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Diagnosis: prostatitis.

The severe throbbing pain in my bottom (called perineum, in medical language) woke me from a sound sleep. During the previous two weeks, I had been awakened by the urge to urinate (called nocturia), and had noted an increased need to urinate during the day (called frequency). But now, this severe throbbing pain radiating from my perineum to my groin and back had me worried. It was painful when I tried to urinate; the stream started and stopped (called hesitancy) and there was dribbling after the stream finally did finish--painfully, and much to my relief. I couldn't get back to sleep, in spite of the partial relief I got sitting in a warm tub of water. Being 46 with a strong family history of cancer of the prostate, I was scared.

The prostate is one of the male sex glands. Its normal function is to produce seminal fluids that help transport sperm during ejaculation. Located just below the bladder (the organ that stores urine), the prostate lies in front of the rectum and surrounds a part of the urethra--the tube that carries urine from the bladder. When a male is born, the prostate is about the size of an almond. During puberty, the prostate enlarges, doubling in size. The healthy adult prostate is about the size of a walnut, the shape of an upsidedown pear, and weighs about one ounce. Unfortunately, the prostate begins to grow again after age 45 in many men. Not every man develops an enlarged prostate--a condition called benign prostatic hypertrophy, or BPH. And in those men who have the condition, it's not always a problem. One major study showed that as many as 4 out of 10 men over age 55 have BPH, while as many as 7 out of 10 men in their 70s have it.

BPH can cause the symptoms I'd had the previous two weeks--the abnormal urinary flow patterns, the nocturia, the frequency. I had just gone about my business assuming I had reached another passage of manhood. But this pain, this blockage of flow concerned me very much. I saw my friendly urologist that morning.

"Prostatitis," my urologist proclaimed after just hearing my story. "You wouldn't believe how common a problem this really is, and--unfortunately-how poorly understood this condition is." In fact, studies by the National Health Center for Health Statistics show that between 20 and 25 percent of all adult male office visits to urologists are related to prostatitis --defined broadly as an inflammation of the prostate gland. "But I haven't examined you yet," he said, smiling that funny smile most urologists give you before doing the digital rectal examination (DRE) of the prostate. "I'm going to combine a rather complicated way of collecting urine with my DRE."

In fact, there are very few laboratory tests available to support the diagnosis of prostatitis. Basically, the lab tests consist of a bacterial culture and microscopic examination of the urine and of the expressed prostatic fluid. Some urologists will do a simple urinalysis (UA) just to look for evidence of bladder infection; others will do the "more complicated way of collecting urine," as my urologist put it. This method necessitates collecting four specimens for bacterial culture: (1) the first 5-10 milliliters of my voided urine, or VB; (2) a so-called midstream sample of urine, or VB2; (3) a sampie of the expressed prostatic secretions (EPS); and (4) the first 5-10 milliliters of urine voided after prostatic massage, or VB3. "Most urologists don't get this compulsive," my doctor friend informed me. "If this is prostatitis, these various cultures and microscopic examination will help me to determine the category of prostatitis you have."

The three categories he referred to included a classification for prostatitis introduced in 1978: (I) acute and chronic bacterial prostatitis, or BP; (2) nonbacterial prostatitis, or NBP; and (3) so-called prostatodynia, or PD. This system of classification helps in the long-term management of prostatitis. "It's really pretty simple," he assured me. "Here, jump up on the examining table so I can do the DRE while I explain." He smiled that smile again. "Basically, patients with bacterial prostatitis have documentable bacterial infections of the prostate, either on a short-term (acute) or long-term (chronic) basis. Those with nonbacterial prostatitis have evidence of inflammation of the prostate but no sign of bacterial infection. And those with socalled prostatodynia have complaints associated with prostatitis without bacterial infection or inflammation." He began his exam. I wasn't smiling.

One major study I later reviewed evaluated 600 men attending a special prostatitis clinic. The study indicated that 5 percent had BP, 64 percent had NBP, and 31 percent had PD. I wondered which type of prostatitis I had, as I realized that the DRE wasn't really as painful as I had anticipated. "With either bacterial or nonbacterial prostatitis," the urologist chimed, "you would have been hanging off the chandelier by now." He smiled again. "Your examination is fairly normal," he continued as he placed one sample of the expressed prostatic fluid on a culture plate for bacterial culture and another sample on a slide to examine under the microscope.

"Look," he pointed to the microscope. "No white blood cells or macrophages in the field." He quickly prepared another slide of the urine, then peered into the microscope again. "And your urine is clear: no white blood cells. In the world of urology, the presence of at least 15 white blood cells per viewing field seems to be the magic number indicating infection. And I'll bet all of your cultures come back negative," he casually remarked as he threw away the slides. (And sure enough, three days later, all the cultures were negative.) "You've got prostatodynia, most likely."

"So what do I do?"I asked suspiciously. Being a simpleminded surgeon, I'm always leery of diagnoses I have trouble pronouncing: prostatodynia. And besides, it just didn't seem logical. How could a noninflammatory pain syndrome (prostatodynia) be a category of an inflammatory condition (prostatitis)?

"That's all part of the dilemma of treating this condition," the urologist replied. He explained that if this were a straightforward bacterial prostatitis, he could treat me with an appropriate antibiotic like trimethoprim-sulfamethoxazole, nitrofurantoin, or one of the newer fluoroquinolone agents. Antibiotics, combined with adequate hydration, pain relievers, anti-inflammatories, bed rest. and stool softeners, will take care of an acute episode. Really severe acute episodes may sometimes require hospitalization for intravenous antibiotics and bladder drainage using a catheter put in through the abdominal wall (suprapubic catheter). Chronic bacterial infections of the prostate are more difficult. Recurrences are common, necessitating long-term usage of oral antibiotics for suppression.

"Even the so-called nonbacterial form of prostatitis,, he continued, "we treat shotgun fashion with an antibiotic just in case .the inflammation is being caused by an infectious organism like chlamydia, which doesn't show up in our routine cultures."

Shotgun therapy meant a random trial, in the case of nonbacterial prostatitis of tetracycline, erythromycin, minocycline, doxycycline, or one of the newer fluoroquinolones. Unfortunately, the "cure" rate is not spectacular; the recurrence rate is high--all meaning chronic trials of antibiotics and liberal usage of symptomatic treatments like sitz baths, anti-inflammatories, and an observance of any dietary factors that seem to affect the occurrence of symptoms, especially spicy foods. The role that zinc plays in this disease is receiving some intriguing study presently.

Experts can't agree on the cause of any of these categories of prostatitis. The bacterial variety may be due to a retrograde seeding of bacteria up the urethra--though doubtful. Another theory is seeding of the prostate by way of the lymphatic drainage from the nearby rectum: hence, the association with chronic constipation and straining. Nonbacterial prostatitis may be caused by an as yet unidentified bug or, like prOstatodynia, may be initiated by a socalled reflux of urine washing back through the prostatic channels that open into the back of the urethra, setting up a severe spasm of muscles as a "chemical" prostatitis is created. In any event, muscle relaxants like diazepam or smooth muscle blocking agents like prazosin may offer some symptomatic relief. Unfortunately, responders must continue this medication indefinitely.

"Basically," my friend summarized, "you need to consider your condition something like an arthritis or bursitis. You may get chronic or intermittent symptoms, but it won't kill you, and it won't lead to cancer."

"Cancer?"I exclaimed. "You know my family history," I reminded him. "I've used the PSA (prostatic-specific antigen) as a screening blood test in the past. I suppose it's not valid in light of a prostatitis diagnosis?"

"Correct," my friend reminded me. "Prostatitis can cause a falsely elevated value of the PSA well above normal. Your screening for cancer should be done with the transrectal ultrasound." The ultrasound is a device that creates sound wave pictures of the prostate. "The PSA will usually be reliable once the symptoms of the prostatitis have been gone for at least 8 to 10 weeks."

He paused before delivering his final pronouncement. "Prostatitis is the most frustrating condition a urologist treats. You've just got to try to understand as much about it as you can. Study your own lifestyle to see what factors may be associated--stress, exercise, diet. It's one heck of a dilemma.''

That it is. Since the initial episode of prostatodynia last year, I've had two more episodes. I've managed both symptomatically with sitz baths, muscle relaxants, and stress reduction. I'm certainly reading a lot more--especially about prostatitis.
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Author:Dittman, Ralph E.
Publication:Saturday Evening Post
Date:Nov 1, 1993
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