The Outcome of a Combination Treatment for Chronic Recurrent Prostatitis (Chronic Pelvic Pain Syndrome – CPPS)
Sang tae Park, M.D.,- Seoul Family Clinic. Won jae Cho, M.D., Ki byung Lee M.D.,
Keun mi Lee M.D., Prof . Seung pil Jung .M.D., Yeungnam University Medical Center
INTRODUCTION
A chronic recurrent prostatitis causes urinary difficulties and sexual discomforts in male adults, and it is also characterized by continuous pelvic pain or symptoms of sexual organ. Half of the male population experiences intermittent prostatitis related symptoms, and a study shows that the twenty five percent of those clients who seek medical help in urology clinic complain of one or more prostatitis related symptoms. 1)2) Although, large number of male population suffers chronic recurrent prostatitis, it does not respond effectively to classical treatments, such as antibiotic therapy, and it frequently recurs which typically presents slow recovery. 3)4)5) It is still a standard practice to use antibiotic therapy even though majority of prostatic secretion did not contain traces of bacterial components. However, clients still experience recurrence due to non-responsiveness or discontinuation of antibiotic therapy. Even though it has not been medically proven, there are possibilities that incomplete antibiotic therapy or other factors such as neuromuscular problems could have been the reason of the treatment failure.
A prostate massage is often combined with antibiotic therapy, and it improves the condition by promoting prostate to excrete infected cells and prostate fluid for prevent prostatic concretion , and it is also proven to provide a positive outcome when it is combined with antibiotic therapy for chronic recurrent prostatitis clients. 6) However, even with the combination treatment of antibiotics and massage therapy, clients still struggle with problem of recurrence. Therefore, we are at the point where we need to plan a new treatment to prevent recurrence and to improve clients’ symptoms. Among many other symptoms of prostatitis, the most frequently presented form is Chronic Pelvic Pain Syndrome which falls under Category III in NIH. This syndrome is frustrating to both clients and physicians since it can not be precisely diagnosed and treated. (7)
The purpose of this study is to find out characteristics of symptoms in clients whose prostatitis recurred after treated with primary method, and also to evaluate outcome of a new treatment which includes antibiotics, prostatic massage, spouse therapy, and physical therapy.
METHOD
1. Participants
The study was done on forty-five clients with Chronic Pelvic Pain Syndrome (NIH cat. III, IIIA, IIIB) who visited Prostatitis Clinic in Dae-Gu, Korea after receiving primary treatment and have been experiencing recurrence. All participants were experiencing recurrence after first treatment. Clients with negative result of presence of bacteria was categorized under III, and it was categorized under IIIA if 10 or more WBCs were found under microsope in prostatic secretions among these clients. If the WBC counts were less than 10 and only experiencing symptoms, it was categorized as IIIB. Participants were eliminated if they had history of cancer in reproductive system, perianal inflammatory disease, urinary tract stone, genital herpes, inflammatory bowel disease, chemotherapy or radiation therapy in pelvic area, urinary tract obstruction, neurogenic bladder, and prostate surgery in last 3 months.
2. Method
All the participants signed the consent prior to any treatment, and all were informed about tests and treatment plans. Detailed history was obtained retrospectively from the day of the recurrence, and also physical exam.was performed. Bacterial culture of urine and prostatic secretion were performed to draw lab. value. All participants received combined antibiotics and massage therapy, and these participants were divided into groups in random manner, whether or not they have extra-treatments such as combination physical therapy, spouse treatment. NIH-CPSI(National Institutes of Health Chronic Prostatitis Symptoms Index) survey(attached) was given to everyone to fill out before and after the treatment for comparison. Microscopic examination or culture of urine right after prostatic massage was performed for the participants who had difficulty obtaining prostatic secretion and with minimally taken specimens. High powered microscope was used to determine presence of bacteria. 400x was used for microscope. More than 5 fields were averaged out to determine final number of WBCs. Prostatic massage was performed twice a week for 32-40 weeks. Urethral irrigation, hot/cold bath, and combination physical therapy such as Pro Cera heat therapy, low frequency microwave treatment, TDP100 infra-red irradation, and cushion massage which all were consented by participants were also performed. All participants were asked to hold urine for at least 6 hours prior to obtaining specimens, however, were not asked for sexual abstinence. For the prostatic massage, an index finger was used to stroke prostate inward from outside to middle, then stroke it downward to the bottom. This was done 6 times for each side. For hot/cold bath, water with temperature of 18-20 degree in Celsius and 41-43 degree in Celsius were alternately used. Also, they were asked to stay in sauna with temperature of 95-105 degree ( in Finland style) for 5 minutes, then transfer to cold bath to stay another 1 minutes, and stay 10 more minutes in form of sitz bath in warm water. After this, they were asked to rinse scrotum with cold water, back to the sauna for 5 minutes, cold bath for 1 minute, sitz bath for 5 minutes, and finally rinse scrotum with cold water one more time. For urethral irrigation, 1-5% KMnO4 was diluted into N/S and sterilized it, and 20 ml syringe was used to inject. In the combination physical therapies, Pro Cera was used for magnetic heat treatment which was as hot as 41-43 degrees in Celsius, and it was performed for 20 minutes each time, twice a week. The heated magnetic was directly touched on to prostate through rectum as the clients stayed in side lying position.
For the low frequency microwave therapy, less than 5.9mA and 198 Hz was used twice a week. For infrared rays coated tourmaline crystals , 800-1600 nm was used twice a week. Also, in purpose of exercising below the waist in pelvic area and to achieve muscle heat effect, u Zap was used as a cushion massage for 5 minutes each time, twice a week. All participants were given Ciprofloxcine, bactrim, and tetracycline. All participants who experienced recurrence, both antibiotic combination and prostatic massage were provided. Also, these participants were divided into three groups which includes group A of 24 people who received the combination physical therapy , group B of 9 people who received spouse therapy, and lastly, group C of 12 people who only received antibiotics and massage therapy.
3. STATISTIC ANALYSIS
In purpose of evaluating improvement of symptoms between the groups or in a group and to average out continuous variance, paired t-test, t-test, ANOVA (Analysis of variance) was performed, and 0.05 alpha measure was used as a standard based on statistics. For the statistics, software called SPSS ver. 12.0 was used.
RESULT
1. Characteristics of participants
Total number of 46 participants signed the consents and was willing to improve their conditions by receiving treatments during this study. Out of all, one client was eliminated as a result of discontinued treatment and incomplete survey due to moving to another state. All participants were male with average age of 40.1+/- 11.3 years (24 ~ 68 year-old), and did not show any significant differences between the groups.
2. Average treatment period and comparison of before and after the treatment
Average treatment period was 26.9 +/- 35.9 weeks (1 ~ 222.9 week) with difference, yet not significant, between each group. Group B lasted 20.3 +/- 11.8 week, Group A 27.8 +/- 43.7 week, and lastly, Group C lasted 29.7 +/- 32.5 week. NIH-CPSI symptom score tested before the treatment are as follows. Group C 16.9 +/- 4.8, Group A 20.1 +/- 3.9, and Group C 21.5 +/- 2.2. This indicates that Group C who did not receive physical therapy and spouse therapy scored less than other groups(P<0.05).
3. Improvement in symptoms and life styles after the treatment
In order, Group B scored 21.4 ~ 2.2, Group A scored 20.1 ~ 3.4, and Group C scored 16.9 ~ 14.6. This indicates significant improvement statistically. However, Group C who only received antibiotic and prostatic massage showed improvements in pain management (from score 1.9 to 1.2), but did not show significant improvements in urinary symptoms (from score 5.8 to 5.5) and life style (from score 9.2 to 7.9) (P>0.05). On other hand, both Group A and Group B showed improvements in urinary symptoms, pain management, and life style (P<0.05). Based on NIH-CPSI scoring system, B Group who received antibiotics, prostatic massage, physical combination therapy, and spouse therapy scored the highest (before treatment: 21.4 +/-2.2, after treatment: 1.9 +/- 2.4, P<0.05) in improving presenting symptoms. The group who scored second highest was the one who did not receive spouse therapy only (before: 20.1 +/- 2.2, after: 3.4 +/- 3.4, P <0.05), and last group was the one who did not receive physical combination therapy and spouse therapy (before 16.9 +/- 4.8, after: 14.6 +/- 5.8, P<0.05).
CONSIDERATIONS
Stamey and others categorized prostatitis only based on Four-Glass test 8)in 1970 until during a meeting of NIH (National Institutes of Health) in the U.S.A. created new category called Chronic Recurrent Prostatitis to sub categorize chronic prostatitis in 1995 (chart-1) 9). In the new category system, Chronic Prostatitis was divided into two subcategories, Chronic Bacterial Prostatitis (CBP) and Chronic Pelvic Pain Syndrome (CPPS). Again, CPPS was subcategorized into two, inflammatory (previously known as chronic non-baterial prostatitis) and non-inflammatory (currently known as non-inflammatory pelvic pain syndrome). In addition, Non-symptomatic inflammatory prostatitis was included. To be diagnosed as CPPS, client must be 18 years old or older, and experiencing pain around penis, testes, and pelvic area for at least three months. To verify presence of inflammation, prostatic secretions, semen in the urine after prostatic massage are obtained for WBC count or with sonogram. Non-symptomatic inflammatory prostatitis is diagnosed with positive WBC presence in the prostatic tissue or prostatic secretions when there is no symptom. Chronic prostatitis/Chronic Pelvic Pain Syndrome is a multiple symptom complex rather than a single disease. Therefore, combination treatment is more effective than single therapy in treating infection and inflammation which relieves symptoms by improving neuromuscular function. (10) Usage of antibiotic is a classic treatment that is used the most, and currently, physicians use antibiotics for Chronic Prostatitis regardless of presence of bacteria, and many studies proves the effectiveness of antibiotics as well. Numerous studies continues to prove (11) failure of single antibiotic therapy, (12) study of effectiveness of new class of drug such as Quinolon, (13) and benefits of combination antibiotic therapy. Bactrim is used for Chronic Prostatitis for a long time (14)(15), and Tetracycline is used to treat Chlamydia and nano bacteria. (16) Recent study shows that the combination of these drugs improved the effectiveness of treatment. (17) There is controversy in determining effectiveness of prostatic massage to treat Chronic Prostatitis. There was significant symptom relief in 52% of NIH-class II clients, and 29% of Class IIIA clients experienced relief. Even though it is controversial, clients still report effectiveness of prostatic massage, because it improves circulation of prostate which helps to excrete bacteria and improves effectiveness of antibiotics. We performed multiple antibiotic therapy and massage therapy on all participants. The purpose of this study was to determine time frame and effectiveness of classic treatment (multiple antibiotic therapy and massage therapy) and additional treatment such as combination physical therapy and spouse treatment which were performed on 45 randomly chosen Chronic Pelvic Pain Syndrome (III, IIIA, IIIB) clients who experienced recurrence based on NIH category. The effectiveness was determined using NIH-CPSI. Based on the result, new treatment (combination therapy) significantly had shorter time frame and better recovery than classic treatment. This indicates possibility that using the new treatment option in addition to classic treatment will improve effectiveness and help clients who previously had difficulty relieving symptoms and struggle with frequent recurrence. Heat therapy using Pro Cera is being studied, and also, another heat therapy is being tried using microwave to improve symptoms on CPPS clients. (22) Also, recently, a study revealed improvement on CPPS clients after using low frequency wave electrical stimulation through urinary tract and rectum. (23)(24) There are also biofeedback therapy studies (25) and low frequency magnetic stimulation therapy studies. However, it revealed that IIIB clients only experienced a relief with pain but not with symptoms when they received low frequency magnetic stimulation therapy. (26)A variety of studies is being done to improve symptoms of CPPS clients, and some of them significantly has shown improvements. This proves that CPPS is a complex of multiple symptoms rather than a disease, and it indicates that this syndrome is derived from multiple factors such as neuromuscular contraction, neuropsychiatric problems, prostatic calculi and prostatic nerve compression by them, and immunologic problems rather than simple infection and inflammation. Therefore, multiple treatments are required instead of simple antibiotic therapy. Even though, participants experienced relief in many aspects with combination physical therapy, this study still has some limitations. First, age and other factors were not controlled between groups. Second, variances in physical exercise pattern, diet, and nutritional status were not compared before and after the study, especially when CPPS is often affected by client’s psychological stress and life events which were failed to be monitored. However, the exact amount of variances that will affect the result was not identified. Lastly, continuous follow ups on all participants were not done. They are asked to return for evaluation and treatment when the conditions get worse, however, after experiencing improvements with CPPS related symptoms, no participants returned to clinic for follow up during the study which might have affected the results.
Although, there were many limitations, this study accomplished to reveal new concept of CPPS, which frequently recurs, and combination treatment to treat nano bacteria.
Especially, by treating the spouse along with combination treatment, clients will experience a significant improvement in preventing recurrence and symptom relief.
This indicates that, in addition to multiple antibiotic therapy and prostatic massage, using physical therapy and spouse treatment including Pro Cera will shorten treatment time and improve symptoms and the quality of life.
References
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17) Smelov V, Perekalina T, Gorelov A, Smelova N, Artemenko N, Norman L. In vitro activity of fluoroquinolones, azithromycin and doxycycline against chlamydia trachomatis cultured from men with chronic lower urinary tract symptoms. Eur Urol. 2004 Nov;46(5):647-50.
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Table 1. General characteristics of study subjects (n=45)
================================================================
Treatment group (mean±SD)
Characteristics -----------------------------------------------
(Age-yr) Group I Group II Group III p-value*
----------------------------------------------------------------
36.8±8.6 44.6±13.5 44.0±13.3
20-29 4 0 1(9.1)
30-39 14 5 7
40-49 4 2 0
50-59 3 0 3
60-69 0 2 2
----------------------------------------------------------------
Total 25 9 11
=================================================================
* : 0.086 (ANOVA)
Group I : antibiotics + prostate massage +physiotherapy
Group II : antibiotics + prostate massage +physiotherapy +mate's therapy
Group III : antibiotics + prostate massage
Table 2. Duration of treatment
======================================================
Treatment group (mean±SD)
Characteristics -----------------------------------------------
(duration-weeks) Group I Group II Group III p-value*
----------------------------------------------------------------
27.8±43.7 20.3±11.8 29.7±32.5
1-9 2 0 4
10-19 15 8 2
20-29 4 0 1
30-39 1 0 1
40-49 1 0 0
50-59 0 1 1
>59 2 0 2
------------------------------------------------------
Total 25 9 11
=================================================================
* : 0.831 (by ANOVA)
Group I : antibiotics + prostate massage +physiotherapy
Group II : antibiotics + prostate massage +physiotherapy +mate's therapy
Group III : antibiotics + prostate massage
Table 3. Score† of NIH-CPSI before treatment
=============================================================
Group I(25) Group II(9) Group III(11)
-------------------------------------------
mean ± SD 20.1±3.9 21.5±2.2 16.9±4.8
=============================================================
† total score = symptom scale score + quality of life impact
* p value = 0.03
Group I : antibiotics + prostate massage +physiotherapy
Group II : antibiotics + prostate massage +physiotherapy +mate's therapy
Group III : antibiotics + prostate massage
Table 4. Symptoms and results of NIH-CPSI
====================================================================
Group I Group II Group III
-------------------------------------------------------------------
Pain
Perineal 1.0±0.2
0.2±1.2 0.7±0.5 0.0±0.0 0.8±0.5 0.6±0.5
Scrotal 0.5±0.5 0.04±0.2 0.4±0.3 0.0±0.0 0.8±0.5 0.7±0.5
Penile 0.4±0.5 0.04±0.2 0.6±0.3 0.0±0.0 0.2±0.4 0.1±0.3
Suprapubic and Loin 0.5±0.5 0.04±0.2 0.6±0.6 0.0±0.0 0.3±0.5 0.2±0.4
Mean NIH-CPSI score 2.7±0.9 0.7±1.3* 2.2±0.9 0.0±0.0 * 1.9±1.0 1.2±1.1*
Urinary symptoms
Residual urinary
sensation 3.3±1.7 0.6±0.7 4.2±0.9 0.7±0.5 2.6±1.6 2.5±1.5
Frequency 3.8±1.8 0.7±1.1 3.7±0.9 0.4±0.8 3.2±1.5 3.0±1.4
Mean NIH-CPSI score
7.1±3.3 1.3±1.5 * 7.9±1.3 0.7±1.2*
5.8±3.0 5.5±2.8⍑
Quality of life impact
Frequency of life
disturbance 2.6±0.6 0.4±0.6 3.0±0.0 0.1±0.7 2.3±0.9 1.9±0.9
Frequency of thought
about symptoms 2.9±0.7 0.6±0.6 2.9±0.9 0.2±0.4 2.6±0.5 2.7±0.7
Feeling of permanent
symptoms 5.1±0.9 0.7±0.6 5.4±0.7 0.8±0.7 4.7±1.7 3.6±1.2
Mean Quality of life
impact score 10.6±1.6 1.8±1.4 * 11.7±1.0 1.1±1.3 * 9.2±2.3 7.9±2.7 ⍑
Mean symptom scale
score 9.5±3.7 1.6±2.3 * 10.1±1.9 0.8±1.2 * 7.7±3.0 6.6±3.4 *
Mean total score 20.1±3.9 3.4±3.4 * 21.5±2.2 1.6±2.7 * 16.9±4.8 14.6±5.8 *
BT AT BT AT BT AT
Group I : antibiotics + prostate massage +physiotherapy
Group II : antibiotics + prostate massage +physiotherapy +mate's therapy
Group III : antibiotics + prostate massage
B.T : Before treatment, A.T : After Treatment.
NIH-CPSI=National Institutes of Health Chronic Prostatitis Symptoms Index.
Mean symptom scale score = pain + urination.
Mean total score = symptom scale score + quality of life impact
* P-values <0.05 (by paired t-test &ANOVA)
⍑ P-values >0.05 (by paired t-test)