 Guidelines
Technique
Antibiotic Cocktail
Ancillary medical therapy
Ancillary surgery
 
The guidelines for therapy which we apply in cases of
chronic prostatitis follow logically from what we have expounded in the preceding
sections.
 Prostatitis is ALMOST ALWAYS caused by microbes whether
they are detected or not by standard laboratory procedures.
Evidence of Chlamydia,
Mycoplasma, Human Papilloma Virus and herpes simplex virus is very hard to obtain in
cultures or fresh samples of prostatic secretions. DNA amplification
using PCR is more reliable.Anti-Chlamydia, anti-Mycoplasma, anti-HPV or anti-HSV
antibodies are often found in blood samples.
In the course of prostatitis
the content of prostatic secretions undergoes major modifications. It becomes alkaline and
concentrations of zinc, a powerful anti-bacterial agent, are reduced.
During infection the prostate
tries to circumscribe the infected area by surrounding it with a polysaccharide shield
which cannot be penetrated by antibiotics that are administered systemically
Bacteria exist inside the
infected, obstructed calculi and acini which cannot be reached by antibiotics and which
become the source of recurrent infection.
In patients with long-term
chronic prostatitis T-cells, which are reactive to normal prostatic protein, are
frequently detected (Alexander, 1977). Levels of cytokines such as
IL2,IL6 and TNF alpha in the sperm of these patients were much higher
than normal, suggesting prostatitis may be, or may become, an utoimmune
disease.
When prostatitis is caused or
perpetuated by urethral-prostate reflux because of anatomical abnormalities (bladder neck sclerosis or urethral stenosis) these causes
must be removed to ensure a complete cure.
When the pelvic floor
muscles are contracted chronically and are associated with inflammation
of the pudendal nerve, besides the treatment for prostatitis,specific
therapy is required.
The conclusion to these premises is as follows:
Using ultrasound to guide, therapy needs to be
administered directly into the inflamed areas or inside any fibrous calcifications which
may be present. Therapy is based on a cocktail of antibiotics with an acid pH, powerful
anti-bacterial agents - because bacteria cause most prostatitis - and a strong
anti-inflammatory agent like cortisone which reduces oedema in the canaliculi and acini,
re-establishes the normal flow of prostatic secretions and inhibits any auto-immune
process which may have been triggered. At the same time a long-lasting anaesthetic is
injected into the pelvic floor to stop spasm of the elevator anus muscles.
The course of therapy I have just described is repeated three times at 3
to 10 day intervals.
FOR DOCTORS ONLY
The patient is placed in the lithotomic position. After carefully disinfecting
the skin with a sterile soap solution a 15 cm, 23 G mandrinate needle is inserted
transperineally under ultrasound guide as far as the pelvic floor. The needle must be
inserted 10 mm to the left or right of the median rafe
and 10-15 mm in front of the rectal sphincter. Using a trajectory which is parallel
to the horizontal plane this entry point corresponds to the prostate apex. Choice of right
or left of the median rafe is dictated by the inflammation site and if inflammation is
bilateral the procedure must be repeated on the other side. If the manoeuvre is skillfully done discomfort is slight and indeed, it has always been
accepted with no bother by our patients. 15cc Carbocaine in a 2% solution are infiltrated
into the pelvic floor muscles and diaphragm. After waiting a few seconds for the
anaesthetic to take effect the needle is passed over the urogenital diaphragm. This is an
extremely sensitive structure and if not properly anaesthetized, the procedure can be very
painful. The needle moves inside the lesions which have to be infiltrated (see film) with the antibiotic cocktail and cortisone (12 mg desamethazone). When the infiltration is finished the needle is withdrawn and the
ultrasound probe removed from the rectum. The prostate is massaged vigorously to ensure
the drugs are uniformly distributed.
Correctly choosing antibiotics is fundamental
to the success of therapy. As an enormous range is available on the market I shall just
indicate the drugs we use and give the reasons for our choice.
When bacteria have been isolated in cultures we use the most specific antibiotic indicated
on the antibiogram. If the isolated bacteria is Gram- we combine the specific antibiotic. with Gentamycin or Tobramycin to provide wide spectrum cover against Gram+ germs
that might be present, e.g. Streptococcus. If the isolated bacteria is Gram+ we
add Aztreonam or Ciprofloxacin to cover Gram- bacteria.
When Chlamydia or Mycoplasma are detected in fresh or cultured samples or
by DNA amplification or if their presence is hypothesized because of
positive specific IGG and
IGM we administer Claritromycin together with Levofloxacin. When protozoi are identified, they are usually trichomonas, and we give
Metronodazol.If no bacteria can be isolated (as in most
cases) we
administer Gentamicyn to eradicate Gram+ germs in association with Cipro to combat Gram- germs.
Keep in mind that administration of 1gr antibiotic
directly into the prostatic capsule is the equivalent of a systemic dose 2.000-2500
times higher
(that is, it is two to two and half thousand time more powerfull).
Before proceeding to infiltrate an
antibiotic cocktail into a patient who has never before been treated for prostatitis we
always attempt a 15-day oral therapy with
the specific antibiotic if the bacteria has been isolated in cultures and if not, with
ciprofloxacine (*Cipro 500 mg capsules) and roxitromycin (Rulid* 300mg) which also acts upon Chlamydia and Mycoplasma.
This treatment is combined with a 10-day cycle of suppositories containing desamethazone
and tetracycline (*Mictasone, not available in USA or UK).
If the ultrasound scan is indicative of bladder neck sclerosis we provisionally try to
reduce spasm with alphalithic drugs ( *Flomax 2 mg
tablets) for 4-6 months. In cases of pelvic floor muscles spasm we have
obtained very good results with the following therapy:
BACLOFEN (10 mg tablets):1
tablet 3 times daily for 45 days (beginning from half tablet twice daily
for 3 days>>1 tablet daily for 3 days>>1 tablet 3 times daily);
CLIPPER MICROENEMA(not available
in USA and UK is Cortisone):1 enema every evening for 20 days;
DILATAN CONES(not available in
USA and UK.
www.sapimed.com):insert each cone into the rectum for two minutes twice daily
after immersion in a very warm water for 5 minutes for 45 days;
CLONAZEPAM drops: three drops
morning and evening for 30 days.
Surgery is required when anatomical abnormalities cause
or perpetuate chronic prostatitis. Indications include bladder neck sclerosis, suppurating
utricular cysts, urethral stenosis, ejaculatory duct obstruction.
In cases of bladder neck sclerosis we remove the excess
tissue endoscopically (TURP) or by simple incision (TUIP) in younger patients.
TURP can cause retrograde ejaculation in 80% of cases versus 8-10% of cases with TUIP, so it
is not recommended in single men of marriageable age.
When suppurating utricular cysts are present we drain
the cavity transperitoneally under ultrasound guidance and inject antibiotics and
cortisone. In relapses we make a large transperitoneal incision of the utriculus opening.
In cases of urethral stenosis endoscopic removal of the obstruction is
mandatory.
When infiltrations fail in cases of ejaculatory duct
obstruction or impacted stone in the Veru montanum we proceed with transurethral
incision.
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