93 Central European Journal of Urology
original paper URINARY TRACT INFECTIONS
Mental status in patients with chronic bacterial prostatitis Oleg Banyra1, Olha Ivanenko2, Oleg Nikitin3, Alexander Shulyak4 12nd Lviv Municipal Polyclinic, Lviv, Ukraine 2The Communal Institution of Lviv City Council «Lviv Regional Clinical Psycho–Neurological Centre», In–patient Department No.2, Lviv, Ukraine 3O.O. Bogomolets National Medical University, Kiev, Ukraine 4Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
Article history Introduction. Chronic prostatitis is a widespread urological disease with a lengthy course and a propensi- Submitted: Nov. 11, 2012 ty to frequent recurrences. Adequate response to anti–inflammatory therapy is lacking in a high percent- Accepted: Jan. 15, 2013 age of patients, which causes them to seek medical advice from different doctors. Thus, the physicians are challenged to look for other reasons causing the pathological symptoms. Material and methods. We have reviewed the patients with treatment–resistant chronic bacterial pros- tatitis (CBP) from the perspective of psychosomatic medicine. For the evaluation of primary mental status and treatment control we used standard approved questionnaires. All 337 CBP patients initially under- went therapy aimed at pathogen eradication. If psychopathological symptoms were evident and domi- nated over urological ones, the patients were referred to psychiatric evaluation and treatment. Results. The frequency of concomitant psychosomatic disorders (PSD) in patients with CBP was 28.2% and neurotic disorders – 26.4%. Adequate multimodal anti–inflammatory therapy followed by a few sessions of psychotherapy decreased the manifestations of PSD in 30.5%, neurotic disorders in 51.7%, and premature ejaculation in 60.5% of patients with CBP. The addition of pharmacotherapy to psychotherapy is effective in treatment–resistant cases. However, after multimodal treatment, 31.5% of pts. with PSD and 13.5% of pts. Correspondence with neurotic disorders still remain treatment–resistant and required in–depth long–term psychiatric care. Alexander Shulyak Conclusions. A significant portion of CBP patients were diagnosed with neurotic, psychosomatic, and/or 6, Boguna Street Apt. 6, Lviv 79013, Ukraine depressive disorders. phone: +38 06 767 08 952 Antibacterial and anti–inflammatory therapy, when followed by appropriate psychotherapy and pharma- [email protected] cotherapy, significantly decrease the manifestations of mental disorders in CBP patients.
Key Words: chronic bacterial prostatitis ‹› mental status ‹› psychosomatic disorders ‹› premature ejaculation
INTRODUCTION tatitis have been uninterrupted. The main mental disorders among the CBP patients have been consid- For a long time mental status in patients with chronic ered as neurotic and/or psychosomatic disorders ac- prostatitis was a topic for investigation. Green M.R. companied by depression [4–8]. and Dean A.L. (1954) were among the first authors Our aim was to estimate the incidence of mental dis- to describe patients with the combination of chronic orders in patients with CBP, to evaluate the efficacy prostatitis and various mental disorders (referred of their multimodal therapy, and to determine the to as ”psychoneurosis”) [1]. Sometime later, in 1973 principles of comprehensive medical aid in patients Mellan J. et al. coined the term “prostatic neurosis” with such pathology. to describe this patient population [2]. According to Jansen P.L. et al. (1983), “neurotic” disorders, such MATERIALS AND METHODS as sensation of anxiety, insecurity, fear, and depres- sion are present in a significant number of chronic Over the last five years a total of 337 patients with bacterial prostatitis (CBP) patients regardless of CBP had been observed. The duration of disease per- urological findings [3]. Until now, the studies of psy- sistence ranged from two to 11.5 years. The choice of chological condition in patients with chronic pros- diagnostic and therapeutic methods was made accord- 94 Central European Journal of Urology ing to approved clinical protocols that adhered to Euro- gomery–Åsberg Depression Rating Scale (MADRS) pean Association of Urology Guidelines and European as a clinician–administered measure for depression Psychiatric Association Guidance, and did not digress and a guide to evaluate recovery [11, 12, 13]. from the principles of the local ethical committee. After confirming the mental disorder in -our pa The diagnosis of CBP was confirmed if prostatic fluid tients, initially 4–5 sessions of psychotherapy (Ra- contained more than 10 leucocytes per high–power tional Emotive Behavior Therapy (REBT)) were ar- microscopic field and a pathogen was concomitantly ranged upon completion of antibacterial treatment. identified [9]. The intensity of clinical symptoms as- If psychiatric symptoms still persisted then phar- sociated with CBP was measured using the CPSI macotherapy was prescribed on a per case basis ac- pain domain score (0–21) from the National Institute cording to the diagnosis, dynamics, and severity of of Health–Chronic Prostatitis Symptom Index (NIH– symptoms and their regression/progression together CPSI) scale [10]. with consideration given to the tolerance of adverse Initially, all patients were subjected to multimodal effects to drug therapy (Table 2). Psychotherapy was therapy with antibiotics, immunomodulators, and continued, even if changing its form was necessary. physiotherapy that included prostatic massages. Recommendations for diet and lifestyle changes were RESULTS also expressed, which also included the need to as- sess patients’ sexual partner(s) and treat if indicated. At the time of CBP primary diagnostics or confirm- In cases in which sexually transmitted and/or non– ing, different mental disorders were registered in 137 specific pathogens were detected, antibacterial ther- (40.7%) pts. Among them were concomitant psycho- apy was continued until all traces of the pathogen(s) somatic disorders at the onset of CBP treatment that were eradicated. Antibacterial regimens were di- were noted in 95 patients (28.2%), namely: panic at- rected by the sensitivity of pathogens (Table 1). tacks in 44 patients (13.1 %), irritable bowel syndrome If, after pathogen eradication, psychopathological in 35 patients (10.4%), paroxysmal tachycardia in 38 symptoms dominated over urological and/or lack (11.3%) pts., tension headaches in 29 (8.6%), anorexia of efficiency of long–term CBP–specific therapy- oc nervosa in 21 (6.2%) pts., hyperhidrosis in 16 (4.7%) curred, the patients were referred to psychiatric con- pts., and multiform parasthesias in 75 (22.2%) pts. sultation. In most CBP patients, the abovementioned disorders For the evaluation of primary mental status and were present in various combinations. Neurotic dis- treatment control we used our local as well as stan- orders were registered in 89 (26.4%) pts. as well inde- dard approved questionnaires included a Symptom pendently in 42 (12.5%) pts. as in combination with Checklist Scale, a Diagnostic and Statistical Manual PSD in 47 (13.9%) patients. All of the neurotic and IV Text Revision (DSM–IV–TR), depression invento- PSD patients also demonstrated different depressive ries: the Beck Depression Inventory II (BDI–II) as a disorders, which were predominantly mild or moder- self–report scale for depressed mood and the Mont- ate with only a few severe cases. After normalization of the parameters of prostatic fluid and urinalysis, eradication of CBP causative Table 1. Pathogens implicated in chronic bacterial prostatitis pathogens, and 4–5 sessions of psychotherapy and the suitable treatment (REBT), the mental status spontaneously returned Pathogen Treatment to normal in 29 pts. with PSD (30.5% of this sub- group) and in 46 pts. with neurotic disorders (51.7% Non–specific pathogens E.coli,( of this subgroup). This fact demonstrates that the ap- Staphylococcus sp., Streptococcus Antibiotics according to sensitivity sp., Enterococcus sp., Klebsiella plication of rational emotive behavior therapy plays of pathogen pneumoniae, Pseudomonas an important role in treatment strategy for patients aeruginosa, Proteus sp., etc.) with CBP and mental disorders. Doxycycline hydrochloride, Another 66 patients with PSD (66.3% of this sub- Chlamydia trachomatis Azithromycin, Josamycin group) and 43 patients with neurotic disorders (48.3% of this subgroup), after normalization of pros- Metronidazole, Ornidazole, Trichomonas vaginalis Tinidazole tate fluid parameters and a few sessions of REBT, did not demonstrate a subjective response to the Doxycycline hydrochloride, Ureaplasma urealitycum standard treatment and required additional special- Ofloxacin, Levofloxacin ized treatment. This specialized treatment included Tetracycline, Doxycycline Mycoplasma hominis, the continuation of psychotherapy with possible al- hydrochloride, Erythromycin, Mycoplasma henitalium teration of its form combined with pharmacotherapy Azithromycin including the use of tranquilizers, antidepressants, Gardnerella vaginalis Metronidazole, Clindamycin, and/or neuroleptics (Table 2). 95 Central European Journal of Urology
Table 2. Pharmacotherapy of mental disorders concomitant neurotic disorders, a significant -im provement was observed in 31 cases (72.1% of this Mental disorder Treatment subgroup) – a finding that supports such a therapeu- PSD Trazodonum, Flupenthixol, Quetiapine fumarate tic approach (Fig. 2). Sertraline, Citalopram, Escitalopram, Diazepam, Neurotic disorders The addition of pharmacotherapy to psychothera- Gidazepam py in patients with CBP and mental disorders was Venlafaxine, Paroxetine, Gidazepam, Oxazepam, found to significantly decrease the manifestation of Depressions Alprazolam neurotic disorders (Fig. 2). Obtained results reflected by inventory scores are In cases of PSD we used antidepressants and/or neu- presented in Table 3. roleptics. The effect of such pharmacotherapy usu- However, after anti–inflammatory therapy com- ally became evident only after two to three weeks bined with psychotherapy and pharmacotherapy, treatment, which is why patients were informed in 30 (31.5%) pts. with PSD and 12 (13.5%) pts. with advance about the necessity the to follow the pre- neurotic disorders were still treatment–resistant. scribed drug regimes. Moreover, both PSD and neuroses were registered Tranquilizers were predominantly prescribed in cas- in eight of them, which required in–depth long–term es of neurotic disorders and sometimes in patients psychiatric assistance. with mild depressions. Their effect became subjec- A separate subgroup included 114 (33.8%) pts. with tively appreciable by the end of the first or second CBP and premature ejaculation. Abnormalities of day of use. orgasm and ejaculation are among the main symp- After application of the abovementioned psychophar- toms of CBP and appear due to increased tone of macologic treatment to the 66 patients with refrac- alpha–1A–receptors against the background of pros- tory PSD: tatic inflammation [14]. Patients with premature – 36 (54.5%) pts. showed significant improvement ejaculation and without CBP were not included into (partial or complete elimination of the pathological our study because such patients require a different symptoms); therapeutic strategy. – 24 (36.4%) pts. showed moderate improvement; The presence of premature ejaculation more often – six (9.1%) pts. did not demonstrate a subjective re- than not put a patient into a mood of anxiety and sponse to the treatment at all and, thus, a severe con- could be the trigger factor provoking the develop- comitant psychiatric pathology was appreciated during ment of mental disorders. Such disorders have a sig- a more in depth psychiatric assessment (hypochondria nificant psychological burden on men, their partners, in three pts., major depressive disorder in two pts., and the male/female relationship [15, 16]. The pri- and schizophrenia in one pt.) that required prolonged mary treatment should involve psychological/sexual medication therapy and further observation. therapy. Despite the etiology, psychosexual treat- After adding the pharmacotherapy to psychotherapy ment can play an important role in the management in 43 treatment–resistant patients with CBP and of premature ejaculation [17].
70 66 60
50 43
40 PSD Pts. 30 30 neuroc disorders 20 12 10
0 Before A er Before A er treatment treatment pharmacotherapy pharmacotherapy
Figure 1. Efficacy of anti–inflammatory treatment combined Figure 2. Efficacy of previous anti–inflammatory treatment with psychotherapy (REBT) in patients with CBP and mental followed by psychotherapy and pharmacotherapy in patients disorders. with CBP and mental disorders. 96 Central European Journal of Urology
After multimodal anti–inflammatory therapy of CBP Dysuria, incomplete bladder emptying, and espe- followed by several sessions of REBT, various prolon- cially lengthy pain syndrome with frequent exac- gations in terms of intercourse time were observed erbations deplete the psyche of patients with CBP, in 69 patients (60.5%). Another 45 patients (39.5%) contributing to a negative impact on the patient’s required applications of local anesthetics and/or oral quality of life that may trigger the development of administration of selective serotonin reuptake inhib- mental disorders [19, 20]. Almost a third of men ex- itors (SSRIs). By prolonging the intercourse time, periencing urogenital pain or prostatitis–like symp- these therapeutic options consequently improved the toms would be less than satisfied if this was to be mental status in a large group of patients suffering ongoing for the rest of their life [21]. The symptoms from both CBP and premature ejaculation. of chronic prostatitis are strongly associated with The results presented herein are indicative of a sub- psychosocial risk factors such as pain catastrophiz- stantial portion of concomitant PSD (28.2%), neurotic ing, depression, and anxiety [22]. disorders (26.4%), and premature ejaculation (33.8%) According to Keltikangas–Järvinen L. et al. (1982), in patients with chronic prostatitis. In a large fraction there is a correlation between the duration of somat- of patients, mental disorders and/or premature ejac- ic irritative symptoms and the intensity of psychi- ulation reverse spontaneously with adequate anti- atric manifestations [23]. Zhou Q. et al. (2007) have bacterial therapy followed by a few sessions of REBT. also registered that there is a close correlation be- However, some patients demonstrate resistance to the tween the severity of psychological symptoms and conventional multimodal treatment for CBP, which the clinical symptoms in patients with chronic pros- challenges the experts to identify other causes of patho- tatitis. [24]. Symptoms of depression in patients logical symptoms and their respective treatment. with chronic prostatitis are closely associated with clinical symptom intensity. According to Jiang S. et DISCUSSION al. (2012), pain or discomfort in the genital area and urination disorders have an impact on symptoms Very often in daily practice, urologists encounter the and total score in the NIH–CPSI scale. These au- situation in which the application of long–term anti- thors showed a significant positive correlation of the bacterial therapy in patients with chronic prostatitis NIH–CPSI score with the symptoms of depression does not yield adequate results. Some patients still with a simultaneously negative correlation with complain of a variety of disorders despite the use of erectile function in patients with chronic prostatitis all standard treatment options, some of them even (r = 0.32, 0.31, 0.35, 0.38, and –0.36, P <0.05). [25]. lose faith in the ability to remedy after years of futile Intellectualization, redefinition, and flexibility in treatment. Such disappointment hurts the patient’s healthy individuals are higher in frequency in de- mentality and even confuses urologists to the point of scending order comparing to prostatitis patients perplexity, which is why a deeper insight into the es- – fatalism, externalization, and self–pity are corre- sence of the problem is required for a more complete spondingly lower in frequency. Patients with chronic understanding of psychological state of patients with prostatitis often suffer from depression, anxiety, and a CBP, as well as the mechanisms that influence it. higher perception of stress. In particular, these disor- The chronic pain syndrome, caused by antibiotic–re- ders were closely related to the pain and subsequently sistant prostatic inflammation, reduces the working decreased the quality of life in such patients [26]. capacity of patients and worsens their quality of life The manifestations of complex neuroendocrine ab- and their ability to interact socially [18]. normalities are usually present in patients with
Table 3. Efficacy of multimodal treatment in 137 patients with CBP and mental disorders that reflected by inventory scores
CPSI pain domain Depression grade Expressive symptoms (NIH–CPSI scale), pts. (MADRS score), pts. manifestation* (DSM–IV–TR), pts. Mild Moderate Severe None Mild Moderate Severe Neurotic PSD 0–7 8–13 14–21 0–6 7–19 20–34 >34 disorders Before treatment 28 66 43 – 94 39 4 95 89 After anti–inflammatory treatment 69 46 22 52 60 21 4 66 43 and 4–5 sessions of REBT After pharmacotherapy and 103 26 8 98 20 17 2 30 12 psychotherapy
* – in 47 pts. before treatment were present both psychosomatic and neurotic disorders 97 Central European Journal of Urology
CBP that exert a remarkable negative influence. The presence of a traumatic factor (situation) and Statistically significant changes of serum cortisol the patient’s predisposition to PSD are decisive fac- levels were found in patients with chronic prostati- tors in PSD development. Since the presentation of tis/chronic pelvic pain syndrome [4]. Patients with chronic prostatitis is directly associated with the gen- chronic prostatitis have abnormally high levels of ital area and sexual behavior disorders, this condi- progesterone and androstenedione, and abnormally tion is a powerful traumatic factor in patients prone low levels of corticosterone, aldosterone, and 11– to PSD – psychosomatic disorders in CBP are noted deoxycortisol compared to healthy volunteers. Fur- for their particular intensity and duration. The ver- thermore, lower levels of cortisol and higher levels ified fact of prostatitis and/or STD being diagnosed of aldosterone were associated with higher pain and can affect emotional balance and become a trigger CPSI scores. These clinical correlates provide tanta- of negative changes in the patient’s mental status, lizing insights into the systemic nature of CP/CPPS thereby inducing the development of the subsequent [27]. The above–mentioned systemic hormonal vio- mental disorder. lations objectively have a bad affect on a patient’s The risk of psychosomatic or another mental disor- behavior and resistance in stressful situations. der development and progression depends on: A significant part of mental disorders in our CBP – duration and intensity of the traumatic factor; patients was presented by psychosomatic disorders, – presence or absence of patient’s predisposition to which are a group of somatic diseases or conditions mental disorders; in which the predominant role belongs to psychoemo- – inducibility of mental disorders as a result of com- tional factors (imagination, emotions, and fantasies). munication with doctors and other patients; The founder of psychosomatic medicine, Prof. Franz – incorrect interpretation of information obtained Alexander, considered that classical PSDs include from the Internet and/or literature; the following conditions: peptic ulcers of stomach and In turn, a patient’s propensity to develop of mental duodenum, bronchial asthma, hypertension, rheu- disorders is increased under the following circum- matoid arthritis, neurodermitis, hyperthyroidism, stances: and ulcerative colitis [28]. This list is currently ex- – unfavorable heredity; panded by the inclusion of erosive bulbitis, cystalgia, – unstable social status; irritable bowel syndrome, paroxysmal tachycardia, – the presence of any form of addictive behavior (drug and tension headaches among others. The complaints and alcohol abuse, addiction to gambling etc.); or of somatic origin are interpreted as manifestations of – the presence of concomitant psychiatric and severe the ‘symbolic language’ of internal organs, reflecting somatic disorders. the occult libido–related trends, displaced complexes, Based on our experience and the results obtained and negative emotions (anger, jealousy, hatred, re- from inventories, we believe that a mental disorder morse etc.). Depending on the type of emotions and should be suspected in a patient if, in addition to the their duration and intensity, disturbances of certain typical clinical presentation of CBP, the following organs and systems occur. signs and/or symptoms are present: According to Prof. F. Alexander, the development of – distinctive signs of psychological discomfort: com- PSD requires three preconditions [28]: plaints of irrational anxiety, insomnia, nervous 1. The patient should have a psychological conflict– breakdowns, and accelerated or slow speech; specific attitude; – signs of social maladjustment (it is important to 2. A certain specific situation serves as a PSD trig- pay close attention to the patient’s history and ap- ger; e.g., peptic ulcer disease is frequently caused by pearance); a loss of the patient’s significant other; – intense and lasting negative emotions in the pa- 3. The patient must have a constitutional mental tient; vulnerability and a certain biological X–factor in- – changes in eating preferences, such as reducing/ creasing the propensity to PSD. absence of appetite or on the contrary – overeating; The developments of a hypochondriac personality – patients are often uneasy with their surroundings with the projection of fear upon various bodily func- and their opinion of the way they look; tions also facilitate the development of PSD. The pa- – discrepancy between usual clinical manifestations tient’s perceptions of multiform paresthesias and/or of the disease and somatic symptoms described by premature ejaculation, typical for chronic prostatitis, patient; are extremely harmful; the patients usually focus ex- – patients are avoiding mirrors or quite the opposite, cessive attention upon such disorders. The concomi- constantly checking themselves in a mirror; tant psychogenic erectile dysfunction that often devel- – patient’s propensity to describe symptoms in figura- ops by the ‘vicious circle’ mechanism in patients with tive terms (‘goose skin’, ‘wobbly feet’, ‘mist in the eyes’, CBP also negatively influences their mental status. etc.) that are pronounced with pained facial expressions; 98 Central European Journal of Urology
– lengthy and ineffective treatment with medical • Sufficient attention should be paid to each- pa professionals of various specialties – the patient de- tient since trusting the doctor is an important mands multiple diagnostic tests to be performed and factor of recovery and could influence the - ap then treats the test results as ‘collectibles’; pearance of psycho–emotional complications in – the patient has a profound knowledge of his con- the future. dition and frequently engages in disputes with his • Taking into consideration the high degree of urologist, during which he subconsciously seeks to trust to the physician, during communications gain an advantage; he also commonly considers that with neurotic patients the urologist should con- his doctor has made a mistake by wrongfully diag- vey his/her confidence in positive treatment out- nosing the real disease and cause of his disturbing comes whenever treatment is feasible and its symptoms; success can be confidently predicted. Conversely, – etiotropic and pathogenesis–targeted therapies if achievement of expected treatment results is produce brief and/or controversial effects, the most dubious, the patient should not be given vain effective agents eliminating ‘organic’ symptoms be- hopes since this will eventually cause mistrust of ing psychotropic remedies, tranquilizers, and/or an- the physician and may provoke the emergence of tidepressants; exacerbated mental disorders. – temporary relief is produced by either alternative • For effective treatment, all patients with CBP therapies (‘sorcerers’, acupuncture, homeopathy, should be informed of the necessity to assess and ‘modern computer treatment technologies’, etc.) or treat sexual partners as needed. sometimes different minimally invasive procedures. • In cases in which psychopathological manifes- As long as one or more of the abovementioned signs tations dominate over urological symptoms, the are found in a patient by the urologist, a meticulous patients should be referred to a psychiatrist for comparison of the clinical presentation and the in- consultation. tensity of the symptoms described should be per- The population of patients with CBP and mental dis- formed. Then, upon consideration of patient’s his- orders is heterogeneous in their personality traits. tory, the patient should be referred to a psychiatrist In terms of personality traits, these patients can be or a qualified psychotherapist for validation of the divided into four distinctive personality types [23]: complete diagnosis. 1. Psychosomatic type. The prostatic problems are Out of deontological considerations, a single appro- of a secondary nature with the primary disrup- priate way of persuading the importance of psychi- tions being those of the nervous system; atric consultation should be carefully selected for 2. Alexithymic type. The patients are unable to ad- each patient with suspected mental disorder. Keep- equately verbalize their emotions, concerns, and ing in mind the fragile psyche typical of most pa- complaints; tients with CBP, the use of the following wording 3. Borderline type, between neurotic type (health– is recommended during conversation: psychoneu- related anxiety and depression) and psychotic rologist, psychotherapist, and/or neurologist. This type (delusional symptoms, persistent demands is because the patient is likely to be biased against for frequent additional assessments; develop- being referred to a ‘psychiatrist’, which is a common ing their own theories concerning the origin and finding in post–Soviet society, and may cause rejec- treatment of CBP); tion in a patient and, thus, affecting the impartial- 4. Narcissistic type (self–admiration with attention ity of his decisions concerning further assessment increasingly focused on bodily sensations and and treatment. physiological manifestations, such as urination, In our opinion to preserve mental health, the patient urethral discharges, urethral itching, etc.). should adhere to certain practices during the thera- Each patient with mental disorder requires a cus- py of CBP: tomized individual therapeutic approach; however, • First of all, the treatment should be aimed at the general direction of psychological correction dur- eliminating the manifestations of the disease ing psychotherapy should be chosen considering the (such as urethral discharge and genital rash) above types of aberrant personalities. and subjective symptoms that bother the patient In diagnosis of mental disorder and selection of ther- (pain, itching, dysuria, concomitant ED, and/ apeutic tactics, it should be taken into consideration or premature ejaculation etc.). If the findings of that such patients predominantly have concomitant tests improve in the course of treatment without depression (with anxiety, occult or neurosis–like), the elimination of the abnormal symptoms, the as well as other pathologic mental conditions, which patient may develop distrust in his physician may require additional long–term psychotherapy and may be inclined to partake in inadequate al- and pharmacotherapy. There are some publications ternative therapies. on the efficacy of antidepressants in the treatment of 99 Central European Journal of Urology symptoms of chronic prostatitis/chronic pelvic pain trist to exclude/confirm mental disorders with subse- syndrome in patients who are resistant to conven- quent treatment considered thereafter. tional anti–inflammatory therapy [29, 30]. Taking into consideration the obtained results and Conclusions the abovementioned opinions of authorities, it is certain that pathologic manifestations and hor- According to our data, the frequency of concomitant monal violations in patients with chronic prostati- psychosomatic disorders in patients with chronic tis, especially when long–lasting, are capable of a bacterial prostatitis is 28.2% – neurotic disorders negative influence on their mental status. On the were registered in 26.4% pts. Among the neurotic other hand, a part of CBP patients are presented and PSD patients, mild or moderate depressive dis- by persons with different mental disorders at the orders were also demonstrated. time of visiting their urologist. This is why the Adequate antibacterial and anti–inflammatory institution of long–tern antibacterial treatment therapy followed by a few sessions of psychotherapy with prostatic massages must be revised carefully decreased the manifestations of psychosomatic dis- in treatment–resistant patients. The timely reap- orders in 30.5%, neurotic disorders in 51.7%, and praisal of diagnosis should be appropriate by mak- premature ejaculation in 60.5% patients with CBP. ing up a psychiatric investigation before the chang- A substantial portion of patients with CBP required es in mental status and their complications may in–depth psychiatric assistance with pharmacother- become irreversible [31]. apy. The addition of pharmacotherapy in treatment– In cases in which the pathogen is fully eradicated, resistant patients improved treatment results. but CBP patient’s condition has not improved by a Urologists should be able to identify patients with prolonged treatment, it is contraindicated to con- concomitant mental disorders. When the signs of tinue antibiotics use and prostatic massages. Such such disorders are present, the patient with chronic patient should be thoroughly examined by a psychia- prostatitis must be examined by a psychiatrist.
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