Chronic Prostatitis: Why not heal it?

Preliminary interview
General clinical Examination
Prostate examination
Laboratory tests
Transrectal Prostate ultrasound (TRUS)
TRUS and acute prostatitis
TRUS and chronic prostatitis
X- rays
Cystoscopy

*The diagnostic value which is cited at the beginning of each section as reference value is entirely arbitrary and is based on our own personal experience.

(* diagnostic value = 10)

A fundamental part of any approach, this is when the man with prostatitis refers his symptoms to the attending physician and decides whether to entrust in him.
The symptoms which the physician must investigate have already been described.
I recommend that at this stage doctors be particularly patient with cases of prostatitis. Enquiries about symptoms must be repeated for symptoms alone and in association and they should be investigated in depth. In our outpatients clinic the Symptoms Questionnaire(see below) is administrated once and then again by two different operators. Often the person in front of the doctor is a mature or a young man who has lost faith in the medical profession, who may even have been frightened in many preceding consultations which have failed to help him and who may feel his trust has been misplaced. Sometimes he will tend to underrate some aspects of his disease and overestimate others. It is up to the attending physician to put things into a more balanced perspective.

SYMPTOMS QUESTIONNAIRE

Symptoms Questionnaire* (Perugia University)

VOIDING SYMPTOMS
0 1 2 3

During the night I pass water
never once twice more

During the day I pass water
over 3 hours over 2 hours under 2 hours more often

My urinary flow is strong impaired thread-like ***

Flow properties normal abnormal *** ***

Dripping absent sometimes always ***

PAIN SYMPTOMS 0 1 2 3

Micturition burning
absent moderate strong ***

Perineas soreness absent moderate strong ***

Inguinal soreness absent moderate rstrong ***

Scrotal soreness absent moderate strong ***

Ceccygeal sorenesss absent moderate strong ***

Suprapubic soreness absent moderate strong ***

Ano-rectal soreness absent moderate strong ***

SEXUAL SYMPTOMS 0 1 2 3

Sexual desire normal 25% less 50% less absent

Erection normal 25% less 50% less absent

Ejaculation time normal 25% less 50% less premature

Ejaculation feeling normal hampered painful absent

Sperm quality normal insufficient agglutinated bloody

Ejaculation jet energy normal decreased dripping ***

(*diagnostic value = 5)

Some of the symptoms referred in the course of prostatitis may be caused by other pathologies which must be eliminated in the differential diagnosis. To be excluded are:

incomplete or complete inguinal or crural hernia which can cause inguinal or suprapubic pain;
hemorrhoids, perianal fistulas or rhagades which can cause anal or perianal soreness or pain;
torn muscles which in young men can cause pubic or crural pain;
epidydimitis or varicocele can induce testicular soreness and heaviness;

(*diagnostic value = 7)

I do not think it a waste of time to emphasize the exploratory finger should be inserted into the rectum with great gentleness so that any contraction of the elevator muscles of the anal is not missed through the patient’s understandable reaction to rough handling. The contraction can be hypothesized indirectly if the patients complains of elective pain of the pudendum nerves at the sacrospinal ligament. In our experience this is never he primary cause of perineal pain. Caused by chronic contraction of the elevator anus muscles, it is always secondary to either primary prostate pain or repeated microtraumas due to hard bicycle or horse saddles or vibrations from mopeds etc. In any case, even when secondary, it should always be treated.

The DRE may, for teaching purposes, be divided into the lower (rectal sphincter, haemorrhoid area, perineal floor muscles), middle (prostate apex and organ) and upper (prostate base and seminal vesicles) tracts.

After training the patient may perform the DRE himself and obtain information on the course of his disease during treatment. In our experience self-examination may not have any real therapeutic value but it certainly helps reduce the anxiety factor and makes the patient aware of exactly where the origin of his illness - the prostate - actually lies.
In the course of prostatitis the prostate may be soft and enlarged, normal in size and normal or hardened when palpated in acute phase inflammation. The DRE may cause pain irradiating to the penis tip particularly when the inflamed area is felt. In the older age group or in patients with hemospermia the DRE should exclude the presence of tumours which, we must remember, cannot be distinguished by palpation alone, from calcified nodules or granulomatous prostatitis. When diagnosis is uncertain blood concentrations of the prostatic specific antigen (PSA) should be dosed to clarify the picture.
The final stage of the DRE is palpation of the seminal vesicles to determine their consistency, volume and whether pain is present.

(* diagnostic value = 10)

When we started our work in the field of prostatitis we prescribed, as other urologists did, Stamey’s four-glass test (1968), that is, we looked for inflammatory cells and microbes in the urine before and after prostate massage. We do not now prescribe this test even though it is still in widespread use. We opt for the following tests:

Urine culture with antibiogram;
Sperm culture with antibiogram for common germs, protozoa, mycetes and saprophytes on enriched culture medium;
Urethral swab after prostate massage for common pathogens cultured samples, and DNA standardization (using PCR),of Chlamydia,Ureaplasma, Gonococcus,Human Papilloma virus (HPV) and Human Herpes simplex virus (HSV) ;
IGG and IGM for Chlamydia and Mycoplasma and antisecretory Iga for Chlamydia.

If we suspect the patient’s partner is infected we also prescribe:

Vaginal swab for tests on cultured samples of common bacteria, mycetes and protozoa, and DNA standardization of Chlamidia,Ureaplasma,Gonococcus, HPV and HSV;

If sexual disturbances are present we recommend dosing:

total testosterone levels;
free testosterone levels;
DEHA and DEHAS;
LH, FSH and Prolactin.

If we suspect infertility is impaired we request:

Spermiogram;
Nemasperm penetration test;
Post Coital Test.

(<*diagnostic value="10)"
See Glossary of ultrasound Terminology

Ultrasound scanning of the patient with prostatitis is fundamental in the diagnostic and, as we shall see, therapeutic flow charts. Like everything else the scan must be done properly with the proper instrument. The patient’s bladder should be full (but not over-full) and the scan must be carried out by the transrectal route under basal conditions and during the dynamic phase of micturition, that is during urination. From experience we prefer to have the patient standing to facilitate micturition during scanning. For this reason the probe must be of the fine, new generation type so as to avoid bladder neck compression. As at least two planes are required for prostate scanning the probe must bi or multiplane and the crystal vibration in the range of 7-10 MHz.
Only once these technical requisites are satisfied can we be sure of scanning the prostate properly.

Under basal conditions the following ultrasound patterns must be monitored:

prostate volume;
capsule profile;
tissue echogenicity;
presence or absence of calcified fibrous formations,
ejaculatory duct course and echogenicity;
vein calibre in the peri-prostate plexus.

During micturition (see photo) the following patterns must be monitored:

profile and echogenicity of the bladder floor (trigone);

elasticity and morphology of the bladder neck;

distension capacity of the prostatic urethra;

profile and echogenicity of the prostatic urethra walls;

profile and echogenicity of the veru montanum.



LAST UPDATE: 03.13.2007
Federico Guercini PhD M.D. Consultant Urologist Assistant Professor of Urology Department. Via Archimede 44 00197 Roma Italy Tel. 39-06-8074354 Fax 39-06-8070894