Prostatitis

As mentioned previously, the prostate is a gland at the base of the bladder.  Since urine passes through the prostate, it is susceptible to infection and inflammation.  This inflammation, whether from an infection or not, is called prostatitis.  Inflammation can lead to edema (fluid collecting much like you would see in a sprained ankle) or it can inhibit the prostate from secreting prostatic fluid appropriately during emission.  Since the prostate also contains a lot of muscle tissue that assists with ejaculation, its contractions can cause significant pain and discomfort when prostatitis is present.

Prostatitis is perhaps one of the most common ailments to affect men.  It is thought that nearly half of men will experience prostatitis at some point in their lives.  In fact, prostatitis affects over 8-13.8% of men at any given time, including young men in their teens.[i] [ii]  It is a little more common as men age.  Acute episodes are most common in men ages 30-50 while chronic forms of prostatitis are more common in men over 50.  However, teenagers can also get prostatitis and can have chronic symptoms throughout the rest of their life. 

Chronic (long-term) prostatitis often occurs for multiple reasons.  In bacterial prostatitis, it is difficult to eradicate bacteria from the prostate.  First, the prostate does not have a lot of blood flow and the blood flow it does have is protected by a barrier called the prostate-blood barrier.  This barrier allows for certain nutrients to enter the prostate, but many molecules, including many antibiotics have difficulty passing into the prostate tissue.  Secondly, the prostate has many pockets or folds where fluid is produced and stored.  These pockets can be breeding grounds for bacteria.  Since every pocket doesn’t completely empty during ejaculation, some pockets of infection can remain locked thus allowing the infection to spread and cause repeated infections or “flares”.  Finally, in both bacterial and non-bacterial prostatitis, thicker prostate fluid caused by infections and/or inflammation can sometimes make emptying a pocket more difficult (think of a stuffy nose when the mucous is too thick to get out).  Since the pores and ducts that drain the prostate are very small, some prostatic fluid may not be released during ejaculation causing repeated swelling and inflammation.  Image below copyrighted by DNA Illustrations and used by permission.

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SYMPTOMS

Symptoms that often accompany prostatitis include pain, urinary complaints, sexual issues, and in some cases fever and chills.

Pain

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Pain can range from a sharp pain to a dull throbbing ache.  Most pain is a form of referred pain.  Referred pain is when the brain interprets the pain as coming from an area that shares a nerve supply with another area (similar to when people who are having a heart attack feel pain in the left shoulder or arm).  Since the prostate is located next to and connects to the pelvic plexus of nerves, the brain may interpret signals coming from the pelvic plexus as originating from other areas of the body that also connect to the pelvic plexus.  Basically, it can be hard for the brain to determine exactly where the pain is coming from as the signals all “come together” in this same plexus.  So prostatitis may have pain that feels like it’s coming from one or more of the following regions of the body:

  • Lower back – the pain from the prostate can be “felt” as lower back pain in the small of the back or upper sacrum (buttocks).  Pain can also be felt on the belt line around the waist – this type of pain is called flank pain. 

  • Suprapubic pain – this pain is most often felt in the lower abdominals and into the area where pubic hair grows.  This is often felt as a dull ache or discomfort.

  • Scrotal and testicular pain – a dull ache may be felt in the scrotum.  Slight pain (not injury type pain but a persistent dull pain) is often felt in one or both testicles, the left testicle being the most common.  It isn’t uncommon for this pain to appear after ejaculation.  However, severe or sudden testicular pain may indicate another issue with the testicles.

 

  • Perineal pain – this pain is felt in the area directly behind the scrotum – where you would sit on a bike.  In fact, sitting on hard chairs, riding a bike, or placing any pressure in this area can be uncomfortable if not painful for someone with prostatitis.  This is the area of the outer body closest to the prostate itself.  Some men describe feeling like they have a golf ball stuck or shoved in this area that may sometimes feel like it’s “buzzing”.

  • Penis pain – erections may become painful, especially after ejaculation.  This may be another type of referred pain, where the pain from the post-ejaculation contractions of the prostate may be referred to the shaft of the penis during an erection.  Pain can also be felt in the penis when it is not erect.  Some men complain of a painful or tender glans (tip) or a shaft that feels sore or achy.

  • Ejaculation pain – ejaculation may actually be a painful event rather than a purely pleasurable event due to the tender prostate being squeezed by the muscles that cause its contractions.  This pain can radiate outwards to the entire pelvis and genital region during ejaculation and cause some muscles in the pelvis to lock down.

  • Bowel movement pain – sometimes it actually hurts for men to have a bowel movement, especially if the stools (feces) are hard.  This is because the lowest part of the bowel (which the stool must pass through before exiting the anus) sits right next to the prostate.  A hard stool can press against the prostate through the lining of the bowel and cause pain.  In addition, a hard stool may press so hard against the prostate that it may squeeze some of the prostate’s fluid into and out of the urethra.  Orgasm or ejaculation usually doesn’t occur, but a man may recognize something that may look like semen or as thick non-white fluid in the toilet bowl after a bowel movement.

  • All of these pain syndromes together can cause a conscious or subconscious tensing of pelvic muscles as a protective response.  The tension in these pelvic muscles due to this type of pain can cause another disorder called pelvic tension disorder.

Urinary symptoms

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  • Obstructive type symptoms – inflammation and swelling of the prostate can block the flow of urine.   This can be very similar to the symptoms that men with BPH have.  A man may feel that the bladder isn’t empty even though he just went to the bathroom, so he may need to urinate more frequently.  Getting the flow of urine started can also be difficult, and after he’s done urinating he may have issues with dribbling – even a minute or so after he’s finished and walked away from the bathroom.  

  • Uncomfortable urination – some men report that urine feels “hot” or “stings”.  This can be due to infection and inflammation components passing through the urethra as he urinates.

  • Urine color and appearance – with infections, urine can often be cloudy or even have an orange to red color.  This cloudiness can be caused by the bacteria and white blood cells that are fighting the bacteria being present in the urine.  The orange to red color can come from small bleeding that could be occurring in the prostate or bladder due to the infection.  Because there are other components (bacteria, white blood cells) the urine may have a strong smell.

 

Sexual symptoms

  • Semen discoloration – semen can also be a color other than white when prostatitis is present.  Just like nasal mucous can turn yellow to green in color when there is an infection, so can semen.  Men may notice this most often when cleaning up after ejaculating. This is especially true in men who have wet dreams as the semen may be a dark yellow or even green tinged stain in their underwear.  Click HERE to learn more about discolored semen.

  • Semen volumes – when the prostate is inflamed or infected, it may produce more fluid.  This can result in large volumes of semen being ejaculated (greater than 5ml or 1 teaspoon).  Men who are sexually active may feel like they ejaculate for a longer period of time or notice more fluid on ejaculation.  Men who have wet dreams may have an extremely heavy wet dream that soaks through underwear and even onto bedding.  Or these men may have multiple wet dreams during a short period of time (sometimes even multiple times a night or multiple nights per week).  On the flip side, men may notice decreased semen volume if the prostate fluid becomes so thick that it doesn’t release from the prostate sufficiently during ejaculation.   Sometimes when this occurs men may notice that their semen is thicker.

  • Excessive sexual sensitivity – some men with prostatitis may feel like they are on the verge of ejaculating or that they need to ejaculate when they aren’t sexually aroused.  Even slight sexual stimulation such as simply having a spontaneous or nocturnal erection can be felt as highly stimulating rather than mildly stimulating.  In men who are sexually active this can lead to ejaculation that occurs extremely rapidly (within seconds rather than minutes).  In fact, 77% of men[iii] with prostatitis experience premature ejaculation.  In men who experience ejaculation only through wet dreams, it may either lead to more frequent wet dreams or it can cause wet dreams to become interrupted as the excessive stimulation causes the man to wake up during nocturnal erections before ejaculation can occur. 

 

Fever and Chills

 

In acute prostatitis, the infection may spread to the bloodstream causing a fever, body chills, and other flu-like symptoms.


TYPES OF PROSTATITIS

Given that there are so many differing symptoms to prostatitis, it isn’t surprising that there are actually different types of prostatitis – each with similarities and yet distinct differences.  Prostatitis can be caused by bacteria (bacterial prostatitis) or not (abacterial prostatitis).  It can also be short-term (acute) or long-term (chronic).  Bacterial prostatitis is often caused by bacteria that is “seeded” or comes from the urine as it passes through the prostate.  Non-bacterial causes of prostatitis can be caused by irritation from urine that backs up into the prostatic ducts causing inflammation.  The types of prostatitis include:

  • Class I – Acute bacterial prostatitis.  This is a short-term infection of the prostate that has a rapid onset and spreads to the bloodstream.  This is usually accompanied by flu-like symptoms like body aches, chills, and a fever.  Classic symptoms of pain and urinary problems are often present.

  • Class II – Chronic bacterial prostatitis.  This is a long term (months of symptoms) recurrent infection that causes pain and obstruction type symptoms.  Other symptoms may also be present, but a fever is usually absent.  This can be quite common in men that have had an acute infection in the past since it is difficult for antibiotics and even the human immune system to kill all the bacteria in the prostate due to the protective blood-prostate barrier.  This type of prostatitis can recur throughout a man’s life.

  • Class III – Chronic non-bacterial or chronic pelvic pain.  This accounts for over 90% of prostatitis cases.[iv]  There is no evidence of bacteria being present but the men have chronic symptoms that ebb and flow.  Antibiotics are often not helpful in this type of prostatitis.  In many cases, these men’s symptoms are secondary to tension in the pelvic floor muscles.  In some cases, symptoms may be more congestive and this is treated more like prostatic congestion.

  • Class IV – Asymptomatic inflammatory prostatitis.  In this type of prostatitis there is inflammation, but the man doesn’t have symptoms.  This is usually discovered when a man is having medical tests performed for another reason and the inflammation is discovered.

RISK FACTORS FOR PROSTATITIS

Men at the highest risk for getting prostatitis include the following:

  • Men who have had had catheters or scopes in their urethra which allows bacteria to gain access to the prostate.

  • Men who have had a urinary tract (bladder or urine) infection.

  • Men who have multiple sexual partners and are at high risk of sexually transmitted infections as well as men who engage in anal sex.

  • Trauma to the pelvic area.  Injuries to the perineal area either from a biking accident or horseback riding can cause trauma that can lead to inflammation of the prostate. 

  • Men who are dehydrated.  Men who don’t drink plenty of fluids can hold urine in the bladder for long periods of time concentrating the urine so that it may cause more irritation as it passes the prostate.  Dehydration can also lead to constipation.  The passing of hard stool against the prostate is in some ways a form of “trauma” and can cause inflammation.

  • Urethral strictures.  These men have a urethra that can be narrow and prone to spasms.  This allows urine to back up into the prostatic ducts.

  • Sexual abstinence.  Men who have prostates that become overly engorged with prostatic fluid can get prostatitis-like symptoms.  This does not mean that men should engage in sexual activity or masturbate to prevent prostatitis.   For sexually inactive men who don’t masturbate for religious or personal reasons – wet dreams provide the avenue for these men to eliminate excess prostatic fluid. This is often seen in men who masturbate or are sexually active and revert to sexual abstinence.  Since sexual activity (and masturbation) can retrain the male body to not have wet dreams, these symptoms can arise when men are “quitting”.  This is especially true in men overcoming masturbation addiction.  However, men who are sexually inactive and don’t masturbate can fail to have wet dreams as well, and may be at risk of experiencing prostatitis due to prostatic congestion.  In no way should men engage in sexual activity or masturbate simply to prevent prostatitis - as this may cause different problems in men prone to prostatitis.  If in doubt, speaking to a healthcare provider and religious counselor is advised.  In some cases, doctors may encourage ejaculation for certain types of congestive prostatitis.

  • Sexual denial.  Men who prolong sexual activity without ejaculation can cause an accumulation of prostatic fluid.  Since nearly two-thirds of prostatic fluid is produced during stimulation, failure to ejaculate or delaying ejaculation during prolonged stimulation can cause swelling of the prostate gland and subsequent inflammation.  To a lesser level, men who have been aroused (but not necessarily sexually stimulated) may have a small buildup of sexual fluids that cause tenderness in the testicles – often termed “blue balls”.  This is a very short term inflammation of the reproductive tract due to congestion.  It has been established as well that men who engage in coitus interruptus (interrupted intercourse) are at higher risk for prostatitis.[v]

DIAGNOSIS OF PROSTATITIS

The type of prostatitis can be diagnosed by a competent health care provider.  They may ask questions to determine your most common symptoms.  An example of a prostatitis questionnaire a healthcare provider may use is shown below:

 

In the past two weeks which of the following have you had:

  • 0= Never, 1 = only once, 2 = a few times, 3 = most of the time

    • Body aches, chills, or fever

    • Pain or burning when you urinate

    • Smelly or cloudy urine

    • Frequent urges to go to the bathroom or waking up at night to go to bathroom

    • Feels like your bladder isn’t quite empty

    • Dribbling after going to the bathroom

    • Orange/red color urine

    • Painful or tender bowel movements

    • Discharge something that looks like semen into the toilet during bowel movements

    • Discomfort or pain in the lower back

    • Discomfort above pubic bone (lower abs down to pubic hair region)

    • Sore/tender perennial area (between the scrotum and butt – where you sit on a bike)

    • “Throbbing” genitals (testicles, scrotum, penis)

    • Painful or aching testicles or scrotum

    • Pain at the tip of penis

    • Painful or uncomfortable erections

    • Pain when ejaculating or the day following ejaculation

    • Yellowish/light green or pinkish colored semen 

    • Unexplained discharge of fluid during sleep or while awake

    • Frequent erections especially when you don’t want them

    • Waking up in the middle of the wet dream process, but not ejaculating on your own

 

Answering with a “2” (a few times) on a few of these questions or a “3” (most of the time) on one of these items may indicate that something is going on with the prostate and can help your provider pinpoint what may be going on.

 

Some providers may also ask how often you ejaculate.  If not, it may be a good piece of information to share with your provider.  A recent study[va] in 685 men that I performed with a colleague looked at symptom scores based on ejaculation frequency and found that men who ejaculate more than once a week oftentimes may actually mask an underlying prostatitis as the frequent ejaculation reduces some of their symptoms.  On average, men who ejaculate more than once weekly had symptom scores that were 37-57% lower than men who ejaculated once week or less.  See table below:

                                                                                   Prostatitis

Frequency of Ejaculation      Severity Score

<1/month to 1/month                21.21

2-3/month to weekly                 19.40

2-3/week to 4-6/week               12.15

Daily to multiple/day                 14.16

 

 

 

This can oftentimes results in sexually inactive men having more symptomatic prostatitis, especially those who rely on wet dreams for personal or religious reasons and have wet dreams less often than weekly.  This data does not suggest that these men should increase ejaculation frequency (although in some cases this may be prescribed in certain, specific cases which is covered later in the chapter).  Rather, this simply outlines that men who ejaculate frequently may often have prostatitis that goes unnoticed or undertreated due to regular ejaculation frequency. 

Providers may also do an exam and run tests.  One such exam is the digital rectal exam.  This is performed when they insert a lubricated, gloved finger into the anus to feel for the prostate through the lining of the bowel.  An inflamed prostate may feel enlarged or boggy.  They may also be feeling to see if the prostate feels warm, irregular in shape, softer consistency, or swollen.  If the prostate is particularly sensitive, this may be uncomfortable and slightly painful.  However, it is usually a quick process that only takes a few seconds.  A provider may often notice on examination that the prostate feels a little boggy or soft and that it is tender to the touch.

If the health care provider wants to culture the prostate fluid, they will often press on the prostate to force some of the prostate fluid into the urethra.  This almost never causes ejaculation.  Rather, a drop or two prostatic fluid is pressed into the urethra and out of the penis where the fluid can then be checked for bacteria.  Oftentimes, the fluid can come back negative, even though the individual’s symptoms may indicate an infection – so not every provider will do a prostate fluid culture.  Negative results may occur when the infection is concentrated in the anterior (front) part of the prostate or deep inside the prostate which isn’t “pressed” during a prostate massage.  Some providers may simply check the consistency of the prostate rather than doing a prostate massage since pressing the prostate at its rear may press infection into other areas of the prostate that may not be yet infected. 

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If the provider determines you have bacterial prostatitis (especially acute bacterial prostatitis), they may prescribe an antibiotic.  As we stated before, the blood supply to the prostate isn’t all that great, so oftentimes men will have to take the antibiotic for weeks at a time.  It is important for men to make sure they finish all of the antibiotic refills.  If they develop side effects or problems, they should talk to their prescriber before stopping the antibiotic as this may lead to a rebound in “resistant” bacteria that may not respond as well the next time they need to be treated for a prostate infection.

In some cases, a medical professional may need to do further studies of the prostate to see what may be going on.  Tests such as an ultrasound of the prostate done by a small wand inserted into the rectum, or a scope to the prostate through the urethra may be performed both shown below.

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Once the prostate has been infected, it’s very likely that bacteria can survive even

despite antibiotic therapy and it isn’t unusual for men to have “flares” or worsening of chronic prostatitis symptoms throughout their life.  Being aware of your body and how you’re feeling may help you identify when a flare is starting to occur and when to seek treatment.

TREATMENTS

Both medication and non-drug therapy can be used to treat prostatitis. 

Non-drug therapy is often used by men with chronic forms of prostatitis.  Although helpful in some cases, a healthcare provider should be seen if symptoms are accompanied by fever, chills, pain, or if symptoms persist for more than 2 weeks.

  • Avoiding certain foods that can aggravate inflammation in the prostate may help some men.  These include avoiding caffeine, alcohol, and spicy foods. 

  • Walking or jogging can help “massage” the prostate.  Since the prostate includes muscle tissue, it makes sense that massaging can help reduce tension and pain.  Although the leg muscles don’t sweep the prostate directly during walking or jogging, the pelvic muscles become engaged and can massage the gland.  In addition, movement of the lower body can increase blood flow to the prostate to aid in healing.

  • Avoid sitting on hard chairs or sitting in a straddling position which can put pressure on the perineum.  In fact, riding bicycles can cause extreme pain in men with prostatitis as can horseback riding.  Avoiding these straddled sitting positions on hard surfaces can prevent worsening symptoms.  Selecting a soft chair or sitting on a donut pillow can also be helpful for men who suffer from prostatitis.

  • Warm or hot soaking baths can help alleviate pain in the pelvic area.  Since the prostate has muscle tissue it makes sense that warmth can help loosen the muscles and reduce pain.  Electric heating pads are discouraged as the sensitive scrotal skin can be burned or the testicles can get too hot, so a long, warm soaking bath that submerges the entire pelvic area is often preferred.  Many men who take soaking baths report reduced pain and discomfort.  The warmth can also help loosen prostatic fluid so it can be eliminated more effectively during ejaculation.  In men who are not sexually active and ejaculate only through wet dreams, warm baths may improve wet dream functions.

  • In men who are sexually active, regular ejaculation (every 2-3 days) may be recommended to eliminate infected prostatic fluid.  However, frequent ejaculation (more than once a day) may not be helpful and may cause more pain due to over-contraction and over-working of the muscles within the prostate.  Since ejaculation can both assist and worsen symptoms, a man often has to determine what frequency works given certain symptoms.  Regular ejaculation may be more appropriate if the man also suffers from prostatic congestion.  However, in men who are not sexually active and do not masturbate for religious or personal beliefs, this self-therapy is often only used as last line therapy after other therapies (drug and non-drug) fail to alleviate symptoms.  

  • In men who are sexually inactive, masturbation may be prescribed.  As discussed previously, men who ejaculate less frequently (once a week or less) have higher prostatitis symptom scores than men who ejaculate more than once per week (with men who ejaculated 2-3 times a week as having the least prostatitis symptoms).[va]  One study[vi] looked at whether regular ejaculation had any impact on the symptoms of non-bacterial prostatitis in single men who did not masturbate for religious/personal reasons.  These men had all failed to respond to at least a one month trial of antibiotics and anti-inflammatory agents and only ejaculated through wet dreams.  These men were encouraged to masturbate at least twice weekly over the course of six months.  Before beginning prescribed masturbation, men were given a symptom questionnaire resulting in a symptom score.  Prostate fluid was also collected to look for cells (leukocytes) that indicated inflammation in the prostate.  No additional medication treatment was given during the study to see how ejaculation alone would change their disease. ​

    • At the end of the six month period:

      • Two-thirds had followed through with the prescribed masturbation frequency of two to three times per week. 

      • One-fourth had masturbated less frequently (once per week or less)

      • One-tenth had not masturbated and continued to rely on wet dreams for ejaculation

    • Results on how masturbation affected prostatitis are as follows:

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  • Limitations of prescribed masturbation in this study

    • It involved a fairly small number of participants (28 single men overall), so results may vary.

    • These men only previously ejaculated only through wet dreams.  Although we can assume that regular ejaculation of 2-3 times per week can help sexually active men, this trial does not prove that.

    • Including the use of an anti-inflammatory in addition to prescribed masturbation was not reviewed so adding an anti-inflammatory to regular ejaculation may decrease symptoms further.

    • The mental stresses or spiritual concerns on these men were not assessed throughout the study.  For this reason, men who abstain from masturbation for religious reasons should be encouraged to speak with a religious leader in conjunction with a health care provider to find a physically, mentally, and spiritually healthy pathway forward.  Prescribed masturbation is often reserved only for men who fail all other medication and non-drug therapies for prostatitis.

Medications may also be selected by a provider depending on the symptoms and the type of prostatitis.

  • Antibitoics are often only used for bacterial forms of prostatitis.   In acute prostatitis, antibiotics may be used for only 14 days; however, in chronic prostatitis, treatment with an antibiotic can last up to 12 weeks in order to get antibiotics past the prostate blood barrier.

  • Anti-Inflammatories/Pain Relievers are often used since prostatitis is an inflammation of the prostate, anti-inflammatory medications like ibuprofen or naproxen can be used to decrease inflammation and pain.  These can also be effective in preventing erection and prostate pain after ejaculation.  These medications should not be taken daily for more than 2 weeks without checking with a healthcare professional.

  • Alpha blockers (alfuzosin, doxazosin, silodocin, and tamsulosin) are prescription medications that relax the urethra and smooth muscles in the prostate.  These can be prescribed in men that have severe urinary symptoms or spasms in the prostate or urethra.

  • 5-alpha reductase inhibitors (finasteride or dutasteride) are sometimes used on chronic, congestive types of prostatitis.  

  • Zinc supplementation can be an effective treatment for prostatitis.  In fact, the prostate secretes an antibacterial substance called Prostate Antibacterial Factor that is composed of zinc.  Men with established chronic prostatitis have significantly lower levels of zinc in their prostatitic fluid compared to healthy men, even though blood levels of zinc may be normal.  Low levels of zinc correlate with reduced levels of prostate antibacterial factor thus increase the risk for bacterial infections and growth in the prostate.  Supplementation with zinc (typically 25mg per day) can increase prostatic zinc levels and thus increase the production of men’s own defense system against bacterial infections.[vii]

 

 

OTHER ISSUES RESULTING FROM PROSTATITIS

Men may develop secondary pelvic disorders as a consequence of prostatitis.  Although these disorders aren’t widely recognized as separate disorders in many medical references, many men with prostatitis often exhibit the symptoms of these disorders in varying degrees.  The first disorder is often called Pelvic Tension Disorder and the other is called Prostatic Congestion .  A revolving door of worsening inflammation, pain, and congestion can be seen in men who have symptoms of all three disorders.  This often requires balancing the treatment between all three of these disorders – prostatitis, pelvic tension, and prostatic congestion.  

[i] W Sawatan, et.al. Age Related Male Problem: Acute and Chronic Bacterial Prostatitis, Internal Journal of Medicine and Pharmaceutical Sciences, 4(2), Apr 2014,

[ii] Bartoletti R, et. al.; Prevalence, Incidence Estimation, Risk Factors an Characterization of Chronic Prostatitis/Pelvic Pain Syndrome in Urological Hospital Outpatients in Italy: Results of a Multicenter Case-Control Observational Study,  Journal of Urology (2007) 178(6): 2411-2415.

[iii] Hackett, et. al. International Society for Sexual Medicine’s Guildelines for the diagnosis and treatment of premature ejaculation.  J Sex Med 2010; 7:2947-2969.

[iv] W Sawatan, et.al. Age Related Male Problem: Acute and Chronic Bacterial Prostatitis, Internal Journal of Medicine and Pharmaceutical Sciences, 4(2), Apr 2014,

[v] Bartoletti R, et. al.; Prevalence, Incidence Estimation, Risk Factors an Characterization of Chronic Prostatitis/Pelvic Pain Syndrome in Urological Hospital Outpatients in Italy: Results of a Multicenter Case-Control Observational Study,  Journal of Urology (2007) 178(6): 2411-2415.

[va]  Jeffers TJ, Hutchings RD, Prevalence of Chronic Prostatitis and the Impact of Ejaculation Frequency on Prostatitis Symptoms, Doctoral Project, University of Arizona School of Pharmacy, 2020.

[vi] Yavaşcaoğlu I, et. al.; Role of ejaculation in the treatment of chronic non-bacterial prostatitis, International Journal of Urology (1999) 6, 130-134.

[vii] W Sawatan, et.al. Age Related Male Problem: Acute and Chronic Bacterial Prostatitis, Internal Journal of Medicine and Pharmaceutical Sciences, 4(2), Apr 2014,

Images on this page from top to bottom include:

  1. copyrighted by DNA Illustrations and used by permission.

  2. Staras/Shutterstock.com

  3. La Gorda/Shutterstock.com

  4. Rumruay/Shutterstock.com

  5. Rumruay/Shutterstock.com (modified)

  6. Sezer33/Shutterstock.com

  7. Original table