Subject: sci.med.prostate.prostatitis FAQ 5/5
Supersedes: <medicine/prostatitis-faq/part5_825706942@rtfm.mit.edu>
Date: 1 Apr 1996 18:14:54 GMT
References: <medicine/prostatitis-faq/part1_828382217@rtfm.mit.edu>
X-Last-Updated: 1996/01/29

Posting-Frequency: monthly


Appendix C:  Report of 1995 NIH Workshop on Prostatitis 
(garst@sunchem.chem.uga.edu)

I was lucky to get out of Washington on an early flight, after the
Workshop on Chronic Prostatitis at the NIH ended at about 1 pm.  My
immediate and personal post-meeting impressions follow.

(1) It was a good thing, perhaps a great thing.  It is very clear
that Leroy Nyberg, PhD, MD, Director, Urology Programs, KUH, NIDDK
(National Institute of Diabetes and Digestive and Kidney Diseases),
NIH (National Institutes of Health), and his boss, Gary Striker,
MD, Director, DKUHD (?), NIDDK, NIH, are both solid, very
knowledgeable leaders with a deep interest in the problem of
chronic prostatitis.  I believe that they recognize that this is a
neglected, widespread, debilitating, and expensive disease that
needs to be addressed.

(2) I met Mike Hennenfent and Tom Cruse, officers of the
Prostatitis
Foundation.  They are also impressive, and they are carrying the
ball for us, along with Brad Hennenfent, who could not attend, at
the national level.  The Foundation *has* effective leadership.  It
is up to the rest of us to help make it come to be an effective
force.  Right now, I suspect, there is a great need for seed money
to get the operations rolling well.

(3) I met a few fellow sufferers, good people all, Dave Trissel,
Clark Hickman, Dave Johnson.  Others were there, including Ken
Smith, and I'm pleased to report that we spoke up frequently.

(3) The University of Washington group seemed to be there in nearly
full force.  Dr. John Kreiger was the leader for the general
sessions.  I sat by Dr. Richard Berger and chatted with him for a
while.  Earlier, Berger provided an overview that was made an
appendix to the FAQ for alt.support.prostate.prostatitis.  A number
of others from U. Wash. were present, not all urologists.  They are
an impressive group, and I think that their research could help
lead the way.  I asked Berger specifically if he believes that the
bacterial hypothesis for "nonbacterial" prostatitis is still
viable.  Answer: "Yes."  Someone at U. Wash. is pursuing PCR
studies.

(4) Right away I bumped into Paul Fugazzotto, PhD, Director,
Cystitis Research Center, 4021 Wonderland Dr., Rapid City, SD 57702
[(605)342-8989].  Dr. Fugazzotto is a very experienced
microbiologist who uses "pure culture" techniques to try to
culture, identify, and classify (as pathogens, contaminants, etc.)
microbes from the urinary tract (including prostate).  He tells me
that he has a world-wide laboratory consulting operation and that
samples (taken and packaged according to his directions) can be
mailed to his laboratory.  I'm not sure how effective
his procedures have been in identifying pathogens responsible for
chronic prostatitis, but I intend to give his lab a try.  He was
*very* critical of physicians who *count* bacteria as a means of
diagnosis.  He was also critical, implicitly, of the general run of
clinical culture operations.

(5) Dana Weaver-Osterholz, MD, Asst Prof Urology, University of
Missouri, Columbia, led of the session on current diagnosis and
treatment.  She was one of several female urologists present.  I
didn't do a head count, but it seemed to me that perhaps 10-20% of
the attendees at this conference were women.  Dr. Weaver-Osterholtz
was impressive.  She presented her own flow chart for diagnosis and
treatment, and it was attacked immediately.  She defended her
position calmly and pragmatically, and in the end, her
views substantially prevailed.  However, it was opined that her
procedures are much more extensive than what you find among the
general run of urologists in practice.  The prevailing opinion
seemed to be that very little has really shown to have been
effective in the treatment of chronic prostatitis.

(6) Rodney Anderson, MD, Professor of Urology, Stanford University
School of Medicine, CA, described a neuroelectrical method for
determining whether or not a patient suffers from chronically tense
pelvic floor musculature.  If the measurements so indicate, the
condition is treated with physical therapy (anal muscle massage)
and biofeedback.  Someone else reported something similar. 
Anderson's equipment is special, not routinely available.  Some
urologists present expressed to me their skepticism that this
addresses a fundamental aspect of the problem.  Nonetheless, I was
personally very well impressed with Dr. Anderson.  He is Stamey's
successor in prostatitis research at Stanford.

(7) Richard Alexander, Chief or Urology, V.A. Medical Center,
Baltimore, designed an e-mail prostatitis patient survey.  Dave
Trissel handled the computer aspects, and we all had a chance to
respond.  Alexander presented some of the results.  Dr. Krieger was
impressed at the agreement between the internet survey and his own
data that he has collected over the course of 10 years or so.  Some
of the urologists seemed surprised that pain is the central
complaint (instead of voiding or sexual dysfunction).  They
were also surprised that the condition does not have a larger
effect on sexual function, and they were surprised that the great
majority of those reporting claimed to have had monogamous sexual
relationships (a few were virgins).  This is clearly an area where
ancient, unsupported speculations came to dominate the textbooks. 
Alexander's research focus is the hypothesis that chronic
prostatitis is an autoimmune disease or one with an autoimmune
component.  Hormonal therapy is under investigation.

(8) Anthony Schaeffer, Professor & Chairman, Department of Urology,
Northwestern University Medical School, Chicago, provided a
position paper at the outset of the conference.  I have not had a
chance to try to digest it in detail, but it is certainly a
valuable document.  Among the points made:  (a) In virtually all
patients with bacterial prostatitis, urinary tract infections such
as cystitis also occur.  Conversely, patients with nonbacterial
prostatitis have no urinary tract infections.  (b) Transrectal
ultrasound is neither sensitive nor specific enough to allow any
one feature to be diagnostic of prostatitis.  See, however, the
views of Dr. Ivo Tarfusser.  (c) Radical prostatectomy is not
justified because it may not be effective and the other effects may
be disastrous (urinary incontinence, impotence).  Transurethral
resection cures about 1/3 of patients with documented bacterial
prostatitis, but since most inflammation of chronic prostatitis
occurs in the peripheral zone, and all the ducts from the
peripheral zone empty into the urethra distal to the verumontanum,
radical transurethral resection beyound the verumontanum is
required to remove the infected tissue.  Such an extensive
resection carries of higher than usual risk of urinary
incontinence.  (d)  Nonbacterial prostatitis accounts for about 90%
of patients (others say 95%).  Since the etiology is unknown, the
treatment is empiric and often unrewarding.  In this regard,
Schaeffer mentions that he is skeptical of evidence implicating
Chlamydia or ureaplasma as causative agents, but condones a trial
of tetracycline derivatives or erythromycin for 7 weeks if one of
them is suspected.  He believes that continued antimicrobial
therapy without clear effectiveness is futile and unwarranted.  He
suggests patient reassurance (that the disease is not cancer,
etc.), hot sitz-baths, non-steroidal anti-inflammatory drugs, or
alpha-blocking agents (aimed at relaxing pelvic floor musculature).

(9) Gerard O'Dowd, MD, pathologist, Medical Director, Urocor, Inc,
Oklahoma City, OK, commented that it would be inappropriate for
patients using alpha blockers to consume caffeine.  Apparently
caffeine can negate the effects of alpha blockers.

(10) Curtis Nickel, MD, Professor of Urology, Queens University,
Kingston, Ontario, Canada, described an extensive set of
prostatitis research projects underway there.

(11) Stephen Rous, MD, Professor of Surgery (Urology),
Dartmouth-Hitchcock Medical Center, Lebanon, NH, emphasized the
importance of determining that the prostate is the source of the
pain.  The only person to address this point was Dr. Tarfusser.

(12) Ivo Tarfusser, MD, Corso Liberta 63, Merano (137), 39012,
Italy, Telephone 38473-237312, FAX: 39473-237319, was the only
person to address the issue of finding the focus of pain.  As he
describes on his WWW page, he uses the ultrasonic probe to press on
various pelvic structures in attempts to elicit the same kind of
pain that the patient normally feels.  He has devised some
operations (which have not been described in detail in the
literature, he tells me, but which are so simple that any skilled
surgeon ought to be able to do them from a brief description) in
which the affected feature is lanced, drained, washed, etc., to
remove obstruction.  Dr. Tarfusser believes that obstruction is a
cause of pain; that plugs that are invisible to imaging techniques
can be present, resulting in the encapsulation of infections; and
that these must be drained, just as similar infections of other
organs are drained, in order to cure the condition.  He described
his work briefly for the group working on current diagnostic and
treatment procedures.  It did not appear to me that many, if any,
of those present showed much interest, but he did get a chance to
make his case, and I hope that his message was heard.

(13) The disease complex was defined by symptoms and broken into
two groups, the 5% with recurrent bacteruria is called "chronic
bacterial prostatitis" and the other 95% is "(male) chronic pelvic
syndrome (CPS)."  CPS is subdivided as inflammatory (white cells in
express prostatic fluid) and noninflammatory (no white cells). 
Asymptomatic prostatitis was recognized also as it relates to
fertility, PSA values, and perhaps other items.

(14) A list of conditions that would automatically exclude patients
from research protocols was drawn up.

(15) A patient questionnaire was submitted by Dr. Krieger.  It is
one page.  It focuses on (a) pain, (b) voiding problems, and (c)
sexual problems.  It asks the patient to indicate how much he is
"bothered" by various symptoms.  Discussion indicated clearly that
the object of the questionnaire was to evaluate distress caused by
these symptoms, not their frequency.  Nonetheless, I sat down and
took the test before being informed of this, and I interpreted the
question as a frequency question.   I will suggest to Dr. Krieger
that the wording should be changed to ask how much the patient is
"distressed" by various symptoms, rather than "bothered."  This
questionnaire will be further developed, perhaps with funding from
the NIH, to produce a document that can be used to generate symptom
scores for use in research (and possibly in diagnosis).

********************************************************************
John Garst  garst@sunchem.chem.uga.edu
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