But what of the patient with a small, non-tender gland and urinary findings of no significance? Doctors are just beginning to realize that low-grade inflammation may still be lurking in these seemingly innocent glands, and a frequent cause is the ubiquitous bacterium known as Gardnerella vaginalis.
Often the first clue to the subtle presence of this condition is an elevation of the PSA test.
Chronic prostatitis now has a new definition. Thanks to the persistence of scientists dedicated to urological research, this extremely common condition of adult men is now being increasingly recognized as nearly always bacterial in origin--even if bacteria can not be grown in culture.
The former diagnosis of chronic, non-bacterial prostatitis--the "dumping ground" for thousands of frustrated patients, has been greatly over-used in the past. This reflects primarily only our inability to demonstrate the causative bacteria, not their absence.
Most people with chronic prostatitis will respond to the proper use of antibiotics combined with diligent prostatic massage. But what about those who have no symptoms referable to the prostate gland but are still harboring infection?
Recent published results of prostate tissue examinations from routine autopsies reveal a sobering 75-80% incidence of chronic infection. Most of these men, dying from the usual triad of heart disease, cancer or stroke, had no symptoms referable to the prostate gland. One can infer from this largely irrefutable data that asymptomatic chronic prostatitis is not only frequent in our society, but rampant!
Again and again the Gardnerella vaginalis organisms keep appearing in bacteriologic analyses of prostatic secretions from chronic cases--naturally not as the only causative organism, but a very common one. This ubiquitous organism, so common in vaginitis patients, also appears to be a major player in chronic prostatitis. One can now say that Gardnerella--the scourge of the fastidious woman--may well also be a key player in PSA elevations.
Vaginitis associated with Gardnerella organisms is one of the most common conditions seen by primary care physicians. Nearly 50 percent of women presenting with typical vaginitis symptoms will be diagnosed with a Gardnerella infection. This infection was formerly known as Hemophillus vaginitis, and more recently as non-specific vaginitis.
Its prevalence is vastly under-reported because of the reality that many women carrying this organism will have only minimal symptoms--or no symptoms at all. Most of these women are greatly surprised when informed that routine microscopic examination of their vaginal secretions has revealed "abnormal vaginal flora."
Some will be in their doctor's office for evaluation of a mildly atypical Pap smear and will be quite relieved to learn that the presence of a subtle infection with Gardnerella may be the culprit. Others will complain only of abundant vaginal mucus for months and, in some cases, even years may have passed during which time such a discharge is accepted as normal.
Other women, during their yearly checkup, will complain only of a disagreeable fishy odor after intercourse. And many "carriers" of Gardnerella organisms will have no complaints at all. Usually the question of sexual transmission will come up early in the office discussion, especially when considering the advisability of treating sexual partners.
Frequently, the office atmosphere can become quite emotionally charged when a patient will almost immediately blame their partner. The fact of the matter however, is that although Gardnerella vaginitis is most definitely a sexually transmitted disease, Gardnerella organisms can frequently be found in many women--and even young girls having no prior sexual contact.
Thus Gardnerella seems to be a two-faced Janus--capable of both innocence and harm. Wearing its candid, innocent face, Gardnerella can exist in many females as part of their normal vaginal flora. Wearing its worldlier, sultry face, it is both acquired and transmitted by sexual contact.
Complicating the mystery of this Janus organism is its ability to change its face occasionally from innocent to harmful, through the recruitment of anaerobes--other members of the vaginal flora. Activated Gardnerella then emerge to lead their oxygen fearing "hit squads" in a combined attack on the vaginal mucosa creating irritation, inflammation and discharge.
The diagnosis of this common condition is especially easy if the patient mentions a fishy or ammonia-like smell immediately after intercourse. In cases of Gardnerella infection, ammonia is released by the alkaline nature of semen--a purely chemical reaction.
This is the basis of the well known "sniff test," wherein a drop of potassium hydroxide is added to a drop of vaginal secretion on a slide and held to the nose. The other test is the microscopic examination of the vaginal smear. The "clue" cells: Shed vaginal epithelial cells, studded with Gardnerella organisms, are very characteristic. So to is the abundance of other frequently associated bacteria having pleomorphic coccobacillary shapes.
Spread of Gardnerella to sexual partners seems almost inevitable, if sexual contact occurs during the acute phase of infection. This simple fact prompts most physicians to treat both patients and their partners simultaneously, although some physicians will withhold treatment of the partners if the patient is only mildly symptomatic, or of carrier status--insisting first on a therapeutic trial of treatment just for the patient.
The end result of all this is the likely exposure of the male urogenital tract to Gardnerella organisms many times in his life; some based on rampant sexuality and others to simple chance. You might call it the "roll of the dice." When considering these facts, the commonality of this organism in chronic prostatitis should come as no surprise.
Prostate specific antigen (PSA) is an enzyme found only in prostatic tissue. Some of this enzyme is released normally into the blood vessels draining this gland. The PSA blood test is a screening test which measures the amount of this substance circulating naturally in a person's blood.
Under conditions of inflammation or malignancy, more of this compound is released into the blood by damaged or otherwise abnormal prostate tissue. This is an extremely sensitive test of great potential value in the early diagnosis of prostate cancer, yet in 30% of early cancers the PSA is within normal limits.
To this sobering reflection of diagnostic inadequacy must be added that, in the presence of an elevated PSA, some 85% of prostate biopsies will be negative for cancer. In other words, 85% are "false positive" by the PSA screening method. Still, combined with a digital rectal examination, the PSA test remains our best available method to screen for cancer of the prostate. It has also been proven the most useful for the follow-up of response to treatment of prostatic cancer patients. Returning to these "false positive" cases mentioned previously; almost all are due to underlying inflammation unrelated to prostate cancer.
Inflammation of the prostate is a histological finding in almost every set of prostate biopsies done as a follow-up to routine PSA testing: Several recently reported studies in scientific journals now document this observation. This information is now beginning to change protocols for biopsy follow-up and perhaps should demand reassessment of our initial biopsy protocols as well.
The information now available (both from biopsy-follow-up of PSA testing, and from histologic examination of prostate tissue during routine autopsies) presents very compelling evidence that asymptomatic, chronic prostate infection is extremely prevalent in our society. All evidence indicates that Gardnerella, with its proclivity for subtle, low-grade and lingering involvement within human tissue, is a major contributor to the relatively short list of potentially causative organisms.
There is now reason to suspect that our PSA test may be a far more accurate indicator of asymptomatic, low-grade prostate infection, than of cancer. If this is true--and all evidence indicates it is; perhaps a therapeutic trial of an appropriate antibiotic might be in order for most of our cases of newly-elevated PSA--especially those in whom the prostate gland appears small and completely normal to digital rectal examination.
A Case in Point
As a former astronaut, each year I am invited to NASA's Johnson Space Center for my complete physical examination. This is part of a long term, "Longitudinal Study" of astronaut health. A PSA test is part of this examination.
Six years ago my PSA left the normal range and began to climb; symptoms and findings were completely absent. From 3.8, my PSA climbed to 4.7, and then to 5.4. A subsequent value of 6 prompted my visit to an urologist who insisted on a biopsy if I was to remain his patient. Since my prostate gland was normal and even "small" by multiple digital examinations, I declined the biopsy.
My PSA the following year was 6.7 and a year later, 7.4. Another urologist advised biopsy with no other options. Upon reading an article about the unusually high prevalence of chronic, silent prostatitis in routine autopsies, and having over twenty years experience as a family doctor helping women fight Gardnerella organisms, I decided to take a ten day course of a standard Gardnerella treatment (antibiotic) protocol.
Two weeks later my PSA had decreased to 5.1, probably about normal for a 71-year old. I decided to share this information, in hopes that other doctors or worried "PSA patients" find it helpful. My medical intuition tells me this is a very promising area for further investigation, for a few dollars worth of medicine just might cut the exorbitant rate of PSA false-positives with no significant patient risk
Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor