When Is Prostate Pain Serious?

Emergency Indications

Seek immediate medical attention if you experience:

• Acute urinary retention - complete inability to urinate with bladder fullness
• Fever with prostate pain - temperature >100.4°F (38°C) suggests acute bacterial prostatitis
• Gross hematuria - significant blood in urine
• Severe pelvic or perineal pain with systemic symptoms (chills, rigors)
• Urinary sepsis signs - confusion, rapid heart rate, low blood pressure

Indications for Evaluation

Schedule an appointment with your physician if:

• Chronic pelvic pain lasting more than 3 months
• Lower urinary tract symptoms (LUTS) - frequency, urgency, weak stream, nocturia
• Painful urination (dysuria) or painful ejaculation
• Progressive urinary hesitancy or straining to void
• Age >50 with new urinary symptoms (prostate cancer screening indicated)
• Recurrent urinary tract infections in men
• Hematospermia - blood in semen

Anatomy and Function

The prostate is a walnut-sized gland located below the bladder and surrounding the urethra. It produces seminal fluid that nourishes and transports sperm. The prostate continues to grow throughout a man's life, particularly after age 40.

Location: The prostate's position around the urethra explains why enlargement causes urinary symptoms. The gland is accessible via digital rectal examination (DRE).

Etiology

Acute Bacterial Prostatitis

Sudden bacterial infection of the prostate - medical emergency:

• Symptoms: High fever, chills, severe pelvic/perineal pain, dysuria, urinary urgency
• Organisms: E. coli (most common), Klebsiella, Proteus, Pseudomonas
• Risk factors: Recent UTI, urinary catheterization, prostate biopsy
• Examination: Tender, boggy prostate on DRE (avoid vigorous palpation)
• Treatment: Hospitalization for IV antibiotics if severe, oral fluoroquinolones for 4-6 weeks

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

Most common form of prostatitis (90-95% of cases):

• Duration: Symptoms for 3+ months in past 6 months
• Pain location: Perineum, testicles, penis, lower abdomen, lower back
• Associated symptoms: Urinary frequency, urgency, painful ejaculation, erectile dysfunction
• Pathophysiology: Not clearly bacterial - may involve inflammation, pelvic floor dysfunction, nerve hypersensitivity
• Impact: Significantly affects quality of life, similar to angina or Crohn's disease

Benign Prostatic Hyperplasia (BPH)

Non-cancerous prostate enlargement - extremely common with aging:

• Prevalence: 50% of men in 50s, 90% of men in 80s
• Mechanism: Central prostate growth compresses urethra
• Obstructive symptoms: Weak stream, hesitancy, incomplete emptying, straining
• Irritative symptoms: Frequency, urgency, nocturia (waking to urinate)
• Complications: Urinary retention, bladder stones, recurrent UTIs, kidney damage (if severe)

Prostate Cancer

Most common non-skin cancer in men - often asymptomatic early:

• Screening: PSA test and DRE starting age 50 (age 45 for high-risk groups)
• Early stage: Usually no symptoms - found on screening
• Advanced symptoms: Bone pain, weight loss, hematuria, urinary obstruction
• Warning signs: Hard nodule on DRE, markedly elevated PSA, hematospermia
• Risk factors: Age, family history, African American ethnicity

Diagnostic Evaluation

History and Physical Examination

• Symptom assessment: International Prostate Symptom Score (IPSS)
• Digital rectal exam: Assess prostate size, consistency, tenderness, nodules
• Abdominal examination: Check for distended bladder (urinary retention)

Laboratory Tests

• Urinalysis: Detect infection, hematuria
• Urine culture: If bacterial infection suspected
• PSA (Prostate-Specific Antigen): Screening for prostate cancer, monitoring BPH
• Post-void residual: Ultrasound to measure retained urine in bladder

Advanced Testing (If Indicated)

• Transrectal ultrasound: Visualize prostate anatomy, guide biopsies
• Prostate biopsy: If PSA elevated or abnormal DRE
• Uroflowmetry: Measure urine flow rate
• Cystoscopy: Direct visualization of urethra and bladder

Treatment Approaches

BPH Management

Stepwise approach based on symptom severity:

• Watchful waiting: Mild symptoms, no complications
• Alpha-blockers: Tamsulosin, alfuzosin - relax prostate smooth muscle, improve flow
• 5-alpha reductase inhibitors: Finasteride, dutasteride - shrink prostate (takes 6+ months)
• Combination therapy: Alpha-blocker + 5-ARI for large prostates
• Surgical options: TURP (gold standard), laser procedures, UroLift, Rezum for refractory cases

Chronic Prostatitis/CPPS Treatment

• Alpha-blockers: May improve urinary symptoms
• Antibiotics: Trial course if bacterial component suspected
• Anti-inflammatories: NSAIDs, quercetin
• Pelvic floor physical therapy: Highly effective for pelvic floor dysfunction
• Neuromodulators: Amitriptyline, gabapentin for neuropathic pain
• Lifestyle modifications: Avoid caffeine, alcohol, spicy foods; stress management

Prevention and Self-Care

• Regular urination: Don't delay when urge arises
• Hydration: Adequate fluids during day, limit before bedtime
• Limit bladder irritants: Reduce caffeine, alcohol, spicy foods
• Kegel exercises: Strengthen pelvic floor muscles
• Regular ejaculation: May reduce prostate congestion
• Healthy weight: Obesity associated with worsened BPH symptoms
• Regular screening: PSA and DRE as recommended for age and risk