Prostatic pathology
Short Summary

46-year-old-male with symptoms of burning sensation during miction, soreness in perineal region when in seated position and pollakiuria was diagnosed with Prostatic pathology – "prostatodynia", after prostate calcifications and retention microcysts were observed in echography. In the expert's opinion it is inaccurate to localize this symptoms anatomically to the prostate, and the exact diagnosis is Painful Bladder Syndrome.

Patient's Questions
1) Do you confirm the diagnosis of “prostatodynia”?

2) What eventual further medical tests do you think are useful for a more precise and reliable diagnosis?

3) What do you think is the best possible therapy?

4) Taking into account that the patient’s working activity is a sedentary one, that he follows a low-fat diet with regular fruit and vegetables consumption and that he makes a poor physical activity during the weekend, which rules and lifestyles can contribute to improve the over mentioned symptoms?

5) What risks can occur in case of unsuccessful or partial recovery from the described pathology?

6) Could you give us indications on the centers of excellence for the described pathology?
 
Medical Background

Sex: Male, Age: 46 years old
Diagnosis: Prostatic pathology

Symptomatic beginning in 2005 with appearance of a persistent sensation “heat/pain” in the scrotum-perineal region after taking on the seated position during the days of heat.
On August 2005 a scrotal echotomography was, therefore, performed with evidence “at the level of the head of the right epididym of cyst with anecogenic mass of about 18 mm in diameter”.
At the end of the summer 2005 the symptoms disappeared without any treatment.
In 2006 follow-up blood examinations were performed with evidence of PSA 0.289.
On  January 2007 a follow-up urological visit was performed with evidence of: bilobed prostate as parenchymatous chestnut.
During the period July-August 2007 analogous symptoms to those in 2005 appeared with “persistent sensation of heat/ pain in perineal region when in seated position”.
Also in this case, the symptoms disappeared at the end of the summer without any treatment.
On January 2008 appearance of pain and soreness in the lumbosacral region with finding, during the following days, of a cold sensation in the same region.
On February 2008 an abdominal echography was performed, it resulted within normal limits.
On February 2008 an urological visit was performed following the appearance of dysuria and pollakiuria with finding of “subacute prostatitis”; for this reason a therapy with Uniprox 500 mg at a dosage of 1tablet X 5 days + Prostamen (homeopathic remedy with a base of serenoa repens, uva ursi, urtica, etc.) for 2 months was defined.
On April 2008 due of the persisting slight burning sensation symptoms during miction and pollakiuria with a soreness sensation in the perineal region when in seated position, a further urological visit was performed with therapy with Levoxacin 500 mg at a dosage of 1 tablet for 10 days a month for 3 months (April-May-June).
On June 2008 a new transrectal prostatic echography was performed with evidence of “dishomogeneous prostate parenchyma due to the presence of adenoma with well represented surgical cleavage plane. In the context of the adenoma and in the "real" prostate several calcifications and retention microcysts were observed, results of chronic phlogosis. In the gland periphery suspect areas of hypoechogenic tissue are not appreciated.
Prostate diameters: 4.25x2.88x3.21 cm à total volume of 20.57 cc.
Adenoma diameters: 3.42x2.23x2.65 cm à total volume of 11 cc”.
In the meantime a bladder echography was performed too. It shows “relaxed bladder, lack of lesions protruding into the lumen. Elevation of the bladder base due to prostatic impression”. Still suffering from slight and occasional burning sensation symptoms during miction, with considerable discomfort due to soreness in perineal region if he remains in the seated position for more than ten minutes, the patient performed on July 2008 urine culture + complete urine test that were negative and, in the meantime, his wife performed a vaginal tampon with negative results. Diagnostic deepening on July with performance of cytologic examination of urine that, at a microscopic level, is indicative of “inadequate cytologic sample due to shortage of urothelial cells, made up of: floor cells, superficial and deep urothelial cells without atypia. Therefore, the diagnostic conclusion of this examination is the following one: “Not relevant material for diagnosis. A repetition of the examination is advised”. Complete hemochrome + formula on July result within normal limits. Pancolonoscopy + retrograde ileoscopy on August 2008 with the following results: “grade 1 hemorrhoids. In the distal rectum, on the back wall, presence of sessile polyp of 5 mm, removed with forceps. Mucus surface of regular appearance in the colon and in the terminal ileum”. As the patient complained of the same symptoms with burning sensations during the miction, frequent mictions, especially during the morning, soreness in perineal region after a few minutes in seated position, on August 2008, a further urological visit was performed with a diagnosis of “prostatodynia” and following therapy: Ciproxin 250 mg 1 tablet daily for 7 days a month for 2 months + serenoa repens tablets and urine test repetition and possible cistoscopy.

Expert's Opinion

1)    Do you confirm the diagnosis of “prostatodynia”?  

We have come a long way from the 1970's, when we called this problem or constellation of symptoms prostatodynia. We have learned that it is inaccurate to localize it anatomically to the prostate. Therefore, we now label it as Chronic Pelvic Pain Syndrome (CPPS) in order to get away from the prostate, which is not involved. This is very different from actual bacterial prostatitis. And, if it presents with lower urinary tract symptoms, as it does in this case, we have chosen to call it Painful Bladder Syndrome (PBS) or the old term, which we do not yet want to get rid of, interstitial cystitis (IC/PBS). The International Continence Society (ICS) and the International Consultation in Incontinence (ICI) have worked very hard to change this nomenclature.
 
2)    What eventual further medical tests do you think are useful for a more precise and reliable diagnosis?
Our knowledge of this entity is so primitive that there are no good or valid tests for it. As it is, Mr. X has already undergone all the possible tests, if not too many tests.
 
3)    What do you think is the best possible therapy?
We do know that all our best efforts at clinical trials of this entity with any therapeutic modality will only show efficacy in 30-50% of the patients. Therefore, there is no 'best possible therapy'. The various available modalities have to be tried empirically, one at a time, and then in combination, until the patient finds one that improves his symptoms. This may take a considerable amount of time and patience, both of which will test the limits of the patient and the physician.
4)    Taking into account that the patient’s working activity is a sedentary one, that he follows a low-fat diet with regular fruit and vegetables consumption and that he makes a poor physical activity during the weekend, which rules and lifestyles can contribute to improve the over mentioned symptoms?
Again, given our relatively primitive knowledge of this entity, we have no data to support any recommendations in terms of diet or physical activity. Of course, following a careful, balanced diet and exercise is always a good recommendation in terms of overall health. There is plenty of data to support that hypothesis.
5)    What risks can occur in case of unsuccessful or partial recovery from the described pathology?
 
There are no known sequelae or consequences of long-term CPPS/PBS/IC.
 
6)    Could you give us indications on the centers of excellence for the described pathology?
Unfortunately, there are no real centers of excellence. There are many people all over the world trying very hard to promote and carry out good research on this subject matter so that we can promote better quality care for this very difficult and painful problem.
If I may be allowed a bad guess as to the patient's country of origin, let me say that there are excellent people working on this topic in Roma, Padua, Bologna, Milano, Firenze, etc. You do not have to look far to obtain appropriate help.

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