In the April 2001 Urology Times, two articles discuss
prostatitis from viewpoints that substantially differ from the widely
accept one. These articles may be of great importance to men with
prostatitis who have not been helped by regular treatment. Both
articles call into question the standard assumption that the heart
of the problem of prostatitis lies in an inflamed or infected prostate
gland and imply the source of the problem probably lies elsewhere.
The first article states a view that in certain cases , prostatitis
may well be a neuromuscular disorder of the muscles of the pelvic
floor, caused by chronic tension of the pelvic muscles, and not
a problem of the prostate gland.. The article describes a new non-drug
treatment used in the pelvic pain clinic of the Urology Department
at Stanford University Medical Center.
The second article, the lead article of the Urology Times, April
2001 which reports the results of a study of the biopsied prostate
tissue from 97 men diagnosed with chronic prostatitis. This careful
study provides clear evidence that there is simply no inflammation
in the prostates of 66% of men in the study, and in all but 4% of
the remaining men, inflammation is so mild as to be almost an insignificant
feature. Again in this article the role of the prostate in prostatitis
is called into serious question.
David Wise, Ph.D.,
Articles below are reprinted from Urology
Times, Vol 29 Number 4 April, 2001, page 14 & 45, ©2001
Advanstar Communications, Inc. Advanstar Communications, Inc., retains
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Is prostatitis related to pelvic muscle dysfunction?
Myofascial release, progressive relaxation education may correct
condition in some cases
Scott Tennant UT CORRESPONDENT
Arlington, VA—The very idea that the pain
and symptoms of prostatitis have little or nothing to do with the
prostate may be foreign to many urologists, but it was a theory
fostered by two presenters at the Third
International Prostatitis Collaborative Network workshop here.
Wise, Ph.D. a research scholar in urology at Stanford (CA) University,
Hetrick, a physical therapist in urology at the University of Washington,
Seattle, both suggested that chronic prostatitis may in fact be
traced to pelvic floor muscle dysfunction, suggesting that non-medical
intervention may be feasible in some patients.
You don't do open heart surgery when the problem
is heartburn," said Dr. Wise. "Your definition of the
problem determines what you do, and I would suggest that some cases
of prostatitis are actually linked to chronic tension of the pelvic
floor — that it is a problem of the pelvic muscles, not the
Dr. Wise acknowledged that the concept "is
certainly in the minority and not popular. But something in which
I believe deeply and on which we have based our treatment in the
special pelvic pain clinic at Stanford for the past 5 years,"
An overused syndrome?
Dr. Wise suggests that the reason prostatitis is
largely resistant to treatment is because some patients chronically
(and unknowingly) contract their pelvic floor muscles. The pelvic
muscles become chronically tightened in a temporary contracture,
giving irritated tissues little or no chance to heal. This in turn,
can lead to symptoms commonly associated with prostatitis.
"I liken the condition known as prostatitis
to carpal tunnel syndrome of the pelvis. It's an overuse syndrome
in which men chronically tighten their pelvic floor muscles."
Dr. Wise and colleagues take a two pronged approach
to the problem: myofascial release and training in progressive relaxation
of the pelvic floor.
Myofascial release is first performed by a trained
clinician, usually a physical therapist, Dr. Wise said. Contracted
pelvic floor tissues are digitally stretched in 10-40 treatment
sessions that each last 30-45 minutes.
"We like to teach the patient's spouse or
partner to perform the myofascial release so that they don't have
to come to the clinic so often," said Dr. Wise, explaining
that he suffered from prostatitis himself for 22 years and has been
symptom-free for a number of years after undergoing pelvic floor
myofascial release and training the progressive pelvic floor relaxation.
Give it a rest
Patients are taught progressive relaxation so that
they may eliminate habitual contraction of pelvic muscles. The technique
takes 4 months to 2 years to properly learn.
"There is a trick to progressive relaxation,
but it's counterintuitive," Dr. Wise said. "You have to
lower autonomic arousal in general. Specifically, you have to feel
the contracture and actually open yourself up to the pain. I have
measured EMG activity in the anus using a pelvic floor sensor and
observed that the tension almost always reduces as a man adopts
this strategy. Prostatitis — or more accurately, some pelvic
floor pain — can be seen as a gift. It's your body telling
you, 'Give me a rest.' But it needs external help in order to achieve
"Myofascial release and competence in progressive
relaxation of the pelvic floor are equally necessary in my experience,"
he said. "The myofascial release releases the pelvic floor
from its contracture while the relaxation training aims to end the
habitual holding that started the problem in the first place. I
tell patients this is the 'slow fix,' not he 'quick fix.' It is
an inside job requiring the patients' steadfast efforts."
Pelvic muscle tone increase
Dr. Wise said his experience with the techniques
in hundreds of patients has shown that only those who are motivated
and do the program conscientiously have the chance to substantially
reduce or eliminate their symptoms.
"Men with (chronic pelvic pain syndrome)
had more abnormal pelvic floor and abdominal muscular pathologic
findings than those without pelvic pain." —Diane Hetrick
At the University of Washington, Hettrick attempted
to document pelvic floor function in both prostatitis patients and
in normal controls. She performed standardized physical therapy
evaluations on 30 men with chronic pelvic pain syndrome and 51 controls.
Hetrick said that she found statistically significant
higher incidences of pelvic floor muscle tone increase (53%, p=.01),
pain with palpation of pelvic floor muscles (70%, p = .001), abdominal
myofascial pain and tension with palpation (23%, p=.01), and decreased
strength of pelvic floor contractions (28%, p=.036 in CPPS patients.
To further validate the data, Hetrick was blinded
during subsequent evaluations and found similar trends to those
discovered in an unblinded fashion.
"Ultimately what we found was that men with
CPPS had more abnormal pelvic floor and abdominal muscular pathologic
findings than those without pelvic pain," she said
More information about the treatment of tension
disorder prostatitis can be found at www.prostatitis.org/tensiondisorder.html.
Is Inflammation a reality in 'chronic prostatitis'?
Only one-third of patients in study found to have detectable prostatic
By its very definition, the term "chronic prostatitis
would appear to refer to an inflammatory disease of the prostate
gland. But according to a University of Washington pathologist,
that may not necessarily be so.
Lawrence D. True, M.D., reported data here suggesting
that chronic prostatitis as a diagnostic term may be a misnomer.
Dr. True and colleagues conducted a study in which only one-third
of patients with category III prostatitis (chronic pelvic pain syndrome)
actually had detectable prostatic inflammation. I've come to the
conclusion that research into this clinical entity should probably
focus on mechanisms other than those that cause tissue inflammation."
Said Dr. True, an associate professor of pathology at the University
of Washington, Seattle. "For example, we may be well-served
to look at prostatitis as more of a neuromuscular disorder than
an inflammatory disorder"
In a presentation at the International Prostatitis
Collaborative Network workshop here, Dr. True discussed the basis
of his conclusions, a study of 97 men who presented with chronic
pelvic pain syndrome and underwent bilateral prostate biopsies (J
Urol 1999; 162;2014-8).
He and colleagues analyzed a total of 368 biopsies
from the men and found that 33% had inflammtion, only 4% of which
was characterized as 'moderate' (10 to 200 leukocytes per 1-mm field)
or "sever" (more than 200 leukocytes per 1-mm field).
Interestingly, 14 of the 97 patients had inflammatory
cells in expressed prostatic secretions, but there was no apparent
connection between the number of inflammatory cells in the secretions
and the presence or absence of tissue inflammation in the biopsies.
"We (the investigators) have discussed the
lack of direct correlation between neutrophils in the expressed
prostatic secretions and tissue inflammation, and we don'' have
a clear-cut explanation," Dr. True told Urology Times,. "I
suspect that the neutrophils concentrate in the secretions by a
mechanism different than that which leads to inflammation, and that
the number of neutrophils and their transit time in the tissue is
such that they don't collect in sufficient numbers in tissue to
Re-assess diagnosis, treatment
Part of the disparity may be explained by the location
of inflammation in the subjects, noted John Krieger, MD, study co-author
and moderator of the session at the workshop. The researchers found
that while biopsies were taken from the prostatitc parenchyma, inflammation
was generally diffuse and stromal, "and therefore very little
of it was actually associated with the glands themselves,"
Dr. Krieger said.
Perhaps not surprisingly, Dr. True's presentation
generated a good deal of discussion among workshop attendees. Some
questioned the investigators' methods for collecting prostatic secretions.
Others wondered why inflammation, which is so common a in pathologic
specimens from older patients, would be absent in younger patients
such as those in the Washington study (median age, about 40 years).
Still Dr. True stood by his team's findings and
called for a re-assessment of diagnosis and treatment of category
"At this point, I believe it would be more
accurate — albeit less specific — to use the NIDDK term
of 'chronic pelvic pain syndrome' to describe what is happening
to these patients," he said.
The Washington researchers have already undertaken
a number of other investigations into ways in which inflammation
affects the prostate such as in BPH and cancer.
"It would probably help, too, to localize
these inflammatory cells and characterize their interaction with
the parenchymal cells of the prostate," said Dr. True.