Facts About Chronic Prostatitis and Pelvic Pain Syndrome

• While prostatitis* means an inflammation or infection of the prostate gland, most men diagnosed with prostatitis do not have a prostate infection or inflammation.
• Prostatitis is a condition that can confuse both doctors and patients.
• Approximately ninety-five percent (95%) of what is called prostatitis is not related to a prostate infection. Most cases diagnosed as prostatitis have no pathology of the prostate gland that can account for symptoms of urinary frequency, sexual and sitting pain, and internal pelvic pain among other symptoms.
• Major studies have shown that treating the prostate gland with anti-inflammatory drugs and antibiotics fails to help the symptoms of prostatitis in the long term.
• Symptoms of prostatitis can become chronic and very distressing.
• In 1995, the National Institutes of Health, in a consensus conference on prostatitis, acknowledged that the terms chronic nonbacterial prostatitis and prostatodynia neither explained nor were even related to the symptoms. They recommended a new name that was adopted for this condition: chronic pelvic pain syndrome (CPPS). In changing the name of the most common disorder seen by urologists, there was the clear implication that the prostate may not be the cause of this disorder.
• Studies have shown that men undergo severe impairment in their self-esteem and their ability to enjoy life in general because the pain and urinary dysfunction is so profoundly intimate and intrusive. The effect of nonbacterial prostatitis on a man’s life has been likened to the effects of having a heart attack, having chest pain (angina), or active Crohn’s disease (bleeding/inflammation of the bowel). If nonbacterial prostatitis moves from a mild and intermittent phase to a chronic phase, sufferers tend to live lives of quiet desperation. Having no one to talk to about their problem, usually knowing no one else who has it, and receiving no help from the doctor in its management or cure, they often suffer depression and anxiety.

*Prostatitis (National Institutes of Health categories)

I Acute bacterial prostatitis

II Chronic bacterial prostatitis

IIIA CPPS nonbacterial inflammatory prostatitis

IIIB CPPS nonbacterial non-inflammatory prostatitis

IV Asymptomatic inflammatory prostatitis

Cutting edge treatment of the symptoms of prostatitis focuses on the muscles of the pelvis and not the prostate gland. Treating chronically contracted pelvic muscles associated with the symptoms of prostatitis can significantly reduce or resolve these symptoms in a majority of men. Those who are seeking facts about Chronic Prostatitis should ultimately learn about the Wise-Anderson Protocol. This is a pioneering treatment that has been shown in studies to help reduce the symptoms in a majority of men diagnosed with chronic prostatitis.

NOTE: While it is our hope that these facts about Chronic Prostatitis are helpful, this information is not to be misconstrued as medical advice. This should be presented as general information about the disorder.

Chronic Prostatitis Symptoms

In this essay I want to address the issue of the validity of many speculative theories on the internet about chronic  prostatitis symptoms and CPPS symptoms and our view of the issue of the healing of the pelvic floor and the resolution of symptoms of prostatitis and chronic pelvic pain syndromes.

What causes the symptoms of prostatitis and chronic pelvic pain syndromes?

There are numerous ideas on the internet about what causes symptoms of prostatitis and chronic pelvic pain syndromes. For example, a few people propose that prostatitis and CPPS may be related to reflex sympathetic dystrophy. Attempts to make a case for pelvic pain as reflex sympathetic dystrophy are not new. While I am not an expert in RSD this is what I do know. It is generally agreed among clinicians and researchers that RSD is a condition that is complex and has features that are perplexing and poorly understood. It is characterized by regional pain, often in the hands or feet, autonomic, tissue and vasomotor changes, disorders of movement, muscle atrophy, and almost always psychological and social disturbance. Part of the controversy about RSD is whether the psychosocial disturbances and suffering are causative or at the effect of other factors – an issue of the chicken or the egg. The controversy about RSD reached a point where the name was changed to regional pain syndrome to eliminate the implication of agreement about the mechanism of the disorder. In a discussion I had with our senior physical therapist, in his experience RSD is an entirely different problem from one involving myofascial/trigger point pain. Your reader is correct that Trigger Point Release is not indicated with RSD although in some cases a patient originally diagnosed with RSD may simply have a hyper irritable myofascial pain syndrome and the diagnosis of RSD may have been incorrect.

Diagnostic criteria have been proposed for RSD by an international organization but these criteria are not universally accepted. Bottom line here is that this is a poorly understood and controversial condition that has no effective treatment.

RSD, as a general rule, does not respond to Trigger Point Release therapy. Furthermore, muscle atrophy, edema or swelling or disorders of movement are not prominent features in the pelvic pain we treat. What is telling for me is the fact that many patients with pelvic pain have responded favorably to our protocol whose physiotherapy component involves myofascial Trigger Point Release where RSD does not respond to this methodology. All of this makes the RSD/CPPS hypothesis dubious.

So pelvic pain as RSD is a speculation with little supporting evidence … a speculation that is no different from the speculation that pelvic pain is the result of an occult bacteria or is an autoimmune disease. At this point this idea offers no course of treatment or action that helps or protects someone, it offers no definitive evidence and importantly it tends to promote fear and helplessness in many who suffer from pelvic pain. I take the view that pelvic pain as RSD is an idea with little foundation that I choose to ignore until there is some compelling reason to entertain it.

In our book, A Headache in the Pelvis, we address a very important issue related to the question I am discussing here. This is the question of what to do with speculative theories about pelvic pain like the one that it may be related to RSD – theories that offer no treatment and serve to scare the reader. I quote our book below:

“We are often asked about other theories regarding the nature of chronic pelvic pain from people suffering with pelvic pain, a subject we touched upon earlier. Many of these individuals are already in an anxiety state and are looking for some kind of reassurance or guidance as to the nature of their condition and the best course of treatment. When they go on the internet, they read about various theories contending that chronic pelvic pain may be an auto-immune disorder, a condition in which occult bacteria are yet to be discovered, or a deteriorating neurological pelvic condition.

These theories do what we have described earlier. They tend to promote fear and helplessness in the sufferer.

When you have pelvic pain, it is deeply disturbing to read theories which promote fear, helplessness, and confusion or hear stories of people who are not doing well with their pain or dysfunction. When you have pain and dysfunction, you usually feel some degree of anxiety and helplessness which is often exacerbated by these kinds of theories. Some of our patients have asked us whether they should ignore the ideas that they read on the web or simply avoid the internet websites devoted to pelvic pain. Others have asked us if there is some way to find out if in fact they have the problem that these theories purport.

If a theory or an idea about your condition carries some course of action or treatment to help you without unacceptable risks, then it may be an idea that merits your careful consideration. You may wish to investigate the efficacy of such a course of treatment along with the risks and costs.

If the theory, on the other hands, carries with it (a) no course of treatment or action to be done to help or protect you, or if its treatment carries dangers you are not willing to risk, or (b) it offers some non-definitive evidence, and (c) it only helps to create fear, doubt, and disempowerment in your life, we suggest you tell yourself the following: “This is someone’s theory. There is no definitive proof for it. It offers nothing to help me or protect me. What it offers carries unacceptable risks. It creates fear and doubt in me. It is okay for me to disregard it as somebody’s unproven idea which I will consider if there emerges substantial evidence and/or something to do about it. Therefore I can ignore it as simply someone’s unproven idea. This kind of self-talk … is particularly important because anxiety tends to increase symptoms.”

A person who wrote about RSD and whether it is related to pelvic pain was obviously distressed that his symptoms of prostatitis did not improve with Trigger Point Release that was aggressive, and he was looking for some other answer to his difficulties. In my response to the description of his treatment, let me say that we at Stanford do not advocate aggressive physiotherapy in our protocol but a very specific method aimed at locating and deactivating trigger points inside and outside of the pelvic floor that tend to recreate symptoms of prostatitis as well as methods that systematically stretch the shortened and contracted pelvic tissue. It is common that the in beginning stages of treatment, temporary flare-ups occur. It is the normal course that the discomfort diminishes over time during and after physiotherapy. If it doesn’t, in my experience, the problem is often that the physical therapist is missing something.

In my view the whole issue we are dealing with about treatment for pelvic pain is simply this–how to allow the body to heal itself? I think contemporary medicine tends to forget that it is almost always the case that ‘the body heals itself and the doctor collects the fee.’ In the National Library of Medicine today, I found there were 3743 research articles listed on prostatitis and the symptoms of prostatitis. An infinitesimal 7 articles even contained the word healing. My view about treatment for pelvic pain is that we want to optimize the circumstances for the body to heal itself, we want to get out of the way of the healing of prostatitis, the tissues, muscles, and structures inside the pelvic floor. Healing is what we want as well as prostatitis relief. In my own case, when I began thinking this way, my condition began to resolve.

The Wise-Anderson Protocol is about healing. It is about creating a hospitable environment for the restoration of normal happy tissue inside the pelvic floor. The relaxation protocol allows the nervous system to quiet down so that the irritated tissues can heal and can stop being squeezed into an irritated state… a squeezing that in most people who have pelvic pain has become habitual and chronic. The relaxation protocol aims to change the habit of tightening the pelvic muscles under stress. The physiotherapy we do stretches and lengthens the pelvic tissue and deactivates trigger points to make room for a healthy life in the pelvic floor.

https://www.youtube.com/watch?v=yyDIcyk4Uwc

The idea of RSD as it is understood today, at least as I read it, implies a condition where healing is remote. I balk at theories that imply healing isn’t possible because of my personal experience and others who have gotten better with this problem. Healing is possible. The patients I have seen who have done the worst – especially those who have suffered from unwise medical interventions, have given the entire responsibility for curing their condition to someone or something outside them. They come to the doctor and say “fix me doc”. Any treatment for the kind of pelvic pain we treat needs to be the servant of the body’s healing mechanisms. This requires the intimate and whole hearted participation of the patient.

Physiotherapy alone, while an essential component, is usually inadequate to resolve symptoms because it alone cannot make this healing occur. I understand this experientially. It is tempting for someone to think that physiotherapy, this outside procedure, will fix them. In my experience, this person will be disappointed as I was. I had over 50 physiotherapy treatments and at the end of them all, I was still symptomatic and in pain. It was only after I saw that my problem came from my chronic tension, anxiety and habitually squeezing my pelvis – and particularly when I began the relaxation protocol in earnest, often up to 2 hours a day for over two years and doing moment-to-moment pelvic relaxation throughout the day, that my symptoms began to resolve. The pelvic pain of those we help is not simply a mechanistic problem that can be fixed from the outside with a physical therapist’s finger. The habit of tightening the pelvic floor is usually decades old and has been practiced thousands of times. It is part of a coping repertoire. Tightening their pelvic floor under stress is the default mode and keeps the tissue of the pelvic floor irritated and shortened.

Consider that there are 168 hours in a week. Let us say that a person goes to see the physical therapist 2 times a week. That quite a bit of physiotherapy. In the physiotherapy session, after a person takes off their clothes, gives the PT a report on their week and begins the physiotherapy itself, at the most there is probably 30-45 minutes of hands-on treatment. After the treatment, the tissue is lengthened (although sometimes temporarily irritated in the process). That is between 1 hour and 1.5 hours of therapeutic treatment per week. In a good pelvic floor physiotherapy session, the pelvic floor tissue has been lengthened and life has been made more livable for it. But after physiotherapy, there are 167-166 hours per week to live. The old habit of going 100 miles an hour in one’s life and tightening up the pelvis regularly and squeezing and shortening the irritated tissue can easily and quickly undo the therapeutic impact of the physiotherapy session. It makes no sense to think that a physical treatment that lasts less that .023% of your life can work if the old, symptom provoking habits go on unabated. In my view, the resolution of the kind of pelvic pain we treat is an inside job of cooperating with the healing mechanism of the body in the short run and the long run.

We have received hundreds of emails from people telling us that our theory described in A Headache in the Pelvis is the first one that makes sense to them. While I appreciate these comments, I am unmoved by them. I am moved when someone’s symptoms improve or go away. I am moved when the body responds to treatment with a big ‘yes’. Theories are cheap and yet to the lay person, they can sound convincing and formidable. In my view, a theory about pelvic pain is only as good as the efficacy of the treatment that it informs and serves the healing of the body. In other words, the most important issue is results — i.e., does the method that derives from the theory help the body’s healing thereby reducing or resolving symptoms? We do not help everyone who comes to see us. But if they do fit into a certain profile, they must do the entire protocol properly before making a judgment about its efficacy. They must participate and support their own healing. Results are what counts. Results mean that the patient has helped rally his or her body in healing itself.

Sincerely,

David Wise, PhD

(AN EARLY DISCUSSION OF THE WISE ANDERSON PROTOCOL)

1999 Selected Abstracts from American Urological Association annual meeting

Anyone with prostatitis should be aware of the disagreement among professionals about the cause of prostatitis.

This is especially true if he currently has pain or discomfort:

• in the penis
• in the testicles
• above the pubic bone
• in the low back, down the leg, in the groin or perineum
• during or after ejaculation
• while sitting

The condition often involves:

• having a sense that there is a golf ball in the rectum that can’t be dislodged
• urinary frequency and urgency
• dysuria or burning during or after urination
• a need to urinate even after one has just urinated
• some sense of pelvic discomfort
• no evidence of infection in the urine or prostatic fluid
• no evidence of disease in the prostate or elsewhere in the pelvic floor

The reason that understanding this lack of agreement about the cause of prostatitis is important, especially for sufferers of the problem, is that the definition of a problem determines what you do about it. If you have chest pain caused by indigestion, you don’t elect to have open heart surgery to correct the pain. Indigestion tells you what to do about your chest pain.

Similarly, if prostatitis is caused by a chronic tension disorder in the pelvic muscles where there is no evidence of infection, you might take pause before you elect to have your prostate removed or take another course of antibiotics or have your prostate gland painfully squeezed and massaged.

There is a genuine controversy about what prostatitis is among urologists and professionals treating this problem. There are three basic views outlined below:

• Prostatitis is a condition caused by chronic squeezing of the pelvic muscles that, after a while, causes a self-perpetuating and chronic irritation of the contents of the pelvic floor, including irritation of the nerves and other delicate structures involved in urination, ejaculation, and defecation.
• Prostatitis is caused by a bacteria or unknown microorganism in the prostate gland.
• Prostatitis is an autoimmune problem.

The majority of urologists tend to propound the second and third theories. Because of this, their treatments tend to focus on the use of antibiotics or pain medications. Sometimes urologists will tell their patients that there may be a microbe responsible for the problem that still has not been identified.

Similarly, prostatitis as a tension disorder sees abacterial prostatitis/prostatodynia essentially as a ‘headache in the pelvis” or “TMJ of the pelvis”. In this view it is a condition usually manifesting itself after years of tensing the pelvic muscles. It usually tends to occurs in men who hold their tension and aggression inside. They squeeze themselves rather than lashing out at others. Often they have work in which they sit for long periods of time and the only way they have found to express their frustration is to tense their pelvic muscles. This tension disorder has become a habit with them. Often they do not know they tense themselves in the pelvic floor.

If in fact abacterial prostatitis/prostatodynia (which happens to make up about 95% of all cases of chronic prostatitis) is a condition of chronic tension disorder in the pelvic floor, one would have to question whether drugs or surgery are a correct treatment. In fact, there is no effective drug regimen or surgical procedure for this condition although at Stanford we have had men consult with us who, in moments of desperation, have had their prostates resectioned or removed and who have taken heroic doses of antibiotics and other drugs. None of these treatments have helped them. Not infrequently, these treatments have made the problem worse or created other problems.

In a pilot study, men with abacterial prostatitis/prostatodynia often are found to have trigger points or “knots” of contracted muscle fiber that are very painful when pressed and refer pain to different places in the pelvic floor. Not infrequently, men will report that pressing on these trigger points recreates the pain that they usually have. From the view of prostatitis as a tension disorder, trigger points and tender points in the pelvic floor come about because of chronically contracted muscles there. To deactivate the trigger points is a method borrowed from physiotherapy called “myofascial release” or “soft tissue mobilization”. This is done inside the pelvis where the therapist pushes against the trigger points, stretching the tender contracted tissue.

After a number of sessions, there is often a significant reduction of symptoms. Frequently, with an extensive course of these treatments, symptoms tend to continue to diminish or disappear but only if the patient learns to stop chronically tensing the pelvic muscles.

Learning to profoundly relax the pelvic muscles is not an easy thing. Chronic pelvic tension has usually been a long-standing habit for many men who have pelvic pain. Learning to relax the pelvic muscles requires a major commitment of time. It involves learning a relaxation method we have developed aimed at stopping this chronic squeezing of the pelvic floor muscles.

Seen this way, prostatitis is a secret language that the body is using to tell the man that he needs to handle his stress in his life differently. In offering a treatment based on the view that abacterial prostatitis is a tension disorder, there has been a difficulty with reimbursement from insurance companies. This makes it very difficult for a patient to follow a minimal protocol of intrapelvic myofascial release and progressive relaxation of the pelvic floor.

Because we who see prostatitis from this viewpoint want to get patients off of drugs, we get no financial support for research from drug companies who are often the major source of research funding. Furthermore, because no surgery is involved and urologists are not extensively trained in looking at conditions which result from the direct interaction between mind and body, there has not been much interest in learning and using this treatment among our colleagues in urology.

I hope that this discussion is useful to the many men who suffer from prostatitis and chronic pelvic tension.

https://www.youtube.com/watch?v=DWNPuQfcEbA

CPPS

Many men diagnosed with prostatitis and CPPS are confused about what the doctor is saying is wrong with them. As we have written about extensively on our website, in our book, A Headache in the Pelvis and in our published research, most men diagnosed with prostatitis and CPPS have no prostate infection or inflammation responsible for their symptoms. Yet most men given the diagnosis don’t understand this and suffer silently when medicines aimed at the prostate fail to help. This is an essay featuring the writing of a renounced physician and expert in prostatitis/chronic pelvic pain syndrome who speaks strongly to doctors to clarify their misunderstandings about prostatitis. In his admonitions to the doctors who treat pelvic pain, he clarifies the issues than many patients are confused about.

Men are typically diagnosed with prostatitis and CPPS and are given antibiotics without any evidence of infection in the prostate.

Today, when a man comes into the physician’s office and complains about the following issues, the doctor often treats the patient as if the cause of the problem is an infected or inflamed prostate gland and routinely gives antibiotics:

• Pain: pelvic, urinary, rectal, or genital
• Urinary symptoms such as: frequency, urgency, dysuria (pain during urination), sitting pain, or ejaculatory discomfort

However, there is no evidence of structural disease if one types in ‘prostatitis and CPPS’. If you search these terms on the internet, this misinformation, unfortunately, comes right up from a large number of sources.

Prostatitis, meaning an infection or inflammation of the prostate gland, is often diagnosed without the doctor doing any tests to establish the validity of such a diagnosis. We have seen men who have been given multiple rounds of antibiotics who have had no evidence of infection in the prostate. We do not consider it a good practice without verifying the presence of infection.

Antibiotics are not effective for symptoms diagnosed as prostatitis when the source of symptoms is pelvic muscle dysfunction.

Antibiotic treatment of bacterial prostatitis is an achievement of modern medicine. If you have bacterial prostatitis, antibiotics are a very good treatment—certainly the only treatment. Viewing all conditions of pelvic pain and dysfunction in men, however, as acute or chronic bacterial prostatitis is an error in therapeutic judgment, diagnosis, and treatment. Despite the clear scientific evidence to the contrary, it is shocking that giving antibiotics routinely for nonbacterial prostatitis is common. This is very important to understand, particularly if you have been diagnosed with prostatitis and it has not been determined whether infection or inflammation is present.

Below, Daniel Shoskes, MD, a urologist and expert in the research and treatment of prostatitis, understands this confusion particularly from the physician’s viewpoint. He writes an excellent article that also explains how prostatitis is typically misdiagnosed and treated.

He uses the analogy of Martin Luther who nailed 95 ‘theses’ on the door of a Church in the 16th century protesting the ‘selling of salvation from sins’ where a priest would grant you absolution by giving you a piece of paper called an indulgence if you paid the priest. Luther’s protest was to protest and stop this behavior of the Catholic priests at the time.

If you have been diagnosed with prostatitis, you and your physician can learn from the article below written to physicians.

What is Chronic Pain?

Since the beginning of our work at Stanford, we have held the idea that the prostate gland is not the problem in a very large proportion of men who are diagnosed with prostatitis. Like Martin Luther, Shoskes ‘protests’ against the common confused treatment of prostatitis. If you are a patient, you can learn from his instruction to physicians. If you are physician his article is sure to be enormously instructive. Here is a summary of the theses or points he makes to doctors who treat what is commonly called prostatitis/chronic pelvic pain syndrome. At the bottom of this article is Shoskes article in full. Here are excerpts of Dr. Shoskes advice to physicians diagnosing prostatitis:

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis and CPPS, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness.

Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients chronic pain relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis and CPPS, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

1. Stop telling everyone that they have prostatitis and CPPS as though it is one disease.
2. You should not tell a man with pain in between his nipples and knees that he has prostatitis and CPPS without doing a proper history and physical examination.
3. Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post-massage urine sample instead.
5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
7. Not everyone with prostatitis and CPPS needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (e.g., tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6]
10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteri in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement
14. Do not forget to tell men about simple and often effective supportive measures
15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
16. Learn and use simple and effective therapies for the different clinical domains
17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless.
18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
19. Take new symptoms seriously.
20. In patients without UTI, do not treat an elevated prostate specific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
23. Assemble a good referral team.

Full Article

Commentary on Chronic Prostatitis and CPPS: The Status Quo Is Not Good Enough (But It Can Be)

Daniel Shoskes

Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA

Submitted March 5, 2010 – Accepted for Publication April 5, 2010

www.urotodayinternationaljournal.com

Volume 3 – June 2010

COMMENTARY

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness. Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

1. Stop telling everyone that they have prostatitis as though it is one disease. The National Institutes of Health (NIH) classification may not be perfect, but it is a start and simple to use [1]. Category I is an acute febrile urinary tract infection (UTI). Category II is recurrent UTI with the same bacteria that is recovered from the prostate between acute bladder infections. Category III is persistent pain with or without lower urinary tract symptoms (LUTS) in men without UTI who have no other demonstrable cause. Category IV is asymptomatic and found during semen analysis or prostate biopsy. Stop telling everyone that they have the same condition and treating them all the same.
2. You should not tell a man with pain between his nipples and knees that he has prostatitis without doing a proper history and physical examination.
3. Nobody has to do a full Meares-Stamey 4-glass test. Who cares if there is Escherichia coli in VB1 vs VB2? It makes no difference. You should test at least a midstream sample of urine and then obtain a culture of either prostate fluid or post massage urine [2]. Unless you want false negatives, do Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post massage urine sample instead.
5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
7. Not everyone with prostatitis needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (eg, tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6].
10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteria in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement (eg, severe refractory frequency; pain that worsens with bladder filling and improves with emptying) [9].
14. Do not forget to tell men about simple and often effective supportive measures such as sitting on a donut-shaped cushion and avoiding caffeine and spicy foods.
15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
16. Learn and use simple and effective therapies for the different clinical domains: Urinary symptoms: alpha blockers or antimuscarinics. Prostate pain or inflammation: quercetin [11] and cernilton [12]. Systemic neurologic symptoms: pregabalin or amitriptyline [13]. Pelvic floor spasm: pelvic floor physiotherapy myofascial release, NOT Kegel’s) [4].
17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless. This reaction is called catastrophizing [14]. Find out if they are feeling these emotions with a few simple questions and refer those with symptoms to other professionals for chronic pain treatment or chronic pain medication.
18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
19. Take new symptoms seriously. Patients with prostatitis also can develop kidney stones and genitourinary (GU) cancers.
20. In patients without UTI, do not treat an elevated prostatespecific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
23. Assemble a good referral team. Urologists cannot be expected to treat the parts of these conditions that do not pertain to the GU system. Team members may include physical therapists who know myofascial release therapy, pain management specialists, and psychologists who have experience with catastrophizing, chronic pain, or stress.

Conflict of Interest: Dr. Shoskes is a paid consultant to Farr

[1] Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236-237.

[2] Nickel JC, Shoskes D, Wang Y, et al. How does the pre massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.

[3] Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008;179(2):556-560.

[4] Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-160.

[5] Bjerklund Johansen TE, Gruneberg RN, Guibert J, et al. The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. Eur Urol. 1998;34(6):457-466.

[6] Gleckman R, Alvarez S, Joubert DW. Drug therapy reviews: nitrofurantoin. Am J Hosp Pharm. 1979;36(3):342-351.

[7] Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet Infect Dis. 2003;3(6):359-371.

[8] Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170(3):818-822.

[9] Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology. 2007;69(Suppl 4):60-63.

[10] Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009;73(3):538-543.

[11] Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960-963.

[12] Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brahler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol. 2009;56(3):544-551.

[13] O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(Suppl 10):S22-S32.

[14] Nickel JC, Tripp DA, Chuai S, et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int.2008;101(1):59-64.

[15] Shtricker A, Shefi S, Ringel A, Gillon G. PSA levels of 4.0 – 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy. Int Braz J Urol. 2009;35(5):551-558.

[16] Propert KJ, Litwin MS, Wang Y, et al. Responsiveness of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Qual Life Res. 2006;15(2):299-305.

©2010 UroToday International Journal / Vol 3 / Iss 3 / June doi:10.3834/uij.1944-5784.2010.06.12

http://www.urotodayinternationaljournal.com

ISSN 1944-5792 (print), ISSN 1944-5784 (online)

Abbreviations and Acronyms

GU = genitourinary

LUTS = lower urinary tract symptoms

NIH = National Institutes of Health

PSA = prostate-specific antigen

UTI = urinary tract infection

ABSTRACT

CORRESPONDENCE: Daniel Shoskes, MD, Department of Urology, Cleveland

Clinic, 9500 Euclid Ave, Desk Q10-1, Cleveland, Ohio, 44195, USA (dshoskes@mac.com).

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.12

Most of the symptoms of pelvic pain or discomfort, urinary frequency and urgency, and pain related to sitting or sexual activity in cases diagnosed as prostatitis are not related to infection. They can be caused by chronically tightened muscles in and around the pelvis. Our natural protective instincts can tighten the pelvic basin, causing pain and other perplexing and distressing symptoms. Stress is intimately involved in creating and continuing these symptoms. Once the condition starts, the symptoms tend to have a life of their own.

And the good news is that it is possible for a large majority of sufferers to reduce and sometimes eliminate symptoms. A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, now out in the 6th edition, describes how chronic tension in the pelvic muscles can cause many of the bewildering symptoms of prostatitis and chronic pelvic pain syndromes.

In most cases of men with prostatitis, the prostate is not the problem.

In 95% of prostatitis cases, the prostate is not the problem. In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of patients who are diagnosed with prostatitis do not have an infection or inflammation that can account for their symptoms. The prostate is not the issue.

Chronic Nonbacterial Prostatitis represents by far the largest number of cases of men with prostatitis. It has been estimated that this category involves 90-95% of all cases diagnosed as “prostatitis.” Studies have shown that men undergo impairment in their self-esteem and their ability to enjoy life in general because the pain and urinary dysfunction is so profoundly intimate and intrusive.

The effect on a person’s life of nonbacterial prostatitis has been likened to the effects of having a heart attack. This includes chest pain (angina) or having active Crohn’s disease (bleeding/inflammation of the bowel). If nonbacterial prostatitis moves from a mild and intermittent phase to a chronic phase, sufferers tend to have lives of quiet desperation. Having no one to talk to about their problem, usually knowing no one else who has it, and receiving no help from the doctor in its management or cure, they often suffer depression and anxiety. Symptoms may be intermittent or constant. Few sufferers have all of the following symptoms.

In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of men with prostatitis symptoms do not have an infection or inflammation that can account for their symptoms. The evidence is compelling that in these cases, the prostate is not the issue. It is the muscles of the pelvis that have gone into a kind of chronic spasm or charlie horse that is responsible for the symptoms.

The Wise-Anderson Protocol was developed at Stanford University in the Department of Urology specifically to treat what has been diagnosed as prostatitis by relaxing the pelvis and stopping the chronic spasm in the muscles of the pelvic floor. Below is a list of symptoms that the Wise-Anderson Protocol can typically help in selected men with prostatitis:

https://www.youtube.com/watch?v=cE_Uv5h0HRw

Symptoms typically helped by the Wise-Anderson Protocol
NOTE: Most men have 2 or more of these symptoms

• Urinary frequency (need to urinate often, usually more than once every two hours)
• Urinary urgency (hard to hold urination once urge occurs)
• Sitting triggers or exacerbates discomfort/pain/symptoms
• Pain or discomfort during or after ejaculation
• Discomfort/aching/pain in the rectum (feels like a “golf ball” in the rectum)
• Discomfort/pain in the penis (commonly at the tip or shaft)
• Ache/pain/sensitivity of testicles
• Suprapubic pain (pain above the pubic bone)
• Perineal pain (pain between the scrotum and anus)
• Coccygeal pain (pain in and around the tailbone)
• Low back pain (on one side or both)
• Groin pain (on one side or both)
• Dysuria (pain or burning during urination)
• Nocturia (frequent urination at night)
• Reduced urinary stream
• Sense of incomplete urinating
• Hesitancy before or during urination
• Reduced libido (reduced interest in sex)
• Anxiety about having sex
• Discomfort or relief after a bowel movement
• Anxiety and catastrophic thinking
• Depression
• Social withdrawal and impairment of intimate relations
• Impairment of self-esteem