"Chronic Prostatitis": part 5
by Ivo Tarfusser, MD (© 1996)
In this section, the author does not want to explore the vast field of "alternative"medical treatment with herbs, homoeopathy and alike. The documentation of thesemethods is very poor or inexistent. Their wide-spread use is only explainable bythe disappointment many patients experience from conventional treatment. Thefrustration is not only confined to the patients, but also to their doctors whoare not supplied with efficient guide-lines of diagnosis and treatment by theofficial researching medicine. Therefore, many urologists tend towards anihilistic attitude after the failure of their initial treatment attempts,informing the patient that he has to live with his problem. In the following, Iwill list the therapeutical measures I have adopted through the past 7-8 years.Being this a field almost totally neglected by scientific papers, many of thepoints of view are personal and not officially supported. I hope they can be asource of ideas which may incite interested urologists to dig, judiciously,deeper into the matter or, at least, start a discussion.
- Keep warm!
Warmth will reflectorily relax smallsmooth muscle fibers which are present everywhere in the prostate and theseminal tract. The relaxation of these muscular tissue components will help toopen up the outlet zone of the prostatic and ejaculatory ducts, reducing theoutlet resistance which improves drainage of more or less inflamed secretionsand detritus. Less contraction will reduce the metabolism of the smooth musclecells, leading to better tissue oxygenation and recovery of the muscle cells andlessening edema; it reduces tissue pressure inside the prostate and intraluminalpressure inside the prostatic glands and seminal vesicles. Therefore, the oftenrecommendated hot sitz baths are, without doubt, rational and often veryhelpful, and can be resolutive in certain cases.
- Regular sexual life:
The seminal tract (prostate,seminal vesicles, epididymitis) can only be drained by ejaculation. Clearingthis tract regularely from secretions is very important, more especially if thesecretions are physically, chemically or biologically altered by an inflammatoryprocess (alterations in density, pH, electrolytes, nutrients; high content ofwhite blood cells, microorganisms). Many patients with discomfort in theperigenital area tend to avoid sexual engagement, inconsciously worsening thecondition.
Three types of drugs are usually employedin "CP"
Indicated in patients with Chronic Bacterial Prostatitis(extended treatment for several weeks). Most urologists try them independentlyfrom the presence of bacteria, which seems not very rational and has beencritisized by researching urologists. Every urologist active in the field has,however, seen a certain percentage of his clientele without evidence of bacteriain the exprimate, especially NBP-patients, improving after a course ofantibiotics (possibly because in some patients the concentration ofmicroorganisms is too low to show up in the culture, but enough to maintain alow intensity inflammation). If indicated, most urologists would agree on amedium-term course of 3 weeks, in some cases 2-3 months or even longer if thereis 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 theinflamed prostatic tissue) is trimetoprim-sulfamethoxazole.
Anti-inflammatory drugs are often beneficial inreducing edema and pain and are often combined with antibiotics. Examples:ketoprofene, diclofenac. Draw-back: they often cause an inflammatory reaction ofthe stomach and are definitively contra-indicated in individuals with ulcer andgastritis.
alfuzosine and terazosine are useful to improverelaxation of the smooth muscle cells, especially if there are irritativesymptoms of the bladder neck (hesitancy, poor stream, frequent voiding).
- Prostatic massage:
The rationale of thisprocedure is to try to expel dense inspissated prostatic secretion and/or toforce an obstructed outled duct. In order to avoid damage to the integrity of aprostatic acinus which could lead to worsening of the inflammation, it should bedone with care, and in my opinion, not before the patient has had hot baths anddrugs for a couple of days. It seems very helpful in those patients in whom TRUShas shown a sectorial edema in the prostate. In my experience, patients withmassive 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 thesituation. I see my patients 2-3 times a week for a total of about 6-8 sessions.
Surgery is controversial in "chronicprostatitis". Some advocate a "radical" TURP (transurethralprostatic resection) for patients with uncurable Chronic Bacterial Prostatitis,but those cases are few, and for the "big bulk" of NonbacterialProstatitis and Prostatodynia, surgery has never had a place in the treatmentarsenal. In the author's opinion, the Drach-classification cannot constitute abase for decision (or at least not the only one) as far as treatment isconcerned. In the past years, I have operated on quite a few patients with NPDand PDy, using targeted, in some cases, new procedures in selected patients,basing the indications for surgical treatment on:
a. the intensityof symptoms: Of course, only patients with heavy discomfort which does notsubside after conventional treatment can be considered as candidates forsurgery.
b. the age of the patient: In young men, fertility isan important concern: a heavily pathologic spermiogram will strenghthen theindication for surgery (and indicate the type of procedure to adopt), a normalspermiogram would make me cautious.
c. the ultrasonographicevaluation at TRUS: determinant for the appreciation of the underlyingpathogenetic mechanism of the disorder and for the choice of the procedure.LISTOF PROCEDURES
As a rule, surgeryshould only be considered in patients with severe persisting symptoms whichdecisively interfere with normal quality of life. Pain is more likely tosubside after surgery than frequent urge of voiding. The more severe thecondition, the better the results. The least invasive procedure likely toresolve the problem should be chosen. One has to be conscious of the fact thatthe operation not always does or has to remove all inflamed or pathologicallyaltered tissue. Many times, the procedure eliminates obstruction or astrategical area, improving the chances of the inflamed or chronically dilatedzones to normalize. It is also useful to bare in mind that a condition whichpre-exists for years may take time to cure, and sometimes, the symptoms, thoughimproving, may not disappear completely.
- Focal TURP:
A limited transurethral resection ofthe prostate which consists in removing the part of the prostate affected byfocal prostatitis and/or calcifications with the same technical equipment usedto operate Benign Prostatic Hyperplasia. Suitable for patients with clearlylocalized affection (usually CBP and NBP), especially if the spot is distinctlypainful or if there is a heavy suspicion that it may be the cause ofobstruction. The procedure should always be performed under TRUS-control.
- Deroofing or incision of Müllerian (=utricular) cyst:
This procedure implies transurethral removal or incision of theroof of the cyst.Ithas to be done cautiously and strictly under sonographic control in order toavoid lesions to the ejaculatory ducts or to the bladder neck. Without TRUS, thecysts can be difficult to localize. The results are extremely conforting: almostall patients get defintively rid of their problems.
- Transurethral incision of the ejaculatory ducts (TUIED) -Resection of the Verumontanum:
Technically, it is a minimalprocedure where the ejaculatory ducts are incised with a hook electrode or theveru is resected in one "bite" with a loop electrode, using thetraditional instrument for transurethral resection of the prostate, preferablyof smaller size. The incision can be performed on one ejaculatory duct only, butI now prefer the loop technique because of less risk of re-occlusion of theopened-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 theveru, especially if there was evidence of dilated seminal vesicles, and evenmore if combined with dilated ejaculatory duct(s). Patients with endoscopicalevidence of an engorged, reddened veru or with sonographic signs of veru-edema(there is a large number among patients with this condition) are like-wiselikely to improve after this procedure. The indication is strengthened in thecase of a pathologic spermiogram (in younger men). While performing thisprocedure, I always try to compress the seminal vesicles with the transrectaltransducer before and after the incision while observing the veru-region withthe endoscope. It is amazing how often there is no discharge of fluid at allbefore the incision, while large amounts of discolored brownish or denseyellowish fluid exit the openings of the ejaculatory ducts after. This isespecially impressive in cases with unilateral disease, in whom pathologicalfluid exits only from the affected side, while normal seminal fluid comes fromthe other. In over 100 patients operated by now, I have never seen anydeterioration of the sperm count or mobility, on the contrary, 2 patients withconcomitant azoospermia before the procedure have got children, and in many themobility improves (less storage time? fresher fluid?). Ricovery frompre-existent symptoms can be immediate (about 50%, mostly prostatodyniapatients) or delayed (from days to several months, presumably depending upon thedegree 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 madecorrectly. After 6 weeks, most patients are asymptomatic, reporting a strikingincrease 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 tendernessofeither or both seminal vesicles if I, during a TUIED, got evidence of stricturesin the ejaculatory ducts (if fluid does not exit the incised ejaculatory ductdespite pressure on a dilated seminal vesicle, I always catheterize the ductcautiously with a thin catheter to make sure it is not occluded). A few caseshad large cystic spaces in the lower part of the seminal vesicle, interferingwith free drainage into the ejaculatory duct. Many of these patients have severediscomfort for years, getting rid of it instantly after the procedure. Thedraw-back is that it should be only used exceptionally in young men who stillwant to get children, even if one can suppose that the contribution to totalsperm 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. Itconsists in creating a channal through the prostate to gain access to the spacebeneath the bladder floor where the seminal vesicles come into the field ofvision.They are bluntly dissected out of the surrounding connective tissue withdifferent electrodes and finally resected. The procedure needs a lot ofexperience with transurethral procedures and should not be done by the youngerstaff members. With cautious technique, the risks to damage surroundingstructures (rectum, nerves responsible for erection etc) are minimal. In myexperience, it is only indicated in patients with highly painful SHRUNK seminalvesicles, dilated ones should be incised instead. Most patients get rid of allsymptoms, pain seems to disappear in all, while the need of frequent voiding waspersistent in a few. In those cases, I completed with cortisone injections inthe space beneath the bladder trigone.