Subject: sci.med.prostate.prostatitis FAQ 4/5
Supersedes: <medicine/prostatitis-faq/part4_825706942@rtfm.mit.edu>
Date: 1 Apr 1996 18:14:50 GMT
References: <medicine/prostatitis-faq/part1_828382217@rtfm.mit.edu>
X-Last-Updated: 1996/01/29

Posting-Frequency: monthly


Appendix A.:  Overview by Dr. Richard Berger
(rberger@u.washington.edu)

GENERAL INFORMATION ON PROSTATITIS 

        The following represents some of my thoughts on prostatitis
which I have been asked to provide to support group readers. These
opinions can in no way take the place of proper evaluation of any
man's particular situation and are not all-inclusive.  
        Up to one half of all men have prostatitis symptoms
sometime in their life.  In some they become chronic and severe. 
In most they are a nuisance.  With proper evaluation much anxiety
can be alleviated, and oftentimes symptoms can be improved if not
eliminated.  Other more serious conditions of the prostate and
pelvic organs may mimic prostatitis.  All symptoms need to be
evaluated individually by a physician.  Self-diagnosis is foolish
and can be dangerous.
        "Prostatitis" represents a diverse group of clinical
syndromes.  Often men are diagnosed by physicians with
"prostatitis" based on almost any pain between the knees and the
navel.  Not all men with these symptoms have infected prostates. 
In fact, men with demonstrable prostatic infection are in the
minority. 
        There are four classically recognized "prostatitis!
syndromes. The first two syndromes are uncommon and comprise only
around five percent of all men with symptoms.  These are (1) Acute
Bacterial Prostatitis, with fever, painful and difficult urination,
and urinary tract infection with common infection-causing bacteria.
This is similar to an acute kidney infection and the man is usually
quite ill; (2) Chronic Bacterial Prostatitis, with recurrent
bladder infections and bacteria detectable in the urine.  The man
is usually not acutely ill but has increased frequency and urgency
of urination.  Pus and bacteria can be found in the urine.  After
each often successful antibiotic treatment of symptoms, the bladder
infection reoccurs, with the same bacteria being cultured out of
the urine time after time, because the bacteria are not 
being eradicated from the prostate.  A four-glass urine test (or
"prostatic localization test") is needed to make the diagnosis. 
This is performed by comparing the number of bacteria in the first
little bit of urine that is voided to the number of bacteria in the
urine specimen obtained after a prostatic massage performed during
a rectal exam.  If ten times more bacteria are found in the
post-massage urine than the first voided urine, then the diagnosis
of Chronic Bacterial Prostatis is made.  Inflammation (pus cells)
can usually be found in any secretions that are pressed out of the
prostate at the time of the exam.  Chronic Bacterial Prostatitis is
best treated with 6-12 weeks of an antibiotic to which the organism
is sensitive and which gets into the prostate well.  The cure rate
is around 60 percent.  Those men that aren't cured may need long
term low dose antibiotics to keep symptoms away. 
         Men who do not have the above two syndromes may have the
third recognized prostatitis syndrome, (3) Chronic Idiopathic
Prostatitis. Men may complain of a variety of symptoms, including
genital, back, lower abdominal, perineal (the area between the
scrotum and anus), penile, or scrotal pain.  They may also
experience some urinary symptoms.  This 
syndrome is characterized by the above mentioned pain, pus cells in
prostatic secretions, and the absence of common urinary bacterial 
infection detected by the four-glass urine test.  The cause of this
syndrome is unknown.  It may respond to antibiotics temporarily but
it often recurs.  It may be that the symptoms normally get better
or worse even without treatment. Since men usually get treatment
when the symptoms are at their worst, it may seem like the
antibiotics are helping because the symptoms are getting better on
their own.  Uncommonly this syndrome may be related to a sexually
transmitted disease.  This can be ruled out by urethral cultures or
other tests for gonorrhea and chlamydia.  Rarely these symptoms may
be caused by a structural problem in the urinary tract such as
scarring or a cyst.  These can be diagnosed by tests such as a
urinary flow rate and prostatic ultrasound which your physician may
perform.
        The last syndrome is (4) Prostatodynia.  This syndrome is
characterized by the same pains and urinary symptoms as Chronic
Idiopathic Prostatitis.  There are, however, no or few pus cells in
prostatic secretions.  The four-glass localization test is negative
for infection causing bacteria.  The cause of this syndrome is
unknown.
        In my opinion the evaluation of a man with chronic pains
possibly coming from the prostate should include the following:
1)Urethral cultures for gonorrhea and chlamydia to rule out
sexually transmitted diseases; 2) First-void and post-massage
urinalyses, standard culture and bacterial count to rule out
Chronic Bacterial Prostatitis; 3) A urinary flow rate and post
voiding bladder residual urine test to screen for problems in the
urethra, bladder or prostate. The results of this test may suggest
the need for further diagnostic tests such as cystoscopy (looking
inside the urethra and bladder).  If symptoms are mild, these tests
may be all that is needed and the man can be reassured that he does
not have anything that will turn into cancer, nor may he infect
sexual partners.  If symptoms are severe and debilitating other
tests may be indicated.  These may include 4) cystoscopy under
general anesthesia to rule out other diseases such as stones,
tumors or conditions mimicking prostatitis such as interstitial
cystitis; and 5) transrectal prostate ultrasound to look for
abnormal anatomy in the prostate.
        It is my opinion that treatment should be based on clinical
and laboratory findings.  Too often men are treated with repeated
courses of antibiotics without cultures being obtained, or in the
face of normal culture results.  Many men therefore come to believe
that they have a chronic, untreatable infection.  This is probably
not true.  Although we do not understand the cause for Idiopathic
Prostatitis or Prostatodynia, we have little or no evidence that it
is caused by a chronic infection, is sexually or otherwise
transmittable, or is related to the development of cancer or any
other disease.  If an initial course of antibiotics is ineffective
in the face of normal cultures, it probably should not be repeated.
However, only by obtaining cultures can your physician be sure that
you do not have an infection.
        Few treatment studies have been done on the 95 percent of
"prostatitis" that is not caused by urinary pathogenic bacteria. 
Treatments that may be tried include antihistamines such as
Vistaril, drugs such as Hytrin which block the sympathetic nervous
system, drugs such as Proscar which shrink the prostate, and drugs
which may treat deep pain, such as Elavil.  If cystoscopy reveals
findings consistent with a bladder condition called "interstitial
cystitis" then treatments for this condition may be instituted. 
Pains in the pelvis can be caused by pelvic muscle spasms, which
may feel very different from muscle spasms in the arms or legs. 
Physical therapy can be used to help relax these muscles and may
therefore be very beneficial either alone or in conjunction with
other treatments.  Prostatitis symptoms are often associated with
depression, decrease in social and sexual activity, and sometimes
with sexual dysfunction.  These problems often need to be addressed
beyond treatment of the prostatitis. Help is available. As more
studies into the cause and treatment of Prostatitis are performed,
other rational treatments should be developed and the indications
for each treatment clarified.

John Koch  (KOCH@macc.wisc.edu)
Reference Librarian/Documents Coordinator
Steenbock Memorial Library, University of Wisconsin-Madison
550 Babcock Dr.
Madison, WI 53706-1293
Phone: (608)263-4581    Fax: (608) 263-3221


