Avoiding a "prostatocentric" approach

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Jeannette Potts' new paper called Chronic pelvic pain syndrome: a non-prostatocentric perspective (available at link in News Forum), makes these interesting points:

Thorough evaluation and appropriate therapy for patients has been seriously hindered by decades of a prostatocentric approach to CP/CPPS. ....

Despite evidence indicating that only 5% of symptomatic men have positive cultures localized to the prostate gland, most physicians, including urologists, continue to prescribe antibiotics for this condition [8]. Unfortunately, in clinical practice, most physicians acknowledge treating patients without obtaining cultures. Not only does this perpetuate "antibiotic co-dependency" but also the belief that the patient's constellation of symptoms arise solely from an abnormal prostate gland. A different perspective is long overdue ....


Compelling evidence for a bacterial cause is non-existent. Despite elegant studies measuring inflammatory markers in the prostatic fluid, urologists remain unable to adequately define and treat a large portion of patients. Non-urological literature reveals many similarities as well as shared diagnoses of patients suffering with other chronic elusive disorders such as fibromyalgia (FM), chronic fatigue syndrome (CFS), irritable bowel syndrome, multiple chemical sensitivity (MCS), etc. More plausible causes for prostatitis-like symptoms include musculoskeletal pain, myofascial pain or functional somatic syndromes. ....


There have been a few investigators who proposed other mechanisms for the evolution of the patients' symptoms with respect to pain and voiding dysfunction. One of these was the concept of pelvic floor myofascial pain syndromes by Zermann and colleagues, who observed increased tenderness of the pelvic floor striated muscles in 88.3% of their CP/CPPS patients as well as an inability to relax the pelvic floor. Urodynamically, they observed hypersensitivity of the urethra and external sphincter dyssynergic behavior during voiding. This was explained by an intricate cascade of neural events which could be triggered and perpetuated by pelvic musculature tension and culminated in visceral type pain or perhaps neurogenically mediated inflammation. ....

It is not difficult to notice the similarities between CP/CPPS and interstitial cystitis (IC). Patients share many non-disease characteristics as well as other overlapping diagnoses. Elusive genitourinary infections, such as those caused by mycoplasma or ureaplasma, have been implicated as the cause for LUTS in both men and women, however, patients do not uniformly respond to antimicrobials, and many more have negative cultures. These atypical organisms have also been implicated in other chronic diseases such as FM, CFS, rheumatoid arthritis and systemic lupus erythematosa (SLE). Interestingly, patients with IC are more likely to suffer from FM and SLE, as well as IBS and MCS.

While the correlation between chronic infection with atypical organisms and chronic disease states is plausible, it does not explain the symptoms for most of our patients. Such investigations, however, illustrate the desperation and diligence of investigators in unrelated specialties, searching for the etiology of painful or debilitating syndromes. Herein lies the key to opening the box.

In every medical subspecialty there exists a brand of "prostatitis," representing up to 35% of outpatient consultations. These include chronic headaches, globus syndrome, hyperventilation syndrome, atypical chest pain, non-ulcer dyspepsia, FM and MCS. These disorders are considered functional somatic syndromes (FSS), defined as a constellation of symptoms, frequently persistent, that are associated with distress and disability, and which cannot be explained in terms of conventionally defined disease. The high prevalence of overlapping syndromes among these patients has led some investigators to consider the existence of one unifying syndrome.

Among 127 twins, for example, the CFS twin had a significantly higher prevalence of other FSS co-morbidities than the nonfatigued co-twin. Among the co-morbidities investigated, IC and CP/CPPS were included. We conducted a chart review of CP/CPPS patients in 2000. FSS were identified in 65% of the 89 cases. This is most impressive when one considers the lifetime prevalence of FSS in the general population to be 8%. Further supporting the concept of a unifying syndrome are observations of patients with overlapping syndromes who respond favorably to similar treatment modalities. Such regimens include exercise, relaxation techniques and anti-depressants.

Adopting techniques from rheumatological, colorectal, gynecological, psychological and physical medical specialties, we are more capable of thoroughly evaluating and treating patients with CP/CPPS. After excluding genitourinary, gastrointestinal or neurological pathology, prescribing an exercise regimen incorporating tailor-made stretching, strengthening techniques, along with biofeedback and progressive relaxation has shown success. Over 70% of patients had a greater than 50% improvement within 3 months of initiating therapy. Secondarily, subjective improvement with respect to non-urological complaints was observed; in our experience, compliance rates for physical therapy have been improving over the past 5 years, however, the implementation of exercise as prescribed remains challenging. It is difficult to assess dedication and technique for home exercise programs, making the interpretation of the response less accurate.

Conclusions

Urologists must stop prescribing antibiotics empirically, unless the patient has an abnormal urinalysis. Patients should be committed to 4--6 week antibiotic regimens only when localization cultures prove the diagnosis of bacterial prostatitis, in those presenting with chronic symptoms. Additional testing, especially if invasive, should be pursued with caution. Further testing in the setting of a normal, thorough, physical examination and urinalysis may foment anxiety and exacerbates symptoms, while rarely revealing important pathology.

Urological practices should consider employing specialists interested in chronic pelvic pain who can work closely with physical therapists and rheumatological specialists experienced in treating patients with other forms of FSS. Psychological support and counseling should be made readily available as an integrative component of therapy.

Patients should be guided in their understanding of the interrelation of psychological factors and physical symptoms. Patients with physical complaints require validation and reassurance. To dismiss their symptoms as solely psychogenic undermines the diagnostic and as well the therapeutic interventions. Similarly, a prostatocentric approach to patients with CP/CPPS may be just as detrimental.

[MS]

...prescribing an exercise regimen incorporating tailor-made stretching, strengthening techniques, along with biofeedback and progressive relaxation has shown success

(emphasis added)

Yes! Tailor-made treatment. Dr. Potts is absolutely correct! Urologist must stop lumping all patients with "prostatitis-type" symptoms into one treatment plan. Look at all the symptoms and treatments of sufferers on this board. Many similarities, many differences.

Looks like a step toward redefinition/reclassification of prostatitis.

Pelvic Myoneuropathy?!?

[webslave]

Pelvic Myoneuropathy?!?

I've had very positive feedback about the term "pelvic myoneuropathy." I can tell you that a lot of doctors like it.

:icon14:

[latte]

How difficult is it to find "tailor made treatment" when the uros throw antibiotics to us and that's it. Uros are trained surgeons and patients like us are a waste of time to them. We have to fight to find the proper health care givers to organize the proper treatment. Right now that points right to Stanford and other PTs who will take the time to address the muscular portion of the condition. In the future it may become a team of specialists to address the "whole" problem.

[tractor316]

latte you are so right . maybe we can start on the ground floor by getting our GP's to read this web site and they could put the pressure on the URO's to give CP a new look instead of the old stand by treatments .