Pressure flow studies may be done to assess bladder pressure during voiding and urine flow rate.

Treatment includes medications to reduce tone of smooth muscle (tamsulosin) and size of prostate (finasteride).

Surgery may be indicated in people with urinary retention, recurrent intractable symptoms, back pressure effects leading to insufficiency, recurrent or persistent UTI due to BPH, recurrent gross hematuria due to enlarged prostate and presence of bladder calculi.

Various surgical options include transurethral resection of the prostate or open prostatectomy for people with prostate larger than 100 grams.

Transurethral incision of the prostate is preferred when the obstruction is due to small prostate.

Transurethral laser ablation is useful in patients on anticoagulant therapy

Some of the office based approaches that are preferred for small prostate include transurethral needle ablation and transurethral microwave thermotherapy.

Cancer of prostate presents with features similar to BPH.  In advanced disease pain can occur if the cancer spreads outside the prostate. The pain tends to be persistent, more severe.

Pain due to prostate cancer may require steroids, chemotherapy, radiotherapy, opioids, bisphosphonates, surgery, transcutaneous electrical nerve stimulation (TENS) and nerve block. In many cases complementary therapy is used to deal with cancer pain and includes acupuncture, reflexology, aromatherapy and hypnotherapy.

Prostatic calculi are commonly seen above the age of 50 years. They usually occur in clusters and form due to prostatic disease process like nodular hyperplasia, prostatic carcinoma or metabolic abnormalities. They form as a result of obstruction and stasis of prostatic secretions. Secondary infection may occur aggravating the inflammation. They are mostly asymptomatic though in some cases they may cause severe low backache.