Radical Cure Article

Prostatalgia Clinical

History of Prostatalgia

Symptoms parallel those experienced by persons with chronic bacterial and nonbacterial prostatitis.
The typical patient is a young–to–middle-aged man with variable symptoms of chronic, irritative, and/or obstructive voiding accompanied by moderate to severe pain in the pelvis, lower back, perineum, and/or genitalia.
Erectile dysfunction is the symptom that initially brings many men to seek medical attention; however, the patient often waits until the end of the interview to mention the problem or he may avoid mentioning it at all unless the physician specifically inquires.
To facilitate history taking and to establish a more uniform standard, a US National Institutes of Health (NIH) collaborative panel has proposed the Chronic Prostatitis Symptom Index (NIH-CPSI). This index is calculated using a series of 9 questions that contain 21 items used to assess patient history in a standardized and quantifiable format.
Pain symptoms (4 questions)
In the past week, have you experienced any pain (1) between your rectum and testicles, (2) in the testicles, (3) in the tip of the penis, or (4) below your waist?
In the past week, have you experienced pain or burning upon urination or pain or discomfort during or after sexual intercourse?
How often have you had pain in any of the above areas over the last week?
Over the last week, which number (1-10) best describes your average pain or discomfort on the days that you had it?
Urinary symptoms (2 questions)
Over the last week, how often have you had the sensation of not emptying your bladder completely after you finished urinating?
Over the last week, how often have you had to urinate again less than 2 hours after you finished urinating?
Impact of symptoms (2 questions)
Over the last week, how much have your symptoms kept you from doing the kinds of things you would usually do?
Over the last week, how much did you think about your symptoms?
Quality of life: If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?
The NIH describes 4 categories of prostatitis, as follows:
Type I - Acute bacterial prostatitis
Type II - Chronic bacterial prostatitis
Type III - Chronic abacterial prostatitis, ie, chronic pelvic pain syndrome (CPPS) categorized as either type IIIa (inflammatory CPPS) or type IIIb (noninflammatory CPPS)
Type IV - Asymptomatic inflammatory prostatitis

Physical of Prostatalgia

No finding is pathognomonic.
Examination of the genitalia reveals normal results.
Digital rectal examination may reveal a tight anal sphincter. When the anal sphincter tone is hyperactive, a verifiable spastic neuropathy must be excluded. The hyperactivity may otherwise indicate a spasmodic hyperirritability of the pelvic floor musculature, which may be amenable to medical and biofeedback therapies.
The prostate and adjacent tissues may be moderately to severely tender, and the gland itself may be slightly congested or boggy. However, the presence of a small, relatively firm gland does not exclude the possibility of CPPS type III. Extreme tenderness upon gentle palpation of the prostate should raise suspicion for acute bacterial prostatitis or even a prostatic abscess.
The value of this examination is to exclude other diagnoses, such as prostate cancer, chronic urethritis/meatitis, and granulomatous prostatitis.


Causes of Prostatalgia
Bacteria
An informative review of the possible role for fastidious bacteria (ie, bacteria that cannot be isolated on standard culture media) in the development of chronic prostatitis (CP)/CPPS has recently been presented by a leader in this field, Professor John N. Krieger at the University of Washington.Among the fastidious organisms that have been implicated are Chlamydia trachomatis, the genital mycoplasmas (ie, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium), a protozoan (ie, Trichomonas vaginalis), Neisseria gonorrhoeae, genital tract viruses (eg, herpes simplex virus types 1 and 2, cytomegalovirus), fungi, anaerobic bacteria, and gram-positive bacteria.
Only 10 (8%) of 135 patients with CP/CPPS in this series tested positive for fastidious organisms. However, in another series, 79 (47%) of 170 specimens from patients with CP/CPPS exhibited gene sequencing (16S rDNA) positive for the presence of microbes, while only 21 (20%) of 117 control specimens from patients undergoing radical prostatectomy were positive (P <.01). These observations support a potential role for uncommon organisms in CP/CPPS.
Bacteriologic breakthroughs
Propionibacterium acnes
Intriguing findings from collaborating investigators in Australia and California now suggest that persistent microbial infection with an indolent but persistent organism that is difficult to detect and difficult for the host to eradicate may act as an etiologic agent for CP and for the subsequent development of prostate cancer.The presence of this organism, P acnes, could be detected only via sophisticated gene-sequencing and polymerase chain reaction technology. P acnes could not be identified using routine histology, Gram stain, or routine culture techniques.
These preliminary findings suggest that chronic abacterial prostatitis may, in certain cases, actually be due to an occult, chronic, bacterial infection. Further, persistence of this smoldering infection may lead to the development of prostate cancer.
Confirmation of these findings, along with the identification of effective methods to eradicate these bacteria, could lead to cure and prevention, at least in some cases, of both CP and prostate cancer.
Escherichia coli
E coli infection is a common cause of acute bacterial prostatitis. However, these bacteria cannot be cultured in patients with chronic abacterial prostatitis. Certain strains of these bacteria may have developed a cloaking defense that allows them to conceal their activity and to resist antibiotic therapy.
Biofilms develop when large numbers of bacteria embed in a microscopic slime layer called an exopolysaccharide matrix. Entrenched within this biofilm layer, the bacteria may resist antibacterial treatment, counter the human body's natural defenses, and defy detection by routine culture techniques. By forming these biofilms within the prostate, E coli and related bacterial pathogens may cause chronic, treatment-resistant prostatitis. In some cases, they may also be the cause of chronic abacterial prostatitis. Prolonged (6-wk) courses of effective antibiotics (eg, one of the quinolones), when used to treat the first bout of acute prostatitis, may prevent the bacteria from forming a biofilm. Early vigorous treatment of the first case of prostatitis using this method may help prevent the inflammation from progressing into the chronic phase of bacterial or abacterial prostatitis.
Neuropathy
Findings of spastic hyperactivity in the absence of a definable underlying neuropathy from videourodynamic studies suggest the presence of either an occult neural etiology or an acquired functional voiding disorder.
Myofascial pain syndrome has been postulated as a cause for CPPS/CP. Even in the face of clinical inflammation, a reflex triggering of spasm in the musculature of the pelvic floor can be a secondary, but clinically significant, source of much of the symptomatology.
Immunology
An autoimmune basis for chronic prostatitis has been well established in different murine models. Unfortunately, a clinical correlation in humans has not yet been well elucidated.
Recently, stromal cells in benign prostatic hyperplasia (BPH) tissue have been shown to be capable of acting as antigen-presenting cells and activating CD4(+) lymphocytes, as well as producing interleukins.
The symptoms and complications of prostatitis


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