Changes in white blood cell counts in men undergoing thrice-weekly prostatic massage, microbial diagnosis and antimicrobial therapy for genitourinary complaints

Objective
To report changes in the white blood cell (WBC) counts in expressed prostatic secretions (EPS) conin men with pelvic symptoms undergoing thrice-weekly prostatic massage combined with antimicrobial therapy.

Patients and Methods
The study comprised a retrospective analysis of the records of 35 patients (mean age 45.3 years, range 28–70, SD, 12.03) with pelvic pain, pain in the lower back, obstructive urinary symptoms, who had undergone the same diagnosis and treatment examine protocol in a genitourinary clinic in Manila, irritative urinary symptoms, or sexual dysfunction, Philippines, from September 1992 to September 1995.

Results
EPS were obtained 347 times in 35 patients (median 9 times per patient, range 6 16). In 26 of the 35 (74%) patients the WBC count in the EPS was <10 per oil-immersion field (OIF, ×1000) at the first prostatic massage. In 34 of 35 (97%) patients the WBC count rose to 10 as prostatic massage continued on a thrice-weekly schedule. The mean (range,SD) initial WBC count in the EPS was 8.4 (1– 48, 8.43) and the maximum was 40.9 (6–60, 19.05); the diCerence between these values was 32.5 (3–57,18.78; 95% confidence interval 26.1–40.1) and the diCerence was statistically significant (paired t-test,P<0.001).

Conclusions
The classification of patients into those with prostatodynia or prostatitis based on one EPS examin ation is misleading and thrice-weekly massage of the prostate is better than a single collection of EPS to obtain the most purulent sample for Gram staining and culture.

Keywords
Prostatitis, prostatodynia, sexual dysfunction, benign prostatic hyperplasia, impotence, clinical series

Introduction
Four categories of prostatitis are recognized, i.e. acute bacterial, chronic bacterial, nonbacterial and prostatody nia. The generally accepted threshold between prostato-dynia and prostatitis is 10 white blood cells (WBC)per oil immersion field (OIF, ×1000) [1–4].

The Meares and Stamey localization test [5] has been considered the ‘gold standard’ for diagnosing the prostatitis syndromes. Using the Meares and Stamey classification, #90% of patients with chronic pelvic symptoms are categorized as nonbacterial prostatitis or prostatodynia, which are thought to be incurable diseases [6]. Published in 1968, the original report by Meares and Stamey [5] was based on only six patients and the procedure has been largely abandoned by practising urologists and GPs [7]; it has been estimated that <5% of urologists routinely use the Meares and Stamey localization procedure [8].The protocol of the Manila Genitourinary (GU) clinic for treating prostatitis syndromes consists of thrice-weekly prostatic massage, microbial testing and antimicrobial therapy, and was first described in 1982 [9]. In this clinic, patients with acute or chronic bacterial prostatitis, nonbacterial prostatitis, prostatodynia, sexual dysfunction or BPH receive the same treatment. This paper reports the changes in the WBC counts in the EPS in 35 men with pelvic symptoms undergoing thrice weekly prostatic massage as part of this treatment protocol.

Patients and methods
The medical records were reviewed for 35 patients (mean age 45.3 years, range 28–70, SD 12.03) with pelvic symptoms treated using the same protocol between September 1992 and September 1995. Six (17%) of the patients reported being single and 29 (83%) reported being married. The primary and subsidiary complaints were recorded from the charts when available, symptoms being recorded using terminology based on the symptom scores developed by the AUA [10] and the University of Washington [11]

All patients stayed in the protocol for at least six EPS massages and comprised a unique group undergoing the same treatment protocol and testing regimen; no patients had only 2 5 massages. The urethra was tested for Chlamydia by the direct immunofluorescence (DIF) test (Chlamydia Direct IF, bioMerieux, France). All the patients underwent thrice weekly prostatic massages by DRE, carried out by one of two clinic physicians. For consistency, the first drop of EPS was collected at each massage and Gram stained by one of two laboratory technicians. The maximum WBC count per OIF was recorded at every massage; when the OIF contained too many WBC to count it was recorded as 60 WBC/OIF.

The EPS were cultured for aerobic bacteria (brain-heart infusion broth), anaerobic bacteria (cooked-meat medium), Ureaplasma and Mycoplasma (Mycoplasma IST broth) and Trichomonas (medium consisting of liver digest, glucose and sodium chloride).

Patients were simultaneously treated with ofloxacin 400 mg and minocycline 100 mg (both orally, twice daily) during the protocol. After the fourth massage, metronidazole 2 g orally was given once. After the antibiotics were stopped, the patients were given ketoconazole 400 mg for 5 days. Any patient not tolerating a drug was given a substitute, i.e. another quinolone antibiotic, usually ciprofloxacin, for ofloxacin, doxycycline for minocycline, and itraconazole for ketoconazole.

Results
Sixteen diCerent symptoms were present in the study population, those most frequently recorded in the patient’s charts being pain symptoms, but also including obstructive and irritative urinary symptoms, sexual dysfunction, urethral discharge and fatigue. The most common chief complaints were pain during urination, pain in the penis, pain in the lower back, and pain in the perineum. The most common complaints overall were pain during urination, difficulty obtaining an erection, and the need to urinate again <2 h after urinating (Table 1). That these symptoms are commonly seen in men with prostatitis has been reported recently [12,13].

Using >3 months as the threshold between designating cases as acute or chronic, seven (20%) of the 35 patients were acute and 28 (80%)
chronic, based on their primary complaint on presentation. Patients experienced their primary complaints for periods ranging from 3
days to 20 years, with a median duration of symptoms of 12 months.

Table 2 lists the 35 patients and their WBC count in the EPS as it changed with thrice-weekly massages, with the number of massages that each patient underwent. All patients completed six prostatic massages, one patient underwent 16, the median being 9 (range 6–16, mean 9.9, sd 2.3). At the first massage, 26 of 35 (74%) patients had <10 WBC/OIF and of these 26 patients 25 (96%) had a WBC count of >10 in subsequent EPS (95% CI, 0.78–0.98). By the end of the study, 34 of 35 (97%) patients had 10 WBC/OIF as the thrice-weekly prostatic massage continued. As 10 WBC/OIF is usually used as the threshold to distinguish prostatodynia or prostatitis, the diagnostic category of these patients changed with continued massage.

The initial WBC count in the EPS was never the maximum; most patients had a maximum count between their third and fifth massage, with a wide variation in this peak. At least 10 massages were required for every patient in this study to reach the peak WBC count in

Table 2 Patients and changes in their WBC counts with successive drainages; 35 patients underwent drainage from six to 16 times

the EPS. The changes in WBC with continued thrice-weekly prostatic massage were statistically significant (Fig. 1). The mean (sd) WBC count at the first massage was 8.4 (8.43) and at the second was 14.6 (16.24),giving a mean change of 6.2 (12.03, 95% CI 2.1–10.4);the diCerence was statistically significant (paired t-test,P=0.0043). The count at the fourth massage was 24.1(18.47) and the mean change from the first to fourth massage was 15.7 (19.73; 95% CI 8.9–22.5; P<0.001, paired t-test). The most important change clinically in the WBC count was from the first to the maximum, the mean (sd) of which was 40.9 (19.05), giving a mean change from the first of 32.5 (18.78; 95% CI 26.1–39.0;P<0.001, paired t-test); thus the maximum WBC exceeded the first by a factor of 5. All patients had a complete set of cultures and urethral chlamydial DIF testing at the first EPS examination, the tests being repeated throughout treatment. None of the cultures or slides for Trichomonas or anaerobic bacteria were positive. Two patients (nos 9 and 11) were negative on chlamydial DIF testing and on all bacterial cultures; patient no. 9, 45 years old, had pain in his lower abdomen of 4 years’ duration. His WBC in the EPS never exceeded 10 over nine massages; his initial WBC count was 3 and the maximum 6. For a year, patient no. 11 (44 years old) had had pain in the lower back, pain with ejaculation, difficulty obtaining an erection, and had to push or strain to urinate; his first WBC count was 16 and his maximum 38. The remaining patients had positive bacterial cultures or a positive chlamydial DIF

After six massages, the patients began to discontinue

the thrice-weekly massage regimen, the records suggest-ing that this was because the symptoms resolved, the thrice-weekly treatment was inconvenient, or because of concomithe the expense of treatment compared with the patient’s income. Follow-up of the patients by telephone was inadequate; only nine of the 35 patients had telephones and only five of the nine (14% of the study group) could be contacted for an interview by the first author. Four of the five patients (nos 4, 10, 12, 24 and 25) reported being completely cured of all symptoms by the protocol. Patient no. 25, a diabetic who had undergone a TURP, reported being only partially cured by the protocol. All five of those contacted by telephone reported being unharmed by the protocol and none of the 35 patients had complications from prostatic massage recorded in their charts.

Discussion
Before the production of antibiotics for medical use in 1940s, and even after the introduction of the sulpha antibiotics and penicillin, the ‘gold standard’ for the treatment of prostatitis was prostatic massage [14]. After were introduced, they became the ‘gold stan- dard’ treatment for prostatitis [15]. Prostatitis is the cause of antibiotic treatment in men [16]. Using Medline and manual library searches, we have no studies on the eCect of thrice weekly prostatic on WBCs in the EPS from healthy or diseased men, no studies on what frequency of prostatic massage maximizes the clinical response, nor studies on the combination of the two ‘gold standards’, i.e. prostatic massage and antibiotics, for prostatitis. Obstruction of the prostatic ducts and inflammation of the prostate are both recognized components of prostatitis.