Urology/Chronic infection, testicle cyst pain
Dear Dr Goldstein
I had very intense pain from an old testicular cyst (right testicle) and prostatic pain on DR examination by the urologist. Urethral swabs (this February) indicated a corynebacterium infection that was successfully treated with 10 days of 100mg doxycline (one per day).
After treatment everything felt very good, no pain or inflammation. There was no uncomfortable feeling whatsoever; I wish it had remained so.
Around 4 weeks after the end of the antibiotic treatment, slight/medium cyst/testicle soreness returned. I returned to the Urologist, further urethral swabs indicated the presence of another bacteria. I started treatment on cotrim forte (800/160mg SulfamethoxazolTrimethoprim) stopping 6 days later due to high fever possible side effect (?). I returned to the Urologist 10 days later. The swab results were negative (no bacteria). I had repeat swabs 14 day later and the results were positive for the bacteria, and was still sensitive to the same antibiotic. I restarted on the same antibiotics and completed a 19 day coarse. Also performed a uroflow exam - all OK.
Five weeks after finishing the antibiotic coarse, returned for swabs - positive result. Since then, 2 months ago, I have been taking cranberry supplement capsules (2 a day) and probiotics, allowing my intestine to recover.
Today returned to urologist for swabs to see if the bacteria are still present (results next week). He explained that the previous round of urethral swabs indicated that the bacteria were resistant to around 4 of the 8 antibiotics in the sensitivity test. As I understood this suggested that I have had the bacteria for a long time (possibly a very long time) and it may be difficult to treat this bacteria with further antibiotics and that I may have to accept the associated discomfort. I am not sure of the name of the bacteria, but it was something like siaettia mertens types 1 and 2, which he explained is found in many places in the environment.
My questions are: The initial swabs in February only indicated corynebacterium. Is it possible that this overwhelmed the resistant bacteria? If so, then could one introduce an easily treatable bacteria to overwhelm the resistant one, then treat the resistant one with antibiotics and then the introduced one?
Could you suggest how you believe I should proceed with regard to further treatment?
With very many thanks for your help and advice.
Jon, I do not believe the testicular cyst is causing you pain as these are characteristically asymptomatic. I do believe that the pain is referred to your testicle from an inflammation of the prostate gland, so called prostatitis. Urethral swabs, in my estimation can be quite inaccurate due to contamination. The are mainly useful if one has a urethral discharge (which you apparently do not). The best way to culture the prostate is either by producing a discharge via urethral massage, obtaining the first few drops of urine voided after a prostatic massage or culturing the semen (of which 2/3 is made of prostatic fluid). If indeed you have prostatitis, generally a minimum 4-6 week course of continuous antibiotics is needed. With chronic prostatitis, a prophylactic low dose of antibiotics continuously will generally prevent flare ups. You might want to consider a second opinion regarding your problem.
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.
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.