Chronic Prostatitis
Clinic: Approach to Diagnosis and Treatment
Initial Appointment
Patients should arrive with a fairly full bladder and be off of all antibiotics
for at least 2 weeks (preferably 4 weeks) in order for the cultures to be accurate.
If you are unable or unwilling to stop taking antibiotics, an appointment can
still be made, but cultures will not be done. After registering and filling
out a brief questionnaire, patients are asked to urinate into a machine to measure
urine flow (Uroflow) and have an ultrasound of their bladder to assess adequate
bladder emptying. A full history and physical exam is then performed along with review of any past medical records. Cultures are obtained
from urine and from prostatic fluid expressed during a rectal exam. The fluid
is also examined microscopically for the presence of white cells.
The cultures may take 5-7 days to be reported, particularly if they are
sterile or contain low counts of fastidious organisms. Based on these results
and any symptomatic improvement from the intial prostatic massage, any further
necessary investigations (transrectal ultrasound, cystoscopy, urodynamics) are
arranged and a treatment plan formulated in consultation with the patient. It
is very difficult to predict duration of treatment ahead of time, which may
vary from a couple of weeks to several months. For out
of town patients the first two appointments should be separated by at least
3 days so we can discuss the culture results. It is important to understand
the limitations we face with out of town patients; we can make recommendations
to follow back home, but cannot treat patients over time in a long distance
fashion.
Approach to Prostatitis
Conceptually, there are 3 aspects of all forms of inflammatory
prostatic disorders:
1. Prostatic Injury: The injury to the prostate is
usually from infection but could possibly be
traumatic (vigorous mountain biking), mechanical (obstruction of
ejaculatory ducts) or chemical (reflux of urine into prostatic
ducts). The injury itself does not produce symptoms
2. Injury Response - Inflammation: In response to the
injury and release of chemical messengers (chemokines and
cytokines), an inflammatory infiltrate may develop. It's purpose
is to remove the source of injury (eg bacteria) and assist in the
healing process. This inflammatory response can produce pain and
swelling. Because of the variable and interconnected innervation
of the area, the pain may be felt in the area of the prostate
(perineum), penis, lower back or scrotum. Prostatic calcifications
can be a sign of repeated bouts of injury and repair, but may also result in inflammation themselves.
3. Injury Response - Neuromuscular: In response to the injury, inflammation
and pain, there can be a constellation of voiding symptoms and pain related
to the pelvic muscles, nerves and bladder neck. These may include reduced
stream, double voiding, frequency, nocturia, and urgency. Pelvic muscle spasm
in response to infection or inflammation can propagate all the symptoms (pain,
voiding, sexual). In complex cases, urodynamics may help in sorting out the
source of the voiding symptoms.
Our approach is to determine the relative contribution of each of
these factors and tailor the therapy accordingly. For instance, if
there is ongoing injury from bacterial infection, the injury response
is completely appropriate and necessary. Treatment would then be
focused on eradicating the infection. If there is no infection but
evidence of inflammation, then the inflammation itself is the target
of therapy. If there is no infection or inflammation, then the
abnormal pelvic neuromuscular action is the focus.
Therapies
Based on the classification of the prostatic disorder using the above scheme,
some or all of the following treatment options are available. A study examining
the short and long term results of patients treated at our clinic is
here.
Supportive Measures:
- All chronic prostatitis patients may derive some benefit from general supportive
measures such as hot (sitz) baths, avoiding food triggers (caffeine, spicy
foods, alcohol) and using a cushion for prolonged sitting. If these don't
help the symptoms however, then they need not be continued.
Antibiotics:
- Antibiotics alone, especially if chosen on the basis
of cultures of prostatic fluid and degree of prostatic penetration can be
effective, although protracted courses are often required. Up to 60% of men
with a first occurrence of chronic prostatitis will respond completely to
antibiotics alone. Since most of our patients have typically failed multiple
previous courses of antibiotics, we seldom use them as the only therapy. We
do test for yeast/fungi in our cultures and treat with antifungal medications
if the cultures are positive. We have not found anti-fungal therapy to be
helpful if these cultures are negative. Most men with chronic prostatitis
will have positive cultures for low counts of typical skin bacteria. It is
not clear whether treatment of these bacteria will improve symptoms. If treatment
eliminates the bacteria but symptoms are not improved, prolonged courses of
antibiotics are not helpful and may be harmful.
Antibiotics plus Prostatic Massage
(Drainage):
- There has been interest in combining antibiotics
with prostatic massage. Massage may help by 1) disrupting bacterial biofilms;
2) unclogging pockets within the prostate that have been blocked with inflammatory
debris; 3) activating trigger points in the pelvic muscles or 4) placebo effect.
We have found that this
therapy can sterilize bacteria in close to 100% of true chronic bacterial prostatitis patients who may have failed
previous courses of antibiotics, although symptomatic improvement is seen
in about 2/3 of these patients and a long term durable improvement seen in
fewer than 1/3. This therapy is NOT the panacea for all prostatitis patients, but
for select patients we may recommend this therapy, based upon the assessment
and results from the first visit. If applied to all patients with chronic pelvic pain,
fewer than 15% derive benefit and some patients worsen, either due to repeated
prostatic trauma or to side effects of prolonged unnecessary antibiotic use. We do not offer this therapy based only on patient preference, if we do not believe that it is indicated for the specific clinical situation.
Bioflavonoids:
- We have been using the bioflavonoid
preparation Prosta-Q
in men with nonbacterial prostatitis/chronic pelvic pain syndrome as a new form of
anti-inflammatory treatment.We find that this natural supplement
is helpful in men without active infection in the prostate but
persistent pelvic pain and inflammation. An FAQ
page describes how I use it in my
practice. A new bioflavonoid preparation Q-Urol is a timed release
quercetin formula that also contains bee pollen, which has shown beneficial effects in European studies
Alpha Blockers:
- Use of alpha blocking agents can improve the urinary
stream and often reduce the other voiding symptoms in patients with chronic
prostatitis. Emerging evidence suggests they can help with pain symptoms as
well. We usually start with tamsulosin (Flomax) or alfusozin (Uroxatral).
Neuromuscular Therapy:
- If infection and inflammation have been ruled out,
symptoms may be caused by a primary neuromuscular problem such as pelvic muscle
spasm. Therapies include physiotherapy, biofeedback, acupuncture, muscle relaxants,
and anti-spasmodics. Referral to a pain specialist may be necessary.
Interstitial Cystitis
Therapies:
- The symptoms of interstitial cystitis and chronic
prostatitis can significantly overlap. While the ideal method for definitive
diagnosis is controversial, cystosopy under general anesthesia with stretching
of the bladder can show evidence of this disorder. In our experience, men
with interstitial cystitis typically have more urinary pain and frequency
than those with prostatitis. Therapies we have used with success in men with
interstitial cystitis include Cysta-Q,
Atarax, Elavil, Lyrica and Neurontin. In extreme cases, an implantable bladder
pacemaker (Interstim) can be used.
Transurethral Resection (TUR):
Transurethral resection of the
prostate is rarely indicated in chronic prostatitis and can make
the patient worse if done in the face of ongoing infection and
inflammation. Resection of prostatic calcifications, especially
those along the "surgical capsule" of the prostate is risky and
seldom effective. There are however unusual specific circumstances
where TUR may play a role.
1) In the patient with recurrent
bacterial prostatitis and concurrent significant benign
enlargement of the prostate (BPH). Recurrent infections may be due
to incomplete emptying of the bladder due to BPH. If medical
therapy of the BPH is not effective, then TUR of the prostate
after ensuring that ALL INFECTION IS CLEARED is a reasonable
approach.
2) Central prostatic stones associated
with recurrent infection or obstruction of the ejaculatory ducts
that drain the seminal vesicles. In contrast to the peripheral
speckled calcifications seen most often in patients with chronic
prostatitis, some patients will have larger stones that are nearer
to the urethra and may cause blockage, which is seen by
transrectal ultrasound. A very limited TUR of the prostate and/or
ejaculatory ducts can clear these stones, removing the source of
infection or obstruction.
3) Ejaculatory duct obstruction.
Occasionally transrectal ultrasound will demonstrate obstruction
of the seminal vesicles, either by scar tissue, prostatic cysts or
stones. An incision of the duct or cyst can provide relief in
these rare cases.
Medical Treatment of Prostate Stones
The role of prostatic stones in producing the symptoms of prostatitis is controversial, especially since many older men without symptoms are found to have these stones. Nevertheless, younger men with extensive prostatic calcification are often improved when these stones are eliminated. We have a limited but very positive experience treating these men with combination therapy against nanobacteria, a type of stone forming bacteria impossible to detect using typical culture techniques.Therapy consists of a daily antibiotic (tetracycline), an oral supplement and an EDTA rectal suppository and typically lasts 3 months.
Further
Reading
For further reading, click the picture below to search
Amazon.com
Here are some specific titles that you can click on to buy from
Amazon.com:
Just Released May 2008! A book devoted to all aspects of Chronic Prostatitis edited by me with contributions by leading clinicians, researchers and scientists from around the world. Topics covered include: Evaluating Prostatitis, Acute Prostatitis, Chronic Bacterial Prostatitis, Quality of Life and Economic Impact, Sexual Function and Infertility in Prostatitis, Interstitial Cystitis in Men as well as chapters that focus on individual therapies including antibiotics, alpha blockers, phytotherapy, pelvic physical therapy, pain management and more.
"Chronic Prostatitis/Chronic Pelvic Pain Syndrome" by Daniel A Shoskes Click
Here for Info
Other books of interest:
"The Prostatitis Manual" by Curtis Nickel (2002). A
reference on current thinking and research on chronic prostatitis. Click
here for info
"Overcoming Impotence: A Leading Urologist Tells You Everything You Need to Know" by J Stephen Jones Click
Here for Info
"Complete Prostate Book: What Every Man Needs to Know" by J Stephen Jones
Click
Here for Info
"A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes," by David Wise Click
Here for Info