Is there any cure for congestive prostatitis?

Question

The "Congestive Prostatitis" is described as a condition in which there is excessive fluid accumulated in the prostate gland.

1. Is there any cure apart from ejaculation?

2. Can the condition be improved/helped by,

   • exercise?

   • dietary modifications?

Answer 1

Thank you for the very interesting question regarding the prostate. Let me first briefly explain a few historical confusions regarding the nomenclature of prostatic disorders with particular attention to your ‘congestive prostatitis’, which may be called an almost extinct creature!

Classifications of Prostatic Disorders

Meares and Stamey (1968) suggested a classification of prostatic disorders based on clinical and bacterial culture findings, and their classification had been widely used at least until 1995. Doble (1994) identified Meares and Stamey’s traditional classification of prostatic disorders as:

1. Acute prostatitis
2. Chronic bacterial prostatitis
3. Non-bacterial prostatitis
4. Prostatodynia

In the traditional classification, non-bacterial prostatitis refers to a condition that presents with similar clinical features as chronic bacterial prostatitis, including pyuria, but except that the cultures of urine and expressed prostatic secretions are negative. Prostatodynia also presents with similar clinical features as chronic bacterial prostatitis but excluding pyuria, and the cultures are negative. It is important to note that prostatodynia is more a symptom than a condition itself.

As noted by Krieger, Nyberg & Nickel (1999), the US National Institute of Health (NIH) standardised the classification of prostatic disorders in 1995 by adding a disease entity as asymptomatic inflammatory prostatitis, and combining non-bacterial prostatitis and prostatodynia into an entity as chronic prostatitis/pelvic pain syndrome. Thus, the NIH classifications can be listed as:

I. Acute Prostatitis

II. Chronic bacterial prostatitis

III A. Chronic prostatitis/chronic pelvic pain syndrome, inflammatory

III B. Chronic prostatitis/chronic pelvic pain syndrome, non-inflammatory

IV. Asymptomatic inflammatory prostatitis

Historical Relationship between Congestive Prostatitis & Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

Congestive prostatitis is an outdated nomenclature for a constellation of mostly ill-defined urological and pain symptoms, and a few signs; it had been a poorly understood entity for the most of its time in use. Congestive prostatitis is clinically characterised by urological symptoms, such as urinary frequency, dysuria, and strangury; and pain or discomfort in urogenital and anal areas, such as pain in the inguinal region radiating sometimes even to the testicles, burning in the urethra, and pressure in the perianal region (Diederichs, 1988). It is not clear whether the patients experience an actual pain or just a discomfort. According to Günthert (1983), as mentioned by, Diederichs (1988), many patients, without being asked, stress the fact that they do not experience actual pain, but rather a very unpleasant, disturbing feeling. Some of them cannot even sit comfortably. According to Günthert (1983) and Janssen et al. (1983) as mentioned by Diederichs (1988), over 50% of these patients also complain about sexual disorders, such as erection difficulties, or painful or premature ejaculation.

Poorly defined symptomatology and pathophysiology of congestive prostatitis, along with a host of associated psychological manifestations, either as aetiology or as sequelae, had tempted many to classify congestive prostatitis as a psychosomatic clinical condition in which urological examination may show an actual swelling of the prostate, but where neither bacteria in the expressed prostatic secretions nor any other organic disease can be found (Janssen et al., 1983; Diederichs, 1988; Pavone-Macaluso, di Trapani & Pavone, 1991).

As mentioned initially, congestive prostatitis is an outdated name for the condition it refers to, and there had been a myriad of names used synonymously to the same condition, perhaps reflecting the poor understanding of the condition itself: prostatosis, chronic prostatitis, prostate congestion, chronic congestive prostatitis, prostate neurosis, urogenital neurosis, autonomic urogenital syndrome, chronic recurrent prostatitis, and abacterial prostatitis (Peterson, 1985; Diederichs, 1988).

Considering the current understanding of the pathophysiology and aetiology that ranges from prostatic to extraprostatic causes, diverse nature of the symptomatology, therapeutic options available, and the need to facilitate research with a consistent nomenclature, the condition previously called as congestive prostatitis (and the other names mentioned above) is now included in the broad entity called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The use of the other names is discouraged to minimise the confusions and ensure consistency in medical literature. Terms such as congestive prostatitis, congested prostate, and prostate congestion should only be used, if unavoidable, to describe a particular state or condition of the prostate rather than disease entities themselves.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome described based on urological symptoms and/or, pain or discomfort. It is defined as chronic pelvic pain for at least three of the proceeding six months in the absence of other identifiable aetiologies. Inflammatory and non-inflammatory sub-classification is done on the presence or absence of inflammatory cells in expressed prostatic secretions, post-prostate massage urine, or seminal fluid (Nickel, Nyberg & Hennenfent, 1999; Schneider et al., 2005).

In this discussion, the name ‘congestive prostatitis’ will be used only for the sake of answering the original question. Let us now look into the queries that the original question asks about.

1. Is there any cure apart from ejaculation?

2. Can the condition be improved/helped by,

• Exercise?

• Dietary modifications?

As we have discussed above, 'Congestive Prostatitis' is an outdated name for the vague disease entity it refers to, and the name should be and is avoided in current medical literature. The term congestive prostatitis itself signifies only a state or condition of the prostate rather than a distinct disease entity itself. Whatever constellation of symptoms and signs attributed to congestive prostatitis in the past is now classified and named as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Although CP/CPPS still remains a poorly understood disease entity, as reflected by the many hypotheses of its cause, there have been tremendous improvements in its evaluation, diagnosis, and management (Schneider et al., 2005). The symptoms seem to have a multifactorial origin so it is very important, yet difficult, to exclude underlying diseases with similar symptoms. The identification of the origin of the symptoms is crucial for the effective management; therefore, various attempts have been made to formulate tools to facilitate the evaluation and diagnosis of CP/CPPS, such as NIH-CPSI, I-PSS, and UPOINT (Nickel & Shoskes, 2010).

Because of the multifactorial origin of CP/CPPS, there are a number of therapeutic modalities for CP/CPPS. However, there is no universally a accepted treatment regime. In fact, none of the therapeutic options hitherto available is a cure for CP/CPPS. However, many medications and other forms of treatment can help to alleviate the symptoms and make CP/CPPS more bearable. Over time, this condition may improve or stabilise on its own (Watson, 2017). Few guidelines have been published based on clinical evidence to provide recommendations for the treatment, eg The Prostatitis Expert Reference Group (PERG) consensus guideline, Canadian Urological Association (CUA) guideline.

Although this answer is not intended for a detail discussion on each treatment option available, the overall treatment strategies can be outlined as follows:

1. Pharmacological treatments –

Alpha-blockers (eg tamsulosin, alfuzosin, doxazosin, terazosin, and silodosin), antibiotics (eg ciprofloxacin, levofloxacin, and ofloxacin), and 5-alpha-reductase inhibitors (eg finasteride) are the most efficacious medications for CP/CPPS, provided with they are used judicially considering the nature of individual cases. Anti-inflammatory medication treatment, such as cyclooxygenase-2 inhibitors (eg celecoxib) and glucocorticoids (eg prednisolone), are generally given when pain is not controlled with initial therapy.

The clinical significance of pharmacological treatment for CP/CPPS has been questioned (Anothaisintawee et al., 2011; Cohen et al., 2012). PEGR recommend the following based on the best clinical evidence:

• α‐adrenergic antagonists may have a modest treatment effect regarding total, urinary symptom, pain and QoL scores in CBP and CP/CPPS, and should be considered as an initial treatment option (Level 1).

• Antimicrobial therapy may have a moderate effect on total, urinary, pain and QoL scores in CBP and CP/CPPS and should be considered as an initial treatment option (Level 1).

• There is insufficient evidence to warrant recommending 5α‐reductase inhibitors as monotherapy in CP/CPPS, unless co‐existing BPE is present (Level 2).

• In patients with early‐stage disease who present with pain symptoms, regular paracetamol may be offered. NSAIDs should be offered only for short‐term treatment of pain, to patients with early‐stage CBP or CP/CPPS whose symptoms are suspected to be due to an inflammatory process, or those judged to be experiencing an inflammatory flare. If pain is considered to be neuropathic in origin, treatment with a gabapentinoid (e.g. pregabalin or gabapentin), a tricyclic antidepressant (e.g. amitriptyline, nortriptyline or trimipramine) or a selective serotonin‐noradrenaline (known in the USA as norepinephrine) reuptake inhibitor (SNRI; e.g. duloxetine) is warranted (Level 5).

• Multimodal/combined therapy should be uniquely designed for each individual patient, according to history, physical examination and investigations. Depending on the symptoms at presentation, the following may be considered for adding to first‐line antibiotic therapy (Level 5).

o An α‐blocker and/or an NSAID.

o An agent targeting neuropathic pain (e.g. pregabalin).

o A 5α‐reductase inhibitor (predominantly for patients with coexisting LUTS with BPE).

2. Invasive treatments and other non-pharmacological treatments –

In some cases of refractory CP/CPPS, invasive surgical treatments such as prostatectomy, transurethral resection of the prostate (TURP), transrectal high‐intensity focused ultrasound (HIFU), transurethral needle ablation (TUNA) of the prostate, and transurethral microwave thermotherapy have been used. The evidence on such invasive surgical management techniques is very limited.

Other non-pharmacological treatments such as repetitive prostatic massage, therapeutic ejaculation, neuromodulation techniques (Kabay et al., 2009), and various phytotherapies, including pollen extracts, bioflavonoids and/or Serenoa repens (saw palmetto), have been reported as being successful in treating some cases of CP/CPPS.

Physical dysfunction, such as abnormal pelvic muscle spasm and muscle tenderness, is associated with some cases of CP/CPPS (Hetrick et al., 2003; Shoskes et al., 2008). Therefore, specialist physiotherapy that aim to improve relaxation and coordinated use of the pelvic floor muscles, such as biofeedback physical therapy and pelvic floor re‐education, as well as myofascial trigger point release, may play a role in providing symptom improvement in patients with CP/CPPS. However, the evidence on such treatments is also scarce.

PEGR recommend the following based on the best clinical evidence:

• There is insufficient evidence to warrant recommending surgical techniques, including radical prostatectomy, TURP, HIFU or prostatic massage for the treatment of CBP or CP/CPPS, except in the context of a clinical trial setting (Level 3).

• The following specialist physiotherapy treatment options may be considered: pelvic floor re‐education; local pelvic floor relaxation; biofeedback; general relaxation; deep relaxation/mindfulness; trigger point release; myofascial release; stretches; exercise for pain management; TENS; acupuncture for trigger point release and pain management; bladder retraining (Level 5).

• Phytotherapy has a modest beneficial effect on symptom improvement in CBP and CP/CPPS and may be considered as a treatment option in treatment‐refractory patients (Level 2).

Since the original question mentions ‘ejaculation’ specifically, a brief historical note is made here. According to Christoffel (1944) as cited by Diederichs (1988), the Confessions of Jean Jacques Rousseau (1767) reveals that Rousseau was plagued by the frequent urge to urinate, which disappeared after a visit to a Venetian brothel but reappeared in connection with hypochondriac fears of having a venereal disease. The role of frequent ejaculation in either producing or reducing CPPS symptoms remains controversial. Although patients with enlarged, symptomatically congested prostate glands are often advised that regular sexual intercourse may alleviate their symptoms, the role of frequent ejaculation in either producing or reducing CP/CPPS symptoms remains controversial, and there is little objective evidence if at all (Ahuja, 2016; Watson, 2017).

3. Psychological interventions –

CP/CPPS is associated with a host of psychological manifestations, either as aetiology or as sequelae. Accordingly, various psychological treatment modalities have been used to treat CP/CPPS. However, no evidence from randomised clinical trials or comparative studies is available to support the use of psychological treatment or cognitive behavioural therapy (CBT) in these settings. When referring a patient for psychological treatment, it is important to reassure the patient that his condition is real and that his suffering is not imaginary. Psychological support is appropriate in helping the patient cope more effectively with his serious, real-life problem (Watson, 2017).

PEGR recommend the following based on the best clinical evidence:

• Psychosocial symptoms should be assessed in both the early and late stages of CBP and CP/CPPS. If there is a significant suspicion of psychological factors contributing to a patient's condition, these should be screened for (Level 5).

• CBT should be considered in conjunction with other treatments in later‐stage CBP and CP/CPPS, as it may improve pain and QoL (Level 5).

4. Dietary and lifestyle interventions –

Traditionally, patients have been warned to avoid excessive intake of prostate irritants, such as tobacco (smoking), coffee, tea, caffeine, carbonated drinks, spicy foods, acidic foods, cranberry juice/cranberries, lemon juice, alcohol, and chocolate. However, none of these items is known to cause actual physical damage or to worsen the long-term prognosis. The reported success of this approach is anecdotal, and it will not work for all patients. Nevertheless, responsible limitation of these items may help to control the day-to-day symptoms (Herati et al., 2013; Ahuja, 2016; Watson, 2017). A glass or two of wine or sherry may lessen nocturia symptoms. Alkalinisation of the urine seems to help some patients (Watson, 2017).

The benefits of frequent ejaculation and specific exercises have been discussed above. Sitz baths may provide partial relief from acute exacerbations. Perianal self-massage may also also offer some relief, but the reported success is anecdotal (Ahuja, 2016; Watson, 2017). Sedentary lifestyle is associated with severe pain in patients with CP/CPPS; therefore, the modification of such lifestyle is a potential target for treatment (Chen et al., 2016).