If the situation with infectious (or bacterial) prostatitis is more or less clear, then nonbacterial chronic prostatitis is still a serious urological problem with many unclear questions. Perhaps under the guise of a disease called chronic prostatitis there is a whole range of diseases and pathological conditions characterized by various organic changes in tissues and dysfunctions of the activity of not only the prostate, the organs of the male reproductive system and the lower urinary tract, butalso 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 the prostate, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis ranks first among inflammatory diseases of the male reproductive system and ranks first among male diseases in general. This is the most common urological disease in men under 50 years old. The average age of patients suffering from a chronic inflammatory process of the prostate is 43 years. By the age of 80, up to 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 rough estimates, chronic prostatitis causes men of working age to visit a urologist in 35% of cases. In 7-36% of patients, it is complicated by vesiculitis, epididymitis, urinary disorders, and reproductive and sexual functions.
What causes chronic prostatitis?
Modern medicine considers chronic prostatitis to be a polyetiological disease. The appearance and recurrence of chronic prostatitis, in addition to the action of infectious factors, is caused by neurovegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmunity (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (reflux of urineinto the prostate ducts) and biochemical (possibly the role of citrates) processes as well as aberrations of peptide growth factors. Risk factors for developing chronic prostatitis include:
- Lifestyle features that cause infection of the genitourinary system (promiscuous sexual intercourse without protection and personal hygiene, the presence of an inflammatory process and / or infections of the urinary and genital organs in the sexual partner):
- Carrying out 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 for chronic prostatitis, immunological disorders are important, especially an imbalance between various immunocompetent factors. First of all, this applies to cytokines - low-molecular compounds with a polypeptide character that are synthesized by lymphoid and non-lymphoid cells and have a direct influence on the functional activity of immunocompetent cells.
Symptoms of chronic prostatitis
Symptoms of chronic prostatitis include: pain or discomfort, problems with urination and sexual dysfunction. The main symptom of chronic prostatitis is pain or discomfort in the pelvic area that lasts for three months. and more. The most common site of pain is the perineum, but discomfort can also occur in the suprapubic area, groin, anus and other areas of the pelvis, inner thighs, and scrotum and lumbosacral region. Unilateral testicular pain is usually not a sign of prostatitis. Pain during and after ejaculation is most specific to chronic prostatitis.
Sexual function is impaired, including suppressed libido and deterioration in the quality of spontaneous and/or sufficient erections, although most patients do not develop severe impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE). However, in later stages of the disease, ejaculation may occur slowly. There may be a change ("extinction") in the emotional coloring of the orgasm.
Urinary disorders are more often manifested by irritation symptoms and less frequently by IVO symptoms.
In chronic prostatitis, quantitative and qualitative disorders of the ejaculate can also be detected, which are rarely the cause of infertility.
The disease chronic prostatitis has a wave-like character, which periodically strengthens and weakens. In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.
The exudative stage is characterized by pain in the scrotum, groin and suprapubic area, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful erections.
In the alternative stage, the patient may feel pain (unpleasant sensations) in the suprapubic area, less often in the scrotum, groin and sacrum. Urination is usually not affected (or increased). A normal erection is 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 the urine stream and increased urination (with exacerbation of the inflammatory process). Ejaculation at this stage is not impaired or slightly slowed, the intensity of sufficient erections is normal or moderately reduced.
In the stage of scarring and sclerosis of the prostate, patients fear a feeling of heaviness in the suprapubic area, in the sacrum, frequent urination day and night (total pollakisuria), a sluggish, intermittent stream of urine and a compulsive urge to urinate. Ejaculation is slowed down (even to the point of failure), sufficient and sometimes spontaneous erections are weakened. Attention is often drawn to the "extinction" of orgasm at this stage.
The impact of chronic prostatitis on quality of life is comparable to the impact of myocardial infarction, according to the Uniform Quality of Life Rating Scale. Angina pectoris or Crohn's disease.
Diagnosis of chronic prostatitis
The diagnosis of manifest chronic prostatitis is not difficult and is based on the classic triad of symptoms. Since the disease often proceeds asymptomatically, it is necessary to use a complex of physical, laboratory and instrumental methods, including determining the immune state and neurological status.
When assessing the subjective manifestations of the disease, questionnaires are of great importance. Many questionnaires have been developed that are filled out by the patient and with which the doctor wants to get an idea of the frequency and intensity of pain, urinary disorders and sexual disorders, as well as the patient's attitude to these clinical manifestations of chronic prostatitis and how they judgethe state of the patient's psycho-emotional sphere. The most popular current questionnaire is the Chronic Prostatitis Symptom Scale (NIH-CPS). The questionnaire was developed by the US National Institutes of Health and is an effective tool for identifying the symptoms of chronic prostatitis and determining their impact on quality of life.
Laboratory diagnosis of chronic prostatitis
It is the laboratory diagnosis of chronic prostatitis that makes it possible to diagnose "chronic prostatitis" (since Farman and McDonald in 1961 established the "gold standard" in diagnosing prostatitis - 10-15 leukocytes in the field of view) and make a differential diagnosis between its bacterialand nonbacterial forms.
A microscopic examination of the excreted urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonads, gonococci and non-specific flora.
When examining a scraping of the urethral mucosa using the PCR method, the presence of microorganisms that cause sexually transmitted diseases is determined.
Microscopic examination of the prostate secretion determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.
A bacteriological examination of the prostate secretion or urine obtained after the massage is carried out. Based on the results of these studies, the type of disease is determined (bacterial or abacterial prostatitis). Prostatitis can lead to an increase in PSA levels. Blood sampling to determine the serum PSA concentration should be done no earlier than 10 days after the digital rectal examination. Nevertheless, with a PSA value above 4. 0 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is indicated to rule out prostate cancer.
Of great importance in the laboratory diagnosis of chronic prostatitis is the examination of the immune status (state of humoral and cellular immunity) and the content of nonspecific antibodies (IgA, IgG and IgM) in the prostate secretion. Immunological studies help determine the stage of the process and monitor the effectiveness of treatment.
Instrumental diagnosis of chronic prostatitis
TRUS of the prostate in chronic prostatitis has high sensitivity but low specificity. The study allows not only to carry out differential diagnosis, but also to determine the form and stage of the disease with subsequent monitoring throughout the entire course of treatment. Ultrasound makes it possible to assess the size and volume of the prostate, the echostructure (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), size, degree of expansion, density and echohomogeneity of the contents of the seminal vesicles.
UDI (UFM, determination of urethral pressure profile, pressure/flow study, cystometry) and myography of the pelvic floor muscles provide additional information in suspected neurogenic disorders of urination and dysfunction of the pelvic floor muscles. and IVO, which often accompanies chronic prostatitis.
Patients diagnosed with BOO should undergo an X-ray examination to clarify the cause of its occurrence and determine further treatment tactics.
CT and MRI of the pelvic organs are carried out for differential diagnosis in prostate cancer, as well as in cases of suspicion of a non-inflammatory form of abacterial prostatitis, when it is necessary to exclude pathological changes in the spine and pelvic organs.
What needs to be investigated?
prostate (prostate)
How to examine?
- Ultrasound of the prostate
- Prostate biopsy
What tests are required?
- Analysis of prostate secretion (prostate)
- Prostate-specific antigen in the blood
Whom can I contact?
- urologist
- Andrologist
Treatment of chronic prostatitis
Treatment of chronic prostatitis, as with any chronic disease, should be carried out according to the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's lifestyle, thinking and psychology. By eliminating the influence 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 recovery. This is a preparatory stage of treatment, along with the normalization of sexual life, nutrition and much more. This is followed by the main basic course, in which various medications are used. 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 according to the same principle by which it arose. - from predisposing factors to producing factors.
Indications for hospitalization
Chronic prostatitis usually does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy in the hospital is more effective than outpatient treatment.
Drug treatment of chronic prostatitis
It is necessary to simultaneously use several drugs and methods that act on different parts of the pathogenesis in order to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate) and ensure adequate drainage of the prostatic acini, especially in the prostate, ensuring peripheral zones, normalize the level of essential hormones and immune reactions. On this basis, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators, as well as prostate massage can be recommended for use in chronic prostatitis. In recent years, the treatment of chronic prostatitis has been carried out with drugs that were not previously used for this purpose: alpha1-blockers, 5-a-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs that inhibit the metabolism of urates and citratesinfluence.
In chronic abacterial prostatitis and inflammatory syndrome of chronic abdominal pain (if the pathogen could not be identified through the use of microscopic, bacteriological and immunodiagnostic methods), empirical antibacterial treatment of chronic prostatitis can be carried out with a short course and, if clinically effective, continued. The effectiveness of empirical antimicrobial therapy is approximately 40% in patients with both bacterial and abacterial prostatitis. This indicates the undetectability of bacterial flora or the positive role of other microbial pathogens (chlamydia, mycoplasma, ureaplasma, fungal flora, Trichomonas, viruses) in the development of the infectious inflammatory process, which is currently not confirmed. Flora that is not detected by standard microscopic or bacteriological examination of prostatic secretions can in some cases be detected by histological examination of prostate biopsies or other subtle methods.
In non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is controversial. The duration of antibacterial therapy should not be longer than 2-4 weeks. If the results are positive, it is then continued for up to 4-6 weeks. If there is no effect, it is possible to discontinue the antibiotics and prescribe drugs from other groups (e. g. alpha1 blockers, plant extracts from Serenoa repens).
The drugs of choice for empirical treatment of chronic prostatitis are fluoroquinolones, since they have high bioavailability and penetrate well into the glandular tissue (the concentration of some of them in the secretion exceeds that in the blood serum). Another advantage of drugs in this group is their action against most gram-negative microorganisms, as well as chlamydia and ureaplasma. The results of the treatment of chronic prostatitis do not depend on the use of a specific drug from the group of fluoroquinolones.
If fluoroquinolones are ineffective, combination antibacterial therapy should be prescribed. Tetracyclines have not lost their importance, particularly when a chlamydia 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.
It is also recommended to prescribe antibacterial drugs to prevent relapses of bacterial prostatitis.
If relapses occur, previous treatment with antibacterial drugs can be prescribed in lower single and daily doses. The ineffectiveness of antibacterial therapy is usually due to the incorrect choice of drug, its dosage and frequency, or to the presence of bacteria remaining in the milk ducts, acini or calcifications and covered with a protective extracellular membrane.
Pain and irritation symptoms are indications for the prescription of NPS, which are used both in complex therapy and as a sole alpha-blocker when antibacterial therapy is ineffective (diclofenac dose 50-100 mg/day).
Some studies support the effectiveness of herbal medicines, but this information has not been confirmed by multicenter, placebo-controlled studies.
If the clinical symptoms of the disease (pain, dysuria) persist after the use of antibiotics, α-blockers and NSAIDs, subsequent treatment should be aimed at either relieving pain, solving problems with urination, or correcting both of the above symptoms.
In pain, tricyclic antidepressants have an analgesic effect as they block histamine H1 receptors and anticholinesterase effects. The most commonly prescribed medications are amitriptyline and imipramine. However, they should be treated with caution. Side effects – drowsiness, dry mouth. In extremely rare cases, narcotic analgesics (tramadol and other medications) may be used to relieve pain.
If dysuria predominates in the clinical picture, an ultrasound examination (UFM) and, if possible, a video urodynamic study should be carried out before starting drug therapy. Depending on the results achieved, further treatment is prescribed. With increased sensitivity (hyperactivity) of the bladder neck, treatment is the same as for interstitial cystitis, amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder are prescribed. For detrusor hyperreflexia, anticholinesterase drugs are prescribed. If there is hypertension of the external bladder sphincter, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (spasmodic relief), neuromodulation (e. g. 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 a chronic inflammatory process, the possibility of using cytokine inhibitors, such as monoclonal antibodies to tumor necrosis factor, leukotriene inhibitors (which belong to a new class of NSAIDs), etc. , has been developed in tumor necrosis-Factor inhibitors are considered for chronic prostatitis.
Non-drug treatment of chronic prostatitis
Currently, great emphasis is placed on the local use of physical methods that make it possible not to exceed the average therapeutic dose of antibacterial drugs due to stimulation of microcirculation and, as a result, increased accumulation of drugs in the prostate.
The most effective physical methods for treating chronic prostatitis:
- transrectal microwave hyperthermia;
- Physiotherapy (laser therapy, mud therapy, phono- and electrophoresis).
Depending on the nature of the changes in prostate tissue, the presence or absence of congestive and proliferative changes, as well as a concomitant prostate adenoma, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 ° C, the main effects of electromagnetic radiation in the microwave range, in addition to those mentioned above, are also anticongestive and bacteriostatic effects and activation of the cellular immune system. At a temperature of 40-45 ° C, sclerosing and neuroanalgesic effects predominate, and the analgesic effect is due to inhibition of sensory nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate that is similar to microwave hyperthermia at 39-40°C, i. e. H. stimulates microcirculation, has an anticoagulant 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 congestive-infiltrative changes prevail in the organs of the reproductive system and therefore is used to treat acute and chronic prostatovesiculitis and epididymo-orchitis. Even if there are no contraindications (prostate stones, adenomas), prostate massage has not lost its therapeutic value. Sanatorium treatments and rational psychotherapy are successfully used in the treatment of chronic prostatitis.
Surgical treatment of chronic prostatitis
Despite its prevalence and known difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. This is proven by cases of lengthy 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 danger is posed by complications that not only disrupt the process of urination and affect the reproductive function of the man, 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 a minimally invasive operation) is becoming increasingly important. For severe organic BOO caused by sclerosis of the bladder neck and sclerosis of the prostate, a transurethral incision is made at 5, 7 and 12 o'clock of the conventional dial or low-cost electrical resection of the prostate is performed. In cases where the result of chronic prostatitis is prostatic 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 common calcific prostatitis. Calcifications. Localized in the central and transient zones, they disrupt tissue trophism and increase congestion in isolated groups of acini, leading to the development of pain that is difficult to treat conservatively. In such cases, an electrical resection must be carried out until the calcifications are removed as completely as possible. In some clinics, TRUS is used to monitor the removal of calcifications in such patients.
Another indication for endoscopic surgery is sclerosis of the seminiferous tuberosity, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate.
If an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the sinuses of the prostate) is diagnosed during a transurethral procedure, the operation must be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by selective coagulation of the bleeding vessels with a ball electrode and the installation of a trocar cystostomy to reduce intravesical pressure and prevent the reabsorption of infected urine into the prostatic ducts.