Weak erections + testicular pain

  Thanks in advance for your advice.  I am 26 years old, and
  I've been experiencing two separate problems that
  may be related.
  The first problem is:  For the past four years I've been
  experiencing testicular pain.  At first, it only happened when
  I would wear tight pants, like jeans.  Over the course of the
  day, my testicles would get very sore and swollen.  Eventually,
  it got to the point where it happened all the time, and it was
  so bad that I would be in sheer agony anytime I had to sit down
  for extended periods of time, like on long car rides or airline
  flights.  I went to see my regular doctor who said it sounded
  like a prostate infection.  He massaged my prostate and gave me
  an antibiotics prescription.  The prostate massage cleared up
  the problem almost instantaneously.  However, a month or two
  later, the problem came back.  My doctor gave me the same
  treatment again, and it went away.  A few months later, it came
  back again (though not nearly as badly as before),
  and this time my doctor referred me to a urologist.
  The urologist examined my prostate and said it was normal.  He
  said he thought I might have experienced some trauma to my testicles
  (at that time I was doing a lot of long-distance running, so
  that seemed like a possible explanation).  He suggested I switch from
  boxer shorts to briefs and wait and see if it clears up.  
  Wearing briefs helped somewhat, but not completely.  Around a
  year later, I went to another urologist who said my prostate
  felt normal and that some people just have sore testicles.  One
  other thing about this problem is that it is affected by how
  I masturbate.  I used to try to hold back from ejaculating
  during masturbation to prolong the act, but that seems to increase
  my testicular pain.  If I try to masturbate so that I ejaculate
  as quickly as I can,
  that can sometimes reduce the pain in my testicles.  Either way,
  it never completely goes away.
  Here's my other problem:  For the past few years I've been
  having weaker erections than I used to.  I can get an erection
  by masturbating, but it subsides within a few seconds if I stop
  stimulating myself.  And it is not a full erection.  My penis
  rises to about straight out (instead of pointing upward).  It
  doesn't seem like it gets fully engorged like it used to.
  Another thing I've noticed is that I almost never wake up in
  the morning with an erection anymore, and the few times that I do it
  is also weak.
  In addition, I've also noticed that my urine stream is weaker
  than it used to be.
  I know this was a long message.  Thanks for reading it, and I
  am really grateful for any thoughts you may have.
---------------------------------------------------------------
Dear Bill,
Men with prostatitis syndromes are frequent patients in the urologic office.  Initially, they should be screened with urine analysis, urine culture, urine cytology, and uroflowmetry.  If no bacterial pathogen is found then a special urine analysis with three samples should be performed.   There are several types of prostatitis, infectious prostatitis, either acute or chronic, nonbacterial prostatitis or a third category known as prostadynia. The three part urine sample with prostate massage would put you into a category of which type of prostatitis you have.  I will briefly discuss each type below.
Acute bacterial prostatitis  accounts for less than 5% of cases.  Symptoms would include fever ,chills, malaise, and myalgia.  Local symptoms are frequency, urgency, low back pain and outlet obstruction(difficulty urinating).  Digital rectal exam is exquisitely tender.  The most common pathogens are E. coli, Klebsiella, Proteus mirabilis, Enterobacter, and Staphylococcus aureus.
Chronic Bacterial prostatitis is defined by recurrent Urinary tract infection and persistence of pathogenic bacteria in prostatic fluid.  Primary complaints consist of genitourinary pain(61%),dysuria or painful urination(16%), clear urethral discharge(12%), recurrent UTI(9%), and sexual dysfunction(1%).  Physical exam is usually normal, however the three part urine analysis shows a high number of white cells on one of the three samples(>10 WBC/high power field in the expressed prostatic secretions)  The most common organism found is E.coli in 80% of cases.  Chronic bacterial prostatitis is simply a bacterial infection that recurs. Treatment with Bactrim or one of the Fluoroquinolones for 4-6 weeks is successful 30-50% of the time.
Nonbacterial prostatitis is an inflammatory condition of unknown etiology.  The symptoms are similar to those with chronic prostatitis and this group of patients outnumber all other patients with prostatitis.  Again the physical exam is unremarkable however on the three part urine test there is not only high numbers of white blood cells, but all lipid laden macrophages.  These are cells not characteristically seen in the prostate secretions filled with fat.  There may be a chemical irritation as a basis of this disease.
A trial of antibiotics should be tried but conservative measures such as over the counter anti-inflammatory agents(Motrin, Advil, Aleve), hot sitz bathes and support should be offered.
Prostadynia is a term used to define patients with prostatitis type pain without specific findings related to the prostate.  Typically these patients are younger and have variable urinary complaints.  There is no etiology of this disease established and therefore a generalized work-up should be done.  Again conservative measures should be performed in addition to some limited dietary restriction of caffeine, alcohol, and spicy foods.  Other talked about treatments include Zinc  and saw palmetto however neither of these therapies have been proven.
As you can see the prostate infection can go on for a long time.  At different times, the urinary problem may subside with antibiotics however it will often return.  My recommendations are, follow with a urologist and make sure you get a full coarse of therapy.  If you specifically read the paragraph under recurrent prostatitis, you will note erectile dysfunction (weak erections) can occur.  You mentioned that if you hold back on your climax this causes you more pain.  I would suggest that you give your system a rest for 48 hours and then resume without holding back.  It is possible with recurrent prostatitis to continually infect your urine, epididymus and testicles.  I also believe that wearing briefs can help stabilize the testicles and reduce your discomfort.
This information is provided for general medical educational purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.  More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword: Prostatitis