Repetitive Prostatic Massage and Drug Therapy as an Alternative to ...

Repetitive Prostatic Massage and Drug Therapy as an Alternative to
Transurethral Resection of the Prostate Bradley R. Hennenfent, MD1; Alfred R. Lazarte, MD2; and Antonio E. Feliciano,
Jr, MD3 From 1the Prostatitis Foundation, Smithshire, Illinois; the 2Manila Genitourinary
Clinic (Cebu Branch), Cebu, Philippines; and the 3Manila Genitourinary Clinic,
Manila, Philippines Address correspondence to:
Antonio Espinosa Feliciano, Jr., M.D.
Manila Genitourinary Clinic
G/F Kimvi Building Ground Floor
1191 M. Orosa Street
Ermita, Manila, 1000
Philippines
E-mail: aef@prostate.com.ph
Tel. 63-2-521-7069
Fax. 63-2-522-3564 Abstract Background Acute urinary retention followed by failed attempts at catheter removal, is
considered an indication for transurethral resection of the prostate. We describe
5 men with urinary retention and indwelling catheters, treated with repetitive
prostatic massage, antimicrobials, alpha-blockers, and in two cases, finasteride. Methods We retrospectively reviewed the charts of all patients presenting to the
genitourinary clinic with indwelling urinary catheters during a one-year period. Results Five men (mean age, 70 years; range 64 76; SD, 4.47) presented to the Manila
Genitourinary Clinic (Cebu Branch) wearing indwelling urinary catheters placed
for acute urinary retention. Urologists had told all five men that they needed to
undergo transurethral resection of the prostate. The Cebu genitourinary
physician removed the catheters, instituted repetitive prostatic massage, and
diagnosed all 5 patients with prostatitis. All 5 patients received alpha-blocker
medication and antibiotic therapy, while finasteride was given to 2 patients.
During treatment, statistically significant improvements occurred in several
objective parameters including: global symptom severity scores, urethral white blood cell (WBC) counts, WBC counts of the expressed prostatic secretions
(EPS), EPS red blood cell (RBC) counts, urinary WBC counts, and urinary RBC
counts. Fluorescing Chlamydia elementary bodies disappeared in 3 of the 4
positive patients (one patient was not available for retesting) by the end of
treatment. Conclusions We suggest that men suffering urinary retention who have an indwelling urinary
catheter be tested for prostatitis, as all five men in this study were diagnosed with
prostatitis based on WBC counts of the expressed prostatic secretions. The
treatment protocol of repetitive prostatic massage, antimicrobial therapy, alpha-
blocker therapy, and, in two cases, finasteride, enabled catheter removal in all 5
men (100%), and successful urination in all 5 men (100%). Transurethral
resection of the prostate has been prevented for a mean of 2.53 years (range,
16-38 months). In other case series studies, a significant percentage of men fail
catheter removal even with medical therapy, and go on to surgery within one-
year. We present statistically significant data that has never before been
published for men with indwelling urinary catheters after urinary retention. Further
study is necessary to determine if adding repetitive prostate massage and
antibiotics to treat prostatitis adds to the standard medical therapy of catheterized
men in urinary retention. Controlled studies are warranted. Keywords: BPH, benign prostatic hyperplasia, TWOC, trial without catheter, acute urinary
retention, urinary retention, prostatitis, prostatic massage Introduction Acute urinary retention is a disease of elderly men. One study of 72,114 men
found the mean age of male patients with urinary retention to be 73 years[1]. A
study by Meigs and colleagues showed that 33% of men suffer acute urinary
retention by age 89[2], and research by Peters and colleagues found the
incidence of that disorder to be 4.5/1000 man-years[3]. A large, randomized, double-blind, placebo-controlled study found that treatment
with alfuzosin (Uroxatral) increased the likelihood of a successful trial without
catheter (TWOC) in men with acute urinary retention, but even with continued
alfuzosin therapy, 27.1% of those patients required surgery within 6 months[4].
Another study showed that 56% of men underwent surgery after TWOC and that
the mean time to operation after the first episode of acute urinary retention (even
in those treated with alfuzosin) was 1.85 years[5]. Acute urinary retention is considered an indication for transurethral resection of
the prostate (TURP), especially when medical therapy fails or patients experience difficulty with catheter removal[6]. However, patients who undergo
TURP may experience significant short-term adverse effects such as
postsurgical pain, bleeding, infection, and complications from anesthesia. A study
of 10,000 men indicated that the risk of urinary tract infection after TURP is
15.5%[7]. TURP can also cause significant long-term complications, such as the
need for reoperation (1.9% to 6% of patients) or transurethral resection to correct
bladder neck contracture (2.4%) or the formation of urethral strictures that require
surgical correction (1.7%)[8]. TURP can also result in retrograde ejaculation,
infertility, sexual dysfunction, and incontinence[9,10]. In one study, 67% of the
men who underwent TURP experienced sexual dysfunction[11], and other
research indicates that satisfaction with sex decreased in 44% of men after
TURP[12]. One prior case report appears in the literature of a 69-year-old man who was
spared TURP and experienced improved sexual function by undergoing
repetitive prostatic massage and antimicrobial therapy.[13] Patients Approximately 4 to 8 male patients with urinary retention present to the Manila
Genitourinary Clinic, Cebu Branch (the Cebu Genitourinary Clinic) each year. We
performed a retrospective chart review of the 6 patients presenting with a urinary
catheter for the treatment of acute urinary retention during 2000 to the Cebu
Genitourinary Clinic. The study subjects did not exhibit diabetes mellitus,
congestive heart failure, neurologic, or musculoskeletal disease. All patients were
self-referred to our clinic upon recommendations from other patients. None of the
patients had undergone prostatic massage with EPS collection before being
treated at our clinic. One patient was anemic and was admitted to the hospital for
GI bleeding and blood transfusions. He was never treated at the clinic bringing
our study number down to 5 patients. Certified laboratory technicians performed all laboratory tests and reported their
results independently of the treating physician. Urethral smears were obtained
from all patients by pressing a glass slide against the urethral mucosa of the
penile meatus, after which the smears were Gram-stained. Each slide was
scanned via light microscopy to identify the field with the lowest and highest
number of urethral WBCs. Urethral bacteria were recorded, and urethral smears were evaluated until the
urethral WBC counts and presence of urethral bacteria decreased to zero in all
patients. After each urethral smear had been obtained, the penis of each patient
was cleaned with povidone-iodine 10% and then with 70% isopropyl alcohol. A
paper tissue was placed under the penis as each patient leaned over the
examination table. Prostatic massage was then performed on each patient every
day for 4 days and thereafter 3 times per week. The same physician performed
each massage. During the massage, all drops of expressed prostatic fluid falling on the tissue were counted, as was the drop remaining at the end of the penis
after the massage, which was used to determine WBC and RBC counts. After the
remaining drop had been removed for microscopy, the penis was milked of the
remaining prostatic fluid, which was sent for culture. After EPS collection, a cotton swab was inserted 1 cm or more into the urethra to
collect urethral mucosal cells for Chlamydia testing. Chlamydia testing was
performed by direct fluorescent antibody technique (DFA, BioM

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