If the situation with infectious (or rather, bacterial) prostatitis is more or less clear, then abacterial chronic prostatitis is still a serious urological problem with many unclear questions.Perhaps, under the name of the disease called chronic prostatitis, there are a number of diseases and pathological conditions characterized by various organic changes in the tissues and functional disorders not only of the prostate gland, the male reproductive system and the organs of 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 gland.
- N41.9 Inflammatory disease of prostate gland, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis is the first among the inflammatory diseases of the male reproductive system in terms of prevalence, and occupies one of the first places among male diseases in general.It is the most common urological disease in men under the age of 50.The average age of patients suffering from chronic inflammatory process in the prostate gland is 43 years.Up to 30% of men by the age of 80 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 consult a urologist in 35% of cases.In 7-36% of patients, it is complicated by vesiculitis, epididymitis, urinary disorders, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medical science considers chronic prostatitis a polyetiological disease.The occurrence and recurrence of chronic prostatitis, in addition to the influence of infectious factors, is caused by neurovegetative and hemodynamic disorders accompanied by weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal and chemical urinary flow.biochemical (possible role of citrates) processes, as well as aberrations of peptide growth factors.Risk factors for the development of chronic prostatitis include:
- lifestyle characteristics that lead to infection of the genitourinary system (promiscuous intercourse without protection and personal hygiene rules, the presence of an inflammatory process in the sexual partner and/or infections of the urinary and genital organs):
- Conducting 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, it refers to cytokines - low molecular compounds of polypeptide nature, which are synthesized by lymphoid and non-lymphoid cells and directly affect the functional activity of immunocompetent cells.
Symptoms of chronic prostatitis
Symptoms of chronic prostatitis include: pain or discomfort, urinary problems, and sexual dysfunction.The main symptom of chronic prostatitis is pelvic pain or discomfort lasting 3 months.and more.The most common site of pain is the perineum, but discomfort may occur in other areas of the suprapubic, groin, anus, and pelvic bones, the inner thighs, as well as the scrotum and lumbosacral region.Unilateral testicular pain is usually not a sign of prostatitis.Pain during and after ejaculation is most characteristic of chronic prostatitis.
Sexual function is impaired, including suppression of libido and poor quality of spontaneous and/or adequate erections, although most patients do not develop serious impotence.Chronic prostatitis is one of the causes of premature ejaculation (PE), but in the later stages of the disease, ejaculation can be slow.There may be a change ("wipe") in the emotional color of the orgasm.
Urinary disorders are more often manifested by irritative symptoms, less often by IVO symptoms.
During chronic prostatitis, quantitative and qualitative disorders of ejaculation can also be detected, which is rarely the cause of infertility.
The disease chronic prostatitis has a wave nature, it 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 areas, frequent urination and discomfort at the end of urination, acceleration of ejaculation, pain at the end or after ejaculation, increased and painful erection.
In the alternative phase, the patient may feel pain (unpleasant sensations) in the suprapubic area, less in the scrotum, in the groin area, and in the sacrum.Urine, as a rule, is not disturbed (or does not increase).A normal erection is observed against the background of rapid, painless ejaculation.
The proliferative stage of the inflammatory process can be manifested by a weakening of the intensity of urine flow and an increase in urine output (during the exacerbation of the inflammatory process).At this stage, ejaculation is not disturbed or slows down a bit, the intensity of adequate erections decreases to a normal or moderate level.
In the stage of scar changes and sclerosis of the prostate, patients are worried about heaviness in the suprapubic region, sacrum, frequent urination day and night (total pollakiuria), slow, intermittent urine flow and forced urge to urinate.Ejaculation slows down (even to the point of non-existence), adequate and sometimes spontaneous erections weaken.Often at this stage attention is paid to "erasing" the orgasm.
The impact of chronic prostatitis on the quality of life is comparable to the impact of myocardial infarction according to the single quality of life assessment scale.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, it is necessary to use physical, laboratory and instrumental methods, including determining the state of the immune and neurological condition.
Questionnaires are of great importance when evaluating the subjective manifestations of the disease.Many questionnaires have been developed, filled by the patient, in which 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 the state of the patient's psycho-emotional sphere.Currently, the most popular is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire.The survey was developed by the US National Institutes of Health;is an effective tool to identify symptoms of chronic prostatitis and determine its impact on quality of life.
Laboratory diagnosis of chronic prostatitis
It is the laboratory diagnosis of chronic prostatitis that allows us to make a diagnosis of "chronic prostatitis" (since 1961, Farman and McDonald have defined the "gold standard" in the diagnosis of inflammation of the prostate gland - 10-15 leukocytes per field of view) and allows us to make a differential diagnosis between its bacterial and non-bacterial forms.
Microscopic examination of the discharged urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and non-specific flora.
When examining scraps of the mucous membrane of the urethra using PCR, the presence of microorganisms that cause sexually transmitted diseases is determined.
Microscopic examination of prostate secretion determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.
Bacteriological examination of prostate secretion or urine obtained after massage is performed.Based on the results of these studies, the nature of the disease is determined (bacterial or bacterial prostatitis).Prostatitis can cause an increase in PSA concentration.A blood sample to determine the serum PSA concentration should be taken no later than 10 days after a digital rectal examination.Despite this fact, when the PSA concentration is above 4.0 ng/ml, additional diagnostic methods, including prostate biopsy, are used to rule out prostate cancer.
Studying the immune status (humoral and cellular immunity) and the level of non-specific antibodies (IgA, IgG and IgM) in prostate secretion is of great importance in the laboratory diagnosis of chronic prostatitis.Immunological research helps to determine the stage of the process and monitor the effectiveness of treatment.
Instrumental diagnosis of chronic prostatitis
TRUS of the prostate for 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 further monitoring during the entire course of treatment.Ultrasound examination allows to assess the size and volume of the prostate, its structure (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), size, degree of expansion, density and eco-homogeneity of the content of seminal vesicles.
UDI (UFM, urethral pressure profiling, pressure/flow study, cystometry) and pelvic floor muscle myography provide additional information when neurogenic urinary disorders and pelvic floor muscle dysfunction are suspected.as well as IVO, which is often accompanied by chronic prostatitis.
In patients diagnosed with BOO, an X-ray examination should be performed to clarify the cause of its occurrence and determine the subsequent treatment tactics.
CT and MRI of the pelvic organs are performed for differential diagnosis with prostate cancer, as well as when the non-inflammatory form of abacterial prostatitis is suspected, and when it is necessary to exclude pathological changes in the spine and pelvic organs.
What to check?
prostate gland (prostate)
How to check?
- Ultrasound of the prostate gland
- Biopsy of the prostate gland
What tests are needed?
- 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 principles of consistency and complex approach.First of all, it is necessary to change the lifestyle, thinking and psychology of the patient.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 disease from progressing further, but also promote recovery.It is also a preparatory stage in the treatment of the normalization of sex life, diet and much more.After that comes the main, basic course, which involves 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 according to the same principle as it develops.- from predisposing factors to producing ones.
Instructions for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization.In severe cases of persistent chronic prostatitis, complex therapy performed in a hospital setting is more effective than outpatient treatment.
Drug treatment of chronic prostatitis
In order to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), ensure sufficient drainage of the prostate acini, especially in the peripheral zones, and normalize the level of immune response, it is necessary to use several drugs and methods that affect different parts of the pathogenesis at the same time.Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators, as well as prostate massage can be recommended in chronic prostatitis.In recent years, the treatment of chronic prostatitis is carried out using drugs that were not used for this purpose before: 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 inflammatory syndrome of chronic pelvic pain (if the pathogen is not identified as a result of the application of microscopic, bacteriological and immunodiagnostic methods), empiric antibacterial treatment of chronic prostatitis can be carried out with a short course and continued if it is clinically effective.The effectiveness of empiric antimicrobial therapy in patients with both bacterial and abacterial prostatitis is approximately 40%.This indicates that the bacterial flora was not detected or the positive role of other microbial agents (chlamydia, mycoplasmas, ureaplasmas, fungal flora, trichomonas, viruses) in the development of the infectious inflammatory process is currently unconfirmed.Flora, which is not detected by standard microscopic or bacteriological examination of prostate secretion, can be detected in some cases by histological examination of prostate biopsy 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, after which it continues for 4-6 weeks if the results are positive.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).
The drugs of choice for empiric treatment of chronic prostatitis are fluoroquinolones because they have high bioavailability and good penetration into the glandular tissue (some of them have a higher concentration in the secretion than in the blood serum).Another advantage of drugs in this group is their activity 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 any specific drug from 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.
It is also recommended to prescribe antibacterial drugs to prevent relapses of bacterial prostatitis.
If relapses occur, a previous course of antibacterial drugs in lower single and daily doses can be prescribed.The ineffectiveness of antibacterial therapy is usually due to incorrect selection of the drug, its dose and frequency, or the presence of bacteria persisting in ducts, acini or calcifications and covered by an extracellular protective membrane.
Pain and irritating symptoms are an indication for the appointment of NPS, which is used as a single alpha-blocker, both in complex therapy and when antibacterial therapy is ineffective (diclofenac dose 50-100 mg/day).
Some studies demonstrate 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, further treatment should be directed either to the relief of pain or to the resolution of problems with urination, or to the correction of both of the above symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to the blocking of histamine H1 receptors and their effect on anticholinesterase.The most commonly prescribed drugs are amitriptyline and imipramine.However, they should be taken with caution.Side effects - drowsiness, dry mouth.In very rare cases, narcotic analgesics (tramadol and other drugs) can 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 study should be performed before starting drug treatment.Depending on the results, additional treatment is prescribed.In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as in interstitial cystitis, amitriptyline, antihistamines and antiseptic solutions are prescribed.Anticholinesterase drugs are prescribed for detrusor hyperreflexia.For hypertonicity of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug treatment is ineffective, physiotherapy (elimination of spasm), neuromodulation (for example, sacral stimulation).
Based on the neuromuscular theory of 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 inflammation, the possibility of using cytokine inhibitors, for example, monoclonal antibodies to tumor necrosis factor, leukotriene inhibitors (belonging to the new class of NSAIDs) and tumor necrosis factor inhibitors for chronic prostatitis, has been considered.
Non-drug treatment of chronic prostatitis
Currently, due to the stimulation of microcirculation and the resulting increase in the accumulation of drugs in the prostate, great importance is attached to the local use of physical methods that allow not to exceed the average therapeutic dose of antibacterial drugs.
The most effective physical methods for the treatment of chronic prostatitis:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono- and electrophoresis).
Depending on the nature of changes in the tissue of the prostate gland, the presence or absence of congestive and proliferative changes, as well as the accompanying adenoma of the prostate gland, different temperature regimes of microwave hyperthermia are used.In addition to the above, the main effects of electromagnetic radiation in the microwave range at a temperature of 39-40 "are anticongestive and bacteriostatic effects, as well as activation of the cellular immune system. At a temperature of 40-45 ° C, the sclerosing and neuroanalgesic effects predominate and are inhibited due to the analgesic effect of nerves.
Low-energy magnetic laser therapy affects the prostate close to microwave hyperthermia at 39-40 ° C, that is, it stimulates microcirculation, has an anticoagulant effect, contributes to the accumulation of drugs in the prostate tissue and 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 it is used for the treatment of acute and chronic prostatoviculitis and epididymo-orchitis.In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value.Sanatorium-spa treatment and rational psychotherapy are successfully applied in the treatment of chronic prostatitis.
Surgical treatment of chronic prostatitis
Despite its widespread prevalence and known difficulties in diagnosis and treatment, chronic prostatitis is not 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.Its complications pose a more serious threat, which not only disrupts the process of urination and negatively affects the reproductive function of men, but also causes serious anatomical and functional changes in the bladder - sclerosis of the prostate gland 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 more and more important.In severe organic BOO caused by bladder neck sclerosis and prostate gland sclerosis, a transurethral incision is performed at 5, 7, and 12 o'clock conventionally, or economic electrical resection of the prostate is performed.In cases where the result 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 for common calculous prostatitis.Calcifications.localized in the central and transitional zones, they disrupt tissue trophism and increase congestion in isolated groups of acini, causing 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 the resection of calcifications in such patients.
Another indication for endoscopic surgery is sclerosis of the seminal tubercle, accompanied by prostatic discharge and obstruction of the excretory ducts.
If an exacerbation of the chronic inflammatory process (purulent or serous-purulent discharge from the sinuses of the prostate gland) is diagnosed during the transurethral intervention, the remaining gland should be completely removed and the operation completed.The prostate is removed by electroresection, followed by precise coagulation of the bleeding vessels with a ball electrode and trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.