Therapy of main uro /andrological diseases.
Sexually transmitted diseases. (STD). Sexually transmitted diseases are the more frequent ones bringing young male patient to Specialist consultation. In the majority of cases they represent consequences of a promiscuous sexual life with random partners and without condom.
Must be specified that trasmission not only happens via common hetero/ homosexual ways of intercourse but also by oral sex or simply by a kiss if one of both (or more) partners carries into his mouth pathogen bacteria taken before through an infectious genitalia contact.
The STD initially affect the urethra, Urethritis, but not always give signs at this site. Often infection spreads to male genital annexes as prostate and seminal vesicles with subacute clinical picture and soft or absent at all symptoms; so disease can be revealed only in case of urologic check-up. Typically STD manifest they-self as urethritis caused from Gonococcus ( gonococcal urethritis) or from other pathogens ( non- gonococcal urethritis) among them the one accountable for about half infections, i.e. Chlamydia Trachomatis.
Dr. Fina performs all investigations to detect pathogens by swabs and specimens from anterior urethra; so based on antibiotic sensitivity scale the appropriate therapy can be instituted.
Sometimes, because the infection are already spreading to genital annexes and the pathogens are resistant to antibiotics ( phenomenon even more common since the inappropriate or unnecessary use of them) repeated cycles of antibiotic therapy or complementary therapeutic procedures can be performed.
Among STD must be numbered also HPV infection that seems being transmitted also without sexual contact because some virus genotypes can’t be inactivated by common disinfectants.
To diagnose HPV infection when are invisible external lesions, while the infection has been demonstrated in his habitual sexual partner, can be performed Peniscopy, visual examination by magnifying lenses implying the application of acetic acid on suspected areas that after about two minutes appear different from around mucosa ( commonly more pale). On this area should be made a biopsy to confirm diagnosis and virus genotype. The use of magnifying lenses should allow discover small lesions of first tract of urethra right across meatal rim.
Anyway is of utmost importance collect cellular material by thin brush devices to be inserted deep into anterior urethra and send it to Laboratory for viral genome typing. All visible lesions are ablated under local superficial cream anesthesia by diathermic cauterizer or if the case by thin needle infiltration of Carbocaine. In ogni caso è di fondamentale importanza raccogliere materiale cellulare con spazzoline apposite sottili da introdurre nell’uretra e da inviare in laboratorio per la tipizzazione virale. Possible relapsing starting from micro-lesions non visible at first inspection time can be prevented by appropriate drugs to be applied locally to increase immune response and inhibit lesions growth.
Prostatitis. The prostatitis are the most frequent syndromes affecting young males that more often than others tend to relapse and become chronic. It depends on many factors as a not enough accurate diagnostic care, absent or atypical clinical manifestations, difficulties to identify a pathogenic agent , reduced therapeutic strength of antibiotics in vivo compared to in vitro one, difficulty of those drugs to penetrate into the gland at effective concentration. Whenever the patient complain about some more frequence in micturition , perhaps with burnings or non- complete emptying feeling, associated with tenderness in pubis-scrotum regions , the prostatitis should be suspected. The DRE (digit rectal examination) i.e. the trans-rectal palpation of prostate, if made from expert Specialist, allows for evaluating possible edema of gland, more or less extended, with increased softness, pain and possible discharge from urethra of gland secretions.
During prostate palpation by Specialist patient feel some tenderness or real pain that compel him stopping examination. Prostatitis can be promoted from two orders of factors: 1)sexually transmitted pathogens ( bacterial or infectious prostatitis); non- bacterial factors (a-bacterial prostatitis). The bacterial prostatitis are caused from same agents responsible for urethritis that through the canal spread to the prostate promoting inflammatory processes more or less extended. Can be involved groups of glands, more often peri-urethral or median lobe ones, or more extensively all glands with associated interstitial edema.
According to more or less extended glands involvement, clinical pictures can vary from acute prostatitis, with pain, fever and possible urinary obstruction, to few or a-symptomatic disease diagnosed occasionally during a preventative check- up. When prostatitis starts in acute way, the possible urinary disturbances or complete retention can imply indwelling catheter to resolve retention and possible associated sepsis. The a-bacterial prostatitis are forms where is impossible to isolate pathogens from seminal fluid or urine samples, also after many repeated collections. In those cases must be taken into account irritant processes relating to altered sexual behaviors as coitus interruptus with too much prolonged intercourse. A regular and healthy sexual life, without excesses, is the best way to prevent relapse of disturbances.
Many Specialists think that colon inflammatory diseases should have a prostatitis promoting effect through bacterial colonization from colon to prostate via lymphatic vessels. In those cases therapy of prostatitis must be associated with drugs able to resolve ( or attenuate) colitis.
Therapy of prostatitis is based, in addition to antibiotic administration, on prescription of drugs and supplements able to attenuate inflammatory phenomena and gland edema.
In more recent times many clinical trials have demonstrated how well an old method to treat gland inflammatory processes i.e. prostate massage can greatly cooperate with drugs in quickly healing of disturbances. The massage, in addition to edema reduction by physical action, causes the discharge of infectious materials from squeezed gland into posterior urethra subsequently expelled with micturition. So processes where infection foci tend to persists because of obstruction of glandular ducts can be resolved by help of massage squeezing. Also gland hypertrophy , perhaps associated with infection, seems to get advantage from massage. The massage must be done once or twice a week, lasts few minutes and don’t give too much discomfort.
Vesiculitis. Seminal vesicles are often involved in inflammatory processes of prostate that are commonly labeled as prostatitis. Sometimes indeed vesiculitis are alone without contemporary involvement of prostate and are diagnosed by digit rectal examination feeling by exploring finger those soft saccular expansions behind prostate on both sides: those structures appear swollen and painful to palpation. More often vesiculitis are concomitant with prostate inflammations contributing to compose a clinical picture named with general term of prostatitis.
A fast and superficial rectal exploration without searching for those deep structures in spite of a big bulky prostate could risk from ignoring such pathology sometime so relevant on clinic level. Vesiculitis can be suspected if patient feel burning or pain while ejaculating sometimes associated with hematospermia, i.e. emission of blood with seminal fluid. But not always those symptoms are present; more often disturbances are like prostatitis. Inflammatory processes of seminal vesicles ( and prostate) often are followed by salts deposition with stone formation that can obstruct ejaculatory ducts with low volume of ejaculate (oligoposia) and burning or true pain during ejaculation. Sometimes processes become chronic bringing to formation of cavities containing dense and infectious material with secondary wall sclerosis. Diagnosis by imaging includes trans-rectal sonography and above all NMR by endo-rectal coil.
If an infectious agent is suspected must be prescribed a culture of sperma or better on material expressed under prostate massage and pushed out by some urine drops during urination ( EPS : expressed prostate specimen). or better If, on the contrary, the expression of seminal fluid is avoided from ejaculatory ducts obstruction because of post-inflammatory stenosis or lithyasis of ducts, those ones must be open by endoscopy to let go out vesicle content. If Laser is available this energy can be employed to open ejaculatory ducts.
Erectile dysfunction. Under this term are clustered series of syndromes of different nature but all bringing to same result, i.e. difficulty to start or hold an erection sufficient to have a sexual intercourse. Can interfere with a good erection inflammatory processes of genital annexes, prostate hypertrophy (BPH), metabolic alterations as diabetes, hormone dysfunctions, vascular or neurologic diseases apart from alteration of shaft itself as localized or spread fibrosis.
The most frequent organic cause of E.D. is vascular abnormalities as impaired arterial blood supply or too fast and great venous leakage with the result in both cases of reduced cavernosa blood content and insufficient rigidity . Diagnostic procedure able to define the type of vascular alteration is dynamic Doppler sonography that is performed by intra cavernosa injection of Prostaglandine and blood flow record.
This investigation, almost invasive also because of discomfort, is really useful only when can be performed surgery or vascular x-ray procedures to remove the problem. At present success percentage of those treatments are poor; so dynamic sonography is not so relevant in a therapeutic perspective. A great revolution in this field has been discovery of drugs family, i.e. 5 Phospho- di-esterase Inhibitors, able to promote a valid erection under mental arousal. The effect of those drugs in increasing arterial inflow is so great that also patients with a mild venous blood leakage can get a satisfying erection.
When otherwise the venous leakage is more serious can be weared constrictor rings possibly associated with Vacuum erection. We already saw in physiotherapy chapter how much those procedures can be useful to promote and hold a good erectile performance. In case of patients non responder to pro-erection drugs or in those ones where erection stimulating drugs have too intense side effects or cannot be taken because of contemporary assumption of nitro-derived drugs, physiotherapy represents the only chance to have a sexual life. Low Intensity Shock Waves have some efficacy even though often require contemporary assumption of pro-erection drugs.
Moreover this treatment can be performed only at medical office with further difficulties as higher costs. We think that all rehabilitative procedures must be performed at patient home after a training period under direct doctor control. In case of mild erectile deficiency in young non diabetic patients I propose a physiotherapic trial alone or in association with daily assumption of low doses of pro-erection drugs for prolonged periods. In recent researches has been investigated that the prolonged assumption of PDE-5 Inhibitors is able to promote Testosterone rise with better desire and sexual performances.
Prostate Hypertrophy.(BPH). A great percentage of male people over 60 presents an objective increase of prostate gland volume, documented by a normal abdominal sonography, with urinary troubles as nocturnal micturition and feeling of obstruction or no complete bladder emptying. Some of those subjects, especially the ones affected by hypertension and overweight, can develop with time so named “ metabolic syndrome” a syndrome including indeed BPH, hypertension, overweight, alterations of glucose and fat metabolism. That syndrome requests a multi-disciplinary approach and a dietary and general life habits change. Therapy of BPH takes advantage from many drugs aiming to slowing or blocking gland enlargement while the other ones alleviate disturbing urinary troubles (LUTS).
Drugs against prostate enlargement are, in youngest people where is common an inflammatory process, those containing vegetable extracts as those from Serenoa Repens, Nettle leafs, Pumpkin seeds, Lycopene , Zinc and others. In more aged subjects, can be used synthesized drugs as Finasteride and Dutasteride that avoid transformation of Testosterone in Di-Hydro-Testosterone by prostate gland with partial growth slowing. Urinary troubles from BPH are not directly referable to prostate volume; so quite large prostates entail only light disturbances.
So the best challenge for Specialist is to alleviate LUTS that are the only real problems. Functional disturbs of bladder-prostate complex are owed , in addition to bulking obstruction, to anatomic/functional alterations of bladder neck and detrusor .i.e. the smooth muscle contained into the bladder wall. Following prostate enlargement, especially by medium lobe , or after inflammatory processes previous or associated with BPH, bladder neck no more relaxes well when micturition stimulus arises causing noising disturbances as slow micturition and feeling of obstacle and voiding in two or three times, with feeling of low abdomen weight because of a plenty bladder not able to empty normally.
Moreover the bladder undergoing so continuous functional troubles modifies his reactions to stimuli with more frequent micturitions above all by night and consequent sleep disturbances and wellbeing and mood impairment. By adjusting, on the base of individual reaction, dosing of different drugs able to modify expression and intensity of dysuric troubles, a good emo-dynamic compensation can be achieved with none or only one micturition by night and a satisfactory bladder voiding. Since some time has been verified that the assumption of 5-PDh inhibitors is able to ameliorate, in addition to sexual performances, LUTS. Then in case of patients suffering from BPH associated with erectile dysfunction, they can achieve beneficial effects from same drug.
