QUESTION: Hello Dr Goldstein
About 6 months ago I received unprotected oral sex (my first sexual encounter). The next day my prostatitis symptoms started. This included pain and discomfort in my penis, urethra, lower back, groin and around the testicle area. Multiple std tests were all negative. Despite taking a course of azitromycin (1g) and doxycycline (7 days) my symptoms persisted.
I then made an appointment with a urologist and he confirmed prostatitis and prescribed cipro for 3 weeks. My problems were not resolved and I made a follow up appointment. He performed a prostate massage to test my prostatic fluid and the results showed the presence of E-coli.
The microbiology department conducted a sensitivity test and found that the bacteria was resistant to cipro and trimethoprim. They found it to be sensitive to augmentin, cefpodoxime, cephalexin and nitrofurantoin.
I have tried augmentin for a month and cefaclor for 3 months and there hasn't been a major reduction in my symptoms. Most of my complaints exist and cause problems on a daily basis.
My question is, what can I do to resolve and cure my problems as I have already tried several antibiotics and the bacteria is resistant to the first choice antibiotics. Could I try IV treatment or injection therapy?
Also is my body's immune system capable of killing the bacteria, considering that the antibiotics are failing.
I am 26 years old and this is having a severe impact on my life, both personal and professional.
ANSWER: Bas, it certainly sounds like you have some type of prostatitis causing your symptoms. Although you have been found to have a rather resistant E. coli in the prostatic fluid, it may be that many of your symptoms are due to other forms of prostatitis (such as the abacterial varieties - see my "macro" on prostatitis which will follow). With respect to your bacterial infection, I think you should have an ultrasound of the prostate gland to rule out a prostatic abscess. If present, this needs to be drained as antibiotics cannot penetrate the wall of such a lesion and it can serve as a source of chronic infection. In the interim, I suggest another culture and sensitivity test of the prostatic fluid (or, as an alternative, you can collect a semen specimen in a sterile container). The best antibiotics for prostatitis are sulfas, teteracyclines (such as doxycycline) and fluoroquinolones (such as Floxin and Cipro). According to your history, you have not tried sulfas. in the USA, we mainly use Bactrim which is a combination of sulfa and trimethoprim. Trimethoprim alone (as well as Macrodantin) are useless in the treatment of prostatitis as they do not penetrate well into these tissues. If sulfa or another antibiotics is sensitive, I wolud treat you for a minimum of 6 weeks with a full dose and then a half dose for another few months thereafter to ensure clearing. This, of course, is if the ultrasound is negative. Although you are only 26 years old, as a last resort, sometimes a coring out of the prostatic tissue (TUR of the prostate) is needed to clear this problem. Again, this is only a LAST RESORT and the pros and cons of such therapy should be discussed at length with your urologist before such a consideration.
Prostatitis 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. Even if bacteria are again found in your prostatic fluid, I strongly recommend following all of the other recommendations you will find in the paragraphs below.
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).
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.
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.
---------- FOLLOW-UP ----------
QUESTION: Thank you dr, I just have some follow up questions if you don't mind.
During my initial consultation the urologist did refer me for an ultrasound. An ultrasound sound was done on my kidneys, bladder and prostate area and no abnormalities were found.
I have heard about biofilm in the prostate which can harbour bacteria and form a protective seal against antibiotics. Is this true and what can be done to check for this?
Is it possible to have an std in my prostate despite all the tests showing negative and having appropriate antibiotics (doxyxlcycline, azitromycin, erithromycin).
Also on average with a chronic condition, what is the expected recovery time frame? Can this be a life long condition or do you normally see recovery within a few years. Being 26 I'm dreading the thought of having this all my life.
Thank you once again sir.
Bas, as far as an ultrasound (US) of the prostate is concerned, the type I am talking about is done with a trans-rectal probe. US of the prostate using an abdominal approach would not be a proper technique to look for a prostatic abscess.
Regarding biofilms and prostatitis, I claim no expertise as this concept was developed well after I retired and is presently being still researched. However, I did check the urologic literature on this and there are only scant references and no clinically recommended treatments that I could find. You might have to refer this part of your question to another urologist who might have more experience with biofilms than I do.
Chlamydia and Ureoplasma which may be considered to be STDs can be missed on routine culture of the prostate gland fluid. They require the urologist to request a special culture for them. However, from a practical standpoint, if you had this, they normally would have been eradicated by several of the antibiotic treatments you have already had. Therefore, I do not think this is an issue in your case.
Chronic prostatitis can take several forms. It may be a low grade continuous process or it may periodically flare-up in a more acute manner. Once under control, long term low dose antibacterial treatment is sometimes successful in keeping the patient asymptomatic. Many of the general measures mentioned in my last note to you are just as important as antibiotic therapy and I suggest you follow them as best you can.