If the situation of infectious (or rather bacterial) prostatitis is more or less clear, then abacterial chronic prostatitis remains a serious urological problem with many unclear questions.Probably, under the guise of the disease called chronic prostatitis, there is a series of diseases and pathological conditions characterized by various organic tissue changes and functional disorders not only of the prostate, the organs of the male reproductive system and the lower urinary tract, but also of other organs and systems in general.
ICD-10 codes
- N41.1 Chronic prostatitis.
- N41.8 Other inflammatory diseases of the prostate.
- N41.9 Inflammatory disease of prostate, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis ranks first among inflammatory diseases of the male reproductive system and is generally the first among male diseases.It is the most common urological disease in men under the age of 50.The average age of patients with chronic inflammatory process of the prostate is 43 years.By the age of 80, 30% of men suffer from chronic or acute prostatitis.
The prevalence of chronic prostatitis in the general population is 9%.In our country, according to the most approximate estimates, chronic prostatitis causes men of working age to see a urologist in 35% of cases.In 7-36% of patients, it is complicated by vesiculitis, inflammation of the epididymis, urinary disorders, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medicine considers chronic prostatitis to be a polyetiological disease.In addition to infectious factors, the occurrence and recurrence of chronic prostatitis is caused by neurovegetative and hemodynamic disorders, which are associated with a weakening of local and general immunity, autoimmune (endogenous immune modulators - cytokines and leukotrienes), hormonal, chemical (urine reflux) and their role in the cytoma of the prostate.and disorders of peptide growth factors.Risk factors for the development of chronic prostatitis are as follows:
- lifestyle characteristics that cause infection of the urinary system (promiscuous sexual intercourse without protection and personal hygiene, the presence of an inflammatory process and/or infections of the urinary tract and genitals in a sexual partner):
- performing transurethral manipulations (including TURP of the prostate) without prophylactic antibiotic therapy:
- presence of an indwelling urethral catheter:
- chronic hypothermia;
- sedentary lifestyle;
- irregular sex life.
Among the etiopathogenetic risk factors of chronic prostatitis, immunological disorders, especially the imbalance between different immunocompetent factors, are important.First of all, this applies to cytokines - low molecular weight compounds of a polypeptide nature, which are synthesized by lymphoid and non-lymphoid cells and have a direct effect on the functional activity of immunocompetent cells.
Symptoms of chronic prostatitis
Symptoms of chronic prostatitis include: pain or discomfort, problems urinating, and sexual dysfunction.The main symptom of chronic prostatitis is pain or discomfort in the pelvic area that lasts for 3 months.and more.The most common site of pain is the perineum, but discomfort may occur above the pubic bone, in the groin, anus, and other areas of the pelvis, inner thighs, and the scrotum and lumbosacral region.Unilateral testicular pain is usually not a sign of prostatitis.Pain during and after ejaculation is the most specific for chronic prostatitis.
Sexual function is impaired, including suppression of libido and impaired quality of spontaneous and/or adequate erections, although most patients do not develop severe impotence.Chronic prostatitis is one of the causes of premature ejaculation (PE), but ejaculation can be slow in the later stages of the disease.The emotional color of the orgasm may be changed ("erased").
Urinary tract disorders occur more often with irritative symptoms, less often with IVO symptoms.
In the case of chronic prostatitis, disturbances in the quantity and quality of the ejaculate can also be detected, which rarely cause infertility.
Chronic prostatitis has a fluctuating nature, periodically waxing and waning.In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.
The exudative phase is characterized by pain in the scrotum, groin and suprapubic areas, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful erection.
In the alternative stage, the patient may experience pain (unpleasant sensations) in the suprapubic region, less often in the scrotum, in the groin area, and in the sacrum.Urination is usually not impaired (or increased).A normal erection can be observed against the background of accelerated, painless ejaculation.
The proliferative stage of the inflammatory process can be manifested by a weakening of the intensity of urine flow and increased urination (when the inflammatory process worsens).Ejaculation at this stage is not impaired or slightly slowed down, the intensity of the corresponding erection is normal or moderately reduced.
In the stages of scarring and sclerosis of the prostate, patients are concerned about heaviness in the suprapubic region, sacrum, frequent urination day and night (full pollakiuria), sluggish, intermittent urine flow, and extreme urge to urinate.Ejaculation slows down (even to its absence), the proper and sometimes spontaneous erection weakens.At this stage, attention is often drawn to the "erasure" of orgasm.
According to the unified quality of life assessment scale, the impact of chronic prostatitis on the quality of life is comparable to the impact of a heart attack.angina or Crohn's disease.
Diagnosis of chronic prostatitis
The diagnosis of manifested chronic prostatitis is not difficult and is based on the classic triad of symptoms.Given that the disease is often asymptomatic, a complex of physical, laboratory and instrumental methods should be used, including the determination of the immune and neurological status.
Questionnaires are of great importance when evaluating the subjective manifestations of the disease.Several questionnaires have been developed, which the patient fills out, and the doctor wants to get an idea of the frequency and intensity of pain, urinary disorders and sexual disorders, the patient's attitude to these clinical manifestations of chronic prostatitis, as well as to assess the state of the patient's psycho-emotional sphere.Currently, the most popular is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire.The questionnaire was developed by the US National Institutes of Health;an effective tool for identifying symptoms of chronic prostatitis and determining its impact on quality of life.
Laboratory diagnosis of chronic prostatitis
The laboratory diagnosis of chronic prostatitis enables the diagnosis of "chronic prostatitis" (since 1961, Farman and McDonald established the "gold standard" in the diagnosis of prostatitis - 10-15 leukocytes per field of view) and we can make a differential diagnosis between its bacterial and non-bacterial forms.
Microscopic examination of the emptied urethra determines the number of leukocytes, mucous membrane, epithelium, as well as trichomonas, gonococci and non-specific flora.
The presence of microorganisms that cause sexually transmitted diseases is determined when examining the scraping of the urethral mucosa with PCR.
Microscopic examination of prostatic secretion determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallement bodies and macrophages.
Bacteriological examination of the prostate discharge or urine obtained after the massage is carried out.Based on the results of these tests, the nature of the disease is determined (bacterial or abacterial prostatitis).Prostatitis can cause an increase in PSA concentration.The blood sample for determining the serum PSA concentration should be taken no earlier than 10 days after the digital rectal examination.Nevertheless, if the PSA concentration is above 4.0 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is recommended to rule out prostate cancer.
In the laboratory diagnosis of chronic prostatitis, the examination of the immune status (the state of humoral and cellular immunity) and the level of non-specific antibodies (IgA, IgG and IgM) in the secretion of the prostate is of great importance.Immunological research helps determine the stage of the process and monitor the effectiveness of treatment.
Instrumental diagnosis of chronic prostatitis
Prostate TRUS has high sensitivity but low specificity in chronic prostatitis.The examination allows not only differential diagnosis, but also determination of the form and stage of the disease, followed by follow-up during the entire duration of treatment.Ultrasound makes it possible to determine the size and volume of the prostate, the echo structure (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), the size, degree of expansion, the density and echo-homogeneity of the contents of the seminal vesicles.
UDI (UFM, determination of urethral pressure profile, pressure/flow test, cystometry) and myography of the pelvic floor muscles provide additional information in case of suspected neurogenic urinary disorders and dysfunction of the pelvic floor muscles.and IVO, which often accompanies chronic prostatitis.
X-ray examination should be performed in patients with diagnosed BOO in order to clarify the cause of its occurrence and to determine further treatment tactics.
CT and MRI of the pelvic organs are performed for the differential diagnosis of prostate cancer, as well as in the case of suspected non-inflammatory forms of abacterial prostatitis, when pathological changes in the spine and pelvic organs must be excluded.
What should be examined?
Prostate (Prostate)
How should it be examined?
- Ultrasound of the prostate
- Prostate biopsy
What tests are required?
- Analysis of prostate secretion (prostate gland)
- Prostate-specific antigen in the blood
Who should I contact?
- Urologist
- Andrologist
Treatment of chronic prostatitis
Treatment of chronic prostatitis, like any chronic disease, should be carried out according to the principle of consistency and an integrated approach.First of all, the patient's lifestyle, thinking and psychology must be changed.By eliminating the effects of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others.In this way, we not only stop the further progression of the disease, but also promote healing.This, along with the normalization of sex life, diet and much more, is the preparatory stage of treatment.This is followed by the main, basic course, which includes the use of various drugs.This step-by-step approach to the treatment of the disease allows you to monitor its effectiveness at each stage, make the necessary changes, and fight the disease in the same principle on which it developed.- from predisposing factors to productive factors.
Indications for hospitalization
Chronic prostatitis usually does not require hospitalization.In severe cases of persistent chronic prostatitis, complex therapy performed in the hospital is more effective than outpatient treatment.
Drug treatment of chronic prostatitis
Elimination of the infectious factor, normalization of blood circulation in the pelvic organs (including improvement of prostate microcirculation), proper drainage of prostate acini, especially in the peripheral zones, simultaneous use of drugs and methods that act on different parts of the pathogen, normalization of the level of essential hormones and immune reactions.Based on this, in case of chronic prostatitis, antibacterial and anticholinergic agents, immunomodulators, NSAIDs, angioprotectors and vasodilators, as well as prostate massage can be recommended.In recent years, chronic prostatitis has been treated with drugs that were not previously used for this purpose: alpha1-blockers, 5-a-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs affecting the metabolism of urates and citrates.
In the case of chronic abacterial prostatitis and chronic pelvic pain inflammatory syndrome (when the causative agent could not be identified using microscopic, bacteriological and immunodiagnostic methods), empirical antibacterial treatment of chronic prostatitis can be carried out with a short course, and if it is clinically effective, it can be continued.The effectiveness of empiric antimicrobial therapy in patients with both bacterial and abacterial prostatitis is approximately 40%.This indicates the undetectability of bacterial flora or the positive role of other microbial agents (chlamydia, mycoplasma, ureaplasma, fungal flora, Trichomonas, viruses) in the development of the infectious inflammatory process, which is currently unproven.In some cases, flora that cannot be detected by standard microscopic or bacteriological examination of prostate secretions can be detected by histological examination of prostate biopsies or other subtle methods.
The need for antibacterial therapy in non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis is controversial.The duration of antibacterial therapy should not exceed 2-4 weeks, and in case of a positive result, it will continue for 4-6 weeks.If there is no effect, it is possible to stop antibiotics and prescribe drugs from other groups (for example, alpha1-blockers, Serenoa repens plant extracts).
In the empirical treatment of chronic prostatitis, the drugs of choice are fluoroquinolones, as they have high bioavailability and penetrate well into the glandular tissue (the concentration of some of them in secretions exceeds the concentration in blood serum).Another advantage of drugs belonging to this group is their activity against most gram-negative microorganisms, as well as chlamydia and ureaplasma.The outcome of the treatment of chronic prostatitis does not depend on the use of a specific drug belonging to the group of fluoroquinolones.
If fluoroquinolones are ineffective, combined antibacterial therapy should be prescribed.Tetracyclines have not lost their importance, especially when chlamydial infection is suspected.
Recent studies have shown that clarithromycin penetrates well into prostate tissue and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.
To prevent the recurrence of bacterial prostatitis, the prescription of antibacterial drugs is also recommended.
In the event of relapses, lower single and daily doses of previous antibacterial drugs may be prescribed.The ineffectiveness of antibacterial therapy is usually due to poorly chosen drugs, their dosage and frequency, and the presence of bacteria remaining in channels, acini or calcifications, which are covered by a protective extracellular membrane.
Pain and irritative symptoms indicate the prescription of NPS, which are used both in complex therapy and as an alpha-blocker alone if antibacterial therapy is ineffective (diclofenac dose 50-100 mg/day).
Some studies demonstrate the effectiveness of herbal preparations, but this information has not been confirmed by multicenter, placebo-controlled studies.
If the clinical symptoms of the disease (pain, dysuria) persist even after the use of antibiotics, α-blockers and NSAIDs, the subsequent treatment should be aimed either at alleviating the pain, or at solving the urination problems, or at correcting both of the above symptoms.
In case of pain, tricyclic antidepressants have an analgesic effect due to the blocking of histamine H1 receptors and the anticholinesterase effect.The most commonly prescribed drugs are amitriptyline and imipramine.However, they should be handled with care.Side effects - drowsiness, dry mouth.In extremely rare cases, narcotic pain relievers (tramadol and other drugs) may be used to relieve pain.
If the clinical picture of the disease is dominated by dysuria, an ultrasound examination (UFM) and, if possible, a video urodynamic examination should be performed before starting drug treatment.Depending on the results obtained, further treatment is prescribed.In the case of increased sensitivity (hyperactivity) of the bladder neck, the treatment is carried out as in the case of interstitial cystitis, amitriptyline, antihistamines and the instillation of antiseptic solutions into the bladder are prescribed.Anticholinesterase drugs are prescribed for detrusor hyperreflexia.For hypertonia of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (anticonvulsant), neuromodulation (for example, sacral stimulation).
Based on the neuromuscular theory of the etiopathogenesis of chronic abacterial prostatitis, antispasmodics and muscle relaxants can be prescribed.
In recent years, based on the theory of the involvement of cytokines in the development of chronic inflammatory processes, the use of cytokine inhibitors, such as monoclonal antibodies against tumor necrosis factor, leukotriene inhibitors (which belong to a new class of NSAIDs) and tumor necrosis factor inhibitors, has been considered in chronic prostatitis.
Non-pharmacological treatment of chronic prostatitis
Currently, great importance is attached to the local application of physical methods, which allow exceeding the average therapeutic dose of antibacterial drugs due to the stimulation of microcirculation and, as a result, the increased accumulation of drugs in the prostate.
The most effective physical methods for chronic prostatitis:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono- and electrophoresis).
Depending on the nature of the changes in the prostate tissue, the presence or absence of congestive and proliferative changes, as well as the concomitant prostate adenoma, different temperature regimes of microwave hyperthermia are used.At a temperature of 39-40°C "In addition to the above, the main effects of electromagnetic radiation in the microwave range are the anticoagulation and bacteriostatic effects, as well as the activation of the cellular immune system. At a temperature of 40-45°C, the sclerosing and neuropain effects prevail, and the pain-relieving effect is due to the end-sensitive effect.
Low-energy magnetic laser therapy has an effect on the prostate that is close to microwave hyperthermia at 39-40 °C, i.e. it stimulates microcirculation, has an anti-congestive effect, promotes the accumulation of drugs in the prostate tissue and the activation of the cellular immune system.In addition, laser therapy has a biostimulating effect.This method is most effective when stagnant-infiltrative lesions of the organs of the reproductive system predominate, therefore it is used to treat acute and chronic prostatovesiculitis and epididymo-orchitis.In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value.Sanatorium resort treatment and rational psychotherapy are successfully used in the treatment of chronic prostatitis.
Surgical treatment of chronic prostatitis
Despite the prevalence of chronic prostatitis and its known diagnostic and treatment difficulties, it cannot be considered a life-threatening disease.This is proven by cases of long-term and often ineffective therapy, which turns the treatment process into a purely commercial enterprise with minimal risk to the patient's life.A much more serious threat is its complications, which not only disturb the urination process and negatively affect the reproductive function of men, but also lead to serious anatomical and functional changes in the bladder - sclerosis of the prostate and bladder neck.
Unfortunately, these complications often occur in young and middle-aged patients.That is why the use of transurethral electrosurgery (as minimally invasive surgery) is becoming more and more important.In the case of severe organ BOO, which is caused by sclerosis of the bladder neck and prostate, we perform a transurethral incision or economical electrical resection of the prostate at 5, 7 and 12 o'clock of the traditional clock.In cases where the outcome of chronic prostatitis is prostate sclerosis, with severe symptoms that are not amenable to conservative therapy.perform the most radical transurethral electroresection of the prostate.Transurethral electroresection of the prostate can also be used in case of frequent calculous prostatitis.Calcifications.Localized in the central and transitional zones, they disrupt tissue trophism and increase congestion in isolated acini groups, which leads to the development of pain that is difficult to treat conservatively.In such cases, electrical resection should be performed until the calcifications are removed as completely as possible.In some clinics, TRUS is used to monitor calcification resection in such patients.
Another indication for endoscopic surgery is the sclerosis of the testes, which is accompanied by the blockage of the ejaculatory and excretory ducts of the prostate.
If an exacerbation of the chronic inflammatory process (purulent or serous-purulent discharge from the sinuses of the prostate) is diagnosed during the transurethral procedure, the operation must be completed by removing the entire residual gland.The prostate is removed by electroresection, followed by accurate coagulation of the bleeding vessels with a ball electrode, and a trocar cystostomy is placed to reduce intravesical pressure and prevent absorption of infected urine into the prostatic ducts.