Diagnosing and managing chronic prostatis
Moderator What is the proper approach to investigation of the patient with chronic prostatis?
Sullivan By the time I see a man with chronic prostatitis, he has likely been to several other physicians with the chief complaint of low back pain. Of course, the majority of low back pain patients have musculoskeletal problems, but some of them do have prostatitis as the etiology of their pain; many of these have been to orthopedists or neurosurgeons without getting any help. Finally, someone has said, "Maybe it's your prostate. Why don't you see a urologist?"
What I'm getting at, of course, is that the primary care physician will want to keep in mind that prostatitis may be the cause of long-standing low back pain. Pursuing it first will at least give you a reason to perform a rectal exam, which might tip you off to prostatic cancer that has metastasized to the back and pelvis [see "Causative Factors in chronic prostatitis," page 98].
Prichard Are there other clues to chronic prostatitis in the man with low back pain?
Sullivan The patient with or without back pain may complain of constipation or rectal fullness or say something like, "I always feel as if I need to have a bowel movement." There also may be vague complaints of perineal, testicular, or inguinal discomfort.
When you suspect chronic prostatitis, do the rectal examination, massage the prostate--that is, if there is no painful prostatic inflammation--and examine the secretions under the microscope.
Prichard Will you described your massage procedure?
Sullivan Start on one side, massage it to the midline, then repeat on the other side. You don't just palpate or "feel" the prostate; you roll your finger across the prostate to the midline, several times on each side. Then you go up high, to the base of the prostate, and strip it down toward the apex.
Occasionally the secretions will drip out of the urethral meatus on their own. More often, you'll have to ask the patient to strip the urethra--milk the penis down--to get even a few drops of secretion, for which you have a glass slide ready. Put a coverslip on the slide, and go to the microscope. There's a lot of controversy on interpreting the findings [see "Chronic prostatitis, another view," below], but I do go by the rule that if you have more...