Prostatitis is inflammation of the prostate gland that can affect PSA and cause symptoms such as urinary frequency and urgency, fever, and pelvic pain. Prostatitis can be difficult to identify and hard to treat. This episode discusses diagnosing prostatitis, treating prostatitis, and how it can affect prostate cancer treatment decisions.
Dr. Scholz: [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz.
Liz: [00:09] And I’m your cohost, Liz Graves.
Dr. Scholz: [00:13] Welcome to the PROSTATE PROS podcast.
Liz: [00:16] Prostatitis is inflammation of the prostate, which can have a huge negative impact on quality of life. This episode, we’re going to talk about diagnosing prostatitis, treating prostatitis, and how it can affect prostate cancer treatment decisions.
Dr. Scholz: [00:31] The real reason this topic comes up is because PSA goes up in men that have inflammation in their prostate, which is what we’re calling prostatitis. There are many causes, we’re going to go into that, but the confusing factor is that we’re using PSA to diagnose prostate cancer, to monitor prostate cancer for treatment effect, and for relapse. If inflammation in the prostate intervenes and causes the PSA to go up, everyone gets frightened about the possibility of prostate cancer being out of control. So this podcast will cover trying to make a distinction between a high PSA from prostatitis and a high PSA from prostate cancer.
Liz: [01:17] So prostatitis is inflammation of the prostate, and there can actually be no known cause of this, or it can be due to bacterial infection and it can also manifest in many different ways.
Dr. Scholz: [01:31] There’s so much confusion about what really is prostatitis. It may be sort of an autoimmune phenomenon, the way people get asthma or eczema on their skin, some sort of over activity of the immune system, but it’s quite common and it’s often asymptomatic. So that means that the PSA goes up, but men may not be feeling any urinary irritation. At the other end of the spectrum, of course you have the people that have real discomfort and pain with urination and are getting up at night a lot. When men have these symptoms, it doesn’t necessarily mean that it is prostatitis, it could be a large prostate, it could be an irritable bladder, it could be a urinary tract infection, but prostatitis certainly is on the list of possibilities.
Liz: [02:19] So you mentioned asymptomatic prostatitis, which still has an effect on PSA. Can you distinguish a rise in PSA from prostatitis from a rise from prostate cancer?
Dr. Scholz: [02:32] Actually, PSA is very nonspecific. So when we see a PSA rise, we have to start doing all kinds of tests. The most popular one in the community of course, is to do a prostate biopsy. Our policy has been to do MRI testing, and there are certain blood tests and urine tests like OPKO 4K and SelectMDx that can help sniff out whether prostate cancer is really the problem. But many times, we are left with an ambiguous situation; an elevated PSA without a clear cause. And that’s when people start calling it prostatitis.
Liz: [03:12] For people who do have symptoms, there are two or three different types. There’s acute bacterial, chronic bacterial, and chronic prostatitis.
Dr. Scholz: [03:23] Years past when this problem was encountered, the reflex reaction was just to give some antibiotics. If the PSA would drop after a couple of weeks of antibiotics, then it must be prostatitis. The problem with that is that the antibiotics have potential bad effects. Secondly, they’re not always effective because the many types of prostatitis are not bacterial. Thirdly, the problem with prostatitis is it usually isn’t permanently cured with antibiotics, you get a temporary remission, but then you’re back to having to do antibiotics again and again. Now, these days we don’t usually jump on people with antibiotics, but some doctors still like to use this approach.
Liz: [04:10] This seems like a difficult condition to manage. What other medicines, other than antibiotics do you use?
Dr. Scholz: [04:18] So sometimes we just wait and keep checking the PSA and the inflammation will tend to die down on its own. There are things that are popular over the counter products like Saw Palmetto, anti-inflammatories that you can pick up at the pharmacy like Aleve or Advil. Sometimes a course of anti-inflammatories will cause a PSA decline and encourage us that the underlying problem is related to prostatitis as cancer won’t respond to an anti-inflammatory.
Liz: [04:52] So if someone goes on anti-inflammatories and their PSA declines, and they just have prostatitis and no prostate cancer, should their PSA be zero?
Dr. Scholz: [05:03] So men have to always calculate the normal PSA by looking at the size of the prostate. This is usually determined with an MRI or an ultrasound. The ten-to-one ratio is that if the prostate’s 40 CCS in size, a normal PSA will be around four. So PSAs will typically run in the one to eight range, but there’s so much variability in prostate size. A normal PSA can vary from individual to individual.
Liz: [05:33] PSA is one way to possibly diagnose prostatitis. What other ways do you figure out that this is the problem?
Dr. Scholz: [05:42] Well you mentioned before that there’s certain men that get bacterial infections and they’re uncomfortable: they have soreness in their pelvis, they have pain with urination. If it gets out of hand, it can even cause a fever. So diagnosing prostatitis when there are symptoms like that is really easy. The problem is that 90% of the time, perhaps the prostatitis is asymptomatic and we’re dealing with PSA’s running high over periods of time. This becomes super relevant in men that are on active surveillance because we check PSA frequently in these people and creates real concern that if the PSA is running high, that maybe we’re missing some cancer somewhere.
Liz: [06:22] So there are a lot of symptoms with prostatitis, but these symptoms can also just occur in regular, healthy, aging men. Is telling the difference between those two different people difficult?
Dr. Scholz: [06:36] What you’re referring to is the fact that our aging bladder gets more irritable and you can get up at night more frequently, also prostate glands get bigger and create blockage and all kinds of inconveniences related to the urinary tract. That is a real diagnostic dilemma. There are all kinds of tests to try and sort out which of these issues are going on like imaging tests and urinary flow tests. People should usually get a urinary culture and make sure there’s no infection. So these methodologies are all used to try and sort out what is really going on. After it’s all said and done, if we don’t have a clear answer, usually the term prostatitis is applied to the situation.
Liz: [07:20] Another thing that I’ve read about is tracking your PSA, and if your PSA is fluctuating pretty frequently, that might be a sign of prostatitis.
Dr. Scholz: [07:31] Exactly. Inflammation comes and goes. It’s not a steady, smooth, growth, the way something such as cancer might occur. So the ups and downs when you have men with PSAs that are running high, that suddenly dropped, we know that PSA levels don’t drop in people with cancer. So that’s another strong indication that prostatitis may be the cause of the PSA elevation.
Liz: [07:58] Okay, Dr. Scholz, let’s say you have someone who is suffering with symptoms and you’ve tried antibiotics, you’ve tried anti-inflammatories, and none of it really seems to be providing relief. What do you do next?
Dr. Scholz: [08:12] It’s a tough, tough situation. Consulting an expert is the next step. Sometimes mild doses of Proscar or Avodart to try and shrink the prostate will have some benefit, but there is no satisfying one treatment for prostatitis. Some men have to suffer chronically with only partially resolved symptoms. It’s a very controversial area in terms of what proper treatment is because no one treatment is all that satisfying.
Liz: [08:46] Some men who are newly diagnosed with prostate cancer also have prostatitis. What kind of treatment options can these men look at that don’t inflame the prostate?
Dr. Scholz: [08:57] You can go forward with just about any of the common treatments. This is one potential argument for surgery, because if the inflamed prostate is a big problem, removing it surgically should improve symptoms. Sadly, that’s not universally the case. Sometimes the discomfort that people are having turned out in retrospect to not be from the prostate and men have operations and still have urinary difficulties and issues. There’ve been some that have said that radiation shouldn’t be done because radiation causes a transient increase in inflammation. When the prostate gland is radiated, getting people through that tough period three to six to eight weeks after the radiation can be challenging sometimes, but after the radiation starts to grab hold, the prostatitis symptoms oftentimes will become less and less over time. Hormone therapy will typically improve urinary symptoms in some men and others, for reasons we don’t know, it seems to make the problem worse. When I’m talking about the problem, I’m talking about people waking up at night or having to urinate frequently. When I first started giving hormone therapy to men with prostate cancer, my hope was that since we’re shrinking the prostate that urinary symptoms would universally improve, but that’s not always the case. Why that is, is not clearly understood. There’s a lot going on in the prostate with all these symptoms that we’d still don’t completely understand.
Liz: [10:26] One interesting thing about radiation is that a couple months after the radiation or even up to a few years, you can have a delayed PSA bounce that isn’t cancerous, but it’s due to inflammation of the prostate.
Dr. Scholz: [10:42] It is frequent and this is more frequent in people that have seed implant radiation, so-called brachytherapy. You’re absolutely correct, people can have a normal PSA after radiation and everything’s looking fine with a PSA less than one. Then, all of a sudden, the PSA is rising up to two, three, or four. The suspicion, of course, is that the cancer is coming back. In the old days, which really means just last year, we had to just sit this out and hope that it would go away and watch the PSA go up and reassure people that this type of thing can happen and maybe it isn’t cancer. With these new PSMA PET scans, which are very accurate, we can have people get scanned when their PSA goes above one to detect if there is any cancer causing a problem and make that distinction between delayed PSA inflammation from radiation induced prostatitis, the so-called PSA bump, versus the cancer having a recurrence.
Liz: [11:45] You mentioned this is a really frequent occurrence. When PSAs go up, patients really tend to panic. How do you talk about this with them?
Dr. Scholz: [11:55] Well, it is a common enough thing that there’s plenty of research out there showing that oftentimes a PSA would go right back down after a few months, two to six months, and remain low for the rest of their lives. Unfortunately, I’ve seen patients treated perhaps by doctors that don’t see as much prostate cancer where they assume that it’s a relapse and put them on hormone therapy. Hormone therapy will always cause the PSA to go down. This validates the idea that there was a cancer that now is under treatment. This is a really tragic thing because hormone therapy has a lot of side effects and it certainly shouldn’t be used to treat a PSA bump.
Liz: [12:39] After radiation, the policy is to get PSA tested every three months for two years, then every six months for three years, and annually after that. If the PSA rises over 0.5, you should get the new PSMA PET scan.
Dr. Scholz: [12:58] That’s right, Liz, this technology to finally be able to sort out whether it’s a PSA bump or a cancer recurrence is incredibly valuable.
Liz: [13:08] Prostatitis is a really ambiguous situation and a lot of men have symptoms. Googling symptoms can lead to men believing they’re from prostate cancer. However, localized prostate cancer never has symptoms, so it’s clear these symptoms are from some other condition.
Dr. Scholz: [13:28] Exactly right. So often we were unable to use the word never in the world of treating humans. You know, we said, well, there’s one of this and one of that, but it really is almost universally true that early stage prostate cancer is free of symptoms. People that have an ache here or a pain there and they’re newly diagnosed with a PSA in the 10 to 20 range, they’re wondering if their cancer has spread, should be greatly reassured that it’s almost impossible for prostate cancer to cause any symptoms at these early stages. However, prostatitis and other issues are very common. They certainly do cause symptoms. Thankfully prostatitis doesn’t turn into cancer. They are separate problems and one causes symptoms and the other doesn’t.
Liz: [14:19] This is a great reminder to take things slow when you get back a high PSA. In a future episode, we’re going to talk about men who haven’t been diagnosed with prostate cancer, but who have high PSAs and what the next steps are they should take. Thank you for listening, email questions or topics to podcast@prostateoncology.com. Remember to help us out by rating, reviewing and subscribing on Apple Podcasts.