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In The News:  Editorial 

A Hole in the Fence

Arnon Krongrad, MD, Miami Herald - Feb, 01 2009

There was a hole in the nursery fence. While the other babies napped, I toddled through. Outside I found a statue of an elephant. I looked at it and got lost in a dream. Soon my teachers found me and put me back behind the fence. They were too late: I had seen the outside and been inspired.

Three years ago a colleague from the Cleveland Clinic tried to coax me through a hole in another fence. He asked me to remove the prostate of a man with severe chronic prostatitis. In our professional playground, tucked behind our fence, this is something we don't do. We take out prostates for cancer, not prostatitis.

I said, ``No.''

The man then came to see me. He told me that for eight years he had had pain, burning, bleeding, fever and malaise upon doing such simple things as urinating, having sex and even just sitting. He said he was at the end of his rope, that he knew that there was no evidence to support his request to have his prostate removed, that there was risk in his request. I believed him.

Upon waking from surgery David declared he felt great relief from the pain. For him, it seemed an existential awakening: He would function again. In the three years since surgery he has had no recurrence of symptoms and no ill effects from surgery.

Prostate cancer is a killer that no longer is silent. Not so prostatitis, a nonfatal but potentially ruinous disease. It can produce suffering equated by some with that of a heart attack or inflammatory bowel disease. Despite causing an estimated two million doctor visits a year -- in the United States alone -- it is not on the public radar.

It is also not understood. A national network found that we waste medications treating chronic prostatitis. A recent review found that there is poor evidence in support of prostate massage, a common treatment. There are clinics from Manila to Manhattan that cater to men who shuttle in search of relief. The remedy for severe chronic prostatitis is elusive.

Besides the miserable men, does anyone care? Consider Merlin, who had 25 years of burning, pain and constipation. Initially, he was misdiagnosed with such other maladies as nervous stomach. He received a series of medications that proved ineffective. Then Merlin had a major operation to remove a part of his prostate, which also was ineffective. Then he had a second removal of another part of his prostate; this didn't work either.

When we use ineffective services, we waste money. In the case of severe chronic prostatitis, the waste can stretch for years. Insurance companies, governments, employers and anyone who pays for health service cares. Waste could be capped, as happened with Merlin. Three months after his complete -- not partial -- prostate removal Merlin declared: ``All my symptoms have finally disappeared.''

Men with prostatitis have many nonsurgical options: oral antibiotics, steroid injections, suppositories with EDTA, Chinese herbs, prostate massage, transrectal pelvic muscle massage among them. And many men fail many treatments. For those who have failed nonsurgical options, surgery is a hole in the fence. It is a hole that at least four other surgeons have also looked through. This is a small number of surgeons reporting a small number of cases.

It does not constitute scientific proof. However, it constitutes multiple sightings of a new kind of hope.

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