"Chronic Prostatitis": part 4

Diagnostic Approach

© 1996, Ivo Tarfusser, MD

HISTORY

In my patients, I try to analyze the following three cardinal symptoms in detail:

  1. PAIN/DISCOMFORT
    Duration. Ontset. Intensity. Location (very important to note: assymmetry? - constantly unilateral pain is frequent and usually associated with pathology of the SV of the same side!). Variable or constant? Painfree intervals?
  2. MICTURITION
    Recurrent urinary infections with evidence of bacteria? (--> CBP) Irritative symptoms: Frequency? Urgency? (--> bladder neck irritation). Burning sensation at micturition? (--> urethral irritation; inflammatory changes at the level of the veru is often projected to the distal urethra) Obstructive symptoms: Hesitancy? Reduced flow? Dribble? Haematuria (terminal?)
  3. EJACULATION
    Frequency of ejaculations (often spontaneously reduced due to discomfort and reduced libido)? Burning discomfort at ejaculation? Spasm-like discomfort after ejaculation (on which side)? Reduced ejaculatory pressure (spermatic fluid pouring out slowly)? Reduced volume? Appearance (yellowish, brownish-blood stained = haematospermia, clumpsy, watery thin)?

PHYSICAL EXAMINATION

  1. Exclusion of inguinal hernia and inflammatory changes at the insertion of the adductor muscles in the pubic bone.
  2. Scrotal content: in prostatitis patients often normal palpatory findings, except: a) slight swelling of the epididymis in obstruction, b) diffuse or focalized induration of the epididymis as remnant of prior inflammatory involvment, c) sensitivity on palpation of the epididymis
  3. Digital rectal examination (DRE): The prostate presents frequently varying consistency with softer (edematous) areas (often sensitive to pressure) and harder nodes (calcified areas, prostatic cancer has to be excluded). At digital pressure, the maximum pain can often be elicited in the mid-line near the basis of the prostate, at the site where the ejaculatory ducts pass 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 can be reached with the finger; normally, they should not be palpable; however, in patients 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 it slips under the sacrospinal ligament/muscle through the lesser ischiadic foramen and enters the channel of Alcock. To avoid false positive responses, extreme care (slight touching is sufficient) has to be used. The nature of this paenomenon, which, for practical purposes, I use to call pudendal syndrome, remains obscure. It may represent a form of entrapment neuropathy, similar to e. g. the carpal tunnel syndrome, with the nerve bent and/or compressed under the edge of the ligament in the narrow slot it has to pass to reach the lesser pelvis. It remains to be investigated if this compression is a consequence of continuous reflectory musle contraction of the pelvic floor (due to irritation in the periphery, like prostatitis) or if it may be caused by repeated direct mechanical irritation against the bony prominence of the ischiadic spine (bycicle riding or prolonged sitting in vibrating environment, like truck-driving etc). It may also have a connection to the findings of R. Anderson et al (Stanford) regarding their pelvic-floor-hypertension-theory. I have thought about, but never been forced to surgical exploration of the area, since the few patients with severe pain I so far attributed to this cause, have improved after massage of the sacrospinal ligament (firm pressure on the ligament in an attempt to relax and elongate the muscular components). A similar syndrome in the immediate neighborhood, known as the piriformis syndrome, affecting the ischiadic nerve, is treated successfully by stretching exersizes on the piriform muscle. In refractory cases, transection of the ligament's attachment to the ischiadic spine would be a conceivable way to release the nerve (should be foregone by neurotransmission speed measurement). Another treatment option may be infiltration by cortisone.

MEARES-STAMEY PROCEDURE

The Drach-classification is based on this test. In order to perform it correctly, the prostatic exprimate has to be recovered according to the procedure standardized by Meares and StameyMeares-Stamey procedure in 1968: before prostatic massage, 2 urinary samples are taken (from the first 10 ml and from the mid-stream urine); after prostatic massage, the experessed prostatic secretion and the first 10 ml urine passed after massage are collected. These 4 batches are analyzed for the presence of bacteria and white blood cells. A finding of bacteria and/or inflammatory cells is considered specific for the prostate if the concentration of these components is significantly higher in the samples taken after prostatic massage then in the midstream urine. Unfortunately, this procedure is complicated and time-consuming, and therefore, most urologists are reluctant to perform it routinely. Furthermore, the classification does not change very much in terms of treatment policy: most urologists will try, further or later, a course of antibiotics and antiphlogistics, regardless of the entity of "chronic prostatitis", though puritans among us urologists do not recommend such a trial-and-error policy. On the other hand, in lack of better scientifically accepted treatment resources, few of us can resist the attempt to try such treatment 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 do research on prostatitis, whereas most urologists do not perform it routinely. It is without doubt valuable, because it legitimates a long-term antibiotic therapy in chronic bacterial, and helps to avoid such a potentially risky therapeutical approach in the vast majority of patients, those with nonbacterial prostatitis and prostatodynia, but it offers no concrete guide-lines for how to treat these latter conditions. The author uses a simplified approach, generally starting with cell-count and culture from urine before and from expressed prostatic secretion (EPS) after massage, only. A negative urinary culture combined with positive culture from the EPS is sufficient evidence for CBP, negative EPS and negative culture excludes the diagnosis CBP. If the results are ambiguous, the complete standard procedure has to follow.

TRANSRECTAL ULTRASONOGRAPHY (TRUS)

TRUS has not gained wide-spread use in the assessment of "chronic prostatitis". There have been some isolated reports on sonographic findings associated with "CP", but others have discarded the technique as "not recommended in the routine evaluation of men with prostatitis" (de la Rosette & Debruyne: "Nonbacterial Prostatitis: A Comprehensive Review" in Urology International 1991;46). In my experience, TRUS is by far the most useful 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 exerting careful pressure with the probe (in analogy with clinical experience in other anatomical sites, e g the acute abdomen, I found this test extremely helpful and in many cases diagnostic). It is, however, necessary that the patients are examined during phases with active symptoms, i e the discomfort has to be present; pressure on an obstructed organ is not necessarily painful if the organ is relaxed even in presence of emptying impairment; obstruction can also appear intermittently (kinking, compression form outside etc); in long-standing obstruction, the patient has adapted to the pressure increase and does not experience any discomfort. Therefore, this pressure test is not always positive if 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 the following conclusions regarding the necessary technical equipment:

  1. the probe has to be slim at the tip, not like several electronic transvaginal transducers on the market with broad detection sectors
  2. the examination sector should be shiftable in different planes (transversal and longitudinal), and has in any case to have the capability of axial straightforward projection (in order to allow exact identification of the part of the organ where the pressure is applied in axial direction)
  3. 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 totally useless and will not be able to provide 95% of the information you can get with the 6 MHZ. I have tested this extensively with my Siemens multifrequency multiplane probe.

What can be detected at TRUS?

Click to see Examples of TRUS-findings
  1. Median prostatic cysts (utricular cysts, Müllerian cysts):
    Such cysts can be found in as many as 12.5% of all patients with "chronic prostatitis". A dutch researching urologist, Dr. Pieter Dik of Utrecht, Netherlands, has done a lot of clinical research on young men with "chronic prostatitis", finding cysts in about the same frequency as in the author's series. A report has recently been accepted by the journal of Urology and will be published soon. What is important about detecting these cysts are the results of therapy (a simple transurethral procedure can cure the patient; see section on therapy).

  2. Calcifications:
    These findings are much more frequent in patients with a history of prostatitis then in men who never had any such episodes. However, one has to take into consideration that prostatitis can occur silently, either due to a low degree of inflammatory activity over a longer period of time which does not cause much disturbance, or because of the inflammatory process being located in an area where the density of sensory nervous endings is low and, perhaps, where surrounding high sensitive areas like the urethra or the intraprostatic seminal tract are not involved. After systematic observation of these lesions (comparing symptomatic and asymptomatic individuals), I would categorize them grossly as follows:
    a) Isolated granules distal to the veru in the periphery of the urethra are frequent and not very specific.
    b) Nests of coars or spotty calcifications in either lobe are generally indicative for a focal chronic inflammatory process which may be active or not(burned-out). The presence of edema (a hypoechoic area surrounding these granules) is likely to indicate activity, especially in presence of symptoms. Strikingly often, such nests are located in the median lobe (central zone) in close proximity to the bladder neck, proximal urethra and the ejaculatory ducts (which maybe an explanation for the combination of irritative bladder symptoms and symptoms/changes referable to the seminal tract. It is necessary to point out that these findings are only reliable if the patient has not yet developed significant benign prostatic hyperplasia (BPH), as in the case of older patients; the sonographic appearance of BPH is very inhomogeneous and does not allow detailed evaluation of minor regions in the inner parts of the prostate.
    c) Sometimes, tiny calcified granules are found inside the veru, not rarely combined with dilation of the ejaculatory ducts and/or the seminal vesicles. Such a finding can be diagnostic and almost always related to intermittent obstructive symptoms of the seminal tract and dysuria (burning at micturition).

  3. Edema of the verumontanum:
    With good sonographic equipment readily recognizable as a much larger then expected hypoechoic zone (urologists know from urethroscopy how large an unaffected veru should be). Sometimes, a single or a few tiny calcifications can be seen inside this area, more often the wall of the veru appears as a dotted hyperechoic line, the pendent to the subepithelial microcalcifications often found at cystoscopy in these patients. Edema of the veru, if present and especially if combined with typical irritative symptoms relatable to this meeting spot of urinary and seminal tract (see section on symptoms), is a very important finding. The examinating urologist should try to decide if this is the only area affected or if there are inflammatory changes in the neighborhood (prostatic lobes) which can be the cause or the consequence of changes in the veru. In either case, an operative procedure (transurethral ablation of the veru and, in cases of foci in the prostatic lobes, ultrasound-guides trasurethral resection of affected areas) can resolve the problem in severe cases, in whom pharmacologic therapy trials and prostatic massage has been inefficient.

  4. Edema of the prostatic lobes (peripheral zone):
    Can only be seen if the edema is sectorial as a consequence of obstruction and/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 base towards the prostatic capsule and the point towards the veru) areas, with clean demarcation against the surrounding homogeneous tissue of the peripheral zone. As with other sonographic changes, congruence with specific symptoms (in this case perineal pain) and hypersensitivity to pressure (finger, ultrasound transducer) will strengthen the diagnosis. These patients will consistently do well after some sessions with prostatic massage combined with antiinflammatory drugs, aiming at reducing edema and expressing the retained secretion. Only in cases of calcifications located in the outlet portion of this sector, minimal transurethral resection should be attempted in refractory cases.

  5. Dilated Ejaculatory Ducts:
    Normal ejaculatory ducts are barely visible at ultrasound and merge often totally with surrounding tissue. If they appear as a clearly visible hypoechoic ribbon, they are either filled or their wall or surrounding connective tissue sheeth is edematous (inflamed). Grossly distended ejaculatory ducts indicate always outlet obstruction at the level of the veru. Both ducts pass close to each-other through the prostate and are not always discernable. If only one ejaculatory duct is affected, it can usually be identified, and the distension can be followed 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, in other cases not (possible cause: post-inflammatory shrinkage of the seminal vesicle). Surgery in such cases can be resolutory.

  6. Changes of the Seminal Vesicles:
    The Seminal Vesicles are more frequently involved in prostatitis than usually recognized, and pathology in these glands can often persist for long time after the inflammatory process in the prostate has subsided. My investigations have shown to me, that the Seminal Vesicles are far more often the site of maximum sensitivity when touched with the transducer than the prostate (only the area where the ampullae of the deferent ducts, lying near each-other, pass beneath the bladder base before entering the prostate, is even more often the site of maximum pain). I think that the recognition of this fact is of utmost importance: in fact, even if definitive eradication of the inflammatory process, wherever it starts, seems difficult or unpredictable, the symptoms (=pain) could be treated if therapy is directed towards the Seminal Vesicles in those cases. The appearance of the Seminal Vesicles is often pathologic: Another most important aspect is laterality: in a large group of patients, symptoms are constantly unilateral (e g pain in either groin or testicle). In most of these cases, the Seminal Vesicles show pathological findings (tenderness and/or appearance) on the same side, only. Finally, it is important to note, that patients with prostatodynia with intermittent symptoms should be preferably investigated when the pain is present. The reason for this is that the pain in those patients often is functional: seminal vesicles in spastic contraction (due to irritation from some offending mechanism in the neighborhood or, more often, from functional or organic obstruction) are tender when touched, but may be completely indolent after relaxation. An investigation in an asymptomatic patient is, however, not useless because the painful reaction of the seminal vesicles is sometimes started by the manipulation during the examination. In other case it should be repeated when the symptoms are present. The seminal vesicles, being a hollow muscular organ, could be resembled to the bowel: if the bowel is cramping, it is tender and the pain can easily be related to the offending bowel segment; if it relaxes, it becomes indolent or only slightly tender, rendering the diagnosis much difficult or impossible.

  7. Surrounding organs:
    In case of diffuse pain not referable to the organs listed above, I always try to identify the site where I can generate the maximum pain reaction similar or identical to the pain the patient seeks me for. If no pain similar to the patient's discomfort can be triggered, a thorough DRE of the area around the lesser ischiadic foramen to check for hypersensitivity of the pudendal nerve will often reveal a positive finding, in my view, of great importance (see DRE). Exploring this area with the probe is awkward and not sensitive enough. Other sites external to the urinary or seminal tract causing "prostatitis-like" symptoms seem very rare (e g inflammatory processes in the ischiorectal fossa or in the paravesical space.

In summary, transrectal ultrasonography is, so far, the best investigation at hand to get closer to a diagnosis in "chronic prostatitis". It can provide guidelines to therapy, especially regarding those cases potentially suitable for surgery. It needs, however, significant experience to interpret the different findings and correlate them to the clinical picture and other examinations. "Chronic prostatitis" is a very inhomogeneous disorder with innumerate subentities, difficult to categorize, difficult to investigate. Transrectal ultrasound is not the answer to all questions, far from that, but it delivers a lot of information if properly performed. On the other hand, there is no better method available, today, to dig into this area with very complicated micro-anatomical structure and complex physiological processes, since we have not yet any method at hand which gives us the opportunity to study similar dynamic physical parameters as in the urinary tract.
The findings above are originally based on a controlled investigation I conducted several years ago on a group of patients with "chronic prostatitis" comparing them to a group of symptomfree individuals. The results had been presented at the 11th World Congress on Endourology and ESWL (Florence 1993) and at the Xith Congress of the European Association of Urology (Berlin 1994). An abstract has been published on the Journal of Endourology, Vol 7, Suppl 1, Oct 1993, p. 182.

URETHRO-CYSTOSCOPY

If performed on patients with chronic prostatitis, urethrocystoscopy frequently reveals a congested, reddened verumontanum (a small protuberance in the lower part of the prostatic urethra where the ejaculatory ducts enter the urethra). The technique is invasive and often very painful in men with an irritative process in the prostate. It could induce an exacerbation of the inflammatory process. Therefore, in my opinion, it should be reserved to special cases in whom another pathology cannot be excluded ( e g to exclude bladder tumors in patients with irritative bladder symptoms, haematuria etc). A repeated cystoscopy is nearly always useless and is generally proposed by the urologist when he feels that the patient demands some sort of action. It is my firm impression that cystoscopy is performed more often than needed, and should be avoided if the diagnosis is obvious, especially in younger men with a typical history and DRE-finding, in whom alternate diagnoses are exceedingly rare.

OTHER INVESTIGATIONS

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