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 guise of the disease called chronic prostatitis, there is a whole series of diseases and pathological conditions that are characterized by various organic changes in the tissues and functional disorders of the activity of not only the prostate, the organs of the male reproductive system and the lower urinary tract, but also other organs and systems in general.
ICD-10 codes
- N41. 1 Chronic prostatitis.
- N41. 8 Other inflammatory diseases of the prostate.
- N41. 9 Inflammatory prostate disease, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis ranks first in terms of frequency among inflammatory diseases of the male reproductive system and one of the first among male diseases in general. This is the most common urological disease in men under the age of 50. The average age of patients with a chronic inflammatory process in the prostate is 43 years, and by the age of 80 even 30% of men suffer from chronic or acute prostatitis.
The prevalence of chronic prostatitis in the general population is 9%. In our country, chronic prostatitis, according to the closest estimates, in 35% of cases leads men of working age to visit a urologist. In 7-36% of patients, it is complicated by vesiculitis, epididymitis, disorders of urination, 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 action of infectious factors, are caused by neurovegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (urine reflux into the prostate ducts) and biochemical (possible role of citrate) processes, as well as peptide growth factor aberrations. Risk factors for the development of chronic prostatitis are:
- lifestyle characteristics that cause infection of the genitourinary system (promiscuous sexual relations without protection and personal hygiene, the presence of an inflammatory process and/or infection of the urinary and genital organs in the 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 for chronic prostatitis, immunological disorders are important, and especially the imbalance between different immunocompetent factors. First of all, it refers to cytokines - low-molecular compounds of polypeptide nature that 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 are: 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 3 months. and more. The most common localization of pain is the perineum, but discomfort can occur in the suprapubic, groin, anus and other parts of the pelvis, on the inner side of the thighs, as well as in 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 suppressed libido and deterioration in the 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), however, in the later stages of the disease, ejaculation can be slow. There may be a change ("erasure") of the emotional color of the orgasm.
Urinary disorders are more often manifested by irritative symptoms, less often by IVO symptoms.
In the case of chronic prostatitis, quantitative and qualitative ejaculate disorders can be detected, which are rarely the cause of infertility.
The disease of chronic prostatitis has an undulating nature, occasionally increasing and decreasing. 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, 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 region, less often in the scrotum, groin and sacrum. Urination, as a rule, is not disturbed (or increased). Against the background of accelerated, painless ejaculation, a normal erection is observed.
The proliferative stage of the inflammatory process can be manifested by a weakening of the intensity of urine and increased urination (with exacerbations of the inflammatory process). Ejaculation in this phase is not disturbed or slightly slowed down, the intensity of an adequate erection is normal or moderately reduced.
In the stage of scar changes and prostate sclerosis, patients are concerned about heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total pollakiuria), slow, intermittent stream of urine and imperative urge to urinate. Ejaculation is slowed down (even to the point of absence), adequate and sometimes spontaneous erections are weakened. Often in this phase, attention is drawn to the "deletion" of the orgasm.
The impact of chronic prostatitis on the quality of life, according to the unique scale for assessing the quality of life, is comparable to the impact of myocardial infarction. angina 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. Given that the disease is often asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including determining the state of the immune and neurological status.
When assessing the subjective manifestations of the disease, questionnaires are of great importance. Numerous questionnaires have been developed that are filled out by the patient and which the doctor wants to get an idea of the frequency and intensity of pain, urinary disorders and sexual disorders, the patient's attitude towards these clinical manifestations of chronic prostatitis, as well as to assess the state of the patient's psycho-emotional sphere. The most popular currently is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire. The questionnaire was developed by the US National Institutes of Health, it is an effective tool for identifying symptoms of chronic prostatitis and determining its impact on quality of life.
Laboratory diagnosis of chronic prostatitis
Laboratory diagnosis of chronic prostatitis makes it possible to establish a diagnosis of "chronic prostatitis" (since 1961, Farman and McDonald established the "gold standard" in the diagnosis of prostate inflammation - 10-15 leukocytes in the visual field) and 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 scrapings of the urethral mucosa using the PCR method, the presence of microorganisms that cause sexually transmitted diseases is determined.
Microscopic examination of prostate secretions determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.
A bacteriological examination of prostate secretions or urine obtained after his massage is performed. Based on the results of these studies, the nature of the disease (bacterial or abacterial prostatitis) is determined. Prostatitis can cause an increase in PSA concentration. Blood sampling to determine the concentration of PSA in the serum should be done no later than 10 days after the digital rectal examination. Despite this fact, when the PSA concentration is 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 study of the immune status (state of humoral and cellular immunity) and the level of non-specific antibodies (IgA, IgG and IgM) in prostate secretions. Immunological studies help to determine the stage of the process and monitor the effectiveness of the treatment.
Instrumental diagnosis of chronic prostatitis
TRUS of the prostate for chronic prostatitis has high sensitivity but low specificity. The study enables not only differential diagnosis, but also determination of the form and stage of the disease with follow-up during the entire treatment. Ultrasound enables assessment of the size and volume of the prostate, 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 pelvic floor muscle myography provide additional information if neurogenic voiding disorders and pelvic floor muscle dysfunction are suspected. as well as IVO, which often accompanies chronic prostatitis.
In patients with diagnosed BOO, it is necessary to perform an X-ray examination in order to clarify the cause of its occurrence and determine further treatment tactics.
CT and MRI of the pelvic organs are performed for differential diagnosis with prostate cancer, as well as if a non-inflammatory form of abacterial prostatitis is suspected, when it is necessary to rule out pathological changes in the spine and pelvic organs.
What should be examined?
prostate (prostate)
How to examine?
- Ultrasound of the prostate
- Prostate biopsy
What tests are needed?
- Analysis of prostate secretion (prostate)
- Prostate specific antigen in the blood
Who to contact?
- Urologist
- Andrologist
Treatment of chronic prostatitis
Treatment of chronic prostatitis, like any chronic disease, should be carried out in accordance with the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's way of life, his thinking and psychology. By eliminating the influence of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia, etc. In this way, we not only stop the further progression of the disease, but also promote recovery. This, as well as the normalization of sex life, diet and much more, represents the preparatory phase 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, making the necessary changes, and also fight the disease according to the same principle by which it developed. - from predisposing factors to producing factors.
Indications for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy carried out in a hospital is more effective than outpatient treatment.
Treatment of chronic prostatitis with drugs
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 the improvement of microcirculation in the prostate), adequate drainage of the prostate acinus, especially in the peripheral zones, normalize the level of essential hormonesand immune reactions. Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators can be recommended, as well as prostate massage 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 affect the metabolism of urate and citrate.
In the case of chronic abacterial prostatitis and inflammatory syndrome of chronic pelvic pain (in the case when the causative agent is not identified as a result of the application of microscopic, bacteriological and immunological diagnostic methods), empirical antibacterial treatment of chronic prostatitis can be carried out. with a short course and, if it is clinically effective, continued. The effectiveness of empiric antimicrobial therapy in patients with bacterial and abacterial prostatitis is about 40%. This indicates the undetectability of the 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 not confirmed. Flora not detected by standard microscopic or bacteriological examination of prostate 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, after which, if the results are positive, it should be continued for 4-6 weeks. If there is no effect, it is possible to stop taking antibiotics and prescribe drugs from other groups (eg alpha1-blockers, herbal extracts of Serenoa repens).
The drugs of choice for the empiric treatment of chronic prostatitis are fluoroquinolones, because they have high bioavailability and penetrate well into the tissue of the gland (the concentration of some of them in the secretion is higher than that in the blood serum). Another advantage of drugs of 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 fluoroquinolone group.
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 prostate tissue well and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.
It is also recommended to prescribe antibacterial drugs to prevent recurrences of bacterial prostatitis.
If a relapse occurs, a previous course of antibacterial drugs can be prescribed in smaller individual and daily doses. The ineffectiveness of antibacterial therapy is most often a consequence of the wrong choice of drug, its dose and frequency or the presence of bacteria that persist in channels, acini or calcifications and are covered by a protective extracellular membrane.
Pain and irritative symptoms are indications for prescribing 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 show the effectiveness of herbal medicine, but this information has not been confirmed by multicenter placebo-controlled studies.
If the clinical symptoms of the disease (pain, dysuria) persist after the administration of antibiotics, α-blockers and non-steroidal anti-inflammatory drugs, the subsequent treatment should be aimed either at alleviating the pain, or at solving problems with urination, or at correcting both of these symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to blocking of histamine H1 receptors and anticholinesterase action. The most commonly prescribed drugs are amitriptyline and imipramine. However, they must be taken with caution. Side effects - drowsiness, dry mouth. In extremely rare cases, narcotic analgesics (tramadol and other drugs) can be used to relieve pain.
If dysuria predominates in the clinical picture of the disease, before starting drug therapy, it is necessary to perform ultrasonography (UFM) and, if possible, a video urodynamic study. Depending on the obtained results, further treatment is prescribed. In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as in interstitial cystitis, amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder are prescribed. Anticholinesterase drugs are prescribed for detrusor hyperreflexia. For hypertonus of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (removal of spasms), 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 participation of cytokines in the development of the chronic inflammatory process, the possibility of using cytokine inhibitors, such as monoclonal antibodies to tumor necrosis factor, leukotriene inhibitors (belonging to the new class of NSAIDs) and tumor necrosis factor inhibitors, has been opened up. chronic prostatitis.
Treatment of chronic prostatitis without drugs
Currently, great importance is attached to the local application of physical methods, which make it possible not to exceed the average therapeutic dose of antibacterial drugs due to the stimulation of microcirculation and, as a consequence, increased accumulation of drugs in the prostate.
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 the changes in the prostate tissue, the presence or absence of congestive and proliferative changes, as well as the accompanying prostate adenoma, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40", the main effects of electromagnetic radiation in the microwave range, in addition to the above, are anti-congestive and bacteriostatic effects, as well as activation of the cellular immune system. At a temperature of 40-45°C, sclerosing and neuroanalgesic effects prevail, and the analgesic effect is due toinhibition of sensory nerve endings.
Low-energy magnetic laser therapy affects the prostate, which is close to microwave hyperthermia at 39-40°C, i. e. stimulates microcirculation, has an anti-congestive effect, encourages drug accumulation 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 in the organs of the reproductive system prevail and is therefore used for the treatment of acute and chronic prostatovesiculitis and epididymorrhitis. In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value. Sanatorium-resort 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 long-term and often ineffective therapy, turning the treatment process into a purely commercial enterprise with minimal risk to the patient's life. A much more serious danger 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 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 an economical electrical resection of the prostate is performed. In cases where the outcome of chronic prostatitis is prostate sclerosis with pronounced 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 transient zones, they disrupt tissue trophism and increase congestion in isolated groups of acini, which leads to the development of pain that is difficult to treat conservatively. In such cases, electrical resection must 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, followed by occlusion of the ejaculatory and excretory ducts of the prostate.
If, during the transurethral intervention, an exacerbation of the chronic inflammatory process (purulent or serous-purulent discharge from the prostate sinus) is diagnosed, the operation must be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by precise coagulation of the bleeding with a ball electrode and placement of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.