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Diagnostic Prostatic Massage
Updated: Jan 07, 2014
Author: Lanna Cheuck, DO; Chief Editor: Bradley Fields Schwartz, DO, FACS more...

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Background
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.

Indications
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.
Classification of prostatitis
Classification of prostatitis
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Classification of prostatitis
Classification of prostatitis
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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.

Technique
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Diagnostic Prostatic Massage
Overview
Background
Indications
Contraindications
Technical Considerations
Technique
Approach Considerations
Four-Glass Test
Two-Glass Test
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References
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