Urology/prostatitis testicular pain
QUESTION: Hi Dr. I would really appreciate your expertise.
28 year old male.
10 months ago testicular pain on left testical. Urine culture showed no infection. Nor did blood test. I was referred to a urologist. After giving a DRE. Prostatitis was the diagnoses. Then given a prostate secretions test. The bacteria found was Enterococcus faecalis. Was given a 4 week supply of antibiotics (Cipro). And was told to ejaculate at least every other day when on antibiotics. To help flush the prostate. The problem was solved and was symptom free.
Fast forward 10 months symptoms returned. Mainly pain behind left testical. Did another urine test. It came back clear of infection I am now back on another round of antibiotics. (Cipro)
I told that a prostate flare up will cause epididymis pain.
My questions are.
1. If my epididymis is flared up due to my prostate. Is it still recommended to ejaculate every other day when on antibiotics? Or will that delay the healing in the testical?
2. How is epididymis infection by its self diagnosed?
3. When on antibiotics does ibuprofen help the antibiotic penetrate the prostate?
4. And last but not least what are the types of antibiotics recommended for Enterococcus faecalis? If Cipro fails do I have other options?
ANSWER: Mike, I shall try to answer your 4 questions in order.
1. I believe that ejaculation in moderation is healthy for the prostate so that the prostatic fluid does not build up excessively. However, when having symptoms, I suggest to my patients that they decrease ejaculatory frequency. Think of it this way, if your arm was sore, would you try to throw a baseball more often than normal to try and speed healing? When a body talks to a person, they should listen. However, total abstinence also has it's problems. My advise is to ejaculate 1-2 times a week until better.
2. To answer your question on epididymitis, I am attaching my "macro" on this condition:
During sexual arousal the prostate gland manufactures fluid that accounts for about 2/3 of the volume of ejaculate. The seminal vesicles are paired structures located behind the prostate gland that also manufacture fluid. 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, prostatic fluid is discharged into the urethra (urinary canal) where it mixes with discharge from the ejaculatory ducts forming the semen. The semen volume is in the 2-6 cc range.
The epididymis is the tubular structure located behind the testicle that drains sperm from the testes 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. The discomfort associated with prostatitis can sometimes be referred into the epididymis without actually an inflammation being present in the epididymis. In this case, the epididymis and scrotum are normal although slightly tender.
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. 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. The urologist should follow the patient until the inflammation has totally resolved and the testicle has returned to normal. The reason for this is that occasionally, a tumor of the testicle may present clinically as epididymitis. In this case, the inflammation and swelling initially obscure the true diagnosis. A lack of response to treatment may be due to bacterial resistant to the antibiotic being used, the formation of a testicular abscess (which may be detected on ultrasound), or a misdiagnosis of torsion of the testicle.
3. Ibuprofen does not help the antibiotic penetrate the prostate gland.
4. The best antibiotics for prostatitis are that that can actually penetrate into the prostatic tissues and secretory glands. The most common used are the fluoroquinolones (such as Cipro), sulfas and the tetracyclines. When a bacterium is cultured, sensitivity studies are also done to determine which antibiotics will kill that particular strain of organism. The best guide for selecting the proper antibiotic is one that the organism is sensitive to and one that is sable to penetrate the prostatic tissues.
---------- FOLLOW-UP ----------
QUESTION: Thank you Dr. for your great knowledge. I have one more question if I can. I am trying to get educated on this subject as much as I can. So my treatment plan has the best chance of success.
So just to set the record straight. I was under the impression that when on antibiotics for prostatitis it was best to ejaculate more frequently. This way the antibiotic penetrates the prostate better. And the same for the epididymis flare ups. I understand what you are saying about it being like a muscle it needs rest in till healed. But isn't it best to flush the bacteria out of the prostate and epididymis when on antibiotics? Or does that make no difference? And if it is best to let everything heal. Wouldn't ejaculation twice a week during flare up keep setting the healing process back?
Once again thank you for your time.
Mike, there are no studies that I am aware of that demonstrate that frequent ejaculation allows antibiotics to penetrate better into the prostate gland. As far as prostate health is concerned, it is best to ejaculate in moderation. This is because too frequent ejaculation as well as too infrequent ejaculation can predispose to prostatitis. Moderation is different for each individual and is determined by trial and error. For most men, moderation would be 1-4 times a week. Moderation will not set "the healing process back". In my opinion, it woulds hasten this process. 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.