Acini
and Minor Canaliculi
Urethral
prostate Reflux
Abacterial
Prostatitis?
Spread of infection
Utriculus
Seminal
Vesicles
As university professor I could now describe all the
anatomical and pathological pictures which are present during states of acute and/or
chronic inflammation of the urethra and prostate but in so doing I would simply be
repeating what has already been said by my predecessors who have not been able, in fact,
to cure prostatitis. Those of you who wish to study the pathology as described in standard
texts might like to consult, for example, Campbell’s Urology, which is the
urologist’s Bible.
Those of you who want new insights into the problem can follow me!
To start with, let’s set aside USA National Institute of Health classification of prostatitis
(NIH-PSS) which divides the
disease into acute and chronic, bacterial and non-bacterial forms and adds prostatodynia
to this last group, to cover a multitude of disturbances (e.g. painful male urethral
disease) in patients with few (<10 per field) inflammatory cells and typical prostate
pain who do not fit into any of the other
categories.
Let’s go back to the complex of organs that I described in part 3 and let’s
consider them as a single bladder neck-urethral-prostatic vesical organ (a term which you
will not find in any textbook of anatomy) so
that we can identify weak areas and consequently provide the right remedy.
 
We said the minor canaliculi serve to
transport prostatic secretions from the acini to the urethra. The canaliculi draining the
central acini are tortuous in form while those draining the peripheral acini are straight
and joined to the urethra in a position which is countercurrent to the urine stream
(fig.4). These anatomical details prompt the following inference: given the
tortuous course of
their canaliculi, periurethral acini are more easily obstructed by inflammation and are
more likely to release substances and even produce stones. Peripheral acini with their
straight canaliculi are more subject to urinary reflux and urethral bacteria.
This has major therapeutical implications because if true, periurethral prostatitis might
benefit temporarily from strong gland expression while no improvement would be seen in
cases of peripheral prostatitis because the straight canaliculi are not prone to stasis.
When discussing the peripheral acini we mentioned  the
urethral-prostate reflux. This is the abnormal passage of urine from the urethra into the
prostate. Like all fluids, urine flows where pressure is lowest and finds it
“convenient” to leave the urethra and flow into the prostate only under certain
pathological conditions.
These include:
1) increased endourethral pressure due to urethral narrowing
below the prostate, the most common causes being nerve-based periurethral
and sphinteric musculature
rigidity, congenital stenosis or stenotic outcome of previous episodes of
urethritis,particularly if due to gonorrhea;
2) abnormalities in the first urethral tract due to a narrow or poorly elastic bladder
neck i.e. bladder neck sclerosis or dysectasia, which may be congenital or develop early
in life.
In the first tract of the prostatic urethra urine flows hard against the posterior wall
rather than parallel to the lateral walls. Unable to withstand this high pressure the
posterior wall cedes and urine filters into the prostate (fig.5). Barbalias (1997)
recently confirmed this hypothesis with his finding of high urethral closure pressure in
patients with abacterial prostatitis who benefited from a course of alpha-blockers and
antibiotics (Therapy). Kirby (1982) instilled
water containing carbon microspheres into the bladders of 10 patients with chronic
prostatitis and found the microspheres in 70%
of prostate sections taken during transurethral resection (TURP) a few days later. In
samples of prostatic secretion from patients with urethral-prostate reflux Persson and
Ronquist (1996) found high urate and creatinine levels which not only facilitate stone
formation but which also by their very presence induce an inflammatory response in
prostate tissue.
A transrectal ultrasound scan performed during the dynamic
phase of micturition reveals signs of widespread prostatitis when urethral stenosis is
present and shows prostatitis is localized in the periurethral area immediately below the
bladder neck when bladder neck sclerosis is
present (photo 1).
Obviously, prostatitis cannot be cured until the anatomic abnormalities which are the
underlying cause are rectified.
Although mechanical causes are among the factors leading
to the onset of acute or chronic prostatitis, microbial super-infection ALWAYS produces
the devastating effects of the disease. But, I can hear you object, what about the
abacterial forms of prostatitis? I am sorry to disillusion you gentle reader but
abacterial forms of prostatitis as early stage disease, pratically do
not exist. And what of all the studies? All the papers? All
the laboratory tests showing no bacteria in the prostate secretion, sperm and urine? Are
they all wrong?
Surely not, but let’s ask ourselves and our trusted urologist two questions! First
was every single type of microorganism including the saprophytes or non-pathogens found
and cultured? And were the cultures always done in the right medium with the right
laboratory timing to promote development? And
if, as we have seen, some glandular acini become obstructed under the inflammatory
stimulus might not some microorganisms remain
entrapped inside and be unavailable for detection in laboratory tests on fresh samples or
cultures? If you have found no satisfactory answers to these questions anywhere else I can provide the following replies:
- a) Bacteria like staphylococcus aureus or staphylococcus
epidermis and so forth which are usually found as normal inhabitants of the skin but not
the prostate cannot be considered non-pathogens. You may object that whenever these
pathogens were found they did not come from the prostate but were collected in the prostate secretion, maybe in the tract closest to the urethra or even
outside on the penis. To confute this hypothesis we performed transrectal
ultrasound-guided sampling within inflamed areas of the prostate in
patients with high concentrations of saphrophyte bacteria in their
prostatic secretion and found,as we expected, high concentrations of
these bacteria. The results of this study were presented at the
Italian Congress of Urologist in 2001, at the European Congress of
Urology in 2002 and at the World Congress of International Continence
Society in 2002. This type of study had already been carried
out by Berger and Krieger in 1996 but their
results were different. Their mistake was to
take a blind harvest of the endoprostatic sample rather than use ultrasound as a guide so
they did not collect samples from specifically inflamed areas of the prostate.
- b) By using the same technique i.e. taking micro-samples
of tissue from obstructed acini we have always found multiple microbial agents even when
samples of prostatic secretion collected by standard methods were sterile.
- c) Some microorganisms such as Chlamydia or Ureaplasma are
difficult to detect in fresh samples and hard to culture so that even when they are
present results are negative for infection. Often they can be detected
directly in sperm or urine by DNA amplification technique using PCRb.
- d) Fungi are another question, particularly Candida
albicans. Cultures and antibiogrammes have
only recently been developed and are done only in advanced laboratories.
These data are been presented and
discussed in the 3rd Annual NIH International Prostatitis Collaborative Network held
in Washington D.C.(October 23-24th, 2000).
Spread of infection into prostate tissue appears to be
achieved by three pathways:
 along the urethral canal after
intercourse (very frequent);
 through the lymphatic pathways from
the ampulla of the rectum (frequent);
 by the hematogenic via (rare).
This embryological
remnant may be another cause of disturbances in the prostate. The opening of this
structure into the urethra may facilitate the passage of germs inside it, and this
gives rise to acute or chronic inflammation.
Utricular cysts and dilation may also cause prostatitis-like symptoms, which can be cured
only with proper therapy.
The seminal
vesicles are not always but quite often involved in forms of prostatitis. Because of their
anatomy, eradicating an infection in them can be difficult and requires specific
therapy.
When describing the anatomy of the seminal vesicles
we referred to the ejaculatory ducts through which the sperm passes on its way to the
urethra. Sometimes stones may form in the ducts and their typical “rosary bead”
form can be seen during an ultrasound scan. The stones
may cause pain during intercourse, reduce the quantity of ejaculate and when persistent,
increase obstruction. |
