CASE REPORTS
PROSTATODYNIA AND HERPES SIMPLEX VIRUS INFECTION A. DOBLE, ER.C.S. J. R. W. HARRIS, ER.C.E D. TAYLOR-ROBINSON, F.R.C.PATH. From St. Mary's Hospital, London, and Clinical Research Centre, Harrow, Middlesex, England
ABSTRACT--The etiology of chronic abacterial prostatitis remains obscure, although viral agents have been postulated. Herpes simplex virus was isolated from the prostatic fluid of a patient with symptoms of prostatitis and the implications are reviewed.
Chronic prostatitis is a difficult condition to diagnose. Urethral contamination of prostatic i~retions by cells and micro-organisms cannot be~!excluded with certainty, though performing ~:Stamey localization procedure reduces this Source of error.' However, even when the diagnosis of chronic abacterial prostatitis is not !n doubt, the etiology is still a subject of much ~ebate. The role played by viruses has been ex~10red to some extent. Their possible involvement was postulated from a study of prostatic Issue by electron mmroscopy. ~ More speclhi~iiy, cytomegalovirus (CMV) and herpes sim!!ex virus (HSV) have been implicated, but they have been isolated only from semen.3 describe a case in which the symptoms of ~prostatitis coincided with the isolation of HSV Ifr~ the expressed prostatic secretion and rei~ew the relevance of this finding. I
Case Report
! A forty-one-year-old white man presented 'iWitha six-year history of intermittent testicular, iperineal, and penile pain made worse by ejaeu!lation and associated with dvsuria and lowiback pain. In addition, he complained of ;P orly sustained erections and premature ejacui!ation. Previously, he had had a Neisseria gonorrheae genital infection on three occasions, inOngonoeoceal urethritis twice, and had suf-
fered from genital herpes simplex for nine years. At initial presentation, the patient complained of the aforementioned symptoms, but there were no abnormalities on clinical examination. All investigations for prostatitis, ineluding a Stamey localization procedure, and for sexually transmitted organisms were negative. The patient was advised to return if his symptoms became worse. He did so three months later with more severe symptoms which coincided with an attack of HSV affecting the penile shaft. Investigations on this occasion again did not reveal evidence of prostatitis using the Stamey technique. However, HSV was cultured from the expressed prostatic secretion but not from the urethra. The patient was treated subsequently with Acyclovir, 200 mg given orally five times per day for two weeks and then 200 mg three times per day for another four weeks. At the end of this period the symptoms had disappeared, and HSV could not be recovered from the prostatic fluid. Comment This case highlights the problem of associating a micro-organism with disease. Whether or not HSV existed within the prostate is an important issue. Isolation of virus from the prostatic fluid could simply indicate contamination
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from the urethra. The only certain way of answering this question would be to undertake prostatic biopsy and search for virus directly in the tissue. In our patient, we did not isolate virus from the urethra but from prostatic fluid; this suggests that it was present within the prostate at the same time as a penile herpetic lesion existed. However, there was no evidence of prostatitis on two occasions, using the Stamey criteria, so that it is impossible to say that there was active HSV infection of tissue within the gland. The most plausible explanation for these findings would be involvement of the prostatic nerve supply by HSV. This would account for the symptoms of prostatitis without evidence of prostatic infection (prostatodynia) and for the response to anti-viral therapy. Anatomically,
248
this is possible since the penile shaft skin derrna, i~ tome (S 2,3,4) coincides with the nerve supply:i to the prostate. ~ Department of Urology Battle Hospital Oxford Road! RG3 lAG Englandii Reading, Berkshire (MR" DOBLE)I References i 1. Meares EM, and Stamey TA: Bacteriological loealizati6r patterns, Invest Urol 5:492 (1968). 2. Webber MM, and Bouldin TR: Ultrastrueture of hurnai prostatic epithelium: secretion granules or virus particles? Invesi Urol 14:482 (1977). 3. Blaekloek NJ: Prostatitis--pathogenesis, elinieal featur~ and management, in Hendry WF (Ed): Reeent Advances in ur01~ ogy/Andrology, New York, Churchill Livingstone,- vol 3, ehap 1~ 1981, pp 185-197.
UROLOGY
/
SEPTEMBER 1991 /
VOLUME XXXVIII,
: ~.~
PROSTATODYNIA AND HERPES SIMPLEX VIRUS INFECTION A. DOBLE, ER.C.S. J. R. W. HARRIS, ER.C.E D. TAYLOR-ROBINSON, F.R.C.PATH. From St. Mary's Hospital, London, and Clinical Research Centre, Harrow, Middlesex, England
ABSTRACT--The etiology of chronic abacterial prostatitis remains obscure, although viral agents have been postulated. Herpes simplex virus was isolated from the prostatic fluid of a patient with symptoms of prostatitis and the implications are reviewed.
Chronic prostatitis is a difficult condition to diagnose. Urethral contamination of prostatic i~retions by cells and micro-organisms cannot be~!excluded with certainty, though performing ~:Stamey localization procedure reduces this Source of error.' However, even when the diagnosis of chronic abacterial prostatitis is not !n doubt, the etiology is still a subject of much ~ebate. The role played by viruses has been ex~10red to some extent. Their possible involvement was postulated from a study of prostatic Issue by electron mmroscopy. ~ More speclhi~iiy, cytomegalovirus (CMV) and herpes sim!!ex virus (HSV) have been implicated, but they have been isolated only from semen.3 describe a case in which the symptoms of ~prostatitis coincided with the isolation of HSV Ifr~ the expressed prostatic secretion and rei~ew the relevance of this finding. I
Case Report
! A forty-one-year-old white man presented 'iWitha six-year history of intermittent testicular, iperineal, and penile pain made worse by ejaeu!lation and associated with dvsuria and lowiback pain. In addition, he complained of ;P orly sustained erections and premature ejacui!ation. Previously, he had had a Neisseria gonorrheae genital infection on three occasions, inOngonoeoceal urethritis twice, and had suf-
fered from genital herpes simplex for nine years. At initial presentation, the patient complained of the aforementioned symptoms, but there were no abnormalities on clinical examination. All investigations for prostatitis, ineluding a Stamey localization procedure, and for sexually transmitted organisms were negative. The patient was advised to return if his symptoms became worse. He did so three months later with more severe symptoms which coincided with an attack of HSV affecting the penile shaft. Investigations on this occasion again did not reveal evidence of prostatitis using the Stamey technique. However, HSV was cultured from the expressed prostatic secretion but not from the urethra. The patient was treated subsequently with Acyclovir, 200 mg given orally five times per day for two weeks and then 200 mg three times per day for another four weeks. At the end of this period the symptoms had disappeared, and HSV could not be recovered from the prostatic fluid. Comment This case highlights the problem of associating a micro-organism with disease. Whether or not HSV existed within the prostate is an important issue. Isolation of virus from the prostatic fluid could simply indicate contamination
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from the urethra. The only certain way of answering this question would be to undertake prostatic biopsy and search for virus directly in the tissue. In our patient, we did not isolate virus from the urethra but from prostatic fluid; this suggests that it was present within the prostate at the same time as a penile herpetic lesion existed. However, there was no evidence of prostatitis on two occasions, using the Stamey criteria, so that it is impossible to say that there was active HSV infection of tissue within the gland. The most plausible explanation for these findings would be involvement of the prostatic nerve supply by HSV. This would account for the symptoms of prostatitis without evidence of prostatic infection (prostatodynia) and for the response to anti-viral therapy. Anatomically,
248
this is possible since the penile shaft skin derrna, i~ tome (S 2,3,4) coincides with the nerve supply:i to the prostate. ~ Department of Urology Battle Hospital Oxford Road! RG3 lAG Englandii Reading, Berkshire (MR" DOBLE)I References i 1. Meares EM, and Stamey TA: Bacteriological loealizati6r patterns, Invest Urol 5:492 (1968). 2. Webber MM, and Bouldin TR: Ultrastrueture of hurnai prostatic epithelium: secretion granules or virus particles? Invesi Urol 14:482 (1977). 3. Blaekloek NJ: Prostatitis--pathogenesis, elinieal featur~ and management, in Hendry WF (Ed): Reeent Advances in ur01~ ogy/Andrology, New York, Churchill Livingstone,- vol 3, ehap 1~ 1981, pp 185-197.
UROLOGY
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VOLUME XXXVIII,
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