The guidelines we apply in the therapy of chronic prostatitis/chronic painful syndrome of the pelvic floor are the logical consequence of the knowledge exposed in the previous chapters. Let's start from the concept that there are basically four categories of patients who however all complain of more or less the same symptoms. Let us remember that these categories are not always so clearly distinguishable and sometimes one category passes insensitively into another or the same patient can belong to one or more categories. Therefore it is up to our experience to know which therapy to apply.
The four categories of patients are:
1)Patients with active acute prostatitis.It is a rare category, but easily identifiable due to the association of precise symptomatic components such as fever, perineal pain, urination difficulties and often an easy "cause-effect" mnemonic association (e.g. recent risky sexual intercourse).
2) Patients with the presence of a true chronic prostate-vesicular infection. In my current experience these are the statistically least frequent patients. However, let us remember that the identification of bacteria such as Chlamydia, Ureaplasma, Gonococcal Mycoplasma or Virus (HPV) in the prostatic secretion or in the urethral swab is practically impossible with cultures or fresh tests, while it is possible with the qualitative amplification of their DNA with the PCR technique. Let us also remember that the serum dosage of anti-Chlamydia antibodies, if absent, does not exclude the presence of the microorganism. During the disease, the prostate on the one hand tries to limit the infection by incorporating it into a polysaccharide belt and on the other some microorganisms such as Chlamydia themselves cause the formation of so-called "bacterial biofilms". These situations make the chronically infected areas poorly penetrable by antibiotics administered systemically (orally or i.m.). Furthermore, in these subjects bacterial prostatitis is sometimes complicated by a situation of autoimmunity. In the blood of these patients the presence of T cells, reactive to normal prostatic proteins, can be detected (Alexander 1997). The dosage of Cytokines (IL2-IL6-TNFalpha) in sperm often documents much higher values than in normal subjects.
3) Patients in whom the previous prostatitis it evolved into a situation of spasm of the perineal floor and inflammation of the pudendal nerves. These are the most frequent patients.
4) Patients whose symptoms are the result of anatomical alterations
of the neck of the bladder (sclerosis) or of the urethra (stenosis, malformations, etc.). In these cases the therapy must necessarily involve surgery.
Prostatitis therapy
1) In patients belonging to the first category, once the infecting agent has been identified, suitable antibiotic therapy must be carried out for cycles of at least 10 days. In the acute phase, cortisone and painkillers are often combined. In the presence of a possible prostatic abscess (which is not uncommon in these subjects), the abscessed area will be drained and sterilized under ultrasound guidance.
2) In patients belonging to the second category, systemic therapeutic cycles must necessarily be very long and require the use of various antibiotics. After the execution of repeated systemic therapeutic cycles, followed by continuous relapses and in the presence of ultrasound findings of intraprostatic fibrosis or fibrocalcifications, the disease must be classified as chronic and the areas of fibrosis must be interpreted as non-sterilizable bacterial nests. In these cases, and only in these, it is necessary to consider the possibility of bringing into the prostate, under ultrasound guidance, specifically within the areas of inflammation or within any fibrocalcifications, a cocktail of antibiotics with an acid pH, bactericides, for the largest part of the microbial agents causing prostatitis, associated with a powerful anti-inflammatory such as cortisone which acts on the edema of the canaliculi and prostatic acini, re-establishing the regular flow of their secretion and interrupts, if present, any autoimmune mechanism. In our clinical practice, to improve their penetration into the fibrocalcific areas, we also add a calcium chelating substance (EDTA) to the drugs exposed above, with the aim of increasing the dissolution of the chemical bonds that keep the calcium molecules adhered to each other.
3) For patients in the third category, obviously, antibiotic therapy, as well as being useless, can be considered harmful as, rather than curing, it will decrease the immune defenses and may alter the intestinal and skin bacterial flora, often leading to fungal superinfections. However, it is a common experience that sometimes antibiotic therapy provides relief from acute symptoms in any case. This improvement, interpreted by many patients as proven proof of their infection, is instead usually due to the anti-inflammatory effect linked to some antibiotics (specifically quinolones such as Ciproxin, Levoxacin etc.). The demonstration of this statement is unfortunately the immediate return to the initial symptoms after a short time after the suspension of this therapy.
The therapy will instead be based on the use of combinations of drugs with the ability to implement a specific despasm of the pelvic floor, such as BACLOFENE, BENZODIAZEPINES WITH NON-HYPNOTIC EFFECT, NIFEDIPINE-BASED CREAMS, CORTISONIC CLISTERINES. Furthermore, all those mechanical "devices" that help despasm the anal sphincter, such as the DILATAN CONES, will be used.
Furthermore, accurate external and transrectal exploration of the pelvic floor will always allow us to identify the so-called "trigger points", i.e. points of spastic accumulation of pain. These points must be treated with extreme benefit, following the indications given by David Wise in his famous Stanford Protocol. The treatment of these points, although very simple, cannot usually be self-managed, and therefore it will be very useful to have a partner available to carry out digital therapy. Let us remember that very often we are treating a pathology with an occult or manifest onset dating back months or years. Therefore, although the first results will usually be almost immediate, recovery or, rather, the ability to manage the situation, will require a few months of therapy.
From this perspective, attention to diet is also very important. I must say that more or less all patients recognize "forbidden" foods or drinks over time. These can be grouped into four groups, with negative effects in various ways:
- various spices such as pepper, chili pepper, paprika, curry etc.
- acidic foods or foods with acidifying properties such as vinegar, pickles, citrus fruits, berries, chocolate, etc.
- alcohol and spirits. From this perspective, beer is also harmful for many people.
- exciting drinks (e.g. RedBull) or exciting drinks in general (from coffee up!).
4) In the fourth category, for patients whose cause of their symptoms is linked to sclerosis of the bladder neck, we temporarily administer courses with alphalytic drugs. Any significant improvement in symptoms will be a convincing indication for performing a destructive surgery (TUIP).
However, in the presence of urethral strictures, the only feasible and advisable treatment, depending on the severity of the obstruction, will be urethrotomy, urethroplasty or treatment with the brand new device Optilume which produces a dilation of the urethra through the intraurethral distension of a balloon whose walls are soaked in a chemotherapeutic agent which opposes the reformation of the stricture.