By Stephanie Prendergast, MPT and Urology Expert Joshua Gonzalez, MD
Most men who develop the symptoms of Chronic Pelvic Pain Syndrome (CPPS) are given unnecessary courses of antibiotics, at least once. How do we know they were unnecessary? Most of our patients have never been properly tested for a prostate infection. Men with CPPS account for up to 97% of visits to urology offices and these men do NOT have infections, they have pelvic floor dysfunction. This has been published over and over, yet here in 2021 a disappointingly low number of general urologists and primary care physicians understand what CPPS actually is. It is therefore not unexpected that they do not know how to perform a very brief digital pelvic floor exam to identify painful muscles. This blog may surprise people, most people do not realize how cumbersome it is to accurately test for prostate infections. Many men reading this likely thought they were tested and they were not. Antibiotic use and overuse comes with consequences, including gut dysbiosis, muscle tearing and sometimes irreversible peripheral neuropathies. We see this daily and it needs to stop.
I sat down with our trusted urology colleague, Dr. Joshua Gonzalez, to help set the record straight. Here are my questions and his answers.
Q: PSA: what it means and does not mean, what does it tell us?
A: PSA stands for prostate specific antigen. It is a protein produced by the prostate gland. It is a test commonly used for the screening of prostate cancer. It is typically combined with a digital rectal examination of the prostate to assess someone’s risk of prostate cancer. An abnormally high PSA can indicate underlying prostate cancer and other non-cancerous conditions such as benign prostatic hyperplasia (BPH, or enlarged prostate) or prostatitis.
Can a high PSA signify a prostate infection? What is considered normal range?
Yes, elevated PSA can signify a prostate infection. Generally, PSA < 4 is considered normal. But what qualifies as a normal PSA depends on the person’s age and history. PSA trends are more helpful than looking at one specific value.
Take Home Message: A PSA test alone should NOT be used to diagnose a prostate infection. It may have useful information for a doctor when combined with other tests, patient history and age, and clinical examination.
Q: What can a urine sample tell us?
A: A urine sample can be analyzed for bacteria, yeast, red and white blood cells, and additional markers to determine whether an infection may be present.
Can a urine sample tell us if there is a bladder infection and/or prostate infection?
Urine samples can be helpful in determining whether an infection is present. Many clinicians often assume infection simply by checking an in-office urinalysis. These are not always accurate, so typically we recommend checking a formal urine culture, which will indicate if bacteria or yeast are present (along with quantity and antibiotic susceptibility).
Take Home Message: A urine test alone is not a reliable way to identify a true prostate infection. We are heading towards the correct way to figure out if this is a problem.
Q: What can a blood test tell us?
A: Blood may be collected if an acute or serious infection is suspected. Generally, an elevated white blood cell count may indicate infection. Blood can also be cultured if the infection is thought to have spread there.
Take Home Message: A blood test cannot determine if a prostate infection is present.
Q: What is the difference between a prostate infection and a UTI and a bladder infection?
A: I explain a prostate infection as a more serious UTI. Prostate infections are caused by the same bacteria that cause most urinary tract infections (including bladder infections). The bacteria typically ascend via the ejaculatory ducts into the prostate where they can replicate and cause a more serious infection. Prostate infections often require a longer course of antibiotics than traditional UTI.
Take Home Message: UTIs and prostate infections are not the same and they need to be treated differently.
Q: Finally, we need to talk about the 4-glass test. Most urologists empirically treat young men with CPPS symptoms with antibiotics without doing this test because basically, it’s a pain in the ass. Please explain what it is and how it is done.
A: The 4-glass test involves collection and analysis of fluid obtained pre- and post- prostate massage. The first sample is the initial 10ml of urine voided. The second sample is a midstream urine collection. After the second sample is collected a vigorous massage of the prostate is performed. The third sample is a collection of expressed prostatic excretions. The fourth sample is the first 10ml of urine voided after prostatic massage. All 4 collections are then cultured and help distinguish between acute and chronic bacterial prostatitis. If all cultures are negative, the diagnosis is more consistent with either inflammatory or non-inflammatory chronic pelvic pain syndrome (CPPS). Most urologists treat men with CPPS symptoms with antibiotics empirically because performing this test can be time-consuming and uncomfortable for the patient.
Take Home Message: Most men have definitely NOT been through this test and it is truly the only accurate way to see if there is a true prostate infection.
In Conclusion…
The majority of men with CPPS symptoms do NOT have a prostate infection, but they do have pelvic floor floor dysfunction with or without prostate inflammation. Men can develop prostate infections and we need to accurately test people to know what the proper course of treatment is. Men presenting with the signs and symptoms of CPPS should see a pelvic floor physical therapist. If the doctor is unwilling to do a 4-glass test to help you figure out if there is an infection or not we likely know a doctor who will. Say No to Cipro and avoid the consequences of unneeded antibiotics.
Dr. Gonzalez can be found here on his website and on TikTok!
For more information check out our YouTube Channel Resources:
Inguinal Hernias and Male Pelvic Pain
Male Pelvic Pain – What is it? Why Do Men Get it? And What Can They Do About it?
Penile Pain – Why it Happens and How to Fix it
Erectile Dysfunction and Your Pelvic Floor
An Explanation of Hard Flaccid
What to Expect at a Pelvic Floor Physical Therapy Appointment
An Introduction to Your Pelvic Floor
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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