The majority of men listed as having prostatitis (prostatic inflammation/discomfort) more often than not have a symptom complex that is commonly stress-related and not due to an infection. This problem is more accurately called prostatodynia and is much more common than true chronic prostatitis or acute prostatitis, where antibiotics are necessary. 

The majority of patients with prostatitis/prostatodynia will get better regardless of the antibiotic used or whether an antibiotic is used at all. The most effective treatment for these men is reassurance that they do not have cancer, an infection, or a venereal disease. In many of these men with various combinations of low back or perineal discomfort, urinary frequency, urgency, suprapubic and/or ejaculatory discomfort, burning or pressure, pelvic floor spasm is often the cause. This problem can respond to low-dose Diazepam 2-5 mg 3 times a day, alpha-blocking agents such as Hytrin or Cardura, or sitz baths. 

Many men will tell you that their symptoms are often exacerbated after alcohol ingestion, bike riding, working out or eating spicy foods, or because of business pressures. These causes further highlight stress as a likely factor behind the symptom complex known as prostatitis/prostatodynia. 

In most cases, men can minimize or prevent recurrences of the problem by recognizing the factors that bring it about.

BENIGN PROSTATIC HYPERPLASIA (BPH)

Etiology 

The cause behind BPH is unclear, but two factors are necessary. The first is aging and the second is the presence of dihydrotestosterone (DHT). The enlargement of the prostate, which may be extremely variable from man to man, can result in various symptoms of voiding dysfunction, either obstructive or irritative in nature. 

The various symptoms associated with voiding dysfunction, including incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and getting up at night. The American Urological Association (AUA) has grouped some of these complaints as a symptom index for BPH. These symptoms are not necessarily related to the size of the prostate. In fact, some men with very large prostates have only mild symptoms of voiding dysfunction. Furthermore, acute urinary obstruction with acute urinary retention may occur in men independent of the size of the enlargement. Many such men will experience a return to normal voiding patterns after one or more voiding trials with catheter removal. In some men, acute retention may be precipitated through cough and cold medications, alcohol, excessive fluids, constipation, immobilization, anesthesia or urinary tract infections. 

MEDICAL TREATMENT OF BPH 

BPH is not necessarily progressive. Patients may present with varying degrees of irritative symptoms or in urinary retention. 

Medical Treatment for Irritative Symptoms 

1. Alpha-1 blockers. 

These medications, such as Hytrin, Cardura, and  Flomax, relax the smooth muscle in the prostate, allowing the bladder to empty better. In addition, these medications may also lower the serum cholesterol and triglycerides. However, in some men, they may affect ejaculation by allowing retrograde ejaculation to occur. 

2. Anti-androgens. 

Finasteride (Proscar) is an anti-androgen that blocks the conversion of testosterone to dihydrotestosterone. The conversion to DHT is through the enzyme 5-alpha reductase and Proscar blocks this enzyme. 

Phytotherapeutic agents (herbs) 

The most common over-the-counter agent available for the treatment of BPH is saw palmetto berry extract. This berry comes from the saw palmetto palm plant. Although the clinical usefulness of saw palmetto and many other agents is still unproven, a number of patients believe their symptoms are improved on this agent alone or further improved after they add saw palmetto to an alpha-1 blocker such as Hytrin, Cardura or Flomax. Also, it is not known to what degree the placebo effect plays a role. 

 

URINARY RETENTION 

Acute Urinary Retention 

In women, this may occur after delivery or in various conditions such as multiple sclerosis, while in men it may also be caused by enlargement of the prostate. These patients are quite uncomfortable and require a catheter to relieve the bladder obstruction. Ordinarily, many of these patients can be given a voiding trial after one or more days of bladder decompression, and many will regain normal bladder function, especially those patients who have had a precipitating event such as anesthesia, alcohol, cough medicines, constipation or a urinary tract infection. 

Residual prostatic symptoms may be treated with one of the various medications outlined above. 

Chronic Urinary Retention 

This may occur in women because of diabetes or various neurological disorders, while in men it is usually secondary to outflow obstruction, of which prostate enlargement is the most common cause. In this scenario, patients have very severe bladder outlet obstruction affecting the drainage of their kidneys or compromising their function. Patients are generally not too symptomatic but may complain of lower abdominal fullness and some incontinence. 

Men may have some mild prostatic symptoms. These patients will require slow drainage of their bladder, as rapid decompression can result in significant hematuria. Because the bladder muscle has been so overexpanded over a period of time, it is possible that the muscle may not regain its function sufficiently after surgical treatment to relieve the obstruction. In order for the bladder to work properly, the patient may also be required to empty his bladder with clean, intermittent catheterization. The addition of a medication like Bethanechol may be helpful in improving bladder contractions.

 SURGICAL TREATMENT OF BPH 

1. Transurethral resection of the prostate (TURP). 

It is the standard procedure for relieving prostatic obstruction in those with significant symptoms. This procedure is extremely effective, is usually done under a spinal block, and takes about an hour. This usually requires an overnight stay in the hospital but can be done as an outpatient. 

2. Open Prostatectomy. 

In those with very large prostates or associated bladder stones or other bladder pathology, a small suprapubic incision is made to enucleate the prostate. Recovery may take 2 or 3 days extra than that needed for the transurethral resection but more importantly offers definitive treatment so the patient has an excellent chance of normalizing his lifestyle once more. 

3. Minimally Invasive Procedures for the Treatment of BPH. 

Many of the procedures listed below may be acceptable alternatives to those described above, particularly for those with small prostates. However, although there may be less risk with these procedures, the trade-off may be less improvement in urinary symptoms than one would expect. 

A. Electroresection. 
1. Transurethral incision (TUIP). This procedure is indicated in patients with obstructive symptoms from normal-sized or very small prostates, where resection would be considered excessive. 
2. Transurethral vaporization (Vaportrode or Rollerball) 

B. Radiofrequency. 
 Dry electroresection-TUNA. Transurethral needle ablation (TUNA) delivers radio-frequency energy to the prostate. A temperature probe is placed in the rectum, the TUNA catheter is placed into the urethra, and two specialized needles (which act as radiofrequency antennae) are passed through the catheter into the enlarged prostate. Radiofrequency energy is then transmitted via the needles into the tissues and the needles repeatedly replaced, with each treatment section lasting for about 5 minutes. This procedure takes about an hour and is done as an outpatient using local anesthesia. (See TUNA Therapy) 

C. Microwave. 
Transurethral microwave therapy (low or high energy). This procedure (TUMP) damages the muscular components of the prostate tissue, bringing about their relaxation and therefore improvement in urinary symptoms. The procedure is done as an outpatient, and the patient reclines on a specially designed couch with a temperature probe in the rectum. A small catheter containing the microwave antenna is then positioned in the urethra adjacent to the prostate. The treatment usually lasts for an hour. (See Thermatrix)

D. Laser. 
Transurethral laser-induced prostatectomy (TULIP) has fallen out of favor due to irritative voiding problems postoperatively. Visual laser ablation of the prostate (VLAP) has similar problems to TULIP. Holmium:YAG laser resection. Interstitial laser coagulation (Indigo). The Greenlight PVP laser procedure may be performed as an outpatient.The Greenlight PVP laser procedure of the prostate may be performed as an outpatient through a virtually blood free treatment under regional anesthesia and with restoration of urinary flow.
(See Laserscope)  

E. Others. 
Prostatic stents. Permanent spiral metal stents have been used in certain situations to keep the prostate open but have the complications of encrustation, obstruction with inflammatory granulation tissue, and migration. Some stents have also been made with a shape memory alloy with thermal expansion of the stent taking place after the positioning catheter is removed. Bioabsorbable and biodegradable urologic stents are also being evaluated. 
Balloon dilatation. The prostate is dilated with a special balloon catheter under an outpatient anesthetic. The effects on the prostate are usually transitory.