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Simplified Prostatitis Test is put to the Test (pdf)
Sequential Monotherapy Yields Poor Results in CPPS (pdf)

Ejaculatory Pain Affects 75% of Men With CPPS (pdf)

Managing chronic prostatitis: A modern approach (pdf)
Costs related to prostatitis extend beyond the obvious (pdf)
Inflammation, infection are not sole causes of CPPS (pdf)
New bacteria strains found in prostatitis patients (pdf)
Chronic prostatitis symptoms stabilize over time (pdf)

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In the April 2001 Urology Times, two articles discuss prostatitis from viewpoints that substantially differ from the widely accept one. These articles may be of great importance to men with prostatitis who have not been helped by regular treatment. Both articles call into question the standard assumption that the heart of the problem of prostatitis lies in an inflamed or infected prostate gland and imply the source of the problem probably lies elsewhere.

The first article states a view that in certain cases , prostatitis may well be a neuromuscular disorder of the muscles of the pelvic floor, caused by chronic tension of the pelvic muscles, and not a problem of the prostate gland.. The article describes a new non-drug treatment used in the pelvic pain clinic of the Urology Department at Stanford University Medical Center.
The second article, the lead article of the Urology Times, April 2001 which reports the results of a study of the biopsied prostate tissue from 97 men diagnosed with chronic prostatitis. This careful study provides clear evidence that there is simply no inflammation in the prostates of 66% of men in the study, and in all but 4% of the remaining men, inflammation is so mild as to be almost an insignificant feature. Again in this article the role of the prostate in prostatitis is called into serious question.

David Wise, Ph.D.,

Articles below are reprinted from Urology Times, Vol 29 Number 4 April, 2001, page 14 & 45, ©2001 Advanstar Communications, Inc. Advanstar Communications, Inc., retains all rights to this material. To subscribe to Urology Times, call 1-888-527-7008 or visit www.advanstar.com

Is prostatitis related to pelvic muscle dysfunction?
Myofascial release, progressive relaxation education may correct condition in some cases
Scott Tennant UT CORRESPONDENT

Arlington, VA—The very idea that the pain and symptoms of prostatitis have little or nothing to do with the prostate may be foreign to many urologists, but it was a theory fostered by two presenters at the Third International Prostatitis Collaborative Network workshop here.

David Wise, Ph.D. a research scholar in urology at Stanford (CA) University, and Diane Hetrick, a physical therapist in urology at the University of Washington, Seattle, both suggested that chronic prostatitis may in fact be traced to pelvic floor muscle dysfunction, suggesting that non-medical intervention may be feasible in some patients.

You don't do open heart surgery when the problem is heartburn," said Dr. Wise. "Your definition of the problem determines what you do, and I would suggest that some cases of prostatitis are actually linked to chronic tension of the pelvic floor — that it is a problem of the pelvic muscles, not the prostate."

Dr. Wise acknowledged that the concept "is certainly in the minority and not popular. But something in which I believe deeply and on which we have based our treatment in the special pelvic pain clinic at Stanford for the past 5 years," he said.

An overused syndrome?

Dr. Wise suggests that the reason prostatitis is largely resistant to treatment is because some patients chronically (and unknowingly) contract their pelvic floor muscles. The pelvic muscles become chronically tightened in a temporary contracture, giving irritated tissues little or no chance to heal. This in turn, can lead to symptoms commonly associated with prostatitis.

"I liken the condition known as prostatitis to carpal tunnel syndrome of the pelvis. It's an overuse syndrome in which men chronically tighten their pelvic floor muscles."

Dr. Wise and colleagues take a two pronged approach to the problem: myofascial release and training in progressive relaxation of the pelvic floor.

Myofascial release is first performed by a trained clinician, usually a physical therapist, Dr. Wise said. Contracted pelvic floor tissues are digitally stretched in 10-40 treatment sessions that each last 30-45 minutes.

"We like to teach the patient's spouse or partner to perform the myofascial release so that they don't have to come to the clinic so often," said Dr. Wise, explaining that he suffered from prostatitis himself for 22 years and has been symptom-free for a number of years after undergoing pelvic floor myofascial release and training the progressive pelvic floor relaxation.

Give it a rest

Patients are taught progressive relaxation so that they may eliminate habitual contraction of pelvic muscles. The technique takes 4 months to 2 years to properly learn.

"There is a trick to progressive relaxation, but it's counterintuitive," Dr. Wise said. "You have to lower autonomic arousal in general. Specifically, you have to feel the contracture and actually open yourself up to the pain. I have measured EMG activity in the anus using a pelvic floor sensor and observed that the tension almost always reduces as a man adopts this strategy. Prostatitis — or more accurately, some pelvic floor pain — can be seen as a gift. It's your body telling you, 'Give me a rest.' But it needs external help in order to achieve that.

"Myofascial release and competence in progressive relaxation of the pelvic floor are equally necessary in my experience," he said. "The myofascial release releases the pelvic floor from its contracture while the relaxation training aims to end the habitual holding that started the problem in the first place. I tell patients this is the 'slow fix,' not he 'quick fix.' It is an inside job requiring the patients' steadfast efforts."

Pelvic muscle tone increase

Dr. Wise said his experience with the techniques in hundreds of patients has shown that only those who are motivated and do the program conscientiously have the chance to substantially reduce or eliminate their symptoms.

"Men with (chronic pelvic pain syndrome) had more abnormal pelvic floor and abdominal muscular pathologic findings than those without pelvic pain." —Diane Hetrick

At the University of Washington, Hettrick attempted to document pelvic floor function in both prostatitis patients and in normal controls. She performed standardized physical therapy evaluations on 30 men with chronic pelvic pain syndrome and 51 controls.

Hetrick said that she found statistically significant higher incidences of pelvic floor muscle tone increase (53%, p=.01), pain with palpation of pelvic floor muscles (70%, p = .001), abdominal myofascial pain and tension with palpation (23%, p=.01), and decreased strength of pelvic floor contractions (28%, p=.036 in CPPS patients.

To further validate the data, Hetrick was blinded during subsequent evaluations and found similar trends to those discovered in an unblinded fashion.

"Ultimately what we found was that men with CPPS had more abnormal pelvic floor and abdominal muscular pathologic findings than those without pelvic pain," she said

More information about the treatment of tension disorder prostatitis can be found at www.prostatitis.org/tensiondisorder.html.

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Is Inflammation a reality in 'chronic prostatitis'?
Only one-third of patients in study found to have detectable prostatic inflammation

Scott Tennant
UT CORRESPONDENT
Arlington, VA

By its very definition, the term "chronic prostatitis would appear to refer to an inflammatory disease of the prostate gland. But according to a University of Washington pathologist, that may not necessarily be so.

Lawrence D. True, M.D., reported data here suggesting that chronic prostatitis as a diagnostic term may be a misnomer. Dr. True and colleagues conducted a study in which only one-third of patients with category III prostatitis (chronic pelvic pain syndrome) actually had detectable prostatic inflammation. I've come to the conclusion that research into this clinical entity should probably focus on mechanisms other than those that cause tissue inflammation." Said Dr. True, an associate professor of pathology at the University of Washington, Seattle. "For example, we may be well-served to look at prostatitis as more of a neuromuscular disorder than an inflammatory disorder"

In a presentation at the International Prostatitis Collaborative Network workshop here, Dr. True discussed the basis of his conclusions, a study of 97 men who presented with chronic pelvic pain syndrome and underwent bilateral prostate biopsies (J Urol 1999; 162;2014-8).

He and colleagues analyzed a total of 368 biopsies from the men and found that 33% had inflammtion, only 4% of which was characterized as 'moderate' (10 to 200 leukocytes per 1-mm field) or "sever" (more than 200 leukocytes per 1-mm field).

Interestingly, 14 of the 97 patients had inflammatory cells in expressed prostatic secretions, but there was no apparent connection between the number of inflammatory cells in the secretions and the presence or absence of tissue inflammation in the biopsies.

"We (the investigators) have discussed the lack of direct correlation between neutrophils in the expressed prostatic secretions and tissue inflammation, and we don'' have a clear-cut explanation," Dr. True told Urology Times,. "I suspect that the neutrophils concentrate in the secretions by a mechanism different than that which leads to inflammation, and that the number of neutrophils and their transit time in the tissue is such that they don't collect in sufficient numbers in tissue to be diagnosable."

Re-assess diagnosis, treatment

Part of the disparity may be explained by the location of inflammation in the subjects, noted John Krieger, MD, study co-author and moderator of the session at the workshop. The researchers found that while biopsies were taken from the prostatitc parenchyma, inflammation was generally diffuse and stromal, "and therefore very little of it was actually associated with the glands themselves," Dr. Krieger said.

Perhaps not surprisingly, Dr. True's presentation generated a good deal of discussion among workshop attendees. Some questioned the investigators' methods for collecting prostatic secretions. Others wondered why inflammation, which is so common a in pathologic specimens from older patients, would be absent in younger patients such as those in the Washington study (median age, about 40 years).

Still Dr. True stood by his team's findings and called for a re-assessment of diagnosis and treatment of category III prostatitis.

"At this point, I believe it would be more accurate — albeit less specific — to use the NIDDK term of 'chronic pelvic pain syndrome' to describe what is happening to these patients," he said.

The Washington researchers have already undertaken a number of other investigations into ways in which inflammation affects the prostate such as in BPH and cancer.

"It would probably help, too, to localize these inflammatory cells and characterize their interaction with the parenchymal cells of the prostate," said Dr. True.

 

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