CHRONIC PROSTATITIS - part 1 Why not heal it? Federico Guercini MD, consultant urologist Assistant Professor Index INTRODUCTION Although prostatitis is extremely frequent, affecting from 30-50% of sexually active males, it has been called the wastebasket of clinical knowledge (Stamey, 1980). The study of this invalidating disease has not been supported by extensive research as urologists tend to concentrate on major pathologies such as benign prostate hypertrophy (BPH) and cancer. Aware of the worldwide need for valid therapy for prostatitis, this “malignant Cinderella of Medicine”, we decided to investigate its causes and treatment. The results we obtained over 20 years have been published in many international scientific journals but the benefits of our work have been extended only to the few hundreds of outpatients we have personally treated. We are convinced our physiological hypotheses and therapeutical strategies should be shared by urologists. Encouraged and supported by our patients we have decided to use the Web to divulge our approach as widely as possible. Many of the causes of prostatitis have been hypothesized internationally and we have tested and proven them. Our therapeutical strategies have not been fully accepted because of diverging views, lack of practical and technological know-how e.g. in the field of ultrasound and limited ability in administering ultrasound-guided therapy. Despite this, what we propose can be reproduced and tested by any urologist with a basic knowledge of these techniques and ability to use them. Should the experience of others lead to improvements in our methods and techniques we would 2 welcome the opportunity to revise, correct and expand our knowledge in this field. Furthermore, should any specialist, who has obtained good results which are as yet unpublished on the Web or elsewhere, like to contact us it would be an honour and a pleasure to pool our resources in an attempt to cure this pressing and invalidating disease which affects millions of men. For them it is, in fact, extremely frustrating to be really ill, to refer obvious symptoms of a disease with a clear aetiology and pathological process and to be treated as hypochondriacs or to be given advice such as “Don’t dwell upon it! There’s nothing to be done in any case!” Now let’s have a closer look at the prostate and the causes of its becoming diseased. 3 CHRONIC PROSTATITIS Part 2 WORK IN PROGRESS ANATOMY AND PHYSIOLOGY Federico Guercini MD, consultant urologist Macroscopic Anatomy Microscopic Anatomy Prostate Canals Seminal Vesicles and Bladder Neck Macroscopic Anatomy In shape the prostate is usually described as a squashed cone with the base upwards, the apex downwards and four sides with rounded corners. The four sides are known as the anterior, posterior and lower-lateral faces. A normal prostate is 4 mm in length, 3 mm at the cross-section and 2.5 mm at the antero-posterior section. Weight ranges from 15 to 20 gr. Lodged in the pelvis, the prostate adheres strongly to the bladder neck and is anchored to the pelvic bones (mainly anteriorly to the pubis) by many ligaments and other supporting structures e.g. the urogenital diaphragm (see fig. 1). 4 Microscopic Anatomy Thirty percent of the prostate is muscle fibre and the other 70% is made up of glandular cells which are grouped together in 30 glandular units known as acini. The prostate can be divided into three areas: the peripheral, the central and the periurethral transitional area (fig.2). This subdivision is extremely important as prostate tumours almost always originate in the peripheral area and BPH in the transitional. Depending on its causes, prostatitis originates in the periurethral or peripheral areas and causes different symptoms in each instance. Prostate Canals The prostate contains three large canals, a small central canal known as the utriculus and as many small canals as there are acini. The three major canals are: - the urethra (1) through which urine flows from the bladder; - to the right (2) and left (3) of the urethra the ejaculatory ducts which join the urethra at the veru montanum and through which sperm pass from the seminal vesicles. The utriculus is a small duct which joins the veru montanum between the two ejaculatory ducts. It is considered a pre-sex differentiation embryological remnant of what becomes the uterus in females. After birth in males the utriculus may atrophy and almost totally disappear as become a closed canal, dilate and form cysts (utricular cysts) which may cause prostatitis-like symptoms if inflamed. During ejaculation fluid produced by each acinus flows through the minor canals (which also join the urethra at the veru montanum) to mix with the sperm from the seminal vesicles. This prostatic fluid is essential for sperm motility and vitality and indeed, in the course of prostate inflammation, abnormalities in it may impair fecundity. 5 Seminal Vesicles and Bladder Neck Any presentation of the anatomy of the prostate is incomplete without a description of the seminal vesicles and the bladder neck. Although not part of the prostate these organs play in integral part in its functioning. As the name suggests the seminal vesicles are two small, internally pluriseptate sacs (mean diameter 5x4 cm) which contain the sperm produced by the testicles- By means of strong pelvic muscle contractions during orgasm the sperm are forced into the ejaculatory ducts which join the urethra. There they are mixed with the prostatic fluid from the acini before being ejaculated. The bladder neck is the area at the base of the bladder which opens into a funnel at micturition to allow urine to flow along the lines of minimal force in the proximal urethra. It distends when urine is passing and when pulled by specific extra- urethral muscles. From the above description we can now provide an answer to a common question “What is the prostate for?” The function of the prostate is to produce and store the prostatic fluid which is secreted by its glandular acini because this fluid nourishes and propels the spermatozoi in the sperm, which is stored in the seminal vesicles. During orgasm the pelvic muscles force the prostatic fluid and the sperm into the urethra at the same time. There they are mixed and ejaculated. 6 CHRONIC PROSTATITIS part 3 WORK IN PROGRESS PATHOLOGY AND PATHOGENESIS Federico Guercini MD , consultant urologist Classification Acini and Minor Canaliculi Urethral-Prostate Reflux A-Bacterial Prostatitis? Spread of Infection Utriculus Seminal Vesicles As university professor I could now describe all the anatomical and pathological pictures which are present during states of acute and/or chronic inflammation of the urethra and prostate but in so doing I would simply be repeating what has already been said by my predecessors who have not been able, in fact, to cure prostatitis. Those of you who wish to study the pathology as described in standard texts might like to consult, for example, Campbell’s Urology, which is the urologist’s Bible. Those of you who want new insights into the problem can follow me! To start with, let’s set aside Drach’s 1978 classification of prostatitis which divides the disease into acute and chronic, bacterial and non-bacterial forms and adds prostatodynia to cover a multitude of disturbances (e.g. painful male urethral disease) in patients with few (<10 per field) inflammatory cells and typical prostate pain who do not fit into any of the other categories. 7 Let’s go back to the complex of organs that I described in part 3 and let’s consider them as a single bladder neck-urethral-prostatic-vesiclar organ (a term which you will not find in any textbook of anatomy) so that we can identify weak areas and consequently provide the right remedy. ACINI and MINOR CANALICULI We said the minor canaliculi serve to transport prostatic secretions from the acini to the urethra. The canaliculi draining the central acini are tortuous in form while those draining the peripheral acini are straight and joined to the urethra in a position which is countercurrent to the urine stream (fig.4). These anatomical details prompt the following inference: given the course of their canaliculi, periurethral acini are more easily obstructed by inflammation and are more likely to release substances and even produce stones. Peripheral acini with their straight canaliculi are more subject to urinary reflux and urethral bacteria. This has major therapeutical implications because if true, periurethral prostatitis might benefit temporarily from strong gland expression while no improvement would be seen in cases of peripheral prostatitis because the straight canaliculi are not prone to stasis. 8 URETHRAL-PROSTATE REFLUX When discussing the peripheral acini we mentioned the urethral-prostate reflux. This is the abnormal passage of urine from the urethra into the prostate. Like all fluids urine flows where pressure is lowest and finds it “convenient” to leave the urethra and flow into the prostate only under certain pathological conditions. These include 1) increased endourethral pressure due to urethral narrowing below the prostate, the most common causes being nerve-based periurethral musculature rigidity, congenital stenosis or stenotic outcome of previous episodes of prostatitis; 2) abnormalities in the first urethral tract due to a narrow or poorly elastic bladder neck i.e. bladder neck sclerosis or dysectasia, which may be congenital or develop early in life. In the first tract of the prostatic urethra urine flows hard against the posterior wall rather than parallel to the lateral walls. Unable to withstand this high pressure the posterior wall cedes and urine filters into the prostate (fig.5). Barbalias (1997) recently confirmed this hypothesis with his finding of high urethral closure pressure in patients with abacterial prostatitis who benefitted from a course of alpha-blockers and antibiotics.