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 a disease called chronic prostatitis, there is a whole range of diseases and pathological conditions 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 part of the body. the 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 gland.
- N41. 9 Inflammatory disease of the prostate gland, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis is the most common inflammatory disease of the male reproductive system and one of the most common male diseases in general. It 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. 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, chronic prostatitis, according to the most approximate estimates, causes men of working age to consult a urologist in 35% of cases. In 7-36% of patients, it is complicated by vesiculitis, epididymitis, disorders of urination, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medicine considers chronic prostatitis as a polyetiological disease. The appearance and relapses 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 (reflux of urine into the prostatic ducts) and biochemical (possible 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 (indiscriminate intercourse without protection and personal hygiene, presence of an inflammatory process and / or infections of the urinary and genital organs 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 way of life;
- irregular sex life.
Among the etiopathogenetic risk factors for chronic prostatitis, immunological disorders are important, in particular the imbalance between various immunocompetent factors. First of all, this applies to cytokines - low-molecular 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 are: 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 localization of pain is the perineum, but a feeling of discomfort can occur in the suprapubic, groin, anus and other areas of the pelvis, 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 most characteristic of 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), but in the later stages of the disease, ejaculation can be slow. There may be a change ("erasure") of the emotional coloring of the orgasm.
Urination disorders are manifested more often with irritative symptoms, less often with IVO symptoms.
In chronic prostatitis, quantitative and qualitative ejaculate disorders can also be detected, which are rarely the cause of infertility.
The disease chronic prostatitis has a wave-like character, 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 area, 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 feel pain (unpleasant sensations) in the suprapubic area, less often in the scrotum, groin area 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 the urine stream and increased urination (with exacerbation of the inflammatory process). Ejaculation at this stage is not disturbed or slightly delayed, the intensity of adequate erections is normal or moderately reduced.
At the stage of scars and sclerosis of the prostate, patients are worried about heaviness in the suprapubic area, in the sacrum, frequent urination during the day and night (general pollakiuria), sluggish, intermittent flow of urine and an imperative desire to urinate. Ejaculation is delayed (even absent), adequate and sometimes spontaneous erections are weakened. Often at this stage attention is paid to the "erasure" of the orgasm.
The impact of chronic prostatitis on quality of life, according to the Unified Quality of Life Rating Scale, 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.
In the assessment of the subjective manifestations of the disease, questionnaires are of great importance. Numerous questionnaires have been developed, which 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, the patient's attitude to these clinical manifestations of chronic prostatitis, and as an assessment of the state ofthe psycho-emotional sphere of the patient. The most popular currently is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire. The questionnaire was developed by the US National Institutes of Health and 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 diagnose "chronic prostatitis" (since 1961, Farman and McDonald established the "gold standard" in the diagnosis of prostate inflammation - 10-15 leukocytes in the field of view) and make a differential diagnosis between its bacterialand non-bacterial forms.
Microscopic examination of the expelled urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonads, 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 prostatic secretions determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.
Bacteriological examination of prostate secretion or urine obtained after her massage is performed. Based on the results of these studies, the nature of the disease (bacterial or abacterial prostatitis) is determined. Prostatitis can lead to an increase in the concentration of PSA. Blood sampling to determine the serum PSA concentration should be performed no earlier than 10 days after a digital rectal examination. However, 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 (the state of humoral and cellular immunity) and the level of non-specific 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 a differential diagnosis, but also to determine the form and stage of the disease with subsequent monitoring throughout the course of treatment. Ultrasound makes it possible to assess 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. from the contents of the seminal vesicles.
UDI (UFM, urethral pressure profiling, 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, an X-ray examination should be performed to clarify the cause of its occurrence and to determine further treatment tactics.
CT and MRI of the pelvic organs are performed for differential diagnosis with prostate cancer, as well as in case 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 should be investigated?
Prostate gland (prostate)
How to review?
- Ultrasound of the prostate
- Prostate biopsy
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 in accordance with the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's lifestyle, his thinking and psychology. By eliminating the influence of many harmful factors, such as lack of physical activity, 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 many others, is a preparatory stage in the treatment. Next is the main, basic course, which includes the use of various drugs. This staged approach to the treatment of the disease allows you to monitor its effectiveness at each stage, making the necessary changes, as well as to fight the disease according to the same principle as it developed. - from predisposing to producing factors.
Indications for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy conducted in a hospital is more effective than outpatient treatment.
Drug treatment of chronic prostatitis
The simultaneous use of several drugs and methods that act on different units of pathogenesis is necessary to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improvement of microcirculation in the prostate), adequate drainage of prostate acini, especially inperipheral zones, normalizes the level of basic hormones and immune reactions. Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators can be recommended, as well as prostate massage in chronic prostatitis. In recent years, the treatment of chronic prostatitis is carried out with drugs that were not previously used for this purpose: alpha1-blockers, 5-α-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs that affect urate metabolism andcitrates.
In the case of chronic abacterial prostatitis and inflammatory syndrome of chronic pelvic pain (in the event that the pathogen is not identified as a result of the use of microscopic, bacteriological and immune diagnostic methods), empiric antibacterial treatment of chronic prostatitis with a short course can be carried out and, if clinically effective, to continue. 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, mycoplasmas, ureaplasmas, fungal flora, Trichomonas, viruses) in the development of an 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 biopsy or other subtle methods.
In non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is debatable. The duration of antibacterial therapy should be no more than 2-4 weeks, then, if the results are positive, it lasts up to 4-6 weeks. If there is no effect, it is possible to stop antibiotics and prescribe drugs from other groups (for example, alpha1-blockers, plant extracts of Serenoa repens).
The drugs of choice for empiric treatment of chronic prostatitis are fluoroquinolones because they have high bioavailability and penetrate well into the gland tissue (the concentration of some of them in the secretion exceeds 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 a 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 prove 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 recurrences of bacterial prostatitis.
If relapses occur, the previous course of antibacterial drugs can be prescribed in lower single and daily doses. The ineffectiveness of antibacterial therapy is usually due to an incorrect choice of drug, its dosage and frequency, or the presence of bacteria that persist in the canals, acini or calcifications and are covered with a protective extracellular membrane.
Pain and symptoms of irritation are indications for prescribing NPS, which are used both in complex therapy and as an alpha-blocker alone if antibacterial therapy is ineffective (diclofenac at a dose of 50-100 mg / day).
Some studies have demonstrated 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 use of antibiotics, α-blockers and NSAIDs, subsequent treatment should be aimed either at relieving pain, or at solving problems with urination, or at correcting both of the above symptoms.
In 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 should 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, an ultrasound (UFM) and, if possible, a videourodynamic study should be performed before starting drug therapy. Further treatment is prescribed depending on the results obtained. In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as in interstitial cystitis, amitriptyline, antihistamines and infusion of antiseptic solutions into the bladder are prescribed. Anticholinesterase drugs are prescribed for detrusor hyperreflexia. With hypertonicity of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (spasm relief), 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 a chronic inflammatory process, the possibility of using cytokine inhibitors, such as monoclonal antibodies against tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs) and tumor growth factor inhibitorsnecrosis, is considered in chronic prostatitis.
Non-drug treatment of chronic prostatitis
Currently, great importance is attached to the local use of physical methods, which allow not to exceed the average therapeutic dose of antibacterial drugs due to 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 a concomitant prostate adenoma, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 "The main effects of electromagnetic radiation of 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, the sclerosing and neuroanalgesic effects prevail, such as the analgesiceffect is due to inhibition of sensory nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate similar 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 congestive-infiltrative changes prevail in the organs of the reproductive system, which is why it is used for the treatment of acute and chronic prostatovesiculitis and epididymorchitis. In the absence of contraindications (stones in the prostate, adenoma), prostate massage has not lost its therapeutic value. In the treatment of chronic prostatitis, sanatorium-resort treatment and rational psychotherapy are successfully applied.
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 prolonged and often ineffective therapy, turning the treatment process into a purely commercial venture with minimal risk to the patient's life. A much more serious danger is its complications, which not only disrupt the urination process and negatively affect the male reproductive function, 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 more and more relevant. In severe organic BA caused by bladder neck sclerosis and prostate sclerosis, a transurethral incision is performed at 5, 7, and 12 o'clock of the conventional dial, or economical electrical resection of the prostate is performed. In cases where the result of chronic prostatitis is prostatic sclerosis with severe symptoms that do not respond to conservative therapy. performs the most radical transurethral electroresection of the prostate. Transurethral electroresection of the prostate can also be used in simple calculous prostatitis. Calcifications. localized in the central and transitional 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 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 the sclerosis of seminal tuberculosis, 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 intervention, the operation must end with the removal of the entire remaining gland. The prostate is removed by electroresection, followed by accurate coagulation of bleeding vessels with a spherical electrode and placement of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.