Prostatitis is a general ailment in primary care practice. Chronic prostatitis is an infection that needs prompt treatment and accurate recognition. Acute prostatitis is a more general state, and its etiology is more mysterious. pain in the male perineum can arise from both non-infectious and infectious inflammation and can represent pain referred from retro peritoneal structures and low sacral nerve roots.

Chronic prostatitis is readily verified by the onset of fever, dysuria, perineal pain and diminished urine flow. on normal rectal analysis, the gland is found to be enlarged, boggy and exquisitely tender. Abdominal verification generally discloses striking bladder distention. Some men may show toxic at the time of presentation.

In elder people, the signs are normally those of bladder outflow obstruction, often times associated by pelvic pain. Patients complain of urgency, hesitancy, double voiding, loss of stream volume and force, dribbling and frequency. Younger adult more generally complain of dribbling and dysuria, intermittent discomfort in the perineum, testicle or low back. Some people show initially with painful ejaculations, hematospermia or hematuria. Rectal analysis generally discloses an enlarged prostate with flexible amount of asymmetry, tenderness and bogginess. Incompletely treated or untreated chronic  prostatitis is featured by recurrent symptomatic exacerbation, even though these may be separated by long asymptomatic intervals. This has been known as male chronic pelvic pain syndrome.

Both chronic and acute prostatitis can provoke systemic and urinary tract complications. the severely infected gland may drive to bacteremia or parenchymal infection. Rarely, severe infection will develop to a well defined abscess. Chronic infection can generate small prostatic stones, which may work as a nidus for further recurrent symptomatic bouts of infection and inflammation.

Acute prostatitis is readily evident by the clinical presentation and exquisitely tender prostate found on rectal examination. Nevertheless, chronic prostatitis shows a more hard diagnostic issue, generally resembling, in clinical presentation, other general form of urinary outflow tract obstruction, such as benign prostatic hyperplasia, urethral stricture, prostatic carcinoma. the lower urinary tract irritative signs combined with chronic prostatitis may be seen with urethritis, neurogenic bladder, sphincter dyssynergy, bladder carcinoma.

Therapeutic recommendations

Document an infectious organism and the presence of prostatic inflammation, either with EPS examination, the pre massage post massage test or sequential urinary culturing.

When a bacterial agent is identified, treat with a prolonged course of antibiotics, such as ciprofloxacin, levolflosacin, or dobule strength TMS for 4 to 6 weeks. Doses of the fluroquinolones should be adjusted for renal insufficiency.

After treatment, follow closely for return of infection. a second course of antibiotics with the same or an alternative drug for up to 12 weeks may be necessary in partially responsive infections.

For patients who present with the new onset of chronic abacterial prostatitis, consider a 12 week course of doxycycline, erythromycin or carbenicillin indanyl sodium.Schedule a return 1 to 2 weeks after the completion of treatment to assess the effects of therapy by checking the EPS or VB3.

Consider an alpha adrenergic blocker such as prazosin, doxazosin, terazosin, tamsulosin or alfuzosin to reduce sphincter resistance. Prazosin, doxazosin and terazosin are more likely to cause clinically significant hypotension.

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A fascinating new paper: Morgellons Disease, or Antipsychotic-Responsive Delusional Parasitosis, in an HIV Patient: Beliefs in the Age of the Internet

“mr. A” was a 43-year-old man…His most pressing medical complaint was worrisome fatigue. he was not depressed…had no formal psychiatric history, no family psychiatric history, and he was a successful businessman.

He was referred to the psychiatry department by his primary-care physician (PCP) because of a 2-year-long complaint of pruritus [itching] accompanied by the belief of being infested with parasites. Numerous visits to the infectious disease clinic and an extensive medical work-up…had not uncovered any medical disorder, to the patient’s great frustration.

Although no parasites were ever trapped, mr. A caused skin damage by probing for them and by applying topical solutions such as hydrogen peroxide to “bring them to the surface.” after reading about Morgellons disease on the Internet, he “recalled” extruding particles from his skin, including “dirt” and “fuzz.”

During the initial consultation visit with the psychiatrist, mr. A was apprehensive but cautiously optimistic that a medication could help. the psychiatrist had been forewarned by the PCP that the patient had discovered a website describing Morgellons and “latched onto” this diagnosis.

However, it was notable that the patient allowed the possibility (“30%”) that he was suffering from delusions (and not Morgellons), mostly because he trusted his PCP, “who has taken very good care of me for many years.”

The patient agreed to a risperidone [an antipsychotic] trial of up to 2 mg per day. [i.e. a lowish dose]. Within weeks, his preoccupation with being infested lessened significantly… Although not 100% convinced that he might not have Morgellons disease, he is no longer pruritic and is no longer damaging his skin or trying to trap insects. he remains greatly improved 1 year later.(Mr A. had also been HIV+ for 20 years, but he still had good immune function and the HIV may have had nothing to do with the case.)

“Morgellons” is, according to people who say they suffer from it, a mysterious disease characterised by the feeling of parasites or insects moving underneath the skin, accompanied by skin lesions out of which emerge strange, brightly-coloured fibres or threads. other symptoms include fatigue, aches and pains, and difficulty concentrating.

According to almost all doctors, there are no parasites, the lesions are caused by the patient’s own scratching or attempts to dig out the non-existent critters, and the fibres come from clothes, carpets, or other textiles which the patient has somehow inserted into their own skin. it may seem unbelievable that someone could do this “unconsciously”, but stranger things have happened.

As the authors of this paper, Freudenreich et al, say, Morgellons is a disease of the internet age. it was “discovered” in 2002 by a Mary Leitao, with Patient Zero being her own 2 year old son. since then its fame, and the reported number of cases, has grown steadily – especially in California.

Delusional parasitosis is the opposite of Morgellons: doctors believe in it, but the people who have it, don’t. It’s seen in some mental disorders and is also quite common in abusers of certain drugs like methamphetamine. it feels like there are bugs beneath your skin. There aren’t, but the belief that there are is very powerful.

This then is the raw material in most cases; what the concept of “Morgellons” adds is a theory, a social context and a set of expectations that helps make sense of the otherwise baffling symptoms. and as we know expectations, whether positive or negative, tend to be become experiences. the diagnosis doesn’t create the symptoms out of nowhere but rather takes them and reshapes them into a coherent pattern.

As Freudenreich et al note, doctors may be tempted to argue with the patient – you don’t have Morgellons, there’s no such thing, it’s absurd – but the whole point is that mainstream medicine couldn’t explain the symptoms, which is why the patient turned to less orthodox ideas.

Remember the extensive tests that came up negative “to the patient’s great frustration.” and remember that “delusional parasitosis” is not an explanation, just a description, of the symptoms. To diagnose someone with that is saying “We’ve no idea why but you’ve imagined this”. True, maybe, but not very palatable.

Rather, they say, doctors should just suggest that maybe there’s something else going on, and should prescribe a treatment on that basis. Not rejecting the patient’s beliefs but saying, maybe you’re right, but in my experience this treatment makes people with your condition feel better, and that’s why you’re here, right?

Whether the pills worked purely as a placebo or whether there was a direct pharmacological effect, we’ll never know. Probably it was a bit of both. It’s not clear that it’s important, really. the patient improved, and it’s unlikely that it would have worked as well if they’d been given in a negative atmosphere of coercion or rejection – if indeed he’d agreed to take them at all.

Morgellons is a classic case of a disease that consists of an underlying experience filtered through the lens of a socially-transmitted interpretation. but every disease is that, to a degree. Even the most rigorously “medical” conditions like cancer also come with a set of expectations and a social meaning; psychiatric disorders certainly do.

I guess Morgellons is too new to be a textbook case yet – but it should be. everyone with an interest in the mind, everyone who treats diseases, and everyone who’s ever been ill – everyone really – ought to be familiar with it because while it’s an extreme case, it’s not unique. “All life is here” in those tangled little fibres.

Freudenreich O, Kontos N, Tranulis C, & Cather C (2010). Morgellons disease, or antipsychotic-responsive delusional parasitosis, in an hiv patient: beliefs in the age of the internet. Psychosomatics, 51 (6), 453-7 PMID: 21051675

But while the multi-component intervention, which was administered through primary care settings, also helped participants reduce the risks their drinking posed when combined with medications, psychiatric or medical conditions, and other comorbidities common to older adults, the reduction was not much greater than that seen among other older adults who were provided with only general information on healthy behaviors.

At-risk drinking among older adults could potentially result in injury or even death.

Data from the study are published in the January issue of the journal Addiction.

“We have an aging population and more than half drink alcohol,” said lead investigator Dr. Alison Moore, a professor of medicine in the division of geriatrics at the David Geffen School of Medicine at UCLA. “Older adults have additional risks compared with younger adults because of age-related physiological changes that increase the effect of a given dose of alcohol and because of the increase in medical and psychiatric conditions and the use of medications that may interact negatively with alcohol.

“We wanted to test an intervention to reduce alcohol-related risks in primary care, where most older adults receive care,” she said.

The findings were based on the Healthy Living as you Age study, a randomized clinical trial that tested a screening and multi-component intervention among older at-risk drinkers in primary care settings. the study included 631 adults aged 55 and older recruited between October 2004 and April 2007 from three primary care sites in Southern California.

Participants in the yearlong study were identified as being at-risk by the Comorbidity Alcohol Risk Evaluation Tool, which utilizes information on alcohol use, medications that can interact negatively with alcohol (such as those for ulcers, pain and sleeping) and medical and psychiatric conditions, and symptoms that could be caused or worsened by alcohol (such as hypertension, depression, abdominal pain and memory problems).

The study subjects were randomly assigned during a primary care office visit to either receive a booklet on general healthy behaviors for older adults, which including recommended drinking limits, or the intervention, which included a personalized report of their alcohol-related risks, a drinking diary to help them keep track of their consumption, a booklet on aging and drinking, and advice from a primary health care provider and telephone counseling from a health educator at two, four and eight weeks after the start of the study.

Participants in both groups consumed about 15 alcoholic drinks each week at the beginning of the study. All were identified as at-risk drinkers, and most were identified as at-risk for multiple reasons, including drinking while taking medications (73 percent), symptoms (60 percent), medical or psychiatric conditions (50 percent) or simply their amount of drinking (47 percent). 

At the three-month point, individuals in the intervention group had lowered their alcohol consumption to an average of nine drinks a week; those in the control arm had reduced their consumption to 11. these numbers remained roughly the same at the one-year point, a statistically significant difference between the groups.

At three months, only 40 percent of the intervention group and 61 percent of the control group were still at-risk drinkers, a statistically significant difference. at one year, however, the difference between the groups narrowed: 54 percent of the intervention arm was at-risk, compared with 60 percent of the control group, and the difference then was not statistically significant.

“One of the important messages here is that, for both groups, the amount of drinking declined by 30 to 40 percent and the proportions of those at-risk declined by 50 to 60 percent at three months and generally persisted at 12 months,” Moore said.  “Also older at-risk drinkers typically have multiple risks; most because of combined use of alcohol and medications or medical and psychiatric conditions. It may be that simply giving information on recommended drinking limits for older adults is enough to cause large reductions in at-risk drinking and amount of drinking.” 

The National Institute of Alcohol Abuse and Alcoholism, the National Institute on Aging, the National Institute of Mental Health, the John a. Hartford Foundation, and a Special Fellowship in Advanced Geriatrics from the Veterans Affairs Greater Los Angeles Healthcare System funded this study.

Last year I saw the school therapist but not specifically for depression I seem to have all the symptoms of depression yet he told me that I wasn't depressed because I have decent school grades and good hygiene. I am still suffering with this depression and I want to know if the doctor I saw is right because of these things.

Get a 2nd opinion from another therapist of psychologist.

Don't go by what the school therapist told you. People can be depressed without having all the symptoms of depression. Talk to your parents and let them take you to a real doctor. I hope you're able to get help. good Luck!

Definitely see a doctor! Doesn't have to be a psychiatrist; primary care doctors and pediatricians are now being more alert to discuss depression with their patients.

There are different stages of depression so it is possible to have decent grades and good hygiene and still have depression. Our bodies are chemical factories, there are a number of reasons why something might need correcting once in a while – depression could be the result of a chemical imbalance that could be resolved with dietary changes.

Keep asking questions until you get reliable, satisfying answers.

In nursing school we learn that the best authority on a patient's health is the patient him/herself. Did you tell this therapist that you were depressed? It was dumb and lazy for him to pronounce you not depressed, but maybe you need to correct his misunderstanding. Better yet, is there someone else you could see? can you tell your parents what's happening with you, and ask for their help in finding a counselor you can trust?

It's extremely mature and intelligent of you to recognize the symptoms of depression and want to deal with the issue before it gets worse. good luck, my thoughts are with you.

Press Release Source: Decision Resources On Monday November 15, 2010, 8:00 am EST

BURLINGTON, Mass., Nov. 15, 2010 /PRNewswire/ — Decision Resources, one of the world’s leading research and advisory firms for pharmaceutical and healthcare issues, finds that although four out of five surveyed psoriasis patients in the United States who have requested a brand indicate that physicians are willing to comply with their request to be prescribed a specific drug, only 20 percent of surveyed patients indicate that they have asked for a psoriasis drug by name. Given the fact that moderate-to-severe psoriasis patients are underserved by currently available treatment options, this finding suggests that marketers of psoriasis therapies could improve the uptake of their therapies by increasing patient awareness of their drugs through physicians, web sites and patient advocacy groups.

Additionally, surveyed patients with both mild and moderate-to-severe psoriasis at the time of diagnosis were more likely to be diagnosed during their first doctor’s visit if they were examined by a dermatologist versus being seen by a primary care physician (PCP). Eighty-five percent of surveyed patients with mild psoriasis and 78 percent of patients with moderate-to-severe psoriasis who were first seen by a dermatologist about their symptoms were diagnosed with psoriasis during their initial examination. however, only between 55 and 60 percent of patients with mild or moderate-to-severe psoriasis were diagnosed with psoriasis during their first examination by a PCP.

The findings are from Decision Resources’ new Patient Forum report entitled Underserved Moderate-to-Severe Psoriasis Patients Offer Opportunity for recently Launched and Emerging Agents. With Patient Forum, users can obtain indispensible primary market research on U.S. patient attitudes and perceptions of both their disease and treatment, with a specific focus on how patient segments within the psoriasis population differ from each other in their behavior and disease characteristics.

“Patient acceptance is critically important to the success of a drug brand and by understanding the perspectives, behaviors and attitudes of patients, drug developers can obtain the information they need to effectively market their existing and emerging products,” said Decision Resources Program Manager Jennifer Moniz-Carpenter, M.B.A. “Patient Forum provides primary market research on the patient journey to diagnosis and treatment, how patients perceive their disease and treatment, what drives patient opinion about current treatments and what will prompt patients to request an emerging therapy.”

About Decision Resources

Decision Resources (decisionresources.com) is a world leader in market research publications, advisory services and consulting designed to help clients shape strategy, allocate resources and master their chosen markets. Decision Resources is a Decision Resources, Inc. company.

About Decision Resources, Inc.

Decision Resources, Inc. is a cohesive portfolio of companies that offers best-in-class, high-value information and insights on important sectors of the healthcare industry. Clients rely on this analysis and data to make informed decisions. please visit Decision Resources, Inc. at DecisionResourcesInc.com.

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