Radical Cure Article

Chronic Prostatitis Treatment

 1. Keep warm! 

Warmth will reflectorily relax small smooth muscle fibers which are present everywhere in the prostate and the seminal tract. The relaxation of these muscular tissue components will help to open up the outlet zone of the prostatic and ejaculatory ducts, reducing the outlet resistance which improves drainage of more or less inflamed secretions and detritus. Less contraction will reduce the metabolism of the smooth muscle cells, leading to better tissue oxygenation and recovery of the muscle cells and lessening edema; it reduces tissue pressure inside the prostate and intraluminal pressure inside the prostatic glands and seminal vesicles. Therefore, the often recommendated hot sitz baths are, without doubt, rational and often very helpful, and can be resolutive in certain cases.
 
2. Regular sexual life: 
The seminal tract (prostate, seminal vesicles, epididymitis) can only be drained by ejaculation. Clearing this tract regularely from secretions is very important, more especially if the secretions are physically, chemically or biologically altered by an inflammatory process (alterations in density, pH, electrolytes, nutrients; high content of white blood cells, microorganisms). Many patients with discomfort in the perigenital area tend to avoid sexual engagement, inconsciously worsening the condition.
 
3. Drugs 
Three types of drugs are usually employed in "CP"
ANTIBIOTICS: 
Indicated in patients with Chronic Bacterial Prostatitis (extended treatment for several weeks). Most urologists try them independently from the presence of bacteria, which seems not very rational and has been critisized by researching urologists. Every urologist active in the field has, however, seen a certain percentage of his clientele without evidence of bacteria in the exprimate, especially NBP-patients, improving after a course of antibiotics (possibly because in some patients the concentration of microorganisms is too low to show up in the culture, but enough to maintain a low intensity inflammation). If indicated, most urologists would agree on a medium-term course of 3 weeks, in some cases 2-3 months or even longer if there is persistent evidence of infection. Later generation quinolones, especially those with activity against Chlamydia, are generally preferred, nowadays. Another antibiotic effective in this condition (i e able to enter the inflamed prostatic tissue) is trimetoprim-sulfamethoxazole.
 
ANTIPHLOGISTICS: 
Anti-inflammatory drugs are often beneficial in reducing edema and pain and are often combined with antibiotics. Examples: ketoprofene, diclofenac. Draw-back: they often cause an inflammatory reaction of the stomach and are definitively contra-indicated in individuals with ulcer and gastritis.
 
ALPHA-BLOCKERS: 
alfuzosine and terazosine are useful to improve relaxation of the smooth muscle cells, especially if there are irritative symptoms of the bladder neck (hesitancy, poor stream, frequent voiding).
 
4. Prostatic massage: 
The rationale of this procedure is to try to expel dense inspissated prostatic secretion and/or to force an obstructed outled duct. In order to avoid damage to the integrity of a prostatic acinus which could lead to worsening of the inflammation, it should be done with care, and in my opinion, not before the patient has had hot baths and drugs for a couple of days. It seems very helpful in those patients in whom TRUS has shown a sectorial edema in the prostate. In my experience, patients with massive calcifications in the veru-region are rarely helped by this manouver; this seems understandable, as those calcifications cannot be removed by massage, but, on the contrary, manipulation can traumatize this area and worsen the situation. I see my patients 2-3 times a week for a total of about 6-8 sessions.
 
5. Surgery: 
Surgery is controversial in "chronic prostatitis". Some advocate a "radical" TURP (transurethral prostatic resection) for patients with uncurable Chronic Bacterial Prostatitis, but those cases are few, and for the "big bulk" of Nonbacterial Prostatitis and Prostatodynia, surgery has never had a place in the treatment arsenal. In the author's opinion, the Drach-classification cannot constitute a base for decision (or at least not the only one) as far as treatment is concerned. In the past years, I have operated on quite a few patients with NPD and PDy, using targeted, in some cases, new procedures in selected patients, basing the indications for surgical treatment on: 
a. the intensity of symptoms: Of course, only patients with heavy discomfort which does not subside after conventional treatment can be considered as candidates for surgery. 
b. the age of the patient: In young men, fertility is an important concern: a heavily pathologic spermiogram will strenghthen the indication for surgery (and indicate the type of procedure to adopt), a normal spermiogram would make me cautious. 
c. the ultrasonographic evaluation at TRUS: determinant for the appreciation of the underlying pathogenetic mechanism of the disorder and for the choice of the procedure.

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