"Chronic Prostatitis": part 4
© 1996, Ivo Tarfusser, MD
In my patients, I try to analyze the following three cardinal symptoms indetail:
Duration. Ontset. Intensity. Location (very important to note:assymmetry? - constantly unilateral pain is frequent and usually associated withpathology of the SV of the same side!). Variable or constant? Painfreeintervals?
Recurrent urinary infections with evidence of bacteria?(--> CBP) Irritative symptoms: Frequency? Urgency? (--> bladder neckirritation). Burning sensation at micturition? (--> urethral irritation;inflammatory changes at the level of the veru is often projected to the distalurethra) Obstructive symptoms: Hesitancy? Reduced flow? Dribble? Haematuria(terminal?)
Frequency of ejaculations (often spontaneously reduced dueto discomfort and reduced libido)? Burning discomfort at ejaculation? Spasm-likediscomfort after ejaculation (on which side)? Reduced ejaculatory pressure(spermatic fluid pouring out slowly)? Reduced volume? Appearance (yellowish,brownish-blood stained = haematospermia, clumpsy, watery thin)?
- Exclusion of inguinal hernia and inflammatory changes at the insertion ofthe adductor muscles in the pubic bone.
- Scrotal content: in prostatitis patients often normal palpatoryfindings, except: a) slight swelling of the epididymis in obstruction, b)diffuse or focalized induration of the epididymis as remnant of priorinflammatory involvment, c) sensitivity on palpation of the epididymis
- Digital rectal examination (DRE): The prostate presentsfrequently varying consistency with softer (edematous) areas (often sensitive topressure) and harder nodes (calcified areas, prostatic cancer has to beexcluded). At digital pressure, the maximum pain can often be elicited in themid-line near the basis of the prostate, at the site where the ejaculatory ductspass though the gland and, especially, at their point of entry into the prostate("confluens") and at the veru. Sometimes, the lower part of the SV canbe reached with the finger; normally, they should not be palpable; however, inpatients with "prostatitis", they are sometimes clearly detectable,engorged or indurated, and in some cases hypersensitive.
Not rarely,palpation reveals severe tenderness of the pudendal nerve at the point where itslips under the sacrospinal ligament/muscle through the lesser ischiadic foramenand enters the channel of Alcock. To avoid false positive responses, extremecare (slight touching is sufficient) has to be used. The nature of thispaenomenon, which, for practical purposes, I use to call pudendalsyndrome, remains obscure. It may represent a form of entrapmentneuropathy, similar to e. g. the carpal tunnel syndrome, with the nerve bentand/or compressed under the edge of the ligament in the narrow slot it has topass to reach the lesser pelvis. It remains to be investigated if thiscompression is a consequence of continuous reflectory musle contraction of thepelvic floor (due to irritation in the periphery, like prostatitis) or if it maybe caused by repeated direct mechanical irritation against the bony prominenceof the ischiadic spine (bycicle riding or prolonged sitting in vibratingenvironment, like truck-driving etc). It may also have a connection to thefindings of R. Anderson et al (Stanford) regarding theirpelvic-floor-hypertension-theory. I have thought about, but never been forced tosurgical exploration of the area, since the few patients with severe pain I sofar attributed to this cause, have improved after massage of the sacrospinalligament (firm pressure on the ligament in an attempt to relax and elongate themuscular components). A similar syndrome in the immediate neighborhood, known asthe piriformis syndrome, affecting the ischiadic nerve, is treatedsuccessfully by stretching exersizes on the piriform muscle. In refractorycases, transection of the ligament's attachment to the ischiadic spine would bea conceivable way to release the nerve (should be foregone by neurotransmissionspeed measurement). Another treatment option may be infiltration by cortisone.
The Drach-classification is based on this test. In order to perform itcorrectly, the prostatic exprimate has to be recovered according to theprocedure standardized by Meares and Stameyin 1968: before prostatic massage, 2 urinary samples are taken (from the first10 ml and from the mid-stream urine); after prostatic massage, the experessedprostatic secretion and the first 10 ml urine passed after massage arecollected. These 4 batches are analyzed for the presence of bacteria and whiteblood cells. A finding of bacteria and/or inflammatory cells is consideredspecific for the prostate if the concentration of these components issignificantly higher in the samples taken after prostatic massage then in themidstream urine. Unfortunately, this procedure is complicated andtime-consuming, and therefore, most urologists are reluctant to perform itroutinely. Furthermore, the classification does not change very much in terms oftreatment policy: most urologists will try, further or later, a course ofantibiotics and antiphlogistics, regardless of the entity of "chronicprostatitis", though puritans among us urologists do not recommend such atrial-and-error policy. On the other hand, in lack of better scientificallyaccepted treatment resources, few of us can resist the attempt to try suchtreatment which at least improves the condition in a part of our patients,instead of reiterating the tale of something "to learn to live with".The Meares-Stamey procedure is therefore mostly relegated to clinics who doresearch on prostatitis, whereas most urologists do not perform it routinely. Itis without doubt valuable, because it legitimates a long-term antibiotic therapyin chronic bacterial, and helps to avoid such a potentially risky therapeuticalapproach in the vast majority of patients, those with nonbacterial prostatitisand prostatodynia, but it offers no concrete guide-lines for how to treat theselatter conditions. The author uses a simplified approach, generally startingwith cell-count and culture from urine before and from expressed prostatic secretion (EPS) after massage, only. A negative urinary culture combined withpositive culture from the EPS is sufficient evidence for CBP, negative EPS andnegative culture excludes the diagnosis CBP. If the results are ambiguous, thecomplete standard procedure has to follow.
TRUS has not gained wide-spread use in the assessment of "chronicprostatitis". There have been some isolated reports on sonographic findingsassociated with "CP", but others have discarded the technique as "notrecommended in the routine evaluation of men with prostatitis" (de laRosette & Debruyne: "Nonbacterial Prostatitis: A Comprehensive Review"in Urology International 1991;46). In my experience, TRUS is by far the mostuseful means of investigation in this category of patients. It delivers
1. an image of the prostate and the seminal vesicles
2. allows to identify the point of maximum pain/discomfort by exertingcareful pressure with the probe (in analogy with clinical experiencein other anatomical sites, e g the acute abdomen, I found this test extremelyhelpful and in many cases diagnostic). It is, however, necessary that thepatients are examined during phases with active symptoms, i e the discomfort hasto be present; pressure on an obstructed organ is not necessarily painful if theorgan is relaxed even in presence of emptying impairment; obstruction can alsoappear intermittently (kinking, compression form outside etc); in long-standingobstruction, the patient has adapted to the pressure increase and does notexperience any discomfort. Therefore, this pressure test is not always positiveif the patient comes to the examination in a symptomfree interval.
After examining several hundreds of patients with "prostatitis",using a multifrequency transrectal ultrasound probe, the author has come to thefollowing conclusions regarding the necessary technical equipment:
What can be detected at TRUS?
- the probe has to be slim at the tip, not like several electronictransvaginal transducers on the market with broad detection sectors
- the examination sector should be shiftable in different planes (transversaland longitudinal), and has in any case to have the capability of axialstraightforward projection (in order to allow exact identification of the partof the organ where the pressure is applied in axial direction)
- the best examination frequency is 6-6.5 Mhz, it works better than 7.5 Mhz,but a 7.5 Mhz transducer will be acceptable. 5 Mhz transducers are totallyuseless and will not be able to provide 95% of the information you can get withthe 6 MHZ. I have tested this extensively with my Siemens multifrequencymultiplane probe.
Click to see Examples ofTRUS-findings
- Median prostatic cysts (utricular cysts, Mülleriancysts):
Such cysts can be found in as many as 12.5% of all patients with "chronicprostatitis". A dutch researching urologist, Dr. Pieter Dik of Utrecht,Netherlands, has done a lot of clinical research on young men with "chronicprostatitis", finding cysts in about the same frequency as in the author'sseries. A report has recently been accepted by the journal of Urology and willbe published soon. What is important about detecting these cysts are the resultsof therapy (a simple transurethral procedure can cure the patient; see sectionon therapy).
These findings are much morefrequent in patients with a history of prostatitis then in men who never had anysuch episodes. However, one has to take into consideration that prostatitis canoccur silently, either due to a low degree of inflammatory activity over alonger period of time which does not cause much disturbance, or because of theinflammatory process being located in an area where the density of sensorynervous endings is low and, perhaps, where surrounding high sensitive areas likethe urethra or the intraprostatic seminal tract are not involved. Aftersystematic observation of these lesions (comparing symptomatic and asymptomaticindividuals), I would categorize them grossly as follows:
a) Isolatedgranules distal to the veru in the periphery of the urethra are frequent and notvery specific.
b) Nests of coars or spotty calcifications in either lobeare generally indicative for a focal chronic inflammatory process which may beactive or not(burned-out). The presence of edema (a hypoechoic area surroundingthese granules) is likely to indicate activity, especially in presence ofsymptoms. Strikingly often, such nests are located in the median lobe (centralzone) in close proximity to the bladder neck, proximal urethra and theejaculatory ducts (which maybe an explanation for the combination of irritativebladder symptoms and symptoms/changes referable to the seminal tract. It isnecessary to point out that these findings are only reliable if the patient hasnot yet developed significant benign prostatic hyperplasia (BPH), as in the caseof older patients; the sonographic appearance of BPH is very inhomogeneous anddoes not allow detailed evaluation of minor regions in the inner parts of theprostate.
c) Sometimes, tiny calcified granules are found inside the veru,not rarely combined with dilation of the ejaculatory ducts and/or the seminalvesicles. Such a finding can be diagnostic and almost always related tointermittent obstructive symptoms of the seminal tract and dysuria (burning atmicturition).
- Edema of the verumontanum:
With good sonographic equipment readily recognizable as a much larger thenexpected hypoechoic zone (urologists know from urethroscopy how large anunaffected veru should be). Sometimes, a single or a few tiny calcifications canbe seen inside this area, more often the wall of the veru appears as a dottedhyperechoic line, the pendent to the subepithelial microcalcifications oftenfound at cystoscopy in these patients. Edema of the veru, if present andespecially if combined with typical irritative symptoms relatable to thismeeting spot of urinary and seminal tract (see section on symptoms), is a veryimportant finding. The examinating urologist should try to decide if this is theonly area affected or if there are inflammatory changes in the neighborhood(prostatic lobes) which can be the cause or the consequence of changes in theveru. In either case, an operative procedure (transurethral ablation of the veruand, in cases of foci in the prostatic lobes, ultrasound-guides trasurethralresection of affected areas) can resolve the problem in severe cases, in whompharmacologic therapy trials and prostatic massage has been inefficient.
- Edema of the prostatic lobes (peripheral zone):
Can only be seen if the edema is sectorial as a consequence of obstructionand/or inflammation of one or a few prostatic glands. The image is typical:hypoechoic cone-shaped (on the section appearing as a sector with the basetowards the prostatic capsule and the point towards the veru) areas, with cleandemarcation against the surrounding homogeneous tissue of the peripheral zone.As with other sonographic changes, congruence with specific symptoms (in thiscase perineal pain) and hypersensitivity to pressure (finger, ultrasoundtransducer) will strengthen the diagnosis. These patients will consistently dowell after some sessions with prostatic massage combined with antiinflammatorydrugs, aiming at reducing edema and expressing the retained secretion. Only incases of calcifications located in the outlet portion of this sector, minimaltransurethral resection should be attempted in refractory cases.
- Dilated Ejaculatory Ducts:
Normal ejaculatory ductsare barely visible at ultrasound and merge often totally with surroundingtissue. If they appear as a clearly visible hypoechoic ribbon, they are eitherfilled or their wall or surrounding connective tissue sheeth is edematous(inflamed). Grossly distended ejaculatory ducts indicate always outletobstruction at the level of the veru. Both ducts pass close to each-otherthrough the prostate and are not always discernable. If only one ejaculatoryduct is affected, it can usually be identified, and the distension can befollowed up to the level of the deferent duct above the base of the prostate.Many times, also the seminal vesicle of the same side appears distended, inother cases not (possible cause: post-inflammatory shrinkage of the seminalvesicle). Surgery in such cases can be resolutory.
- Changes of the Seminal Vesicles:
The Seminal Vesicles are more frequently involved in prostatitis thanusually recognized, and pathology in these glands can often persist for longtime after the inflammatory process in the prostate has subsided. Myinvestigations have shown to me, that the Seminal Vesicles are far more oftenthe site of maximum sensitivity when touched with the transducer than theprostate (only the area where the ampullae of the deferent ducts, lying neareach-other, pass beneath the bladder base before entering the prostate, is evenmore often the site of maximum pain). I think that the recognition of this factis of utmost importance: in fact, even if definitive eradication of theinflammatory process, wherever it starts, seems difficult or unpredictable, thesymptoms (=pain) could be treated if therapy is directed towards the SeminalVesicles in those cases. The appearance of the Seminal Vesicles is oftenpathologic:
Anothermost important aspect is laterality: in a large group of patients,symptoms are constantly unilateral (e g pain in either groin or testicle). Inmost of these cases, the Seminal Vesicles show pathological findings (tendernessand/or appearance) on the same side, only. Finally, it is important to note,that patients with prostatodynia with intermittent symptoms should be preferablyinvestigated when the pain is present. The reason for this is that the pain inthose patients often is functional: seminal vesicles in spastic contraction (dueto irritation from some offending mechanism in the neighborhood or, more often,from functional or organic obstruction) are tender when touched, but may becompletely indolent after relaxation. An investigation in an asymptomaticpatient is, however, not useless because the painful reaction of the seminalvesicles is sometimes started by the manipulation during the examination. Inother case it should be repeated when the symptoms are present. The seminalvesicles, being a hollow muscular organ, could be resembled to the bowel: if thebowel is cramping, it is tender and the pain can easily be related to theoffending bowel segment; if it relaxes, it becomes indolent or only slightlytender, rendering the diagnosis much difficult or impossible.
- dilation: general or segmental. Frequent finding: large, dilatedspaces like cysts, generally representing dilated acini.
- shrinkage: small collapsed glands with shortened length, oftenwith thickened wall, more or less painful, no variation in size related tosexual activity/abstinence
- calcifications: appear as: a. calcification of the wall lining;b. calcified detritus; c. stones - especially important to recognize stoneswhich might obstruct the outlet; d. perivesicular calcifications
- Surrounding organs:
In case of diffuse pain notreferable to the organs listed above, I always try to identify the site where Ican generate the maximum pain reaction similar or identical to the pain thepatient seeks me for. If no pain similar to the patient's discomfort can betriggered, a thorough DRE of the area around the lesser ischiadic foramen tocheck for hypersensitivity of the pudendal nerve will often reveal a positivefinding, in my view, of great importance (see DRE). Exploring this area with theprobe is awkward and not sensitive enough. Other sites external to the urinaryor seminal tract causing "prostatitis-like" symptoms seem very rare (eg inflammatory processes in the ischiorectal fossa or in the paravesical space.
In summary, transrectal ultrasonography is, so far, the best investigationat hand to get closer to a diagnosis in "chronic prostatitis". It canprovide guidelines to therapy, especially regarding those cases potentiallysuitable for surgery. It needs, however, significant experience to interpret thedifferent findings and correlate them to the clinical picture and otherexaminations. "Chronic prostatitis" is a very inhomogeneous disorderwith innumerate subentities, difficult to categorize, difficult to investigate.Transrectal ultrasound is not the answer to all questions, far from that, but itdelivers a lot of information if properly performed. On the other hand, there isno better method available, today, to dig into this area with very complicatedmicro-anatomical structure and complex physiological processes, since we havenot yet any method at hand which gives us the opportunity to study similardynamic physical parameters as in the urinary tract.
The findings aboveare originally based on a controlled investigation I conducted several years agoon a group of patients with "chronic prostatitis" comparing them to agroup of symptomfree individuals. The results had been presented at the 11thWorld Congress on Endourology and ESWL (Florence 1993) and at the Xith Congressof the European Association of Urology (Berlin 1994). An abstract has beenpublished on the Journal of Endourology, Vol 7, Suppl 1, Oct 1993, p. 182.
If performed on patients with chronic prostatitis, urethrocystoscopyfrequently reveals a congested, reddened verumontanum (a small protuberance inthe lower part of the prostatic urethra where the ejaculatory ducts enter theurethra). The technique is invasive and often very painful in men with anirritative process in the prostate. It could induce an exacerbation of theinflammatory process. Therefore, in my opinion, it should be reserved to specialcases in whom another pathology cannot be excluded ( e g to exclude bladdertumors in patients with irritative bladder symptoms, haematuria etc). A repeatedcystoscopy is nearly always useless and is generally proposed by the urologistwhen he feels that the patient demands some sort of action. It is my firmimpression that cystoscopy is performed more often than needed, and should beavoided if the diagnosis is obvious, especially in younger men with a typicalhistory and DRE-finding, in whom alternate diagnoses are exceedingly rare.
- Computerized Tomography (CT-scan)
Has not the sameresolution as TRUS and offers, therefore, no advantage over TRUS.
- Nuclear Magnetic Resonance (NMR or MR)
With theendo-coil, a good resolution can be obtained and morphological changes,detectable by TRUS, will also show up on MR (cysts, dilation, etc). However,experience is scarce, yet, and it's value compared to TRUS is yet to be shown.A clinical correlation, like the palpation test, is not possible with MR.Carrying in mind it's costs, it will hardly ever enter into the routinediagnostic arsenal for the assessment of prostatitis