Prostate drainage

[mike]

Since we have the manila protocol Dr here on this forum I think we should ask this question. Does prostate drainage offer symptom relief? I have read hundreds of story's saying no, Many from x manila patients. Yet there are a few out there who were helped or cured from massage. I wonder if the cured were the small percent of suffers with true bacterial prostatitis. Or does massaging actually help release the tense pelvic floor muscles when done, offering some relief? My doc tried the protocol with little results. And has stopped doing it for his patients. some say the anti inflammatory effects from antibiotics, combined with massage may also play a role in some patients getting short term relief..

[Arnon Krongrad, MD]

What is drainage? Same as massage? What protocol are you referring to?

[mike]

yes.. drainage is the same as a vigorous massage to drain out fluid. Test the fluid for pathogens, and give the patients insane amounts of oral antibiotics in a attempt to cure the prostatitis. The massages are done daily along with cultures taken weekly.

[Antonio E. Feliciano,Jr.MD]

Prostatic drainage if done correctly need not be vigorous. The average volume of Expressed Prostatic secrection (EPS) that is extracted is around 10 drops which translates to 0.5ml. Less than this amount will not be very easy to analyze.
Let us call the procedure as the Manila protocol for uniformity. The protocol has 2 phases the first phase is done every day. The main objeective with in the first an average of 4 to an extreme of 8 drainages is to count wbc under high power field (HPO) or with a magnification of 400X. is to be able to collect the most reliable specimen
Once the count reach the highest count or peak then microbiologic examinations are done with the objective of looking for possible pathogens using culture panel with Mycoplasmas and anarobes,fungus. Direct immunofluresence or PCR can be used for chlamydia.
The second phase is for treatment. This is done every other day (to promote drainage and prevent the ducts from closing up) WBC are monitored. When the counts drops (usually as early as 12days,averaage of 21days maximum of 32days.
Test of cure are then done

[mike]

Unfortuantly even after trsting for a cure, and pathogens eliminated, most of the patients still have all there symptoms..

Every prostatitis forum on the net is flooded with negative reviews on the drainage protacal. Many from western men who flew to manila for treatment A select few get temp relief that can be maintained through life long prostate massages.

The symptom cure rate on the forums is hovering around 1 in 20

[soso]

Dr.Antonio E. Feliciano my understanding is that you trained Dr. Polacheck and I did this protocol for almost 7 months and the Protocol helped me but didn’t cure me and it left my stomach messed up for almost a year. I still have liveable symptoms after Dr.Polacheck and going to China for treatment but it feels like it can come back anytime. So getting the prostate out makes sense to me if I have to get on more antibiotics. I don’t think my stomach or tendons can take any more antibiotics. What are you thoughts on this?

Thank you

soso

[Antonio E. Feliciano,Jr.MD]

Dr Polacheck did not train but rather observed under me. He does not follow the Manila Protocol.

[Antonio E. Feliciano,Jr.MD]

The published cure rate of the protocol to this group of patients is around 40% with a continued durability of more than 2 years of follow up.

Many of these patients had sexual contact during treatment and is therfore a poor study. It is still the highest published cure rate.

[Arnon Krongrad, MD]

I have a suggestion: let's post references. Dr. Feliciano, do you have the reference you cited about the 40% cure rate? Do you have it in pdf? If you want I can post it here if you send it to me at [e-mail] Thank you.

For the sake of clarity: how are you defining cure? How are symptoms measured? Thank you.

Antonio E. Feliciano,Jr.MD said:

The published cure rate of the protocol to this group of patients is around 40% with a continued durability of more than 2 years of follow up.

Many of these patients had sexual contact during treatment and is therfore a poor study. It is still the highest published cure rate.

[mike]

Here is a interesting link with past patient stories about felicianos clinic... http://groups.google.com/group/sci.med.prostate.prostatitis/msg/660...


The old dr feliciano website boosted a 95 percent cure rate. This had men flood in droves to manila. They all returned to warn others not to go. The largest prostatitis web site on the net chronicprostatitis.com also has more info on this matter, including warnings. Its ridiculous to fly to another cuntry for drainage, when your wife or yourself can do it yourself for free.



the cure rates are not based off of symptom improvement. They are based off of negative pathogen testing. ?Riding the prostate of pathogens, has been proven time and again to not cure prostatitis symptom. Symptom cure rates and pahogen cure rates are two different things. Men want symptom cures!! not a test that says there cured, but they are still bed ridden

there are published studies on this finding by top American urologists . Apparently finding that bacteria has little do do with most prostatitis cases. I visited one of the doctors who completed the study. Dr Alexander at the University of Md

He went over the study with me in detail.

Dr smolev head urologist at the good Samaritan hospital in Maryland has been following the manila protocol for years. He has stopped because it has no effect on 99 percent of his patients



The Journal of Urology 2003; 169(2):584-588

Prostate Biopsy Culture Findings of Men With Chronic Pelvic Pain Syndrome do Not Differ From Those of Healthy Controls

JAY C. LEE*; CHARLES H. MULLER; IVAN ROTHMAN†; KATHY J. AGNEW; DAVID ESCHENBACH‡; MARCIA A. CIOL; JUDITH A. TURNER; RICHARD E. BERGER

ABSTRACT Purpose: Previous reports have identified bacteria in the prostate of men with chronic pelvic pain syndrome. To examine whether prostatic bacteria are more prevalent among patients with chronic pelvic pain syndrome than among those without pelvic pain, we compared 4-glass urine test and prostate biopsy results.

Materials and Methods: A total of 120 patients with types IIIa and IIIb chronic pelvic pain syndrome and 60 asymptomatic controls underwent a standard 4-glass urine test, examination of expressed prostatic secretion leukocytes by hemocytometer and transperineal, digitally guided prostate biopsies. Tissue was cultured for aerobes, anaerobes, Trichomonas vaginalis, Chlamydia trachomatis and herpes simplex virus. Skin cultures were performed on a subset of patients and controls.

Results: Positive prostate biopsy cultures were obtained from patients and controls. Bacteria were found in 45 of 118 pain patients (38%) and in 21 of 59 controls (36%) (p = 0.74). Older men were more likely to have positive cultures. Men with type IIIa chronic pelvic pain syndrome were more likely than those with type IIIb to have positive prostate biopsy cultures.

Conclusions: Bacteria cultured from transperineal prostatic biopsies do not differ between men with and without chronic pelvic pain syndrome. Prostatic bacteria obtained by biopsy are probably not etiologically related to the symptoms in the majority of men with chronic pelvic pain syndrome.

[Antonio E. Feliciano,Jr.MD]

Dr.ANF is my late father. Unfortunately we drifted apart before he passed away. I filed a libel case againts him in our local court, because of his lies againts me. His clinic and my clinc are 2 different entitiies.
His work was never published in a peer reviewed journal. Mine was published several times. If the group will not mind I can correct some misconceptions that went on from the past.

[Antonio E. Feliciano,Jr.MD]

the study showing the same bacteria between men with symptoms to men without symptoms does not realy prove anything because they have not followed up the the group of men with bacteria in their prostate, it is not known if eventualy they eventualy developed symptoms.

[Antonio E. Feliciano,Jr.MD]

REPETITIVE PROSTATE MASSAGE THERAPY
FOR CHRONIC REFRACTORY PROSTATITIS:
THE PHILIPPINE EXPERIENCE


J. Curtis Nickel, Joe Downey, Antonio E. Feliciano, Jr., Brad Hennenefent,
Kingston, Canada; Manila, Philippines; Chicago, USA


Correspondence to: Dr. J. Curtis Nickel
Department of Urology
Queen’s University
Kingston General Hospital
Kingston Ontario Canada
K7L 2V7





Key Words: Prostatitis, Prostate Massage, Urinary Tract Infection, Prostate



ABSTRACT
Introduction Patients frustrated with failure of traditional therapy for prostatitis are traveling to the Phillippines and elsewhere for repetitive prostate massage combined with specific antibiotic therapy.
Objective To prospectively evaluate the response of North American prostatitis patients who travelled to Manila to undergo this treatment
Patients and Methods: 31 patients were invited to participate in this study. 26 consented and were registered by the Prostatitis Foundation (BH), evaluated (JCN, JD) prior to and following treatment (AEF). Evaluation at baseline and after treatment consisted of standardized history and previously validated prostatitis specific Symptom Frequency Questionnaire (SFQ) and Symptom Severerity Index (SSI), International Prostate Symptom Score (I-PSS) and Quality of Life (QoL) questionnaire, the O’Leary Sexual Function Inventory (SFI) and a Subjective Global Assessment (SGA). Treatment in Manila consisted of triweekly prostatic drainages combined with specific culture directed and/or empiric antimicrobial therapy for 6-12 weeks.
Results: There was a significant decrease in average symptom severity (SSI) by 4 months which continued for 22 months, and significant improvement in symptom frequency (SFQ), Quality of Life (QoL) and voiding symptoms (I-PSS) at time of final followup (22 months). There was no significant change in sexual function (SFI). 56% had >60% decrease (significant improvement) in symptom severity (SSI) while 47% had similar significant improvement in frequency of symptoms (SFQ). 42% reported marked subjective improvement (SGA) by the end of the study period. The presence of uropathogens, presumed non-pathogens or sterile cultures; average induction WBC EPS count (6.6/HPF), zenith count (31/HPF) or final nadir count (9.6/HPF)) were not predictive for favourable response.
Conclusions: The combination of prostate massage and antibiotics for treating difficult refractory cases of prostatitis may be promising. Studies in patients with less refractory and shorter duration disease may allow us to predict who will respond to this therapeutic approach.
INTRODUCTION

The treatment of chronic prostatitis is dismal. Antibiotics, anti-inflammatory agents, alpha-blockers, antispasmodics, analgesics, allopurinol, muscle relaxants, and various modalities of invasive and minimally invasive surgical procedures have been advocated and each and every one has shown some degree of efficacy in a small minority of patients (1). However, for the majority of patients, these treatments do not result in cure and patients are left to wander from one physician to another, hoping that the next will have the key to ameliorating his symptoms. Frustrated patients, scouring the internet for information on their disease, discovered that Physicians in the Manila were achieving remarkable success rates in treating Philippine patients diagnosed with chronic prostatitis and other genitourinary complaints with repetitive prostate massage combined with specific antibiotic therapy. The successful results of such therapy in Philippine prostatitis patients has been presented at North American urologic meetings (2). Encouraged by the success reported by the first few patients who underwent this treatment in Manila, patients frustrated with failure of North American traditional therapy traveled to the Philippines in 1996 and 1997 to take advantage of the possible benefits of this therapy. With the assistance of Brad Hennenefent of the Prostatitis Foundation and the cooperation of Dr. Antonio E. Feliciano, Jr., we prospectively evaluated the response of these first North American prostatitis patients who travelled to Manila to undergo repetitive prostatic massage combined with antibiotic therapy.


PATIENTS AND METHODS

31 patients with a North American diagnosis of chronic prostatitis were contacted and invited to participate in the study. 26 patients were subsequently registered by the Prostatitis Foundation (BH), their symptoms were audited (JCN and JD) prior to and at least three months following treatment which was undertaken in Manila (AEF). Symptom evaluation by audit at baseline and after treatment consisted of a standardized history and previously validated and published (3) prostatitis specific Symptom Frequency Questionnaire (SFQ) and Symptom Severity Index (SSI), the International Prostate Symptom Score (I-PSS) and Quality of Life (QoL) questionnaire , a Subjective Global Assessment (SGA) (3) and the O’Leary Sexual Function Inventory (SFI) (4). Treatment in Manila consisted of tri-weekly prostatic drainages combined with specific culture - directed (expressed prostatic secretion or EPS) and/or empiric (if no growth after several repetitive cultures of EPS) antimicrobial therapy for 6-12 weeks. At each of the tri-weekly clinic encounters, the prostate was vigorously massaged and aerobic, anaerobic and chlamydial cultures were performed. Antibiotics were prescribed according to emerging culture results. If cultures were negative by the third drainage, patients empirically received ofloxacin or other wide spectrum antibiotics followed in the majority of patients with antifungal antimicrobials (ie fluconazole). Patients were continued on this tri-weekly evaluation and treatment schedule until (a) they were cured, (b) they noted significant improvement or (c) twelve weeks of therapy had been undertaken.

Statistical analysis performed employing Mann-Whitney T-test or Rank Sum Test (for non-paramentric data).

RESULTS

26 patients completed the pre-evaluation symptom audit, at least six weeks of therapy and at least one post treatment symptom audit. These patients (mean age of 44.8 +/-2.1 years) had been diagnosed with prostatitis for a mean of 8.6 +/- 2.1 years and have had continuous symptoms refractory to all traditional therapies for 5.3 +/- 0.9 years. The patients had seen an average of 9.0 +/- 1.8 physicians for their disease. All patients received therapy for 6-12 weeks (receiving an average of 20 massage treatments) and were evaluated 4.2 +/- 0.5 (first follow-up) and 21.8 +/- 1.4 months (final follow-up) after therapy. Patients did not consistently complete all 5 questionnaires. The average symptom scores (including number of patients completing specific assessment) at baseline, first and final follow-up after prostate massage therapy are presented in Table 1. Most patients received multiple alternative therapies for prostatitis between the first post-treatment assessment and final assessment. These treatments included courses of anti-microbial therapy, repeat regime of repetitive prostatic massage, alpha-blockade (i.e terazosin), phytotherapy (i.e. saw palmetto and/or quercetin) and other various treatments employed in attempt to alleviate prostatitis symptoms.

There was a significant decrease (p<0.05) in the severity of symptoms (SSI) at first and final followup. The frequency of specific prostatitis symptoms (SFQ) decreased slightly by 4 months, and this improvement became significant by 22 months. Patients experienced a significant improvement in average voiding symptoms (I-PSS) and quality of life (QoL) by the end of the study. There was no change in sexual function score (SFI) during study.

It has been observed that patients who had a greater than 30% decrease in symptom score felt they had a perceptible improvement while those that had a greater than 60% decrease in symptom scores felt that they had achieved significant improvement (studies in progress by JCN). The percentage of patients experiencing these magnitudes of symptom score decrease in shown in Table 2. 56% of patients experienced significant improvement in severity of symptoms (SSI), while 47% of patients had significant reduction of frequency of symptoms (SFQ), at end of study period compared to baseline values. The subjective global assessment (SGA) was a measure by which the patient could estimate the degree of improvement that they had achieved with their therapeutic program. 42% (of the 12 patients who completed SGA assessment) reported marked improvement on at the final evaluation (Table 3).

Eighteen patients had reliable serial culture data. 80 % of patients grew bacteria in their serial EPS. 50% grew more than 1 organism over the treatment period (average: 1.9 organisms). The distribution of postive cultures is outlined in Figure 1. A subgroup analysis showing symptom score improvements and SGA assessments in patients growing uropathogens and those with no growth or growing presumed non-uropathogens did not demonstrate any difference. In other words, the organism cultured did not predict ultimate outcome of therapy.

The microscopic white blood cell count/high power field (WBC/hpf) did not show a lot of variation during the treatment cycle (Figure 2). The mean WBC/hpf on induction was 6.6 (+/- 5.7), the mean zenith WBC/hpf was 31 (+/- 13.7) at a mean of 9.1 (+/- 6.1) treatments. The mean nadir WBC/hpf after treatment commenced was 9.6 (+/- 7.0) at a mean of 20.7 (+/-8.4) treatments. A secondary subgroup analysis determined that the induction, zenith or nadir WBC/hpf count in the expressed prostatic secretion was not predictive for response.

DISCUSSION

In the early 1890’s, treatment of diseases of the prostate by massage came in to popular favor. Before the turn of the century, prostatic massage was adopted by Royal Institute of Massage at Stockholm (5) and this procedure would remain the main stay of prostatitis treatment for almost the entire 20th Century.

In 1936, O’Connor (6) published one of the best descriptions of the digital rectal examination and the technique of prostate massage. He felt that the therapeutic benefit of prostatic massage derived from digital expression of the prostatic ductal and acinar contents with resultant improved drainage through normal channels, the stimulation of circulation in the region of the prostate proper and increased absorption from affected areas brought about by the above reactions. At that time it was felt that vigorous massage should not be done more than once a week while mild massage may be done up to twice a week.

In the 1940’s, urologists recognized that the cardinal principle of surgery was being violated in treating patients by massaging a presumed infected area, yet they felt that there was significant clinical evidence accumulated to justify prostatic massage, since many patients were relieved of their symptoms (7) Controversy existed as to whether or not prostatic massage by itself could induce inflammation. But Hinman (8) insisted that three serial prostatic examinations (on alternate days) would not in itself cause the appearance of white blood cells in the secretion if it was absent at the start. The treatment of chronic prostatitis, then, revolved for most of the century around the principle of establishing adequate drainage of presumed infected prostate ducts. In the 1950’s, the object of prostatic massage was to increase the blood supply to the prostate (aid in carrying away infection and stimulating absorption) to evacuate pus and bacteria through prostatic ducts. This method of treatment in the 1940’s and 50’s was universally adopted by all urologists, yet some differences of opinion existed as to the frequency with which such massage be carried (9). On average, it appeared that most urologists massaged the prostate gland twice a week and as the amount of pus in the EPS diminished the treatments were given less frequently. Shortly after antibiotics were introduced to medicine during the early 1940’s, Cooper and MacLean (10) advocated prostatic massage combined with antibiotics at least twice a week is an essential part of treatment. The patients at that time were treated as inpatients with intravenous antibiotics. It was recognized, however, even in the 1960’s (12) that antibiotics by themselves as a treatment for chronic prostatitis might be little more than just placebos.

In 1968 Meares and Stamey published their landmark paper in Investigative Urology (12) describing their technique for specific quantitative cultures of the lower urinary tract. It was at that time that the concept of repetitive prostate massage was abandoned by most of the urologic profession in North America. Urologists adopted the approach advocated by Meares and Stamey (12), that proper use of effective antibiotics for culture proven bacterial infection of the prostate gland (determined by a single EPS culture) was optimal therapy. Unfortunately, over the last three decades our treatment record for curing prostatitis is no different than that reported by our predecessors decades previously. It is no wonder, then, that repetitive prostate massage may be making a comeback.

Why should repetitive prostate massage even work? It appears that prostatic inflammation may be initiated by reflux of urine into the prostatic ducts, with or without bacteria. The resulting inflammation, caused by either a pathogenic micro-organism or by some immunologic factor within the refluxing urine, begins an inflammatory process within the prostatic duct. In the later stages, the prostatic ducts may drain less effectively, bacteria present in the prostate gland may form quiescent, but immunologically active (“hibernating”) bacterial biofilms and eventually the inflammation spills through the basement membrane into the surrounding peri-glandular stroma (13). Prostate massage may do nothing more than physically assist in drainage of these inflamed prostatic ducts and acini. In those patients without infection (so called chronic nonbacterial prostatitis) this improved drainage may reduce inflammation. In the patients with bacteria trapped in bacterial biofilms, prostatic massage may not only stir up bacteria biofilms and make them more susceptible to antibiotics, but improved drainage of the ducts will allow antibiotic penetration into these sequestered areas.

Feliciano and Hennenfent (2) have earlier reported significant success rates in Philippine patients who were treated for the first time for their prostatitis symptoms. This same group recently published (14) their findings that repetitive prostate massage “unmasked” inflammation (noted as white blood cells in EPS) and pathogens that were not evident in the original first time prostate massage EPS specimen.

This study demonstrated that many patients had improved symptom scores, global assessments and better quality of life almost 2 years after traveling to the Philippines and undergoing 6-12 weeks of repetitive prostate massage and antibiotic therapy. Many of these patients had other multiple treatments after their initial prostate massage treatment and it is impossible to ascribe all the benefits experienced by the responder subgroup to prostate massage alone. Not all patients were available for analysis at the end of the study, and the results may be skewed by a responder subgroup. Just as many patients had no improvement or even deterioration of their symptoms in the months following their prostate massage treatments. It is also very probable that these patients, who were refractory to traditional therapy, were the most difficult cohort of prostatitis patients to treat in this manner. In an ongoing clinical series (15) we have found that patients who have had their symptoms for less than two years and had significant leukocytosis on initial EPS microscopy derived the greatest benefit from repetitive prostate massage and antibiotic therapy. Other North American investigators have not reported a consistent pattern of improvement and there is no agreement on the ultimate benefits of prostate massage for the treatment of chronic prostatititis (15).

The combination of prostate massage and antibiotics for treating difficult cases of prostatitis does show some promise. Studies in patients with less refractory and shorter duration disease may allow us to predict who will respond to this particular therapeutic approach.

REFERENCES
1. Nickel JC: Prostatitis: Myths and realities, Urol 51:362-366, 1998
2. Hennenfent BR, Feliciano AEJr: Thrice weekly prostatic drainage, microbial diagnosis, and antimicrobial therapy for bacterial prostatitis, nonbacterial prostatitis, prostatodynia, and benign prostatic hyperplasia as practiced in the Philippines. J Urol 157 (Suppl):239A, 1997.
3. Nickel JC, Sorensen R: Transurethral microwave thermotherapy for nonbacterial prostatitis: A randomized double blind sham controlled study using new prostatitis specific assessment questionnaires, J Urol 155:1950-1955, 1996.
4. O’Leary M, Fowler F, Lenderking W, et al: A brief male sexual function inventory for urology. Urol 46:697-706, 1995.
5. Farman F: Classification of Prostatitis, J Urol 23:113-117, 1930.
6. O'Conor VJ: Therapeutic value of prostatic massage: With a discussion on prostatitis and significance of proper rectal palpation of the prostate gland, Medical Clinics of North America 19:1181-1185, 1936.
7. Henline RB: Prostatitis and seminal vesiculitis: Acute and chronic, JAMA 608-615, Nov 6, 1943.
8. Hinman F: The principles and practices of urology, Philadelphia: WB Saunders Co., 1936.
9. Campbell MF: Principles of Urology; An Introductory text to the diseases of the urogenital tract, Philadelphia: WB Saunders Co, 1957, pp 311-314.
10. Cooper HG, MacLean JT: Chronic prostatitis associated with nonspecific urethritis. Can Med Assoc J, 54:136-144, 1946.
11. Gonder MJ: Prostatitis, Lancet 83:305-306, 1963.
12. Meares EW, Stamey TA: Bacteriologic Localization Patterns in Bacterial Prostatitis and Urethritis, Investigative Urology 5:492-518, 1968.
13. Nickel JC, Bruce AW, Reid G: Pathogenesis, diagnosis and treatment of the prostatitis syndromes, In Krane RJ and Siroky MB, Clinical Urology, Philadelphia, JB Lippincott Company, 1994, pp 925-938.
14. Hennenfent BR, Feliciano AEJr: Changes in white blood cell counts in men undergoing thrice-weekly prostatic massage, microbial diagnosis and antimicobial therapy for genitourinary complaints. Br J Urol 81:370-376, 1998
15. Nickel JC, Alexander R, Anderson R, Krieger J, Moon T, Neal D, Schaeffer A, Shoskes D: Prostatitis Unplugged: Prostate Massage Revisited. Techniques in Urology, 1999 (in press)

Figure Legend

Figure 1: Bacteria identified from serial cultures of EPS

Figure 2: White blood cells per high power field (+/- standard deviation) in EPS during treatment with repetitive prostate massage.