Asymptomatic Inflammatory Prostatitis

Inflammation is a complex process that involves many substances and different cells. It is a healthy reaction against invaders and the way our body defends when microbes are around.

However, inflammation can quickly turn against us when it is very severe. In these cases, it damages our healthy tissues and causes pain. That’s when non-steroidal anti-inflammatory drugs come in handy.

But there are many types of inflammation, and some of them are subclinical. It is relatively easy to diagnose localized inflammation. For example, when you endure a direct hit or get burned. But inflammation of inner organs is not that easy to interpret. It is usually associated with diffuse and unlocalized pain.

The intensity varies depending on the degree of inflammation. Sometimes inflammation becomes subclinical, and sometimes we can get low-grade inflammation in several parts of the body simultaneously.

Prostatitis is the inflammation of the prostate gland. The definition and descriptions above can also apply to prostatitis. We can have prostatitis patients with sudden and very severe pain. Others have mild and diffuse symptoms. And still, others remain subclinical. In other words, they do not give out any sign of prostatitis.

That’s why the classification of prostatitis according to the National Institutes of Health includes four groups (1):

In this article, we are covering a type of prostatitis that doesn’t have particularly bothering symptoms. It is known as asymptomatic inflammatory prostatitis.

What is asymptomatic inflammatory prostatitis?

Asymptomatic inflammatory prostatitis has many names. You can find it as subclinical prostatitis, asymptomatic prostatitis, histological prostatitis, or type IV prostatitis. As the name implies, these patients do not have symptoms.

It is very different from the other types of prostatitis. For example, in acute bacterial prostatitis, patients have urinary symptoms and pelvic pain. They also experience a sudden temperature rise.

In chronic bacterial prostatitis, the most common problems are obstructive symptoms of the urinary tract-for example, a reduction in the urinary flow or urinary retention. In pelvic pain syndrome, the symptoms do not resolve, and the most uncomfortable is chronic pelvic pain.

But then you have this fourth type of prostatitis that does not have any particular symptom. Bacteria can trigger inflammation. But sometimes, no infection is found in the prostate tissue. This group of patients is living proof that there’s a lot we don’t know yet about prostatic inflammation. That is why some researchers have become interested in asymptomatic prostatitis. Even if patients are no bothered by symptoms, are there any long-term consequences?

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What the research says

Closely after releasing this classification system of prostatitis, a group of investigators started to study the answer to this question. They showed evidence that 98% of prostates with BPH also had an inflammatory reaction. Thus, the link between BPH and asymptomatic prostatitis is very likely.

Bacteria likely cause this inflammation because an infection was in 28% of these patients. The probability is higher still when patients are catheterized. However, the severity and degree of inflammation are similar in both groups (2).

Asymptomatic prostatitis is not yet a risk factor for benign prostatic hyperplasia (BPH). However, it appears to play a role in the development of the disease. Similar findings are reported in prostate cancer. Asymptomatic inflammatory prostatitis leads to prolonged and untreated inflammation of the prostate. Cancer cells use inflammation to grow faster and create new blood vessels. Thus, asymptomatic inflammatory prostatitis could be making the conditions for cancer growth.

Another problem with asymptomatic prostatitis is that it still raises our PSA level. The Prostatic Specific Antigen or PSA is a prostate cancer tumor marker. It also detects other forms of prostate enlargement and prostatitis. Subclinical prostatitis can also raise our serum levels of PSA. So, just imagine a healthy patient with asymptomatic prostatitis screening for prostate cancer. His doctor would be alarmed by the sudden rise in PSA levels. He would repeat the exam after a while to confirm the finding, and PSA is still high.

A prostate biopsy is taken, which denies the existence of prostate cancer. But the patient ends up with chronic bleeding of the urinary tract and pain. These side effects could have been spared if we knew more about asymptomatic inflammatory prostatitis. That is why the topic is essential, even if we won’t experience any symptoms at all (3).

Causes

What causes asymptomatic inflammatory prostatitis? This subtype is particularly difficult to study because most patients are detected by chance. Doctors are running tests for something else and find a case of asymptomatic prostatitis.

Patients feel nothing and would not be able to mention any relevant data to trace back prostatitis to a single cause. However, we have a series of risk factors and a reasonable explanation of how it happens. These are the most critical risk factors (4):

  • Older age: We usually think that prostatitis is more common in young men. However, asymptomatic inflammatory prostatitis is the exception. Young men are at risk, of course. But the risk increases as we age.

  • Smoking: Even smoking now and then increases the risk of asymptomatic prostatitis. 15 packs of cigarettes a year or more can give you an increased risk.

  • Heavy drinking: Similarly, drinking alcoholic beverages can increase the chance. Drinking as little as one drink per week links with an increased risk.

  • Low education levels: For some reason, people with less than college education appear to have a higher chance of asymptomatic prostatitis. This could be related to their social background or high-risk behaviors.

  • Sexually transmitted diseases: It is a risk factor for acute bacterial prostatitis. However, sexually transmitted infections may also lead to a subclinical infection in the prostate.

  • Recurrent urinary tract infections: Patients with lower urinary tract infections and reflux into the prostatic ducts may contaminate and infect the prostate. This infection can also be subclinical, depending on each particular patient.

After reviewing the above, the recommendation is to live a healthy life. Enjoy protected sex, and do not neglect your condition if you suddenly have urinary symptoms. Doing that will lower your risk of asymptomatic prostatitis and its consequences.

Symptoms

How do you know that you have asymptomatic inflammatory prostatitis? Actually, you have no way to know. It won’t give you any symptoms at all. You won’t feel any different. However, doctors can diagnose this problem with a few tests. 

Inflammatory signs in laboratory tests

Asymptomatic prostatitis can’t be detected without exams. They include:

  • PSA and PSA density: As noted above, PSA can be significantly increased in asymptomatic prostatitis. However, this is often taken as a sign of prostate cancer or benign prostatic hyperplasia. That’s why PSA density is important to detect cases of prostatitis. PSA density is obtained by measuring the gland volume and adjusting PSA values to them. This allows to standardize PSA and is useful to detect inflammation instead of an enlarged prostate as the cause of PSA increases. However, your doctor may recommend additional tests to rule out prostate cancer. PSA and PSA density provides a first glance but won’t give you a final diagnosis. They are only useful as warning signs (5).

  • Semen analysis: We can run several studies in semen. The prostate fluid makes up an important part of semen volume. As such, it is useful to detect what is happening inside of the prostate. The official threshold of white blood cells in the prostate is 1×106 per milliliter. Patients with more than this number are considered for the diagnosis of asymptomatic inflammatory prostatitis. However, recent studies suggest that we should use a lower threshold (6,7).

  • Prostate biopsy: This is the final test, which bears the most accurate diagnosis of asymptomatic inflammatory prostatitis. Through a prostate biopsy, urologists would assess the presence and degree of inflammation. It will also be useful to rule out another entity such as BPH or cancer. However, a good clinician would not try to detect asymptomatic prostatitis with a biopsy. They will be performed in patients with suspected prostate cancer. Otherwise, we could be causing pain and additional symptoms to a patient who feels nothing and doesn’t have a dangerous disease (7).

Symptoms of prostatitis in BPH

Prostatitis shares similar symptoms to BPH so that it will be a significant confounder in many studies. However, asymptomatic prostatitis may increase the symptoms of BPH and contribute to the progression of the disease. 

If a patient with asymptomatic prostatitis develops BPH, he would likely have more severe symptoms than the rest. Inflammation is one element that contributes to lower urinary tract symptoms (LUTS). Thus, subclinical inflammation could be the reason why men with a smaller prostate have more symptoms than men with a larger volume (2).

Treatment options

The official recommendation is not to treat asymptomatic prostatitis. There is currently no evidence to support any treatment plan for type IV prostatitis.

These patients do not have any symptoms and do not require any treatment at all. Still, many doctors prescribe antibiotics after diagnosing asymptomatic prostatitis. This has become a common practice because it is suspected that long-term inflammation favors prostate cancer.

Additional medications include anti-inflammatories, commonly used to treat subclinical inflammation (8).

  • Antibiotic therapy: According to one clinical trial, antibiotic therapy can be a helpful first step to improve the detection of prostate cancer. Instead of doing unnecessary biopsies, doctors can treat patients with a high PSA with antibiotics. A reduction of PSA levels after therapy would reveal that they had asymptomatic prostatitis. Thus, they may not require to undergo a prostate biopsy (9). Based on these findings, some doctors may prescribe antibiotics. However, others may abstain from antibiotics based on meta-analyses that show the absence of statistically significant difference (10).

  • Anti-inflammatory therapy: Another recommendation would be using anti-inflammatories. They will typically be over-the-counter meds for a limited period. They would reduce the synthesis of certain substances that trigger inflammation in the prostate. The rationale is acceptable, but there are no relevant clinical trials to support it.

Management

If your doctor did not consider treatment appropriate for you, there are still alternative treatments and phytotherapy you can try to relieve prostatic inflammation. This is one way to manage asymptomatic prostatitis at home, and it is very safe.

This is a type of chronic prostatitis. Thus, we can follow the same recommendations as chronic prostatitis and chronic pelvic pain syndrome. Phytotherapy options may include (11):

Quercetin

This flavonoid can be found in many fruits and vegetables. It has potent anti-inflammatory potential. Quercetin works by reducing the expression of inflammatory cytokines. It also has an antioxidant ability and protects the prostate from damage. According to studies, quercetin improves inflammatory markers. It can be used in supplements for a minimum of 4 weeks.

Bee pollen

There are many types of pollen, and their properties depend on the hive and its localization. However, most of them have potent antioxidant capacity and antimicrobial activity. Studies also show anti-inflammatory properties by inhibiting the enzyme COX-2. Most successful studies with bee pollen are very long, up to 12 weeks.

Terpenes

Terpenes are substances with anti-inflammatory properties. They reduce swelling and control inflammation in the urinary tract and the prostate. The effects of a terpene mixture work better for prostatic inflammation than ibuprofen.

Pumpkin seed oil

This type of oil contains unsaturated fats, especially oleic and linoleic fatty acids. It is an exciting candidate for asymptomatic inflammatory prostatitis, especially in nonbacterial prostatitis. It may also slow down prostate growth in patients with BPH.

Keep in mind that it is recommended to discuss these methods with your doctor. Especially if you have significant health problems. But they are all safe to try and sometimes very effective.

You may not feel different, but your prostate may start reversing the inflammatory process. You could even discuss with your doctor the possibility of running a PSA test before and after using natural therapy to assess their effectiveness.

Conclusion

Symptomatic prostatitis includes acute prostatitis and two types of chronic prostatitis. Prostatitis symptoms in these cases are similar to each other and can be mistaken as BPH. However, there is also a type of asymptomatic inflammatory prostatitis. A bacterial infection also triggers it, but we can have a kind of asymptomatic disease without a real prostate infection.

These patients do not feel different than the rest of the population. But if we take a sample of the prostate, it is infected or inflamed. Prostatic secretions may have white blood cells (infection-fighting cells) and bacteria. In most cases, this asymptomatic disease does not require any treatment.

However, recent findings suggest that patients with BPH may experience more severe symptoms if they also have asymptomatic prostatitis. Sustained inflammation may also contribute to cancer growth.

That’s why many doctors prefer to use antimicrobial medications to solve asymptomatic prostatitis. They would run tests right after to make sure that the inflammatory process has improved.

Alternative management for asymptomatic inflammatory prostatitis would be based on natural anti-inflammatories and antimicrobial substances. They are also useful in chronic prostatitis and may improve the inflammatory process.

The current guidelines do not contemplate treatment for asymptomatic inflammatory prostatitis. There is actually no substantial evidence to support this treatment. However, doctors should keep this entity in mind when interpreting high PSA values and treating patients at an increased risk of prostate cancer.

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Sources

  1. Krieger, J. N., Nyberg Jr, L., & Nickel, J. C. (1999). NIH consensus definition and classification of prostatitis. Jama, 282(3), 236-237.
  2. Nickel, J. C., Downey, J., Young, I., & Boag, S. (1999). Asymptomatic inflammation and/or infection in benign prostatic hyperplasia. BJU international, 84(9), 976-981.
  3. Terrone, C., Poggio, M., Bollito, E., Cracco, C. M., & Scarpa, R. M. (2005). Asymptomatic prostatitis: a frequent cause of raising PSA. Recenti progressi in medicina, 96(7-8), 365-369.
  4. Wu, C., Zhang, Z., Lu, Z., Liao, M., Zhang, Y., Xie, Y., … & Mo, Z. (2013). Prevalence of and Risk Factors for Asymptomatic Inflammatory (NIH-IV) Prostatitis in Chinese Men. PLoS One, 8(8), e71298.
  5. Onder, Y., Catagay, G., Tokatli, Z., Orhan, D., Tulunay, O., & Ozden, E. (2002). Increased PSA in subclinical prostatitis: the role of aggressiveness and extension of inflammation. European Urology Supplements, 1(1), 175.
  6. Korrovits, P., Ausmees, K., Mändar, R., & Punab, M. (2008). Prevalence of asymptomatic inflammatory (National Institutes of Health Category IV) prostatitis in young men according to semen analysis. Urology, 71(6), 1010-1015.
  7. Senior, K. (2009). Urine leukocyte threshold for detection of subclinical prostatitis too high. Nature Reviews Urology, 6(9), 462-462.
  8. Khan, F. U., Ihsan, A. U., Khan, H. U., Jana, R., Wazir, J., Khongorzul, P., … & Zhou, X. (2017). Comprehensive overview of prostatitis. Biomedicine & Pharmacotherapy, 94, 1064-1076.
  9. Tang, P., Xie, K. J., Wang, B., Deng, X. R., & Ou, R. B. (2010). Antibacterial therapy improves the effectiveness of prostate cancer detection using prostate-specific antigen in patients with asymptomatic prostatitis. International urology and nephrology, 42(1), 13-18.
  10. Buddingh, K. T., Maatje, M. G., Putter, H., Kropman, R. F., & Pelger, R. C. (2018). Do antibiotics decrease prostate-specific antigen levels and reduce the need for prostate biopsy in type IV prostatitis? A systematic literature review. Canadian Urological Association Journal, 12(1), E25.
  11. Hu, M., Wazir, J., Ullah, R., Wang, W., Cui, X., Tang, M., & Zhou, X. (2019). Phytotherapy and physical therapy in the management of chronic prostatitis–chronic pelvic pain syndrome. International urology and nephrology, 51(7), 1081-1088.

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