Dr. Goldstein, I am a 63 yr old male with a 25 year history of mostly non-bacteria prostatitis - diagnosed by a urologist and confirmed with cystoscopy because of blood in the urine. The condition comes and goes, particularly reacting to stressful situations. Symptoms are generally mild (frequency, urgency), but have flared up at times. On 3 or 4 occasions the prostatitis responded to various antibiotics. I am writing because I've been experiencing discomfort in my right testicle. This has not happened before. This symptom coincides with a very stressful move of our residence, an extreme amount of lifting, and too frequent (for me)ejaculation.
I was examined by my family physician on two occasions. After one month of Doxycyclene I am now on a month of Cipro. After palpitation he has diagnosed me with epidymo-orchitis. the symptoms have gotten much better over the last 5 weeks, but I still feel a nagging sensation of sensitivity, as if my testicle was being squeezed ever so slightly - like I can feel the cloth of my underwear. The feeling is worse at night, when my scrotum is relaxed and basically one testicle (the unaffected one) hangs low.
It feels better in the morning when testicles are even, higher, and I guess firmer. This problem is exacerbated because I suffer from anxiety. I am very afraid of more examinations and seeing a urologist. I've been drinking several glasses of wine at night because it relieves the sensation, and the anxiety. Can you please advise me regarding what I might expect. I've been on the Cipro for 6 days. The prostatitis usually resolves without meds. Thanks so much I know you hear this a lot.
Sam, as you might imagine, for this type of problem it is not possible for me to make an exact diagnosis over the internet because of the inability to do a physical examination. However, I shall try to help you.
First, one has to determine if the testicles are anatomically normal or not. If they are NORMAL, there are several causes for discomfort. Let me give you some background information to make this easier for you to understand. The testicles in the fetus are formed high up just below the kidneys and under the diaphragm in a space called the retroperitoneum. Just before birth, they begin to descend toward the scrotum. In order to reach this site, they must actually force a whole in the lower abdominal muscles. The spermatic cord supports the testicle(s) and contains the vas deferens, arteries, veins and nerves necessary for their function. Remnants of the abdominal muscles actually wrap around the cord as a permanent envelopment called the cremaster muscles. When one contracts the abdominal muscles, they simultaneously contract the cremaster muscles. The cremasters can be injured by strenuous physical activity. The pain is often transmitted to the testicles, exacerbated by activity (such as the heavy lifting you did) and lessened by resting. Rest, heat, elevation, anti-inflammatory drugs and avoiding the activity leading to excessive strain are the treatment. Hernias and referred pain to the testicle from other problems such as kidney stones, colitis and prostatitis have to be considered. Of these, inflammation of the prostate gland (prostatitis) is by far the most common.
If the testicle is anatomically ABNORMAL, the most common cause is epididymitis. The epididymis is the tubular structure located behind the testicle that drains sperm from the testis to the vas deferens and eventually out the ejaculatory ducts. Inflammation or infection of the prostate gland (prostatitis) often will spread down the vas and into the epididymis causing inflammation in this area (epididymitis). This is the most common cause of epididymitis although it may also occur without prostatitis. Typical signs of epididymitis are swelling of the scrotal skin with loss of the normal skin folds (rugae), redness of the skin, enlargement of the epididymis and testicle, and local tenderness and pain that is eased by elevation of the testicle. Epididymitis is treated with antibiotics, warm baths, scrotal supporter and mild pain relievers. Probably the best antibiotics to use are from the fluoroquinolone group, such as Cipro and Levaquin. Usually the pain is gone in a few days but the swelling may persist for several weeks. Treatment should be instituted by a urologist after a proper and prompt evaluation.
That being said, the most common cause of testicular pain in the presence of normal testes is an inflammation of the prostate gland so called prostatitis. This is often flared up both by anxiety and too frequent ejaculation. Your history suggests that this is indeed the etiology of your symptoms. This is a disorder that I have commented on extensively on this web site. In case you have not read it before, to follow is a "macro" I have written on this problem that will explain the various types of prostatitis and their treatment to you.
Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, urethral discharge, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”) and constipation. The passage of blood at the initiation or termination of urination or in the semen can also be noted. During sexual arousal the prostate gland & seminal vesicles manufacture fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement. Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts. These structures empty into the prostatic portion of the urethra. At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen. The average semen volume is 2-6 cc. With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles.
It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis. Even without such spread, prostatic discomfort is often referred into the testicle. Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition. For the latter, it is best not to sit more than 2-3 hours at a time. Stop the vehicle periodically, take a short walk and go to the bathroom to urinate. A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate. One should avoid any of the above that apply. Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication! Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable. A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.
There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. Typically, pus cells and bacteria are found in the prostatic fluid. The infection usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work). Treatment courses shorter than this are associated with more frequent flare ups.
Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis is an elusive entity that has been called by a variety of names including nonbacterial prostatitis, prostadynia, pelvic congestion syndrome and most recently pelvic myoneuropathy. The latter name was coined by Dr. David Wise of Stanford. He believes that this may represent up to 95% of all cases of prostatitis. This variant may be an expression of interstitial cystitis and possibly is due to autoimmune or neurogenic factors. Dr. Wise suggests that the primary cause of the symptoms involves pelvic muscle spasm, nerve trigger points and some degree of anxiety (either the cause or result of the symptoms). His therapy involves the use of anti-depressents (we have used Elavil for years in refractory patients), relaxation techniques, trigger point physiotherapy, and biofeedback. Some others recommend Yoga & meditation as being useful. Although he may well prove to be correct, I generally recommend an initial course of antibacterial therapy for patients who clinically have symptomatic prostatitis of any variety. The majority of patients (even those with nonbacterial prostatitis) seem to respond favorably. It has been know for decades that many patients with the abacterial variety of prostatitis do well with antibiotics but the reason has been vague. Some theorized that they may harbor bacteria in the tissues of the prostate that are not being picked up in cultures (possibly walled off loci of infection). For more information on Dr. Wise's studies check out:
In my experience, symptoms usually responds to the general measures mentioned in the initial paragraph. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral). The latter require a prescription from you physician if he thinks it is indicated. More recently, a naturally occurring flavinoid with anti-oxidant and anti-inflammatory properties (such as quercetin) has been used in prostatitis. It's success is yet to be confirmed. As a last resort, in individuals where anxiety may be a factor, a short course of medication to treat the anxiety may be indicated.
Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. In chronic bacterial prostatitis, long term low dose antibacterial therapy often works well in suppressing symptoms. In refractory cases, culture of the prostatic fluid or semen often will disclose the offending bacteria. If found, sensitivity studies can identify which antibiotics are most likely to eliminate that particular germ. One should be off of all antibiotics for 7-10 days before the culture is taken. Otherwise, if there is residual antibiotics in your system, this may prevent bacteria from growing in culture.
In other cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles.
Therefore, if symptoms persist, consultation with a urologist should be scheduled. In cases with recurrent prostatitis or hematuria, it often is necessary to study the urinary tract more completely. Predisposing factors to prostatitis such as a urethral stricture (narrowing) and other disorders can then be evaluated. A man should learn to listen to his body. Good luck.