First, it
must be clearly understood that the term "prostate trouble" so commonly
used is misleading. Many different things happen to the prostate gland
including infection (acute and chronic prostatitis), enlargement, and
nonspecific prostate pain and swelling. Enlargement can be due to a benign
(or noncancerous) growth known as benign prostate hypertrophy, also called
benign hyperplasia or B.P.H. Or, it can be due to cancer of the prostate
which is also termed malignancy of the prostate gland.
While
chronic prostatitis, with which we are dealing here, sometimes produces
mild to moderate enlargement as a result of inflammation, this enlargement
is only temporary and has no direct relationship to the permanent slowly
progressive benign enlargement which occurs with age. Chronic prostatitis
is more commonly seen in younger man, particularly between the ages of 30
to 50. However, it can and does occur in all ages from puberty on.
The term
"prostate trouble" encompasses all of these conditions, but it is
imperative that the patient does not get the idea that because he has
chronic prostatitis, he will need surgery for "blocked kidneys" caused by
benign hypertrophy, or that he has or will have anything as serious as
cancer of the prostate. As a matter of fact, cancer of the prostate rarely
occurs in an individual who suffers with chronic prostatitis.
General
Chronic
prostatitis is extremely common. Many urologists feel that from 60 to 80%
of men are afflicted to some degree. It may be present for many years
without producing symptoms and finally become troublesome. The condition
can and does occasionally result in rather severe symptoms but generally
it is more of a nuisance than anything. It may be compared to chronic
sinus trouble that will come and go. It may require regular treatment for
months, even years on end, or it may respond favorably to one or two
visits to the doctor. While chronic prostatitis may cause recurrent
infections and may never really be "cured", the patient may be completely
free of symptoms for weeks, months or years.
It is
important to realize most doctors feel that elimination of symptoms of
this condition is their principal aim, particularly since the prostate
rarely returns to its normal state for any length of time regardless of
how much it is treated.
The patient
should not be discouraged in learning these things. Treatment will usually
give him relief of his symptoms - often it will not be long before he
realizes his improvement. However, as in any other problem, improvement
can be slow and at times almost imperceptible.
Whenever
improvement is delayed or very slow and frequent flareups of symptoms
occur even the most patient patient becomes discouraged and depressed.
Those who are not inclined toward patience will often become extremely
dissatisfied with their progress, often with their physician.
Should the
reader be of this nature, it is well for him to heed these words carefully
and be reassured as patience will pay off if he can develop it. If not, he
is doomed to continued and everlasting troubles as his physical disease
will be complicated and exaggerated by anxiety. This type of individual
goes from doctor to doctor and clinic to clinic seeking help, never giving
one doctor a chance to afford the patient any appreciable relief.
Fortunately, these individuals are finally convinced, but only after
repeated costly investigations and treatments by various doctors, that
they should stay with one qualified, competent doctor until they realize
results. Rarely this may take years, not infrequently months, but
improvement will show itself in time. "Stay with it and have patience" is
the only answer. Once improvement, if only slight, is noted, anxiety and
nervous tension will decrease and symptoms will abate markedly.
To the
majority of patients who will respond rapidly, a word of reassurance. Do
not let the foregoing depress you. Difficult cases are unusual.
Cause of Chronic Prostatitis
The first
question always asked of the doctor once he has announced the diagnosis to
the patient is, "What causes it?" This will be answered by translating
medical terminology into "plain English", for a background of anatomy,
physiology and some understanding of bacteriology and disease processes is
necessary to completely understand this condition.
We shall
start with a brief course in anatomy to be followed with a few words
regarding what happens to the anatomy of the prostate when it becomes
chronically infected. The reader must understand that the writer is
reducing a vast amount of information and detail to an oversimplified
picture for our purposes here.
The
prostate is located at the neck of the bladder. In fact, it might best be
described as being incorporated into and surrounding the neck of the
bladder. As the bladder neck joins the urethra (or tube we pass urine
through) the prostate forms this area, and the ducts or drainage tubes of
this gland empty into the urethral channel. Into the same area (and
closely related) empty the ejaculatory ducts or channels through which
semen passes after it leaves the seminal vesicles.
Since the
seminal vesicles, the ejaculatory ducts, and the prostate are so closely
related, chronic prostatitis also involves the seminal vesicles in many
instances. The ejaculatory ducts pass through the prostate on their way to
the urethra.
The
prostate is made up of glandular tissue interlaced by and completely
encapsulated by a fibrous capsule. This means the prostate gland is made
up of "meat" resembling liver with a tough skin or shell which holds this
soft gland tissue together and also separates it from surrounding anatomy
If one can picture a small apple with the core removed being fastened to a
neck of a bottle and the cored out apple serving as the bottle neck he
will have a general idea of the relationship of the prostate to the
bladder.
It will be
noted that the prostate and bladder neck lie just in front of the rectum
about 2-3 inches above the anus (outlet of the rectum). In fact, there is
but one thin layer of fascia (fibrous tissue) between the prostatic
capsule and the rectal tube. For this reason the doctor can easily examine
the prostate gland by inserting a finger into the rectum. He can determine
the size, the shape, the mobility, and the consistency of the gland this
way.
All these
things are important in making a diagnosis of prostate trouble and
frequently a simple palpation is the only diagnostic test necessary. On
other occasions, further tests are indicated to corroborate the impression
received by rectal palpation but a vast amount of information is obtained
by this simple, albeit admittedly annoying, examination.
So much for
the gross anatomy and anatomical relations of the prostate gland. Now for
the microscopic make-up of this organ.
There are a
number of "sacks" which have tiny tubes leading to them. These sacks are
like tiny microscopic "bottles" of living tissue which are lined with
cells which secrete fluid. The fluid passes out the tubes or ducts which
join other similar ducts, these groups of ducts joining other larger ducts
until the main prostatic ducts empty the combined production of all these
millions of tiny glands into the urethra.
If one
compared this architecture with that of a bunch of grapes (glands) and the
stems (ducts) all joining to form one main stem (duct), he would have a
similar arrangement. Yet, he must remember the entire prostate gland is
made up of billions of these very tiny glands and their ducts and that
they are so tiny as to be visualized only by the high magnification of a
microscope.
Understanding the microscopic architecture of the prostate with the
realization that this vast system of billions of tiny "sacks" of fluid
drain into a network of ducts which are tributaries of more ducts which
again join and join again to finally empty into the urethra through 14-18
main ducts leads us to an understanding of the problems that develop when
infection (bacterial invasion) occurs. The cause of prostatitis is
infection; however, this answer does not suit the average patient - he
wants to know more. Hence the foregoing details.
Whenever
infection, irritation or allergy involves the prostate gland, inflammation
results. Inflammation results in edema (swelling), an easily
understandable process so far. The usual course of events whenever this
occurs in other parts of the body is that inflammation and swelling
gradually subside as the resistance of the body and medication combat the
infection or irritation. The problem in the prostate (and some other parts
of the body with similar drainage systems) is different, however. The duct
linings swell also, occluding or partially occluding the ducts. Infected
or irritated fluid is retained in millions of tiny microscopic sacs or
glands.
Whenever
drainage of a closed or partially closed space is restricted, inflammation
get a deeper foothold. In this case, it extends through the walls of the
glands and finally enters the spaces and tissues between these glands.
When this happens, the process is, practically speaking, irreversible
inspite of large amounts of medication and treatment. Whether the initial
pathogen invasion is abrupt or overwhelming as in acute prostatitis, or
whether it is gradual, the end result is chronic prostatitis and most
likely will end up as a permanent condition. In short, the case of chronic
prostatitis is pathogen invasion or inflammation and it becomes chronic
because the inflammation has obtained a foothold in closed or partially
closed spaces and crevices of glandular tissue.
What to do
for chronic prostatitis ahs always been a problem for physicians and
whenever a condition is problematical, many different methods of treatment
will be available. Through the years innumerable ways of treatment have
been tried with also many variations of these treatments. Treatment - the
amount and the extent of it - will depend on each individual patient and
the preferences of the individual doctor who renders treatment.
Nonspecific
treatment may be of help in allaying symptoms of prostatitis, such as a
hot tub of warm or hot water for 30 minutes daily to allow the heat to
improve circulation to the prostate region and allow the body defenses to
help fight the inflammation. Diet adjustment may be necessary, as certain
individuals are sensitive to caffeine-containing liquids, alcohol, or
specific nutrients. A diary checklist may help identify an allergy-causing
food. Prostatic massage may be of help in milking out all of the
secretions in the ducts and glands. Massage is carried out by a physician
stroking the prostate with a finger inserted in the rectum. A pleasant
alternative to this massage is regular intercourse by which the prostatic
ducts and glands are emptied. Through the analysis of the expressed
secretions during a rectal exam, a specific drug therapy may be advised.
Unfortunately, each time a new medication is tried, improvement may result
temporarily, but recurrences can often result as the infecting organism
becomes used to the drug therapy.
Other forms
of pharmacological medications may be tried to decrease swelling and
inflammation and they have been used with various degrees of success. Such
medications as anti-edema, anti-inflammatory, muscle relaxant, and
hormones have been used. Vitamins and mineral supplements may also be
helpful in certain selected individuals.
Treatment
of chronic disorders in organs surrounding the prostate and sharing a
common drainage with the prostate may be beneficial. Correction of chronic
constipation and treatment of colitis, diverticulitis, and rectal problems
are examples. An excellent form of therapy that is not pharmacological is
reassurance. Some individuals are unnecessarily preoccupied with their
symptoms, leading to a stress that will further aggravate these symptoms.
Assurance that chronic prostatitis is not a critical disease, that it will
not lead to impotence, sterility, or cancer, and that these individuals
can live a normal lifestyle with normal sexual habits is of help to many
anxious males. Each individual with chronic prostatitis should review his
own lifestyle habits to see if there is any pattern leading to recurrence
of his symptoms.
The patient
should not expect results too soon. He may notice immediate improvement
but should certainly not be disappointed or discouraged if it takes weeks
or even months. This has been emphasized before but it pays to repeat it.
Probably
the next question asked of the physician is, "How does the infection get
there?" Prior to the advent of the miracle antibiotics, gonorrhea or "clapp"
used to be a favorite causative organism. Now, prostatitis can be caused
by a variety of pathogens, varying from bacteria, Chlamydia, Myoplasmum,
Trichomonas, or no pathogens at all. The organisms can reach the prostate
via the blood or lymph stream, or through the urethra directly. A focus of
infection elsewhere in the body can be a contributing factor. Many, many
times we never know how the infection reaches the prostate.
We will now
say a few more things about treatment. Then we will discuss symptoms and
signs and also further diagnostic tests for the patient who wishes to
learn more details regarding chronic prostatitis.
In passing,
we mentioned that the seminal vesicles are frequently involved and it
might be mentioned here that prostatic massage usually includes massage of
the seminal vesicles and the results are the same.
While
surgery is not recommended by most authorities because they feel that the
results are apt to be detrimental rather than beneficial, there are cases
in which surgery is beneficial to a great degree.
These are
the cases in which there is also benign enlargement of the prostate as
well as chronic infection of the gland, thus producing some retention of
urine in the bladder. In cases of this nature the retained (or residual)
urine in the bladder stagnates and becomes another place for infection to
be harbored and propagated. Removal or partial removal of the prostate by
surgery will definitely help in a case like this as it is necessary for
the bladder to empty freely if the prostate is infected.
Surgery
will also help in some cases in which the infection of the prostate is due
to stones in the prostate gland. These occasionally occur and are known as
prostatic calculi. They produce a foreign body effect - that is,
infection.
The writer
has frequently been asked, "Why not remove the prostate and get this over
with?" This question usually comes from a longtime sufferer who is ready
to undergo surgery or anything else to get over it completely. While the
prostate is not at all necessary to a comfortable, normal (in every way)
life, surgery for chronic prostatitis is simply not feasible for the
reasons stated previously.
One hears
of prostate glands being removed frequently and they are. However, this is
done in cases of enlargement due to age and the capsule is not removed in
any of the different types of commonly used operations. There is one
exception and this will be discussed shortly.
The
commonly used operations or approaches to removal of an enlarged prostate
all leave the capsule and a layer of prostatic tissue. This means that
some infected tissue would remain and in chronic prostatitis little would
be accomplished. Thus to remove the capsule as well, a vastly more radical
and complicated procedure is necessary - in fact, a procedure which can
result in incontinence of urine and/or impotence. Thus the reasons for not
recommending surgery should be clear. This brings us to the exceptions
mentioned above. The entire gland, capsule, seminal vesicles, bladder
neck, etc., are removed by radical surgery in cases of early cancer of the
prostate.
Symptoms and Signs
Fortunately
no one has all the symptoms that can result from chronic prostatitis.
Usually, the patient will suffer from one or two of them but many have
quite a number more, particularly if their case is severe.
In the
writer's experience the most common complaint that brings the patient to
the doctor is pain in the testicles - usually mild. He may complain of
pain in both inguinal regions (or one side only), these being either side
of the groin. He may have moderate or mild pain in both inguinal regions
radiating into the testicles (again it may be one side only)
Low
backache is a very common complaint and this is often relieved immediately
by one treatment. Other symptoms include burning on urination, frequency
of urination, increases sexual desires, lack of or reduced sexual desires,
slight discharge from urethra, premature ejaculation, painful ejaculation,
backache following intercourse. Any combination of the foregoing may exist
and to any degree of severity. Rarely there will be pain felt in the
urethra just behind the head of the penis. This is what is known as
"referred pain" and has its origin in the prostate or in the posterior
urethra where the prostatic ducts empty. Sometimes these patients are hard
to convince that their discomfort originates from higher up.
Now as
regards "signs" of chronic prostatitis. Some signs may lead to the
discovery of the disease even though the patient has not had any symptoms
or discomfort. This may occur during a routine physical exam. Pus or blood
cells or both may be discovered in the urine by the doctor. He may also
discover a ascertain consistency of the prostate by routine rectal
examination and tests. The gland may feel soft or "boggy". Other changes
in the consistency may also indicate it. Massage may produce prostatic
secretion with more than a normal number of white (pus) cells when
examined under the microscope.
Occasional
seminal fluid will be noticeably bloody. This is a sign of infection of
the posterior urethra into which the prostatic ducts drain infected
irritating secretion. Often another symptom manifested by pain in the area
between thighs just behind the scrotum is due to posterior urethritis.
It should
be mentioned at this point that very rarely mild cases of chronic
prostatitis can be very easily missed, as a considerable amount of
infection may not produce any changes in the consistency of the gland or
any symptoms. A point is made of this because a routine examination by a
completely able doctor may miss it and a week later or years later, the
disease may be discovered by some other physician.
The
principal diagnostic sign is the consistency of the gland by rectal
palpation and the presence of numerous pus cells in the secretion.
Examination of the expressed prostate secretion by chemical, microscopic
and culture means is of excellent help in making the diagnosis.
Occasionally, further studies are indicated including x-rays of the entire
urinary tract and possibly cystoscopic examination. For example, pus may
be discovered in the urine, examination of the prostate may indicate
prostatitis, but this can also be accomplished by inspection of other
parts of the genitourinary system, including the kidneys. Only a thorough
investigation will reveal this.
In
summarizing, I would like to simply repeat: Chronic prostatitis is rarely
cured. It is a recurrent inflammation of the prostate gland. It is not
dangerous and it will in time respond to proper treatment. It will
probably cause symptoms from time to time and is not apt to cause cancer
of the prostate.
