Warmth will reflectorily relax small smooth muscle fibers which are present everywhere in the prostate and the seminal tract. The relaxation of these muscular tissue components will help to open up the outlet zone of the prostatic and ejaculatory ducts, reducing the outlet resistance which improves drainage of more or less inflamed secretions and detritus. Less contraction will reduce the metabolism of the smooth muscle cells, leading to better tissue oxygenation and recovery of the muscle cells and lessening edema; it reduces tissue pressure inside the prostate and intraluminal pressure inside the prostatic glands and seminal vesicles. Therefore, the often recommendated hot sitz baths are, without doubt, rational and often very helpful, and can be resolutive in certain cases.
The seminal tract (prostate, seminal vesicles, epididymitis) can only be drained by ejaculation. Clearing this tract regularely from secretions is very important, more especially if the secretions are physically, chemically or biologically altered by an inflammatory process (alterations in density, pH, electrolytes, nutrients; high content of white blood cells, microorganisms). Many patients with discomfort in the perigenital area tend to avoid sexual engagement, inconsciously worsening the condition.
Three types of drugs are usually employed in "CP"
- ANTIBIOTICS:
Indicated in patients with Chronic Bacterial Prostatitis (extended treatment for several weeks). Most urologists try them independently from the presence of bacteria, which seems not very rational and has been critisized by researching urologists. Every urologist active in the field has, however, seen a certain percentage of his clientele without evidence of bacteria in the exprimate, especially NBP-patients, improving after a course of antibiotics (possibly because in some patients the concentration of microorganisms is too low to show up in the culture, but enough to maintain a low intensity inflammation). If indicated, most urologists would agree on a medium-term course of 3 weeks, in some cases 2-3 months or even longer if there is persistent evidence of infection. Later generation quinolones, especially those with activity against Chlamydia, are generally preferred, nowadays. Another antibiotic effective in this condition (i e able to enter the inflamed prostatic tissue) is trimetoprim-sulfamethoxazole. - ANTIPHLOGISTICS:
Anti-inflammatory drugs are often beneficial in reducing edema and pain and are often combined with antibiotics. Examples: ketoprofene, diclofenac. Draw-back: they often cause an inflammatory reaction of the stomach and are definitively contra-indicated in individuals with ulcer and gastritis. - ALPHA-BLOCKERS:
alfuzosine and terazosine are useful to improve relaxation of the smooth muscle cells, especially if there are irritative symptoms of the bladder neck (hesitancy, poor stream, frequent voiding).
The rationale of this procedure is to try to expel dense inspissated prostatic secretion and/or to force an obstructed outled duct. In order to avoid damage to the integrity of a prostatic acinus which could lead to worsening of the inflammation, it should be done with care, and in my opinion, not before the patient has had hot baths and drugs for a couple of days. It seems very helpful in those patients in whom TRUS has shown a sectorial edema in the prostate. In my experience, patients with massive calcifications in the veru-region are rarely helped by this manouver; this seems understandable, as those calcifications cannot be removed by massage, but, on the contrary, manipulation can traumatize this area and worsen the situation. I see my patients 2-3 times a week for a total of about 6-8 sessions.
Surgery is controversial in "chronic prostatitis". Some advocate a "radical" TURP (transurethral prostatic resection) for patients with uncurable Chronic Bacterial Prostatitis, but those cases are few, and for the "big bulk" of Nonbacterial Prostatitis and Prostatodynia, surgery has never had a place in the treatment arsenal. In the author's opinion, the Drach-classification cannot constitute a base for decision (or at least not the only one) as far as treatment is concerned. In the past years, I have operated on quite a few patients with NPD and PDy, using targeted, in some cases, new procedures in selected patients, basing the indications for surgical treatment on:
a. the intensity of symptoms: Of course, only patients with heavy discomfort which does not subside after conventional treatment can be considered as candidates for surgery.
b. the age of the patient: In young men, fertility is an important concern: a heavily pathologic spermiogram will strenghthen the indication for surgery (and indicate the type of procedure to adopt), a normal spermiogram would make me cautious.
c. the ultrasonographic evaluation at TRUS: determinant for the appreciation of the underlying pathogenetic mechanism of the disorder and for the choice of the procedure.
- Focal TURP:
A limited transurethral resection of the prostate which consists in removing the part of the prostate affected by focal prostatitis and/or calcifications with the same technical equipment used to operate Benign Prostatic Hyperplasia. Suitable for patients with clearly localized affection (usually CBP and NBP), especially if the spot is distinctly painful or if there is a heavy suspicion that it may be the cause of obstruction. The procedure should always be performed under TRUS-control. - Deroofing or incision of Müllerian (=utricular) cyst:
This procedure implies transurethral removal or incision of the roof of the cyst.
It
has to be done cautiously and strictly under sonographic control in order to
avoid lesions to the ejaculatory ducts or to the bladder neck. Without TRUS, the
cysts can be difficult to localize. The results are extremely conforting: almost
all patients get defintively rid of their problems. - Transurethral incision of the ejaculatory ducts (TUIED) -
Resection of the Verumontanum:
Technically, it is a minimal procedure where the ejaculatory ducts are incised with a hook electrode or the veru is resected in one "bite" with a loop electrode, using the traditional instrument for transurethral resection of the prostate, preferably of smaller size. The incision can be performed on one ejaculatory duct only, but I now prefer the loop technique because of less risk of re-occlusion of the opened-up ducts.
I have used this procedure extensively in patients with prostatodynia and NBP,
if there was suspicion of any obstruction (like stones) at the level of the
veru, especially if there was evidence of dilated seminal vesicles, and even
more if combined with dilated ejaculatory duct(s). Patients with endoscopical
evidence of an engorged, reddened veru or with sonographic signs of veru-edema
(there is a large number among patients with this condition) are like-wise
likely to improve after this procedure. The indication is strengthened in the
case of a pathologic spermiogram (in younger men). While performing this
procedure, I always try to compress the seminal vesicles with the transrectal
transducer before and after the incision while observing the veru-region with
the endoscope. It is amazing how often there is no discharge of fluid at all
before the incision, while large amounts of discolored brownish or dense
yellowish fluid exit the openings of the ejaculatory ducts after. This is
especially impressive in cases with unilateral disease, in whom pathological
fluid exits only from the affected side, while normal seminal fluid comes from
the other. In over 100 patients operated by now, I have never seen any
deterioration of the sperm count or mobility, on the contrary, 2 patients with
concomitant azoospermia before the procedure have got children, and in many the
mobility improves (less storage time? fresher fluid?). Ricovery from
pre-existent symptoms can be immediate (about 50%, mostly prostatodynia
patients) or delayed (from days to several months, presumably depending upon the
degree of chronicity of inflammatory changes which may take time to subside).
Failure rates should be lower than 10% or better, if the diagnosis had been made
correctly. After 6 weeks, most patients are asymptomatic, reporting a striking
increase in sperm fluid volume and ejaculatory pressure and decreased viscosity.
Control sonography reveals normalized seminal vesicles in most cases. - Transurethral incision of the seminal vesicles (TUISV):
I have chosen this procedure in cases with gross dilation and tenderness
of
either or both seminal vesicles if I, during a TUIED, got evidence of strictures
in the ejaculatory ducts (if fluid does not exit the incised ejaculatory duct
despite pressure on a dilated seminal vesicle, I always catheterize the duct
cautiously with a thin catheter to make sure it is not occluded). A few cases
had large cystic spaces in the lower part of the seminal vesicle, interfering
with free drainage into the ejaculatory duct. Many of these patients have severe
discomfort for years, getting rid of it instantly after the procedure. The
draw-back is that it should be only used exceptionally in young men who still
want to get children, even if one can suppose that the contribution to total
sperm fluid on the affected side is neglectable. - Transurethral resection of the seminal vesicles (TURSV):
This is quite a radical procedure I have done in some extreme cases. It consists in creating a channal through the prostate to gain access to the space beneath the bladder floor where the seminal vesicles come into the field of vision.
They are bluntly dissected out of the surrounding connective tissue with
different electrodes and finally resected. The procedure needs a lot of
experience with transurethral procedures and should not be done by the younger
staff members. With cautious technique, the risks to damage surrounding
structures (rectum, nerves responsible for erection etc) are minimal. In my
experience, it is only indicated in patients with highly painful SHRUNK seminal
vesicles, dilated ones should be incised instead. Most patients get rid of all
symptoms, pain seems to disappear in all, while the need of frequent voiding was
persistent in a few. In those cases, I completed with cortisone injections in
the space beneath the bladder trigone.