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,
From 1the Prostatitis Foundation, Smithshire, Illinois; the 2Manila Genitourinary
Clinic (Cebu Branch), Cebu, Philippines; and the 3Manila Genitourinary Clinic,
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
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.
We retrospectively reviewed the charts of all patients presenting to the
genitourinary clinic with indwelling urinary catheters during a one-year period.
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
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, alphablocker
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 oneyear.
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.
BPH, benign prostatic hyperplasia, TWOC, trial without catheter, acute urinary
retention, urinary retention, prostatitis, prostatic massage
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. A
study by Meigs and colleagues showed that 33% of men suffer acute urinary
retention by age 89, and research by Peters and colleagues found the
incidence of that disorder to be 4.5/1000 man-years.
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.
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.
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. 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%. 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%). 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, and other
research indicates that satisfaction with sex decreased in 44% of men after
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.
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, BioMérieux). We
considered the test results positive if any fluorescing elementary bodies were
seen and recorded the number. A previous study and our ongoing clinical
experience suggest that even one fluorescing elementary body found by DFA
may be significant. The manufacturer; however; recommends that 10 or more
fluorescing elementary bodies be considered a positive test result. The
Chlamydia test was performed immediately after the first prostatic massage in all
Next, each patient was asked to urinate the first 10 mL of urinary flow into a
sterile container for urinalysis.
Because the data had no outliers that changed our conclusions, we used the
mean as the measure of central tendency. We compared the first and last
treatment values when the values tended to decrease in a straight-line fashion.
Because our previous work showed that the white blood cell count in prostatic
fluid usually peaks not at the first prostatic massage but somewhere between the
fourth to sixth massage, we compared the peak and last values of WBC
counts and RBC counts in samples of the subjects’ prostatic fluid. Statistical
analyses were performed with the SPSS software (SPSS software (Statistical
Package for the Social Sciences, version 11.0, SSPS Inc, Chicago, Ill, USA). The
Staff of the Cebu Genitourinary Clinic records each patient’s global symptom
severity score at each clinic visit. Scores range from 0 (no symptoms) to 10
(worst possible symptoms). First and last symptom scores were compared with
the paired t test. To determine whether there was a significant change in other
values during treatment among the 5 patients, the nonparametric Wilcoxon
signed rank test (2-tailed) was used because we did not assume a normal
distribution for the data. A P value of < .05 was considered statistically significant.
Patient 1, a 68-year-old man with urinary retention, presented to our clinic after
having worn an indwelling urethral catheter for 1 month. His former physician had
removed the catheter twice, after which obstruction recurred and the catheter
was replaced. Results of prior TRUS revealed a 92.8-g prostate.
Our clinic physician requested that during the patient’s initial visit, Patient 1 take
the 5-mg dose of terazosin that he had brought with him. One hour later, the
indwelling urinary catheter was removed and prostatic massage was performed.
The patient’s prostate was very large and bulged 2 cm into the rectum. The
prostate was slightly firm, smooth, and tender to palpation and 4 to 5 drops of
EPS were expressed during the massage.
Oral alfuzosin (Xatral) 5 mg twice daily and a single dose of both oral
metronidazole (Flagyl) 2 g and oral ofloxacin (Inoflox) 1200 mg were prescribed.
The patient was able to urinate before the conclusion of his first clinic visit.
By the fourth prostatic massage, the results of an EPS aerobic culture were
positive for Staphylococcus intermedius. Treatment with oral ofloxacin 400 mg
twice daily was initiated. Because the results of testing for Chlamydia were
positive, oral minocycline (Minocin) 100 mg twice daily was added to the
After having undergone 14 prostatic massages, antimicrobial therapy, and
treatment with alfuzosin, this patient reported an improvement in his condition.
His prostate was markedly smaller to palpation and less tender. He underwent
transrectal ultrasonography (TRUS) of the prostate, which revealed a 27.6-g
prostate (a 70% reduction from the pretreatment value). At the time of the
fifteenth prostatic massage, the results of testing for Chlamydia were negative.
Patient 1 was discharged from the clinic with the prescribed treatment of
finasteride 5 mg 4 times daily and alfuzosin 5 mg 4 times daily to be taken for 6
to 8 months as tolerated. TURP remained unnecessary in this patient 27 months
after his first episode of acute urinary retention.
A 70-year-old man with acute urinary retention presented to our clinic. At the time
of his initial examination, he had worn an indwelling urethral urinary catheter for 2
months and was not receiving treatment with any medication. Patient 2 reported
nocturia 4 to 5 times per night before he had undergone catheterization and also
complained of difficult urination of 4 years’ duration.
The clinic physician removed the catheter, massaged the patient’s prostate, and
collected more than 5 drops of EPS. Patient 4 had a large, broad-based prostate
that projected 1 to 2 cm into the rectum; it was a smooth, swollen, tender
Oral cefixime (Tergicef) 400 mg and oral metronidazole, 2 grams, were
prescribed as one-time doses. Oral alfuzosin 5 mg twice daily was also
prescribed. This patient was able to urinate before he left the clinic after his first
visit. At the time of the second massage, the clinic physician prescribed oral
itraconazole (Sporanox) 200 mg twice daily for 3 days to relieve a possible yeast
At the fourth massage, the results of laboratory testing revealed chlamydial
elementary bodies for which oral minocycline 100 mg twice daily was prescribed.
In addition, the analgesic naproxen sodium (Flanax Forte) 550 mg every 6 hours
as needed, was prescribed. The results of TRUS indicated a prostate volume of
74 g. Culture of the EPS revealed both Serratia liquefaciens and Staphylococcus
epidermidis, for which oral ofloxacin 400 mg twice daily was prescribed. At the
time of the fourteenth prostatic massage, the results of testing for Chlamydia
were negative, and at the fifteenth massage, there was no growth from the
culture of EPS after 72 hours of incubation. All antibacterial treatment was
terminated, and oral itraconazole 200 mg twice daily for 1 week was prescribed.
At the time of Patient 2’s seventeenth massage, the results of repeat testing for
Chlamydia were again negative, and culture of the EPS revealed Staphylococcus
epidermidis. Therapy with minocycline was initiated. By the 30th massage, this
patient’s prostate was markedly smaller on palpation, and his symptoms had
markedly improved from those described during his first visit. Oral finasteride 5
mg 4 times daily and oral alfuzosin 5 mg twice daily were prescribed. The results
of culture from the patient’s prostatic fluid revealed Proteus mirabilis, for which
oral ofloxacin 400 mg twice daily for 1 week was prescribed. At follow-up 3 years
and 2 months after his first visit to the clinic, Patient 2 had not undergone TURP.
He stated that his symptoms were mild and that he experienced nocturia only 2
to 3 times per night. He declined further treatment with finasteride and alfuzosin.
A 76-year-old man presented to the Cebu clinic after having worn an indwelling
urethral catheter for 1 month. His prior physician had attempted to remove the
catheter 4 times, but each time the patient was unable to void, and a new
catheter was subsequently placed. Patient 3 complained of dysuria, urinary
frequency, and nocturia 5 times per night before the onset of his acute urinary
retention. His current medication was terazosin 2 mg 4 times daily. He supplied
his clinic physician with the results of prior transabdominal ultrasonography,
which revealed a prostate weighing 16 g.
The clinic physician removed the urinary catheter and massaged the Patient 3’s
prostate, which was normal in size, smooth, and tender when palpated. Four to 5
drops of prostatic fluid were expressed. The patient was unable to urinate and
said that his bladder was empty. Oral alfuzosin 5 mg twice daily, a single dose of
oral metronidazole 2 g, and oral ofloxacin 400 mg twice daily were prescribed.
That evening urinary obstruction recurred, and Patient 3 was catheterized in an
emergency department with a 12-French urinary catheter, which was removed
after urinary drainage. The following morning, our clinic physician increased the
dosage of oral alfuzosin to 10 mg twice daily and performed a second prostatic
massage. The patient was able to urinate before he left the clinic. At the time of
the fourth prostatic massage, the results of testing for Chlamydia were positive,
and oral minocycline 100 mg twice daily was prescribed. The results of culture
from the first specimen of EPS revealed Escherichia coli and Staphylococcus
epidermidis. Treatment with ofloxacin was terminated, and therapy with oral
cefaclor 375 mg twice daily was initiated.
By the eleventh massage, yeast was identified in a urine sample, and oral
itraconazole 100 mg twice daily for 1 week was prescribed. The results of the
EPS culture from the eleventh massage revealed S epidermidis. At the time of
the fourteenth massage, results were negative for Chlamydia. Because Patient
3’s prostate was small and nontender on palpitation, neither an alpha-blocker nor
finasteride was prescribed at the time of his discharge from the clinic. Sixteen
months after his last treatment, this patient remained free from repeat urinary
obstruction or catheterization and had not undergone TURP.
A 73-year-old man presented to our clinic after having worn an indwelling urethral
catheter for 21 days. His symptoms included low back pain, testicular pain,
nocturia, and suprapubic pain when his bladder was full, all of which he had
experienced before the onset of his acute urinary obstruction. This patient had
left the hospital in which he had been undergoing treatment with oral terazosin 2
mg 4 times daily and oral finasteride 5 mg 4 times daily to be treated in our clinic,
where our physician removed the catheter and performed prostatic massage.
The patient’s prostate, which was large, smooth, and tender on palpation,
projected 2 cm into the rectum. Prostatic massage yielded more than 5 drops of
Oral forms of alfuzosin 5 mg twice daily, cefixime 400 mg as a single dose,
ofloxacin 400 mg twice daily, and metronidazole, 2 g, as a single dose were
prescribed, and the patient was able to urinate before he left the clinic.
At the second massage, scrotal skin changes suggestive of fungal infection were
noted. Isoconazole nitrate cream and oral ketoconazole 200 mg twice daily for 7
days were prescribed. At the time of the third prostatic massage, the results of
testing for Chlamydia were negative. The culture of the first EPS specimen
revealed S epidermidis and P mirabilis, and oral minocycline 100 mg twice daily
was prescribed. At the fifteenth massage, repeat testing revealed no Chlamydia,
but the results of EPS culture indicated antibiotic-resistant Staphylococcus
saprophyticus and E coli.
After the patient had undergone 16 massages, his prostate was smaller and was
no longer tender on palpation. He was asked to undergo a TRUS, after which his
discharge medications were to be prescribed. However, he did not return to the
clinic and was lost to follow-up. Two years and 11 months after treatment, this
patient had not undergone urinary catheterization or TURP. He was not taking
finasteride or any alpha-blocker and reported good urinary flow.
A 64-year-old man with acute urinary retention underwent urinary catheterization
at a local hospital. Patient 5 had worn a urethral catheter for 3 weeks before his
presentation at our clinic, at which time he reported a history of frequent urination
and nocturia. His medications consisted of terazosin (2 mg p.o. q.d.) and oral
finasteride (5 mg q.d.). He had completed a 1-week course of oral norfloxacin
400 twice daily when he first underwent catheterization. The clinic physician
removed the urethral catheter and massaged the patient’s prostate, which was
smooth, tender, and enlarged. Four drops of EPS were obtained from the first
massage. Treatment with the medications prescribed elsewhere was
discontinued, and therapy with oral forms of alfuzosin 5 mg twice daily,
metronidazole 2 g as a single dose, ofloxacin 400 mg twice daily, and cefixime
400 mg as a single dose was initiated. The patient was able to urinate before he
left the clinic after his first visit.
At the fourth massage, the results testing for Chlamydia were positive, and the
culture from the first EPS specimen revealed Citrobacter freundii and
Staphylococcus intermedius. Both bacteria were resistant to ofloxacin treatment,
which was replaced by oral erythromycin 500 mg 3 times daily. Oral minocycline
100 mg twice daily was prescribed to treat the chlamydial infection.
After the fifth massage, the Patient 5’s symptom score had decreased from 10 to
5, he reported a good flow of urine, and his nocturia had decreased to 2 to 3
times per night. However, he failed to return for further treatment or testing and
was lost to follow-up.
Patient 5’s family physician eventually reported that Pateint 5 had died from a
heart attack 36 months after he was treated at our clinic. At the time of his death,
per his family physician, Patient 5 had experienced good urinary flow and had not
undergone either urinary catheterization or TURP.
Before presentation to the Cebu Genitourinary Clinic, Patient 1 had failed two
catheter removal challenges, and Patient 3 had failed 4 catheter removal
None of the 5 men in this study, by their reports, had received prostatic massage
or EPS collection prior to arrival at the Cebu Genitourinary Clinic. In our study,
EPS was collected 79 times from the 5 patients in 100% of attempts. The mean
number of prostatic massages with EPS collection per patient was 15.80 (range,
5-30, SD, 9.01).
Patients 1, 2, 4, and 5 were able to urinate after one prostatic massage. Patient 3
was straight catheterized his first night and then was able to urinate after his
second prostatic massage.
Patient 3, Patient 4, and Patient 5 were only treated only once for acute urinary
retention. Patient 1 re-obstructed 6 months after treatment and underwent a
second round of therapy. Patient 2 re-obstructed 7 months after therapy and
underwent a second round of therapy. Each retreatment was successful in that
both Patient 1 and Patient 2 improved and continued to avoid surgery. Below, we
compare the data from the first rounds of treatment for all 5 men.
All the men complained of nocturia prior to their first episode of acute urinary
retention. Three of the 5 patients had their frequency of nocturia documented
prior to treatment at the Cebu Genitourinary Clinic, and the frequency of nocturia
decreased in those 3 men. Besides nocturia, the men complained of other
symptoms (extracted from the medical records) such as dysuria; frequency of
urination; and low back, rectal, and testicular pain (Table 1).
Urethral bacteria disappeared in all 5 men over the treatment period (Table 2).
Statistically significant data
The global symptom severity scores in the five men decreased dramatically
(Figure 1).We compared the first and last symptom scores in the five men. The
mean first symptom score was 9.80 (SD 0.45) and the last mean symptom score
was 2.6 (SD 1.34), and the decrease was significant (P < .0005).
The mean urethral WBC high peak was 27.60 (range, 20-36; SD, 6.88), and the
mean urethral WBC high last value was 0.00. This decrease was significant (P =
0.043) (Table 3).
Patients 1 and 4 had their highest EPS WBC high counts at their first massage,
while patients 2, 3, and 5 had EPS WBC high peaks at their sixth, fifth, and third
massages, respectively. The mean peak EPS WBC high count was 43.40 (SD,
16.36). The mean last WBC EPS high count was 13.40 (SD, 5.73). This
decrease was significant (P = 0.043) (Table 4).
The mean peak EPS RBC low count was 37.20 (SD, 31.25), and the mean last
EPS RBC low count was 0.00. This decrease was significant (P = 0.039).
The mean peak RBC high count was 39.00 (SD, 28.81). The mean last EPS
RBC count was 0.00. This decrease was significant (P = 0.039).
The mean urinary RBC count low peak was 36.80 (SD, 31.78), and the mean last
urinary RBC count low was 0.00. The change from the mean peak urinary WBC
low count to the mean last urinary WBC low count was significant (P = 0.039).
The mean urine RBC high count peak was 39.40 (SD, 28.23). The mean last
urine RBC high count was 2.00 (SD, 1.22). The decrease from the mean urine
RBC high peak count to the last was significant (P = 0.042).
The mean urinary WBC low count peak was 29.40 (SD, 20.54). The mean last
urinary WBC low count was 2.07 (SD, 2.07). The change from the mean peak to
mean last urinary WBC low count was significant (P = 0.042).
The mean urinary WBC high count peak was 43.40 (SD, 17.54). The mean last
urinary WBC high count was 6.40 (SD, 4.88). The change from the peak urinary
WBC high count to the last urinary WBC high count was significant (P = 0.042).
All 5 men had a culture of their first EPS specimen. Patients 1 and 4 had one
repeat set of EPS cultures, while Patient 2 had 4 sets of EPS cultures. All 5
patients were positive for Staphylococcus species. Patients 2, 3, and 4 also
cultured positive for Gram-negative bacteria (Table 5).
Four of the 5 men tested positive for 5 to 10 fluorescing Chlamydia elementary
bodies by Chlamydia DFA at their first presentation. In 3 of these 4, the
Chlamydia DFA test turned negative for any fluorescing elementary bodies after
undergoing treatment with repetitive prostatic massage combined with antibiotics.
It is not known if the fourth case turned negative as Patient 5 never returned for a
repeat Chlamydia DFA test (table 6).
Ultrasounds of Patient 1 and Patient 2
Over the course of repetitive prostatic massage, the Cebu Genitourinary Clinic
physician noted palpable changes in the men’s prostates, with the prostates
becoming smaller and more normal in consistency over time. In two patients,
ultrasound data, within the limitations of technique and interpretation, supported
this finding. There is one prior case in the literature of ultrasound-documented
reduction of prostate size by repetitive prostatic massage. Patient 1
underwent abdominal ultrasound prior to arriving at the Cebu Genitourinary
Clinic, and his prostate was 92.8 g. After therapy, his prostate was reported as
26.6 g by transrectal ultrasound. Patient 2 underwent TRUS at his fourth
massage, and his prostate was reported as 74 g. There was no TRUS at the end
of his first round of therapy, but at the end of all his therapy, his prostate was
reported to be 54 grams by TRUS. Since, there were differences in technique,
one ultrasound being transabdominal instead of transrectal, and differences in
machines, examiners, and timing, so we present the ultrasound data without
making any conclusions (Table 7).
At discharge, Patient 1 was prescribed alfuzosin and finasteride. Patient 2 was
prescribed alfuzosin, finasteride, and itraconazole. Patient 3 was prescribed
itraconazole. Patient 4 was not prescribed any medication, and Patient 5 left
treatment still taking erythromycin and minocycline.
Avoidance of Surgery
The 5 men in this study have avoided surgery for acute urinary retention for an
average of 2.53 years at last follow-up (Table 8.)
All subjects in our study had been advised to undergo TURP. Urologists have
traditionally used acute urinary retention as an indication to perform a TURP, in
one of its many forms especially if medical therapy fails and catheter challenges
The complications from TURP are well-known, but the medical management of
acute urinary retention is also less than perfect. Alpha-blockers can produce
adverse effects such as dizziness or orthostatic hypotension, sexual
dysfunction – especially retrograde ejaculation, and dry mouth.
Finasteride, which can produce sexual dysfunction by causing a decreased
amount of semen per ejaculation, is associated with impotence, ejaculation
disorders, and decreased libido. Both finasteride and alpha-blockers
prescribed to treat benign prostatic hyperplasia (BPH) must be taken continually,
and noncompliance often occurs.
Prostatic massage has been described in the literature since at least 1906.
However, to our knowledge, no controlled studies have compared the effects of
prostatic massage alone or with antibiotics against surgery for BPH.
In our study, all 5 men were diagnosed as having prostatitis, according to an
established criterion for that disorder. EPS was collected in 100% of attempts
in these men. Theoretically, in the successful treatment of prostatitis, the WBC
count in the EPS should decrease during treatment or should peak and then
decrease. Both results occurred in our subjects.
The results of our study indicate that repetitive prostatic massage improves the
likelihood of urination and the successful drainage of pus from the prostate. We
suggest that prostatic massage enables men to urinate during episodes of acute
urinary retention. Our results indicate that several prostatic massages are
needed to obtain the most purulent EPS specimen for disease classification and
microbial testing. We found that repetitive prostatic massage is not traumatic,
because the RBC in the EPS decreased to zero during the course of therapy.
Prostatic massage has not been properly studied, however, and questions exist
about whether most urologists can perform it effectively.
The results of pretreatment and post-treatment TURP in the patients described in
our first and second case reports revealed a reduction in prostate size; however,
the techniques used in those case reports and the examiners who performed
them differed. We conclude that additional studies in larger numbers of patients
are required to establish the value of prostatic massage and the medical
treatment of acute urinary retention in men with prostatitis and an indwelling
Because none of our subjects had undergone prostatic massage and EPS
collection prior to catheterization, we do not know whether their prostatitis
predated the placement of their indwelling urinary catheter. In addition, controls
were not included in this study.
Five elderly men with histories of acute urinary retention and an indwelling
urethral catheter presented to our clinic for treatment. Each patient had been
advised by his urologist to undergo TURP, yet successful removal of their
indwelling catheter was accomplished in each case, and all 5 men have avoided
prostate surgery for at least 2.53 years. All 5 men were treated with repetitive
prostatic massage, antimicrobial therapy, and alpha-blockers, while two patients
were also treated with finasteride. During the treatment period, statistically
significant improvements occurred in several parameters including global
symptom severity scores, urethral WBC counts, EPS WBC counts, EPS RBC
counts, urinary WBC counts, and urinary RBC counts.
We suggest that men who suffer acute urinary retention resulting in an indwelling
catheter should be examined for prostatitis and we note that that all treatments
performed in this study were done by general practitioners. In our opinion, larger
controlled studies are required to determine whether the effects of repetitive
prostatic massage and antibiotic therapy are superior to those of treatment with
an alpha-blocker, finasteride, or a combination of those drugs.
 Verhamme KM, Dieleman JP, Van Wijk MA, van der Lei J, Bosch JL, Stricker BH,
Sturkenboom MC: Nonsteroidal anti-inflammatory drugs and increased risk of acute urinary
retention. Arch Intern Med. 2005 Jul 11;165(13):1547-51.
Meigs JB, Barry MJ, Giovannucci E, Rimm EB, Stampfer MJ, Kawachi I: Incidence rates and
risk factors for acute urinary retention: the health professionals followup study. J Urol
Peters PC, Boone TB, Frank IN, McConnell JD, and Preminger GM: Urology. In Principles of
Surgery, Sixth Edition. Edited by Schwartz SI, Shires GT, Spencer FC, and Husser WC. New
York. McGraw-Hill, Inc., 1994: 1755-1756.
 Jacobsen SJ, Girman CJ, Lieber MM: Natural history of benign prostatic hyperplasia. Urology.
2001 Dec;58(6 Suppl 1):5-16.
 McNeill SA, Hargreave TB, Roehrborn CG; Alfaur study group: Alfuzosin 10 mg once daily in
the management of acute urinary retention: results of a double-blind placebo-controlled study.
Urology. 2005 Jan;65(1):83-9.
 McConnell JD, Barry MJ, Buskewitz RC, and the Agency for Health Care Policy and
Research: Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline,
Number 8. AHCPR Publication No. 94-0582. Rockville, MD. Public Health Service, U.S.
Department of Health and Human Services. February 1994:98.
 McNeill AS, Rizvi S, Byrne DJ: Prostate size influences the outcome after presenting with
acute urinary retention. BJU Int. 2004 Sep;94(4):559-62.
 Varkarakis J, Bartsch G, Horninger W: Long-term morbidity and mortality of transurethral
prostatectomy: A 10-year follow-up. Prostate. 2004, February 15;58(3):248-51.
 Quek KF, Razack AH, Chua CB, Low WY, Loh CS: Sexual function outcomes following
treatment for lower urinary tract symptoms. A one-year study. Med J Malaysia. 2003,
 Hill B, Belville W, Bruskewitz R, Issa M, Perez-Marrero R, Roehrborn C, Terris M, Naslund
M: Transurethral needle ablation versus transurethral resection of the prostate for the treatment
of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized,
multicenter clinical trial. J Urol. 2004 Jun;171(6 Pt 1):2336-40.
 Gilling PJ, Wright WL, Gray JM: Factors associated with sexual dysfunction following
transurethral resection of the prostate. N Z Med J. 1988 Jul 27; 101(850): 484-485.
 Petsch MJ and Schulze H: Quality of Erection Does Change After TURP – Results of a
Prospective Clinical Study. Abstract presented at the 1999 American Urological Association
 Hennenfent BR and Feliciano AN: Release of Obstructive Prostatic Disease and
Improvement of Erectile Dysfunction by Repetitive Prostatic Massage and Antimicrobial Therapy.
The Digital Urology Journal 1998, October 5. [http://www.duj.com].
 Gilroy CB, Thomas BJ, Taylor-Robinson D: Small numbers of Chlamydia trachomatis
elementary bodies on slides detected by the polymerase chain reaction. J Clin Pathol. 1992
 Hennenfent BR and Feliciano Jr. AE: Changes in white blood cell counts in men undergoing
thrice-weekly prostatic massage, microbial diagnosis and antimicrobial therapy for genitourinary
complaints. Br J Urol. 1998 Mar;81(3):370-6.
 Hennenfent BR, Garcia BS, Feliciano Jr. AE: Symptom Improvement and Transrectal
Ultrasound-Documented Reduction of Prostate Size after Repetitive Prostatic Massage and
Antimicrobial Therapy. Journal of Pelvic Surgery 2002, September 8(5): 265-269.
 Liu CC, Huang SP, Chou YH, Wang CJ, Huang CH: Current indications for transurethral
resection of the prostate and associated complications. Kaohsiung J Med Science 2003
 Roehrborn CG, Van Kerrebroeck P, Nordling J: Safety and efficacy of alfuzosin 10 mg oncedaily
in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a
pooled analysis of three double-blind, placebo-controlled studies. BJU Int. 2003 Aug;92(3):257-
 De Mey C: Alpha1-blocker therapy for lower urinary tract symptoms suggestive of benign
prostatic obstruction: what are the relevant differences in randomised controlled trials? Eur
Urology 2000;38 Suppl 1:25-39.
 Lee E, Lee C: Clinical comparison of selective and non-selective alpha 1A-adrenoreceptor
antagonists in benign prostatic hyperplasia: studies on tamsulosin in a fixed dose and terazosin in
increasing doses. Br J Urology 1997 Oct;80(4):606-11.
 Edwards JE and Moore RA: Finasteride in the treatment of clinical benign prostatic
hyperplasia: A systematic review of randomised trials. BMC Urol. 2002; 2: 14.
 Blute ML, Larson T: Minimally invasive therapies for benign prostatic hyperplasia. UROLOGY
2001 Dec;58(6 Suppl 1):33-40; discussion 40-1.
 Young HH, Gereghty JT, Stevens AR. Chronic Prostatitis. Johns Hopkins Hospital Reports.
 Krieger JN, Ross SO, Deutsch LA, Fritsche TR, Riley DE. Counting leukocytes in expressed
prostatic secretions from patients with chronic prostatitis/chronic pelvic pain syndrome.
UROLOGY. 2003 Jul;62(1):30-4.
 Hennenfent BR and Hickman CJ: Patient-perceived Efficacy of Prostatic Massage as a
Treatment Modality for Prostatitis, Prostatodynia, and BPH: An Exploratory Study. Infections in
Figure. The global symptom severity score decreased in all subjects over the
course of treatment.
Symptoms recorded in the medical records of the 5 patients. NR = not recorded.
This table shows the number of times different bacteria were present in the
urethral Gram stains, with the number of specimens taken as the denominator.
Bacteria were seen in 22 of the 30 urethral smears. Both bacteria and WBCs
disappeared in each patient’s urethral smear over the course of treatment. GPC
is Gram-positive cocci. GNB is Gram-negative bacilli. GPC is Gram-positive
cocci, GNB is Gram-negative bacilli. Gram-positive cocci were most common.
The urethral WBC high counts all went to zero during treatment.
EPS WBC high counts, first, peak, last, and all data points.
Organisms that grew in the cultures of the EPS.
Number of fluorescing Chlamydia elementary bodies seen at the first test and at
the repeat test.
Two patients underwent before and after ultrasounds of the prostate, which
showed a reduction in prostate size.
Number of months that patients have avoided having to undergo transurethral
resection of the prostate at last available follow-up.
The authors thank Rena Pedaria and Hazel Macandandang for their assistance
with statistics. This study was not funded, but the authors would like to thank the
Prostatitis Foundation (www.Prostatitis.org), a nonprofit organization, devoted to
publicizing and researching prostatitis.
BRH and AEF conceived this study. BRH managed the statistical analysis in
consultation with others and wrote the manuscript. ARL saw the patients,
collected the data, and performed follow-up. AEF provided overall clinical
supervision of the project. AEF and ARL helped to edit and review the
manuscript. All authors have read and approved the final draft of the manuscript.
The authors declare that they have no financial disclosures to state or conflicts of