Prostatitis or Enlarged Prostate? How to Tell

A weak stream, going more often, getting up at night, a feeling of not being finished. Two completely different conditions produce that same list, and the treatments for them have almost nothing in common.

This site has covered at length why symptoms cannot distinguish benign enlargement from prostate cancer. There is a second confusion, less discussed and much more common in practice, and it catches younger men in particular: a man of 44 who assumes his prostate has started to enlarge, when what he has is inflammation.

This page is about telling those two apart. It is part of our complete guide to an enlarged prostate after 40.

What is the actual difference?

One is a size problem. The other is an inflammation problem.

In benign prostatic hyperplasia the gland grows, and because it wraps around the urethra that growth narrows the passage. Nothing is inflamed, nothing is infected, and there is usually nothing to feel except the consequences downstream.

In prostatitis the gland is inflamed. Sometimes bacteria are responsible and sometimes no organism is ever found. Inflamed tissue swells, and swollen tissue in a fixed space presses on the same urethra — which is why the urinary symptoms look so similar. But inflamed tissue also hurts, and that is the difference you can actually notice.

Pain is the dividing line

If you take one thing from this page, take this: benign enlargement is not usually painful. It is obstructive, inconvenient, sleep-destroying and demoralising, and it does not typically hurt.

Prostatitis hurts, and it hurts in places men do not immediately associate with the prostate:

• The perineum — between the scrotum and the anus. Often described as sitting on a golf ball.
• The testicles or the tip of the penis, which is referred pain rather than a problem in either place.
• The lower back or lower abdomen.
• On ejaculation, or in the hour afterwards. This is a strong pointer and men rarely volunteer it.
• Burning when passing urine, which suggests inflammation or infection rather than obstruction.

A man with a weak stream and no pain anywhere is describing something that fits enlargement. The same weak stream with an ache in the perineum and discomfort after sex is describing something else, and it will not respond to the same treatment.

Age changes the odds before anyone examines you

Benign enlargement is strongly age-related. It is uncommon before 40, present in a substantial minority of men in their fifties, and in the majority by the seventies. That gradient is one of the most reliable things about it.

Prostatitis has no such pattern. It is one of the commonest reasons a man under 50 sees a doctor about his prostate at all, and it is the diagnosis that a middle-aged man with new urinary symptoms is statistically more likely to have than enlargement.

A man of 62 with a stream that has weakened over three years is describing a different problem from a man of 41 whose symptoms arrived over a fortnight, even though they use the same words.

This matters because of what men do with the assumption. The 41-year-old who decides his prostate is enlarging goes and buys the supplements this site has written about, and treats an inflammatory condition with capsules aimed at a mechanical one.

The four types, and why the labels matter

Prostatitis is not one condition. It is a category containing four, and they are as different from each other as any of them is from enlargement.

1. Acute bacterial prostatitis. Sudden, severe, with fever and often difficulty passing urine. Uncommon, unmistakable, and urgent.
2. Chronic bacterial prostatitis. A persistent or recurring bacterial infection, often showing up as repeated urinary infections with the same organism. Treatable, but courses of antibiotics are long.
3. Chronic prostatitis and chronic pelvic pain syndrome. By far the most common form. Pelvic pain lasting months, with urinary symptoms, and typically no infection found despite looking. This is the one most men labelled with prostatitis actually have.
4. Asymptomatic inflammatory prostatitis. Inflammation found incidentally, usually when investigating something else. No symptoms and generally no treatment.

The distinction between the third category and the others is the reason so many men have a frustrating experience. Repeated antibiotic courses for a condition in which no bacteria are present is a common story, and it is a mismatch between the treatment and the type rather than a sign that nothing works.

When it is an emergency

Being completely unable to pass urine is an emergency whatever the underlying cause, and that applies equally to a man whose prostate has enlarged. The other warning signs that override any waiting plan are set out in what actually happens at a prostate exam.

What each does to a PSA reading

Both raise it, and the difference in degree is clinically important.

Benign enlargement raises PSA modestly and predictably — more tissue makes more of the protein. Prostatitis can raise it sharply, sometimes to levels that would be alarming if nobody knew there was inflammation present.

The practical consequence is a rule worth remembering: do not have a PSA test during a urinary infection or a flare of prostatitis. Wait until it has settled, then test. A result taken during inflammation can trigger a chain of investigation aimed at the wrong thing, and several weeks of avoidable worry. What the figure means in normal circumstances is covered in PSA levels by age.

How a clinician tells them apart

Largely by asking, which is worth knowing because it means the useful information is already in your possession.

1. Your age and how fast it started. Gradual over years points one way; days or weeks points the other.
2. Whether anything hurts, and where. This is the question most likely to change the answer, and the one men most often leave out.
3. A urine test. Looking for infection, which if present settles a great deal at once.
4. Examination. An inflamed prostate is characteristically tender to touch; an enlarged one is typically smooth, firm and not painful.
5. A blood test, in context. Interpreted knowing whether inflammation is present.

Notice that four of those five are conversation. The single most useful thing you can do before the appointment is decide, honestly, whether anything hurts and where — because it is embarrassing to volunteer and it is the fact that most changes the diagnosis.

Why the treatments are not interchangeable

This is where the distinction stops being academic.

Benign enlargement is treated by relaxing the muscle around the outlet or shrinking the gland, using the two drug classes set out in prostate medications explained. Neither does anything about inflammation.

Bacterial prostatitis is treated with antibiotics, and the courses are longer than for an ordinary urinary infection because the prostate is difficult for drugs to penetrate. Antibiotics do nothing whatsoever for an enlarged prostate.

Chronic pelvic pain syndrome — the common form — is managed rather than cured, and pelvic floor physiotherapy, pain management and sometimes an alpha blocker all feature. It is the form where expectations need to be realistic and where a single prescription is unlikely to be the whole answer.

Why prostate supplements fit this badly

Almost every prostate supplement on the market is sold against benign enlargement. The ingredients, the marketing and the few trials that exist are all aimed at a gland that has grown, in a man over fifty.

A man of 43 with pelvic pain and a weak stream is not that man. He has been sorted into the wrong category by an advertisement, and he buys a product that was never intended for his condition and has never been tested against it.

Even taken on its own terms the evidence is poor: the main ingredient in the category performed no better than placebo in the largest independent trials, which is set out in what the Cochrane review found. Buying it for a condition it was not aimed at compounds a weak bet with a wrong one.

The cost is rarely the money. It is the months spent on a capsule while an inflammatory condition goes unassessed, and while pelvic floor work that might actually have helped never gets started.

What helps that is not a prescription

For chronic pelvic pain syndrome in particular, some of the most useful measures are not drugs at all. None of these is a cure and none replaces assessment, but they cost nothing and they are frequently the part nobody mentions.

• Pelvic floor physiotherapy. The single most underused option. Chronically tense pelvic floor muscles are a recognised contributor, and a physiotherapist trained in this can address something a tablet cannot.
• Warmth. A warm bath is a genuinely effective short-term measure for perineal pain, and it is the oldest advice in this field for a reason.
• Breaking up long periods of sitting. Sustained pressure on the perineum aggravates symptoms. So does a long cycle ride, which is also worth avoiding before a PSA test.
• Reducing what irritates the bladder. Caffeine and alcohol worsen urinary symptoms whichever condition is causing them, and cutting back is a fair test you can run in a fortnight.
• Managing stress deliberately. This one gets dismissed as a euphemism for imagining it. It is not: stress measurably worsens pelvic pain in this syndrome, which is a statement about muscle and nerves rather than about character.

When no infection is found

A large proportion of men who arrive with prostatitis symptoms are told, after testing, that nothing has grown. That news lands badly, and it is usually delivered too quickly to be understood properly.

It does not mean the pain is imagined. It means the label is chronic pelvic pain syndrome rather than an infection, that the mechanism involves muscle, nerves and inflammation rather than bacteria, and that antibiotics are unlikely to be the answer however many courses are tried.

It also means a different set of things are worth trying — pelvic floor work in particular, which is often the most effective and least prescribed. A man who spends two years cycling through antibiotics for a condition without bacteria has lost the time, not because nothing works, but because the treatment never matched the type.

Which brings this back to the theme of everything else on this site. The symptom is the starting point, not the answer. Two conditions with one symptom list need something other than the symptom list to tell them apart, and that something is an assessment rather than a guess — or a supplement bought on the strength of the guess.