Sexual health-concluding remark

Erectile dysfunction (ED) and ejaculatory dyssynergia (EDS) strongly affect quality of life in some CPPS sufferers. Why these occur and how many men that are affected is not clear. Research in ED and EDS is in my opinion lacking in standardized procedures and useful measurables (the 2-minute limit is not a good parameter-it is in fact ridiculous). The fact that circumcised and normal men are not distinguished is also a confounding factor. Lack of detailed information on thyroid and gonadal function (prolactin, SHBG, DHEA etc) is yet another.

Infertility in CPPS

Prostatitis is an indicator of infertility risk (e.g. if epidydimial infection / inflammation or zinc or magnesium abnormalities are present). It has been estimated that somewhere between 35-90% of men seeking for help with infertility has had or has some prostatitis-like disease or symptoms (including STD’s)(1). Notice that inflammation or abnormalities in any of the: testicles, prostate, epididymis, seminal vescicles, vas deferens, ampollae, Cowper’s gland and the glands of Littre affect fertility! (There are of course other causes, but the above are prostatitis-related.)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, prostata, infertilitet
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(1) Colpi GM (ed.). Male infertility today, nr 4, 2004. Imprimatur: fotolito e stampa grafiche gelmini, Milano.

Ejaculate (semen) abnormalities in CPPS

Ejaculate is comprised of sperm, prostatic fluid (watery, 15-30%), urethral (Littre’s) and bulbourethral (Cowper’s) gland fluids (viscous, clear) and seminal vesicle fluid (gelatinous, 50-70% of volume). About 1.5-5 milliliters is the average. Anecdotal evidence indicates that semen gets yellowish and thicker or too watery and having a non-homogenous appearance in CPPS, especially during flares. Is this because of abnormal proportions of the various fluids or other causes ?

Ejaculate is slightly alkaline: pH 7.3-8.5 (variation is due to methodology and values as low as about 6.5 can be found in the literature). Higher pH is indicative of infection and too low pH impairs sperm motility. Some CPPS sufferers have high pH.

A small study has found that ejaculate citrate levels are depressed in NIH-II, IIIa and IIIb patients compared to controls. Interestingly NIH-II and IIIa sufferers had very similar levels 3.32 +/- 0.79 mg/ml and 3.41 +/- 0.88 (controls 8.55 +/- 1.20) indicating commonality. IIIb sufferers have intermediate values (4.37 +/- 0.77).(1)

Analyses have also shown decreased levels of magnesium, zinc, fructose(2), spermine, prostate anti-microbial factor (PAF) and other substances. There are also conflicting studies on seminal microflora. There is a case report of CPPS in conjunction with the presence of uric acid in the ejaculate.(3)

Ejaculate main composition: Zinc 0.352 ± 0.048 g/liter; Magnesium 0.120 ± 0.060 g/liter; Calcium 1.200 ± 0.080 g/liter; Citric acid 4.80 ± 26.9 g/liter; Cholesterol 0.078 ± 0.013 g/liter; Spermine 0.243 ± 0.025 g/liter; Lysozyme 0.021 ± 0.006 g/liter; Acid phosphatase 2.56 million IU per liter.(4)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, prostata, ejakulat, sperma
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(1) Chen J, Xu Z, Zhao H, Jiang X. Citrate in expressed prostatic secretions has the feasibility to be used as a useful indicator of category IIIB prostatitis. Urol Int 78(3):230-234, 2007. The essentially same article was also published as Chen J, Zhao HF, Xu ZS, The prostate has secretory dysfunction for category IIIA and IIIB prostatitis in J Urol 177(6):2166-2169, 2007.
(2) Engeler DS, Hauri D, John H. Impact of prostatitis NIH IIIB (prostatodynia) on ejaculate parameters. Eur Urol 44(5):546-548, 2003.
(3) Motrich RD, Olmedo JJ, Molina R, Tissera A, Minuzzi G, Rivero VE. Fertility and Sterility 85(3):751, 2006.
(4) Sexually transmitted diseases, Holmes KK, Mårdh P-A, Sparling PF, Weisner PJ, Cates W Jr, Lemon SM, et al., eds.

Magnesium and zinc in the prostate

CP/CPPS is currently not connected with magnesium or zinc insufficiency, but the prostate is the most zinc and magnesium-rich organ in the body (up to 20 times higher concentration than in other organs). Magnesium is essential for seminal fluid quality and sperm "survival" and uro-genital health. A study (1) has shown that magnesium levels were significantly decreased in the seminal plasma of normozoospermic chronic prostatitis sufferers. But other studies have shown no such correlation(2). Zinc is essential for sperm quality, prostate and uro-genital health in general (3,4) and also for health in general.

Plasma zinc levels are below normal in patients with malignancies (decreased about 60-70%), but above normal in patients with benign hyperplasia and chronic prostatitis(5). Levels in controls is 94.5±10.38 µg/100 ml; with benign diseases of the prostate between 145 and 173 µg/100 ml (highest in BPH) and patients with malignancy 59.6±3.08 µg/100 ml(6).

It is unclear if the raised zinc levels are causing the illness or are an effect thereof(7). Anecdotal data suggest zinc supplementation may improve semen abnormalities.
Both minerals are tightly regulated in the body and not stored (if one does not include the skeleton).

(Curiously MgCl was suggested in France before WWII as an effective diuretic and uro-prostatic function "corrector" [J. Favier, "Equilibre mineral et sante", Librairie Le François, 1951]. Which is popular to mention on self-help and altmed sites.)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, prostata
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(1) Edorh AP, Tachev K, Hadou T, Gbeassor M, Sanni A, Creppy EE, Le Faou A, Rihn BH. Magnesium content in seminal fluid as an indicator of chronic prostatitis. Cell Mol Biol (Noisy-le-grand). 2003;49 Online Pub:OL419-23.
(2) Colleen S, Mårdh PA, Schytz A. Magnesium and zinc in seminal fluid of healthy males and patients with non-acute prostatitis with and without gonorrhoea. Scand J Urol Nephrol 9:192-197, 1975.
(3) "Zinc: a key urological element" by IM Bush et al., presentation at the 1974 AMA annual meeting, Chicago, USA
(4) Yan M, Song Y, Wong CP, Hardin K, Ho E. Zinc deficiency alters DNA damage response genes in normal human prostate epithelial cells. J Nutr 138:667-673, 2008.
(5) Goel and Sankwhar, Comparative study of zinc levels in benign and malignant lesions of the prostate, Scand J Urol Nephrol, 108-12, 2006
(6) Goel T, Sankhwar S. Comparative study of zinc levels in benign and malignant lesions of the prostate. Scand J of Urology and Nephrology, 40(2):108-112, 2006.
(7) Antibacterial effect of intraprostatic zinc injection in a rat model of chronic bacterial prostatitis by YH Cho et al., Int J Antimicrob Agents 19:576-582, 2002

Prostate related findings

Inflammation in bacterial prostatitis is characterized by the "presence of polymorphonuclear leukocytes and macrophages in the glandular ducts, epithelium and/or adjacent stroma" around the acini or ducts. Stromal involvement depends on intraluminal inflammation (1, 2). Other findings are: abnormal glandular ducts, epithelial atrophy, metaplasia and dysplasia, and hyperchromasia ("with polymorphism of the epithelial cell nuclei and cytoplasmic basophilia"). Changes that may be misinterpreted as cancerous. If palpated the prostate is often enlarged and "soft" in bacterial prostatitis while never in CPPS.

In CP/CPPS "glandular atrophy with stromal fibrosis, accompanied by a mild residual inflammatory reaction" is commonly observed(3). But only 5% of biopsies show significant inflammation(4). Although variation between studies is high up to 100% (5) prevalence has been found. The variation is obviously due to the varying (read: poor!) selection criteria of the studies. There is minimal correlation between histopathology and visible/clinical symptoms, but histological findings increase with age and are more commin in infertile men.

It is unclear whether some minimal inflammation of the prostate is normal or not, so if this is of any clinical use remains to be seen.

The recent REDUCE trial involving 5597 subjects has shown that no "clinically meaningful" difference is present between healthy subjects and CP/CPPS sufferers.(6) PSA levels are insignificantly elevated in CPPS (NIH III) and slightly to highly elevated in NIH IV. CPPS sufferers with elevated levels should be screened for cancer and BPH.(7)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, prostata
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(1) Mehik A, Leskinen MJ, Hellström P Mechanisms of pain in CPPS: influence of prostatic inflammation. World J urol 21:90-94, 2003
(2) Dellabella M, Milanese G, Sigala S, d’Anzeo G, Arrighi N, Bodei S, Muzzonigro G. The role of prostatic stroma in CP/CPPS. Inflamm Res. 2009 Sep 11 Epub ahead of print.
(3) Mehik A, Leskinen MJ, Hellström P Mechanisms of pain in CPPS: influence of prostatic inflammation. World J urol 21:90-94, 2003
(4) True LD, Berger RE, Rothman I, Ross SO, Krieger JN. Prostate histopathology and CP/CPPS: a prospective biopsy study. J Urol 162:2014-2018, 1999.
(5) PHF Schatteman, L Hoekx, J J Wyndaele, W Jeuris, E van Marck. Inflammation in prostate biopsies of men without prostatic malignancy or clinical prostatitis. Eur Urol 37:404-412, 2000
(6) Nickel JC, Roehrborn CG, O'Leary MP, Bostwick DG, Somerville MC, Rittmaster RS. Examination of the Relationship Between Symptoms of Prostatitis and Histological Inflammation: Baseline Data From the REDUCE Chemoprevention Trial. J Urol. Jul 13 2007.
(7) Nadler RB, McNaughton Collins M, Propert KJ, Mikolajczyk SD, Knauss JS, Landis JR, Fowler JE jr, Schaeffer AJ, Alexander RB. PSA test in diagnostic evaluation of CP/CPPS. Urology 67:337-342, 2006.

Post-ejaculatory pain

Regarding sexual activity advice goes both ways. It stands to reason that if you have pain during or after intercourse it may not be so smart to proceed with it. But some men’s symptoms (pain, epidydimitis) get relieved by ejaculation (see Treatment below). (Local application of anti-inflammatory and pain relieving medications may help. But check with your doctor first.)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, ejakulation

CPPS and ejaculation

Premature ejaculation / “failed” / “unexpected” ejaculation

Both anecdotal evidence and some research show that ejaculation is un-coordinated in men with CPPS. Problems vary but common problems is ejaculation before climax ("premature ejaculation, PE), no climax and ejaculation (anejaculation/anorgasmia), painful (often sort of “stumbling”) ejaculation and “weak” ejaculation. An Italian study has shown that about 50% of patients with ejaculatory problems had chronic bacterial prostatitis .(1)

A Turkish study showed that over 75% of patients with CP/CPPS had ejaculatory problems .(2) In both cases no other pathology could be found, but in hyperthyroid patients with premature ejaculation ejaculation normalizes after euthyroidism (thyroid hormones within normal range) is attained(3-4). An interesting finding as there seems to be little research on this in CPPS. Could some CPPS patients have undiagnosed thyroid disorder?

Research on ejaculation is, in my opinion, in some regards plain stupid as any ejaculation within two minutes is regarded as premature/abnormal, regardless of how it is experienced or if foreskin is normal or removed. It is also very focussed on "end" results and not the underlying (reflex) dyssynergia.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, ejakulation
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(1) Screponi E, Carosa E, Di Stasi SM, Pepe M, Carruba G, Jannini EA. Prevalence of chronic prostatitis in men with premature ejaculation. Urology. 58(2):198-202, 2001.
(2) Gonen M, Kalkan M, Cenker A, Ozkardes H. Prevalence of premature ejaculation in Turkish men with chronic pelvic pain syndrome. J Androl. 26(5):601-603, 2005.
(3) Krassas GE, Tziomalos K, Papadopoulou F, Pontikides N, Perros P. Erectile dysfunction in patients with hyper- and hypothyroidism: how common and should we treat? J Clin Endocrinol Metab 93(5):1815-9, 2008.
(4) Cihan A, Demir O, Demir T, Aslan G, Comlekci A, Esen A. The relationship between premature ejaculation and hyperthyroidism. J Urol 181(3):1273-1280, 2009.

Physiology of ejaculation

Ejaculation requires exquisite coordination and timing of various muscles and glands. Thus minimal differences in timing cause disruption. Also non-neurological disturbances caused by enlarged prostate (constricting the urether and ejaculatory ducts) and constipation (generalized pressure on the lower abdominopelvic cavity) affect ejaculation.

Ejaculation is divided in two phases: emission and ejaculation proper.

Emission is under control of the sympathetic nervous system, while the ejaculatory phase is under control of a spinal reflex. Emission begins with sperm travelling along the vas deferens (spermatic cord a 30 centimeter long structure that loops over the pelvic bone ! one of these evolutionary trade-offs we carry) and entering the ejaculatory ducts and being mixed with fluids from the seminal vesicles, prostate and bulbourethral glands. The resulting fluid is called semen.

Ejaculation proper consists of approximately 5-15 rhythmic contractions of the bulbospongiosus muscle ejecting the semen through the urethra and out. Total duration of the process is about 15 seconds. (Females differ slightly as they have up to 20-30 contractions and shorter refractory period, i.e. time before next attempt can be made. Women having Skene’s glands may experience orgasm by indirect stimulation of the gland,(1) the so called G-spot. )

N.B. ejaculation is not necessarily concomitant with orgasm or vice versa.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, ejakulation
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Wolters JP, Hellstrom WJG. Current Concepts in Ejaculatory Dysfunction. Rev Urol 8(Suppl 4):S18-S25, 2006.
(1) Gravina GL, Brandetti F, Martini P, Carosa E, Di Stasi SM, Morano S, Lenzi A, Jannini EA. Measurement of the thickness of the urethrovaginal space in women with or without vaginal orgasm. J Sex Med. 2008 5(3):610-8.

Erectile dysfunction and the physiology of erection

Impotence or erectile dysfunction is reported in CPPS, but information on prevalence is highly variable, although rates are higher than in controls, especially in young CPPS sufferers. It is most likely caused by underlying testosterone deficiency, diabetes and obesity and/or stress/fear induced reactions. See discussion on testosterone, nocturia and sleep for causes of testosterone deficiency in CPPS.

Erection is a complex "neurovascular" event "modulated by psychological and hormonal factors" leading to increased blood flow into and decreased flow out of the penis (so called tumescence). Murine (rats and mice) studies indicate that selenium, vitamin E and vitamin C insufficiency may be involved.(1)

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(1) Priviero FBM, Leite R, Webb RC, Teixeira CE. Neurphysiological basis of penile erection. Acta Pharmacol Sin 28(6):751-755, 2007 (this is a concise review).

Sexual health in CPPS

There are a lot of sexual problems associated with CPPS, which is one cause why Freudians have had a field day with CPPS (and other urogenital disorders). Careful anamnesis will show that sexual problems evolve slowly over many years in CPPS sufferers. And it is when those interfere too much in normal life that they are brought to the doctor’s attention. Due to this there is an obvious possibility of many a CPPS sufferer consulting a psychiatrist (or "sexologists") rather than a urologist.

Problems are those mentioned below and also: penis / glans pain / discomfort (not associated with urination); penile numbness / insensitivity to "friction" (obviously more noticeable in non-circumcised men); and, discoloration (bluish-whitish-pinkish mottled hue) of glans.

Sufferers have less sexual interest and erectile function(1-2). This is hardly surprising and a well described and known fact as it is both part of the pathology and of sickness behavior (the bodily reactions to pain, illness and infection which cause androgen down-regulation, impaired spermatogenesis, depression etc). The only interesting fact in the study by Aubin et al. (one of many on the subject) is the usage of an adapted form of the BSFQ (brief sexual functioning questionnaire), that, while highly subjective, is useful indicating CPPS sexual symptom severity. About 36% of the CPPS subjects had never had epi- or post-coital pain. 51% occasionally and 13 often or always. The rest of the study was pretty oxymoronic, such as proving that age and disease activity was significant for pain, sexual function and satisfaction… duh! (apologies for this rant).

In a german study of chronic pelvic pain (LUTS) about 30-40% up to 40 years old were affected of loss of libido and erectile dysfunction, and about 50-65% between 40 and 60 years, compared to about 5.5% and 9% respectively in controls. Above 60 years of age the differences vaned. The study also showed that premature ejaculation (defined as before or at the beginning of intercourse or without erection), was noticeably more common in all age groups. 4-10 times more common than in controls.(3)

Marital relations are normal, except in a few cases where it may precipitate a separation (4) (most likely do the mood swings affect an already compromised relationship).

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, sexuell hälsa
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(1) Aubin S, Berger RE, Heiman JR, Ciol MA. The association between sexual function, pain and psychological adaption of men diagnosed with CPPS type III. J Sex Med 5:657-667, 2008.
(2) Davis SNP,Binik YM, Carrier S. Sexual dysfunction and pelvic pain in men: a male sexual pain disorder?. J Sex Marit Ther 35(3):182-205, 2009.
(3) Beutel ME, Weidner W, Brähler E. Der chronishe Beckenschmerz und seine Komorbidität. Der Urologe [A] 43:261-267, 2004. [Chronic pelvic pain and its comorbidity. In german.]
(4) Mehik A, Hellström P, Sarpola A, Lukkarinen O, Järvelin MR. Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland. BJU Int 88(1):35-38, 2001.