Prostatitis: Pre- and Post-Massage Test

Prostatitis: Pre- and Post-Massage Test Topic Overview The pre- and post-massage test is a simple, inexpensive test that may help diagnose the type of prostatitis you have. 1. First, your penis will be cleaned to eliminate any bacteria, then you will give a urine sample (pre-massage sample). 2. The doctor will ask you to stop urinating and bend over so your prostate can be massaged to collect secretions from your prostate gland. The doctor does this by inserting a gloved finger into your rectum and pressing several times on your prostate. 3. You will then be asked to provide another urine sample (post-massage sample). The two urine samples and, if possible, a sample prostate secretion, are examined for bacteria or cells that point to inflammation (leukocytes). If bacteria are found in the post-massage (or prostate secretion) sample, you may have chronic bacterial prostatitis.

If cells that point to inflammation are found in the post-massage (or prostate secretion) sample, you may have inflammatory chronic pelvic pain syndrome. If no bacteria or cells that point to inflammation are found in the post-massage (or prostate secretion) sample, you may have noninflammatory chronic pelvic pain syndrome. There are other possible results, and the test may not always give a clear answer. Related Information

Expressed Prostatic Secretions Prostatitis Prostatic massage is a technique used to extract expressed prostatic secretions (EPS). This technique has value in both diagnosis and treatment. The technique is performed by stroking the prostate several times in order to allow the EPS to reach the urethra. The EPS is then collected and examined under a microscope.

Prostatic massage is mostly used in the diagnosis of prostatitis. The National Institutes of Health (NIH) has characterized prostatitis into 4 categories, as follows: Category I - Acute bacterial prostatitis Category II - Chronic bacterial prostatitis Category III - Chronic Pelvic Pain Syndrome (CPPS), which is divided further into category IIIa (inflammatory) and category IIIb (noninflammatory) Category IV - Asymptomatic inflammatory prostatitis

The tables below show the features of the prostatitis subtypes.

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Classification of prostatitis

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Classification of prostatitis Some studies have shown that prostatic massage may find use as a treatment modality and has been used in the treatment of chronic prostatitis. A study by the Institute of Male Urology at UCLA Medical center evaluated whether combining prostatic massage with antibiotic therapy would improve outcomes in 73 patients with known pelvic pain syndrome due to chronic prostatitis. Twenty-nine (40%) of the patients had completely resolved symptoms, 14 (19%) experienced initial symptom resolution followed by recurrence, 15 (21%) had some improvement, and 15 (21%) had no improvement. The researchers concluded that this combination of massage and antibiotics can be an effective form of treatment in chronic prostatitis.[1] Prostatic massage may also be indicated in patients with enlarged prostates. A study by the Prostatitis Foundation in Illinois evaluated whether repetitive prostatic massage in combination with drug therapy relieves enlarged prostates and prevents transurethral resection of the prostate (TURP). Five patients with urinary retention and indwelling catheters due to enlarged prostate were evaluated in the Philippines and were involved in the study. Staphylococcus was found in the EPS of each participant. All 5 men were treated with repetitive prostatic massage, antibiotics, and alpha-blockers. Two patients were also treated with finasteride. Prostatic massage in combination with drug therapy was found to significantly improve global symptom severity scores, urethral white blood cell (WBC) counts, EPS WBC counts, EPS red blood cell (RBC) counts, urinary WBC counts, and urinary RBC counts. In addition, this treatment combination prolonged the need for TURP by an average of 2.53 years.[2]

Symptoms of prostatitis include the following: Genitourinary pain Back pain Suprapubic pain Perineal pain Dysuria Frequency Urgency Painful ejaculation Erectile dysfunction Differential diagnoses of prostatitis The differential diagnoses of prostatitis include the following: Cystitis/ urethritis Genitourinary tumor Hematuria Bladder stone Urethral stricture Inflammatory bowel disease Perirectal inflammation Interstitial cystitis Perivesical inflammation Indications of prostatic massage in managing prostate cancer Another clinical application of prostatic massage is its use in determining proper management of patients with suspected prostate cancer. Historically, total prostate-specific antigen (t-PSA) has been used as a tumor marker to guide the decision of whether a prostate biopsy is necessary. Since it is a measure of increased prostatic size, which can be a result of many sources of prostatic pathology (prostatitis, BPH, prostate cancer), it has been beneficial in the management of prostate cancer but has also proved to be costly, leading to unnecessary prostatic biopsies due to its lack of specificity. Prostate cancer antigen-3 (PCA3, also referred to as DD3) is a gene that is highly overexpressed and specific to prostate cancer. A study performed in 1999, “DD3: a new prostate-specific gene, highly overexpressed in prostate cancer,” used DD3 -specific primers in reverse transcription-PCR analysis to indicate the specificity of expression of DD3 for prostate cancer.[3] The study found that no DD3 product could be amplified in 18 different normal human tissues studied. Tissues that were tested included normal human artery, brain, breast, bladder, colon, duodenum, heart, liver, lung, ovary, pancreas, placenta, seminal vesicles, skeletal muscle, skin, spinal cord, spleen, and testis. Also, in a sampling of other tumor types and a large number of cell lines, no expression of DD3 could be detected. Human tumor specimen lines that were tested for DD3 expression included 4 breast, 3 ovarian, 2 testicular, 2 cervical, and 2 endometrial tumors. The role of prostatic massage in using the highly specific PCA-3 gene is to make the biomarker more available in the urine sample. The theory of performing prostatic massage upon digital rectal examination is to augment the amount of PCA-3 displaced from the prostate into the urinary tract, which can be picked up and analyzed in a postprostatic massage urine sample. The necessity of performing prostatic massage to obtain a precise PCA-3 measurement was analyzed in a recent study performed at the Portuguese Institute of Oncology. The goal of the study was to evaluate the efficacy of urinary detection of PCA-3 without performing prostate massage, an often-embarrassing procedure for the patient. The study proved that prostatic massage prior to collecting urine sample was necessary, as only 3.8% of prostate cancer patients had detectable levels of PCA-3 in urine collected without a proceeding prostatic massage.[4] A particular area of interest in research is analyzing the diagnostic and predictive value of the PCA3 gene related to prostate cancer. A recent prospective, multicenter study of patients with suspected prostate cancer and who were candidates for biopsy analyzed PCA-3’s diagnostic and predictive value for tumor aggressiveness. Urine collected postprostatic massage was collected to assess the PCA-3 score. Of the 124 biopsies performed, the incidence of prostate cancer or atypical small acinar proliferation was 54%, reaching 68.6% in PCA-3 score of 100 or greater. A statistically significant relationship between the PCA-3 score and tumor grade was demonstrated. In cases with PCA-3 score between 35 and 50, only 23% of prostate cancer was high grade (Gleason ≥7), compared with 76.7% in cases with PCA-3 score over 50. The study concluded that PCA-3 is an indicator of tumor aggressiveness and provides essential information to make treatmentdecisions.[5] Contraindications The major contraindication to prostatic massage is acute bacterial prostatitis, which is most commonly caused by Escherichia coli, as well as other gram-negative bacteria. Acute bacterial prostatitis causes intense pain, fever, chills, painful ejaculation, and dysuria, as well as urinary frequency and urgency. Patients with acute bacterial prostatitis typically have a prostate that is warm, tender, and tense. Prostate massage should never be performed in such patients for diagnosis. Any form of manipulation to the prostate increases the likelihood of inducing bacteremia or sepsis. Instead, it is recommended to diagnose acute prostatitis by culturing the urine directly without massage.[6] In addition, any urethral instrumentation (eg, cystoscopy, urethral catheter placement) is contraindicated in such patients. If the patient has acute urinary retention, a suprapubic catheter can be placed to bypass the acutely infected prostate. Technical Considerations Patients who have recently undergone prostatic massage or any manipulation of the prostate (ie cystoscopy) are not advised to undergo prostate-specific antigen (PSA) screening for prostate cancer immediately after the procedure. Prostatic massage is known to elevate PSA levels, and these levels should not be used to guide cancer screening. A study in Turkey evaluated PSA levels in 51 men 30 minutes after prostatic massage. The study showed significant increases in total and free PSA levels (P < 0.0001) and significant increases in complexed PSA levels (P = 0.047).[7] Although this may not necessarily change the management or lead to transrectal ultrasonography or prostatic biopsy in most cases, it may be clinically relevant in patients with borderline PSA levels or elevated PSA velocity.

Approach Considerations Prostatic massage is performed similarly to a digital rectal examination. The patient is asked to lean forward over the examining table. The physician then puts on gloves and applies lubricant to the examining index finger. Next, the physician spreads the patient’s buttocks and advances the index finger into the anus. The prostate is then massaged by stroking it from the periphery toward the midline several times on each side. EPS is the then collected from the urethra as it exits the penis.

4-glass test



The criterion standard technique of obtaining EPS is known as the Meares-Stamey “4-glass test,” which is difficult and time-consuming. Thus, it is rarely used by urologists. This 4-glass test begins by asking the patient to provide the 10 mL of urine in one glass. Then, 10 mL of midstream urine is provided in the next glass. Next, prostatic massage is performed, and EPS is collected in a third glass. Finally, postmassage urine is collected in the fourth (final) glass.[6] The initially voided urine is tested for urethral infection, while the midstream urine is tested for bladder infection. The EPS fluid is examined for WBCs. Finally, the postmassage urine is used to flush out bacteria in the prostate that may remain within the urethra.[8] The 4-glass test is depicted below.

Two-Glass Test A variation of 4-glass test is known as the Nickel premassage and postmassage test, or the 2-glass test. In this test, the patient is first asked to collect midstream urine into the clean-catch cup, which will be used for premassage culture. The patient is then asked to stop urinating. The physician then massages the prostate from the periphery toward the midline several times. Following the massage, the patient is asked to provide more urine for postmassage urine cultures. A study by the department of urology at Kingston General Hospital in Ontario, Canada, sought to determine if the 2-glass test was a useful alternative to the more cumbersome 4-glass test, evaluating whether the 2-glass test can offer the accuracy of 4-glass test without the EPS fluid obtained with the latter. The study involved 353 men enrolled in the NIH Chronic Prostatitis Cohort study, all of whom had confirmed baseline leukocyte counts and 2-day bacterial cultures that were obtained using the 4-glass test. The study showed that the 2-glass test yielded results in concordance with those of the 4-glass test and was used to predict the correct diagnosis in 96% of cases. They concluded that the 2-glass test is ultimately an acceptable alternative to the 4-glass test despite no prostatic fluid being obtained.[9]

Laboratory Medicine Summary Prostatic massage for EPS is the confirmatory test for the diagnosis of prostatitis; however, other adjunctive tests can be performed to aid the diagnosis of prostatitis, as follows:

Urine cytology Postvoid residual Urine flow rate Symptom index Urodynamics Prostate ultrasonography PSA test Prostatitis questionnaire (see image below)

Background A digital rectal examination affords access to several key structures (see the image below) and enables an observant clinician to identify several disease processes pertaining to the rectum, the anus, the prostate, the seminal vesicles, the bladder, and the perineum. In females, it can be performed in conjunction with a pelvic examination. Before the advent of serum prostate-specific antigen (PSA) testing in 1986, the digital rectal examination was the sole method of screening men for prostate cancer.