There comes a time in every man's life when he will have "issues" with the walnut-sized gland that rests beneath the bladder and surrounds the ureter. Prostatitis is one of them.

Historically, a man complaining of pelvic pain, urinary problems, and other hallmark signs of prostatitis would visit his doctor and receive repeated, prolonged courses of antibiotics. The thought was that a bacterial infection was the underlying culprit. We now know that such infections occur in only a small percentage of men with prostatitis, thus rendering antibiotics ineffective in most cases. Fact is, in many instances, doctors cannot pinpoint prostatitis causes.

We also know that the complications of prostatitis can extend beyond the prostate. Oftentimes, prostatitis causes a broad array of symptoms that vary from person to person, and the most common type of prostatitis—chronic pelvic pain syndrome, or CPPS—can have dramatic effects on a man’s quality of life.

Given the variety of problems that prostatitis causes, only a multifaceted treatment approach provides relief for most men with the disease.

When Bacteria Are to Blame for Prostatitis

You experience a sudden onset of fever, chills, and other flu-like symptoms. You’re fatigued and have pain in your lower back, abdomen, or genitals. It hurts when you urinate, ejaculate, or move your bowels, and you have difficulty urinating and emptying your bladder completely. These are the signs of acute bacterial, or Category 1, prostatitis.

Category 2 (chronic bacterial) prostatitis causes similar symptoms, although they tend to develop more slowly and are less severe. Chronic bacterial prostatitis is characterized by recurrent urinary tract infections due to bacteria that linger in the prostate.

In these first two categories, the cause of prostatitis (a bacterial infection) is understood. Both types of bacterial prostatitis also share risk factors: a recent urinary tract infection, use of a urinary catheter, sexually transmitted diseases, habitually starting and stopping during urination, and unprotected sex, especially anal sex.

Likewise, the treatment of acute and chronic bacterial prostatitis is clear: antibiotic therapy. For acute bacterial prostatitis, a treatment course of up to eight weeks may be prescribed to prevent recurrences that can lead to chronic prostatitis. Typically, a longer course of antibiotics, up to 12 weeks or more, is prescribed for chronic bacterial prostatitis, while some men with this condition may require permanent low-dose antibiotic therapy.

The CPPS Enigma

Unfortunately, only about one in 10 cases of prostatitis has a clear-cut bacterial origin. Most men with prostatitis suffer from the more nebulous Category 3, or CPPS, perhaps the most challenging of the four types of prostatitis. (A fourth category, acute asymptomatic inflammatory prostatitis, causes no symptoms, requires no treatment, and is usually discovered incidentally during tests for other conditions.)

Affecting an estimated 17 percent of all men, CPPS is characterized by prostatic inflammation with no known cause. This type of prostatitis causes urinary problems (such as increased urinary frequency or urgency), pain in the prostate, bladder, or outside the pelvis and abdomen, muscle tenderness/spasm, chronic fatigue, neurological problems, and irritable bowel syndrome.

This broad spectrum of symptoms associated with CPPS necessitates an array of treatments that differ from patient to patient. For instance, one man may have only urinary problems and prostatic inflammation that can be treated successfully with anti-inflammatory drugs and medications to manage his urinary symptoms. Another man with CPPS may suffer from chronic neuromuscular pain outside the pelvis that won’t respond to treatment aimed solely at the prostate.

Alpha-blocker medications—alfuzosin (Uroxatral) silodosin (Rapaflo) or tamsulosin (Flomax)—or anticholinergic drugs like tolterodine (Detrol) or oxybutynin (Ditropan) are commonly used to treat urinary symptoms associated with CPPS. Along with taking pain medications, sitting on a doughnut-shaped cushion or soaking in a warm sitz bath can help relieve CPPS-related pelvic muscle spasms and pain. (A sitz is a shallow bath that cleanses the perineum, the space between the rectum and the scrotum.)

Some physicians recommend quercetin (an antioxidant) and bee pollen for patients with inflammation and pain localized to the prostate that is affected by bladder emptying and refilling. Some of these patients with bladder-specific symptoms may be prescribed drugs such as amitriptyline (Elavil) and pentosan (Elmiron), or undergo neuromodulation, using an implantable device that regulates nerves controlling the bladder.

For CPPS patients with chronic fatigue and pain outside the pelvis and abdomen, neuroleptic drugs—such as amitriptyline, nortriptyline (Pamelor), and pregabalin (Lyrica)—or acupuncture may be recommended. And, antibiotics are necessary for the small percentage of CPPS patients with an underlying bacterial infection.

Find the Help You Need

Just as CPPS often warrants multiple types of treatment, it also may require help from multiple medical specialists. A urologist can help manage most aspects of CPPS, including erectile dysfunction, a common problem among men with CPPS.

However, if you have tenderness or tightness in your pelvic floor muscles, you could benefit from pelvic floor physical therapy from a trained therapist. You might seek a consultation with a psychiatrist if CPPS is causing depression, anxiety, or stress. And, if your persistent pain hasn’t improved after a prolonged treatment, consider a referral to a chronic-pain-management program.

See also these University Health News posts:

• Where There’s Prostatitis, Fatigue and Other Problems Ensue
• Prostatitis Symptoms: What You Should Know
• Prostatitis Treatment: What Are Your Options?
• Is There Such a Thing as a Prostatitis Diet?

Originally published in 2016, this post is regularly updated.