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The "Manila Protocol"

Antibiotics and Massage/Drainage

The Manila Protocol, an outmoded form of treatment, used antibiotics in conjunction with prostate massage to effect improvement in some patients. But recent studies showing that antibiotics are ineffective in chronic pelvic pain suggest that the intrarectal massage component of this protocol is actually the helpful element.


An Interesting Exchange from a Discussion Forum

A poster wrote:

Did you see Dr Guercini's recent post in which he claims a stunning 34% of so-called nonbacterial prostatitis patients test positive for chlamydia [by PCR]?

Another poster replied:

Firstly, PCR is an untrustworthy technique with many false positives. This is well documented in scientific studies. Secondly, similar bacterial traces can be found in men without CP/CPPS, so the significance is uncertain. A 2002 study found no difference in rates of localization of bacteria in prostates of men with or without CP/CPPS.

As for the Shoskes bacterial studies, remember that Dr DS only "cures" (at 4 month follow-up), a small percentage of men. Dr Shoskes has clarified his cure rate of ±38%, explaining that this refers not to the broad mass of men with CP/CPPS, but to a subset of men who have shown possible bacterial infections after unusually exhaustive and sensitive culturing methods have been used. So the ≈38% cured figure shrinks to something <15% if you look at all CP/CPPS patients.

The demand for "antibiotics + massage" treatment expanded significantly after a couple of (non-urologist) Filipino MDs, a father and son team, started claiming 100% cure rates in the mid-1990s. They called their "cure" the Manila Protocol. Hordes of sufferers, eager for an answer, latched onto this claim. Word spread like wildfire thanks to the well-meaning but somewhat misguided efforts of a non-profit foundation devoted to finding a cure for prostatitis. This foundation went through a long romance with the Filipino doctors, thinking their methods to be "the answer" for CP/CPPS. The feeling was that Western doctors had overlooked this simple cure because of their involvement with drug companies. The proponents of this "new" technique overlooked the fact that doctors frequently used this method in the pre- and post-War era to help relieve symptoms, although it fell into disuse in the last 30 years (probably because it is labor-intensive). Very few durable cures have been publicly reported using this method, and this message reflects the experience of many people who sought a cure through this protocol.

Secondly, be careful of the word "cure". About one third of Dr Shoskes selected subset of patients say they are cured at the end of treatment. But what about a much longer follow-up, say, one or two years? What about the intense placebo effect of having a doctor sticking his finger up your rear passage (an action likely to provoke a strong psychological response in a man, especially repeated again and again). Here you have a group of poor men going to see an unusually keen and motivated MD who is engaging them in a highly unorthodox treatment, one which involves the repeated digital penetration of their anuses and an almost sexual massaging of a gland which is reputed to house the male "G-spot". Can you spell P-L-A-C-E-B-O? What about the anti-inflammatory effect of many antibiotics (a documented scientific fact)? What about the relief obtained from getting your prostate decongested the first time in years? What about the myofascial release aspects of this massage? No, no, this is a murky area - we cannot accept the figures as "cures" at all.

Many men have reported near-cures from massage (drainage) alone. Therefore we should all have severe reservations about any study which looks at the "antibiotics + massage" protocol without having 1) a control group and 2) a group receiving massage alone. That's why we cannot accept even Dr Shoskes' low (<20%) "cure" rate (at 4 month follow-up) from the study he performed to test out the "Manila Protocol". I wouldn't be at all surprised if a 1-year follow-up found a negligible cure rate. And remember that most studies find a placebo "cured" or "helped" rate of between 30 and 50%, even if you just give sugar pills.

Also key here is this point: Dr Shoskes found that "Initial cultures and prostatic WBC levels do not predict treatment response". So those most likely to be helped by the "antibiotics + massage" treatment cannot be predicted by looking at their cultures or WBC levels -- all of which rather knocks the scientific basis of "antibiotics + massage/drainage" flat as a cure for our malady. To my mind, it is quite obvious that the beneficial anti-inflammatory effects of the antibiotics combined with the drainage of painfully sequestered prostatic secretions, the placebo effect of strong physician involvement and the massaging of prostate-adherent deep pelvic muscles can combine to make a small proportion of men feel much better for a few months.

View of a Leading Urologist

I have used antibiotics/massage in my practice since 1996. During that time I have modified my technique and indications based on what worked for me and what didn't. For the patient population that I see, I use it in about 10-20% of my patients with about a 50% response rate in this group. I don't know what the response rate would be in the 80% of patients who don't get that treatment, but based on past experience it would likely be less than 10%. I dropped using multiple antibiotics and treating the sexual partner years ago, because these things just didn't seem to make a difference. I also don't continue after 2-3 weeks without improvement because I have never had a patient get better later on who didn't have an earlier improvement.

Some patients don't get recurrences (the "C" word) and others occasionally do and seem to respond to just 1 or 2 massages after that. I saw a patient this week who suffered for years and is almost symptom free after 2 massages and 4 days of Biaxin.

Antibiotics with prostatic massage is a very valuable treatment for some men with prostatitis, but it will do nothing for a large proportion of men. I look forward to seeing the results from clinics like Tucson and Manila published in peer reviewed journals so the data can be critically analyzed.

Daniel Shoskes MD
Cleveland Clinic Florida
August 23 2001

View of the Webmaster

I think it is certainly true that many men receive substantial improvement from pelvic floor massage. Massaging deep muscles adjacent to the bladder and prostate, such as the insertions of the levator ani muscles, is best accomplished by using the Wise-Anderson Protocol Massage Wand.