The Prostatitis Foundation

Dr. Shoskes FAQ

 

Dr. Daniel Shoskes of the Cleveland Clinic Florida in Ft. Lauderdale. (complete citation below ) has provided The Prostatitis Foundation with his answers to some frequent questions. Many of these answers first appeared in the newsgroup sci.med.prostate.prostatitis.

Quick Jumps
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Prevalence of CP  | Tests for CP  | Recurrent Infection  | Chlamydia and CP  | High White Blood Cell (WBC) Count  | Autoimmune Disease  | Diabetic Neuropathy  | Yeast Hyphae  | Symptom - Feeling of sitting on a golf ball  | One-Sided Symptoms  | Withholding Ejaculation  | Fever  | Bladder Stones  | Treatment  | Cure Rate  | Quercetin  | Macrobid  | Elmiron  | Herbal Treatments  | Vitamin C  | Antibiotic Injection  | Effect of Antibiotics

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Prevalence of CP
Q: The question here related to the percentage of men that are estimated to have prostatitis. The percentage had been estimated by someone to be 10% and Dr. Shoskes was asked to respond to that.
A: The 10% number comes from cross-sectional studies of men and seems fairly accurate. CP has a broad spectrum of symptoms, from very mild discomfort to debilitating pain. In fact, several patients have said to me that when they start to discuss this problem with male friends, all of a sudden their friends start to look uncomfortable, and then admit that they have it too.
Tests for CP
Q: Is it possible to use a comprehensive series of blood tests and other diagnostic procedures (sort of a doctor’s diagnostic wish list) to look for a systemic cause for CP when accompanied by these other symptoms? Conversely, could the tests detect a cause for the systemic symptoms themselves, perhaps as an immune response to the CP? Could these tests be used to reveal autoimmune, viral, candida-related, limbic system or other systemic irregularities as a cause?
A: Unfortunately, tests for the types of disorders you are talking about that are readily available are extremely nonspecific, and quite frankly I have never seen a CP patient with any biochemical abnormalities of these kinds (apart from elevation of PSA). The multicenter collaborative NIH study is set to begin soon at which time all the details will be announced, but suffice to say that the clinical arm includes the construction of a very extensive clinical database documenting all symptoms and associated illnesses and laboratory cultures and tests. If there are statistical associations with other disorders, this is the best way to find them. The basic science projects include the search for new markers of CP that will help to sort out the etiologic questions.
Recurrent Infection(back to top)
Q:I have experienced waxing and waning of prostatitis for years, i.e. comes and goes. When there are no symptoms, does this mean the bacterial (if that is the case) infection has cleared up and/or any other type of prostate infection? Does it clear up on it’s own? If not, then why asymptomatic periodically? Our bodies fight off infections of all kinds on their own and antibiotics help speed up the process at times.
A: The answer to this question is completely unknown. Sometimes an anatomic cause is found to account for recurrent infections (large central stone, blocked seminal vesicle) but this is the exception rather than the rule. This is one of the questions that will hopefully be addressed in the upcoming NIH trial.
Chlamydia and CP(back to top)
Q:...recent studies showed that one of the most common venereal diseases, chlamydia, can cause chronic prostatitis. Practicing physicians cannot make this diagnosis, because they cannot order the only dependable test, polymerase chain reaction.
A: As far as these studies being "recent", chlamydia has been suspected as one pathogen responsible for chronic prostatitis since the early 1980’s. PCR for chlamydia is a commonly available test. Smith Kline Beecham labs does it for about $70 I believe.
High White Blood Cell (WBC) Count(back to top)
Q:Is it possible (or likely) to see a high WBC count in EPS/semen in non-bacterial prostatitis, barring an autoimmune condition?
A: By definition, the WBC count is elevated in the EPS of men with nonbacterial prostatitis. If the WBC count is not elevated (on more than one test) and the culture is sterile, then the diagnosis is prostatodynia.
Autoimmune Disease(back to top)
Q:Is chronic prostatitis an autoimmune disease?
A: Patients with "nonbacterial chronic prostatitis" have increased levels of white blood cells in their prostate fluid but do not have bacteria cultured from that fluid. The 2 possibilities are therefore that the white cells are responding to a microbial infection that cannot be cultured or that there is a non-infectious cause for the inflammation. One such possibility would be an autoimmune disease.

In autoimmune diseases, the bodies’ own white cells respond to a "self" antigen as though it were a "non-self" pathogen and attack it as though it were a foreign invader. Diseases with a proven autoimmune basis include some forms of arthritis, diabetes mellitus and multiple sclerosis. These disorders may respond to treatment with anti-inflammatory or even anti-transplant rejection medications.

There are 2 lines of evidence to suggest that chronic prostatitis may be an autoimmune disease: animal models and preliminary human studies.

1) Rodent models
There are established rodent models in which injection with prostatic or other genitourinary tissue produces pathologic changes in the prostate, which appear to be chronic inflammation. Naturally, there is no way to assess voiding symptoms or low level perineal pain in these animals, so it is completely unknown whether these models have anything in common with human prostatitis. The fact that an autoimmune model can produce these pathologic changes in rodents in no way proves that this is a relevant mechanism in humans. It does however show that this mechanism is at least plausible, resulting in immune and endocrine changes that could produce chronic prostatitis.
2) Human studies
Dr. Alexander at Johns Hopkins has recently studied men with or without chronic prostatitis to see whether T cells in their bloodstream reacted with prostatic proteins. They found a positive reaction in 4 of 14 prostatitis patients and in none of 15 normal controls. While this is very interesting and provocative data, it does not prove an autoimmune basis to the disease. These in vitro tests are notoriously poor at predicting in vivo reactivity of the immune system. In fact, despite 30 years of research in transplant immunology, there is still no useful test that can measure how "active" or "depressed" the immune system is (extreme reductions in T cell counts, as seen in AIDS or with certain anti-rejection treatments, are exceptions). Cells that react in the test tube may be completely inactive in the environment of the prostate.
3) Clinical observations
In support of an autoimmune hypothesis, some patients with prostatitis complain of disorders in other parts of the body, which seem to mirror flare-ups of the prostate symptoms. These may include inflammatory bowel disease, joint pains, and rashes. Nevertheless, steroid treatment, which should significantly improve autoimmune conditions despite its often profound side effects, is seldom helpful to these patients.
My view:
I think it is unlikely that "true" nonbacterial chronic prostatitis represents a classical autoimmune disease. I would speculate that it more likely represents a disorder of regulation of the inflammatory response such that the inflammation does not terminate even though all the infecting bacteria have been removed. This type of dysregulation of the injury response is a common feature of several chronic inflammatory disorders, including chronic renal allograft nephropathy. We are currently exploring this hypothesis in our clinical and basic research studies. The hypothesis that nonbacterial chronic prostatitis is caused by non-culturable bacteria will be discussed in a future essay.
Diabetic Neuropathy(back to top)
Q:Is it possible that some prostate symptoms have their cause in diabetic neuropathy? Anyone who’s had this or knowledge, or even speculation - a reply would be very much appreciated.
A: Absolutely. Diabetic neuropathy leads to residual bladder urine which is a prime cause of urinary tract infections.
Yeast Hyphae(back to top)
Q : Does this mean that you confirm the reports of Drs. AEF and ANF and Brad Hennenfent that yeast hyphae can sometimes be seen in the eps? It has been my impression that most urologists doubt this.
A: I can’t believe there is any controversy over the fact that yeast can be seen in EPS. What is controversial, and what I have not been able to decide for myself yet, is whether these yeast can cause local injury and produce an injury response, and whether anti-fungal agents can reverse this.
SYMPTOMS: Symptom - Feeling of sitting on a golf ball(back to top)
Case Study: Institute of Male Urology case study of the week for 9/5/98

The patient, a male in his 40’s complained of a 6 month history of general malaise, burning with urination, burning in the rectum and tingling in the hands and feet as well as the feeling that he was sitting on a golf ball. He had only small periods of relief, which were associated with the use of new antibiotics for his prostatitis. He was seen by a physician who thought he might have a rectal abscess, but a CT scan was negative. He presented to the Institute for Male Urology and underwent evaluation with transrectal ultrasound. His seminal vesicles were enlarged and met the ultrasound criteria for seminal vesiculitis. A transrectal aspiration and x-ray study of the seminal vesicles showed that the vesicles were not obstructed and cultures obtained from the fluid and from a semen culture both grew out E. coli. The E. coli was resistant to most commonly used oral antibiotics and because of an accompanying fever he was admitted to the hospital and treated with intravenous antibiotics. After being released from the hospital he had cystoscopy which revealed a cyst of the Cowper’s gland (this is a very rare condition in adults). These glands, near the base of the urethra, provide the urethra with lubrication. An MRI confirmed this diagnosis and the patient underwent an endoscopic surgical procedure to destroy the cyst wall with a holmium laser. His symptoms have now resolved. This is an interesting case because this patient’s prostatitis and seminal vesiculitis resulted from reinfection from a local source of bacteria in the Cowper’s gland. It is important for patients who do not have resolution of their symptoms to have a full urologic evaluation.

Please note: Features of the IMU case of the week not essential to the medical issues involved have been altered to respect patient privacy.
Q:BTW, I wonder if this "sitting on a golf ball" symptom is a primary indicator for Cowper’s gland problems? My father feels like he is sitting on a golf ball, too. He always lies down...travelling in a car is troublesome due to the sitting.
A: In my experience, the golf ball feeling in the perineum is a common symptom in chronic prostatitis patients in general, and does not of itself point to a different problem such as the Cowper’s gland.
Q: Can ejaculatory duct obstruction cause cp, and if so, can it be treated surgically? What diagnostic tests will show this condition?
A: ED obstruction can be diagnosed with a transrectal ultrasound. In questionable cases, dye can be injected into the seminal vesicles at the time of the ultrasound to see if it can drain into the urethra. Surgical options include cutting the duct from inside the urethra , stretching it open and open surgical removal of the seminal vesicles ( see http://www.ben2.ucla.edu/~dshoskes/cpclinic.html)
"One-Sided" Symptoms(back to top)
Q:Can you tell me please Dr. Shoskes, can one have a "one-sided" immune over-response in the prostate? I ask as several people report "sidedness" to their symptoms.
A: It’s not really the right question I think. The sensory-neural connections in the perineum are such that pain gets referred all over the place, and it is difficult to know what to make of pain that is predominantly on one side or the other. An inflammatory response to a localized bacterial infection or to a site of localized prostatic injury could occur in just one part of the prostate. If a generalized autoimmune response to prostatic proteins is hypothesized, then the inflammation should be diffuse.
Withholding Ejaculation(back to top)
Q:In many posts here, I remember reading the advice by some CP patients that it is important not to withhold ejaculation for too long once aroused. I was wondering what the Physicians think about this and what the physiological reasons might be if they agree with the above statement.
A: There seems to be no consistent pattern in patients I have seen. Some feel worse after ejaculation, some feel better. Prior to ejaculation, the gland surrounding the urethra will produce fluid, which possibly could be irritating in someone who already has prostatic inflammation or a pelvic neuromuscular sensitivity, but that is pure speculation.
Fever(back to top)
Q: . . . all bacterial chronic prostatitis, by definition, is not associated with fever "or any of that stuff". Is this absolutely the case? I have experienced, and others with CP have reported, occasional low grade fevers. It seems like this would be the body’s natural response to any infection, whether or not the disease is acute or chronic. Thoughts?
A: What I was referring to was the high fevers (>38.5 C) associated with chills and sweats and sometimes a drop in blood pressure. It is a result of release of cytokines in the bloodstream such as IL-1, TNF-alpha and IFN-gamma, usually in response to bacterial endotoxin. That is the type of response usually seen in acute prostatitis.
Bladder Stones(back to top)
Q: The question under discussion here was bladder stones
A: Bladder stones typically are visible on a plain abdominal x-ray, without the need for contrast in the bladder (cystogram) or injected in the vein (IVP). The diagnostic yield for these tests for most patients with chronic prostatitis is extremely small, but an IVP or CT is definitely required if there is any blood in the urine (which most stones will produce, at least microscopically).
TREATMENT:(back to top)A comment to an anonymous poster: I have made a point of not responding to ( or reading) the anonymous posts on this newsgroup for reasons obvious to anyone who follows them. For the benefit of the people reading this thread however, I need to make the following clarifications:

What is being referred to here is an abstract about my preliminary results with the combination of antibiotics and regular prostatic massage (see http://www.ben2.ucla.edu/~dshoskes/abstracts.html). An abstract is a statement of data: it is not peer reviewed, it is not published and I have taken GREAT pains to point that out several times in this newsgroup. I did however feel an obligation to make my interim findings available to add to the debate because publications can take over a year to reach the literature and quite frankly , we have not seen any real data presented from any other center that has attempted this approach. The conclusion was that the combination of massage and antibiotics proved beneficial to a group of men who had no prior relief with antibiotics alone ( most of whom had been treated on and off for a median of 3.5 years). Defining cured as symptoms gone, WBC in the EPS gone, and cultures negative gave a cure in 43% of men. I have no idea whether it was the massage, the antibiotics, both, or my magnetic personality that brought these changes about.

I have tried the modifications suggested by Dr. ANF including more frequent massage and combinations of antibiotics and found that the response rate if anything decreased. I suspect that has something to so with the suggested combinations of antibiotics which include both bacteriocidal and bacteriostatic drugs ( which can work against each other). I continue to offer combining massage and antibiotics as one treatment option in my clinics and am trying to better define the subpopulations that are likely to be benefitted or not by it.
Duration of Treatment
Q: I have some questions, really what I want is some hope. How long (median) does it take for your patient to be cured? Is every treatment different? Is the treatment typically antibiotics?
A: Remembering that I typically treat a group of very "hard core" prostatitis patients (median symptom duration 4 years) who usually have failed multiple treatments before they see me, the patients who are cured (on the basis of cultures and symptoms) take between 2 and 12 weeks depending on the treatments used. A summary of the treatments I employ can be found at the 2 web pages listed below. Treatment selection is based on the history, physical and laboratory results. It is clear to me that there is no one etiology that produces the symptom complex of CP and therefore no single treatment is effective for all patients. Until we understand this disorder better, treatment remains as much art as science.
Q: Dr. Shoskes, I really do not understand your perspective. Ignoring possibly helpful patient information and your preference to accept only "stubborn" cases of prostatitis (vs. attacking it early ) seem economically motivated.
A: What in the world are you talking about?? When did I ever say I only accept "stubborn cases" and don’t attack it early?? As it happens, the majority of patients who see me do have long standing histories, but that is selection by patient choice, not mine. I would love to have a patient whose history I could complete in less than an hour and who has not already failed 90% of the available treatments. As for the economic motivation, I collect more money doing a two hour kidney transplant than working 2 days in clinic seeing prostatitis patients so my pure economic motivation would be not to treat chronic prostatitis. That is the monetary equation explaining why so few doctors take this disease seriously and spend the necessary time with the patients.
Cure Rate(back to top)
Q: What is the cure rate among hard-core CP sufferers who seek your treatment vs. those who complete therapy & still have symptoms?
A: The information for individual treatments is available at http://www.ben2.ucla.edu/~dshoskes/abstracts.html and will be updated there when further follow-up is analyzed.

Gross numbers on patients that I have seen and have complete follow up on are 62% resolved, 17% partially improved and 21% not improved at all. Not all these patients actually turned out to have prostatitis but all had chronic pelvic pain syndromes. It’s quite probable that patients who were not improved after a short period did not come for return visits, so the true improvement rates may be lower.

Until I have the opportunity to properly analyze all my data in a scientific way, I am not going to answer questions about these raw data in any further detail. As I said, as more info is available I will post them on my web site and through our list bot mailing list (accessible from http://www.urol.com).
Q: Which begs the question.... Has anyone REALLY been cured?
A: Apart from many of my patients, whose names I wouldn’t list for obvious reasons, I have been completely cured of prostatitis. I had it when I was 22 with a mild recurrence when I was 26 and both bouts went away completely with antibiotics alone and have not come back 11 years later.
Quercetin(back to top) (Go to Prostatitis Website's Quercetin page)
Q: Your web page notes that quercetin should not be given in combination with certain antibiotics. Which antibiotics are those and why? I ask because I have had recommended to me a nutritional supplement that contains many, many things, among them quercetin.
A: Quercetin should not be used with the quinolone antibiotics (Cipro, Levaquin, Floxin, Trovan, etc.) because it binds competitively with the same site on bacteria through which those antibiotics work (DNA gyrase). Therefore, at least theoretically, quercetin could make those antibiotics ineffective. In any case, I try to reserve bioflavonoids for those patients in whom we believe bacteria are not, or at least no longer the cause of symptoms.
Q: I tried this bioflavanoid awhile back, and it helped ease the symptoms of my cp. I am hearing impaired, and know that NSAID’s can cause hearing loss. Is quercetin ototoxic?
A: Not that I have ever seen.
Macrobid(back to top)
Q: Has anyone been treated for a staph infection in the prostate with macrobid? Are there any notable side effects?
A: As has been posted here a few times, Macrobid has zero penetration into the prostate and is completely useless as a drug to treat bacteria in the prostate or any other deep tissue UTI (pyelonephritis, epididymitis, etc.). It remains an excellent drug for bladder infections.
Q: I have had this horrible thing for 1 1/2 years now and it is really bugging me. Some weeks I will feel fine and others I can tell the inflammation is coming back. I am currently on macrobid but the more I take it the less it works. I have been all kinds of vitamins including the saw palmetto thing and they have not helped at all.
A: As has been mentioned in this newsgroup before, macrobid, while an excellent antibiotic for simple bladder infections, has zero penetration into tissues (including the prostate) and as such has no role in the treatment of chronic bacterial prostatitis.
Elmiron(back to top)
Q: I saw this message on a prostate cancer site. Does anyone know if this medicine might be effective for prostatitis? "About two weeks ago, I learned from Dr. Parsons (UCSD) that he made significant progress with the problem of Interstitial cystitis and other conditions that patients suffer from frequent urination, urgency and irritation. He studied specifically patients after radiation treatments that had the same symptoms. He developed new test that can predict the usefulness of the new drug treatment with Elmiron."
A: The test is several years old and involves instilling potassium into the bladder through a catheter. Dr. Parsons has published on this but the results are very controversial. Elmiron is a treatment for interstitial cystitis which is helpful in some people. I have seen several men with symptoms of chronic prostatitis who have been treated with Elmiron based on a presumptive diagnosis of interstitial cystitis, with no effect. On the other hand, if any of these men had been cured with the Elmiron, they probably wouldn’t be coming to see me, so I really don’t know.
Herbal Treatments(back to top)
Q: I am wondering if anyone has had any success with homeopathic cures. I am trying a supplement that has Saw Palmetto, Stinging Nettle, and Lycopene. Also flushing my system with lots of water and Goldenseal Root, and CranDophilus for the urinary tract.
A: Perhaps it’s a small point, but what you are talking about are herbal supplements, which have at least a small chance of having some active biological ingredients that might have some influence on the prostate. On the other hand, true homeopathy involves drops of shaken water on a sugar pill and has no influence on anything in the body beyond a placebo effect; truly one of the great medical frauds of the past century.
Vitamin C(back to top)
Q: Whenever I take any form of vitamins or minerals, even in very small doses, I get a flare-up/inflammation in my prostate that is pretty severe. When I quit taking the vitamins, the inflammation is gone in 48 hours. I have taken very basic sets of multi-vitamins and individual vitamins, B, C, E, Zinc Selenium, etc. Nothing out of the ordinary or mega dosages. Even 500 mg. of Vitamin C causes problems.
A: Vitamin C, even in low doses can acidify the urine. If there is any inflammation in the bladder or urethra, it may exacerbate the symptoms. This type of problem is commonly seen in patients with interstitial cystitis.
Antibiotic Injection(back to top)
Q: Have a question for Drs. reading this and others... I was recently told by two different doctors I know in Pennsylvania that they would treat prostatitis by first withdrawing fluid with a needle from the prostate, examining or culturing the fluid, and then injecting the prostate with the appropriate antibiotic.
A: Unless there is a prostatic abscess (very uncommon and you’d be sick in hospital), sticking a needle into the prostate is not going to produce any fluid worth culturing. Most bacteria in CP live in a biofilm that sticks firmly to the tissues. Transperineal biopsy will produce tissue that can be cultured but is painful and usually only done in a research setting.

There have been several small reports in the literature that injecting antibiotics into the prostate or peri-rectally can produce a cure. Over the past 2 years we have tried it in 5 patients with positive cultures who did not improve with combined massage and oral antibiotics and it helped none of them. It is a very simple technique, and the lack of a large published literature leads me to believe that many others have probably also tried it without much success.
Effect of Antibiotics(back to top)
Q: Please also comment on the validity of this statement. Is it the majority opinion of the docs on this NG (newsgroup) that antibiotics help because of an anti-inflammatory effect? "My answer as to why the antibiotics helped - an answer which no medics here have refuted - is that they have an anti-inflammatory effect, whether by direct action on the cells of the prostate, or by a cortisone-like suppressive action on the immune system."
A: Antibiotics (as all drugs, synthetic and "natural") have multiple effects beyond their "intended" ones. For example, I have used ketoconazole to treat fungal infection, metastatic prostate cancer and to increase blood cyclosporine levels in kidney transplant patients. Remember, Viagra was developed as a heart medication!

Antibiotics will, by definition reduce the inflammation associated with bacterial infection if they kill the bacteria. I am aware of literature on direct anti-inflammatory effects of some tetracyclines (through inhibition of nitric oxide synthase pathways or IL-10 production) and cotrimoxazole (a component of Bactrim/Septra). There is however no proven "effect on prostate cells" or "cortisone-like effect".

These anti-inflammatory effects are quite mild compared to those achieved with steroids or non-steroidal anti-inflammatories (Daypro, Naprosyn etc.).

Daniel Shoskes MD(back to top) http://www.dshoskes.com

 

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