Chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by an infection with the possible addition of autoimmune disorders, characterized by damage to the parenchymal and interstitial tissue of the organ. The disease has been known in medicine since 1850, but to this day it remains poorly understood and poorly responsive to treatment. Chronic bacterial (6-10%) and nonbacterial (80-90%) prostatitis are the most common and socially significant inflammatory diseases in men, significantly reducing their quality of life. The disease is registered mainly in young people and middle-aged people and is often complicated by impaired copulatory and generative functions (reduced potency, infertility, etc. ). The disease is registered in men in 8 - 35% of cases between the ages of 20 and 40 years.

The cause of bacterial prostatitis is the pyogenic flora, which penetrates the gland from the urethra or through the lymphogenic and hematogenous pathways. The etiology of chronic nonbacterial prostatitis and its pathogenesis remain unknown. It mainly affects men over the age of 50.

The reasons for the development of the disease

Chronic prostatitis is currently considered a polyetiological disease. It is believed that the disease occurs as a result of the penetration of infection into the prostate and then the pathological process takes place without its participation. A number of non-infectious factors contribute to this.

Infectious factors in the development of chronic prostatitis

In 90% of cases, the pathogens enter the gland from the urethra, leading to acute or chronic prostatitis. There are cases of asymptomatic transport. The course of the disease is influenced by the state of the human body's defenses and the biological properties of the pathogen. The transition from acute to chronic prostatitis is thought to occur due to loss of tissue elasticity due to excessive fibrous tissue production.

Among the causes of chronic prostatitis are the following pathogens:

• In 90% of cases, the disease reveals such gram-negative bacteria as Escherichia coli (E. coli), Enterococcus faecalis (fecal enterococci), a little less often - Pseudomonas aeruginosa, Klebsiella spp. , Proteus spp. , Pseudomonas aeruginogenes and Enterobacter. Gram-positive bacteria enterococci, streptococci and staphylococci are rare.
• The role of coagulase-negative staphylococci, ureaplasma, chlamydia, Trichomonas, Gardnerella, anaerobic bacteria and fungi of the genus Candida is not fully understood.

The infection enters the prostate in several ways:

• An ascending pathway is most likely, as evidenced by the common combination of prostatitis and urethritis.
• Hematogenous prostatitis develops when the infection enters the gland with the bloodstream, which is observed in chronic tonsillitis, sinusitis, periodontitis, pneumonia, cholecystitis and cholangitis, purulent skin diseases and others.
• Upon contact, chronic prostatitis develops with urethritis and strictures of the urethra, when the infection enters the gland ascending with the flow of urine, with purulent infections of the kidneys, through the canalicular pathway to epididymitis, deferentitis and funiculitis, during diagnostic and therapeutic urological manipulationscatheterization, urethralization), including transurethral.
• Lymphogenic infection penetrates the prostate with proctitis, thrombophlebitis of hemorrhoidal veins and others.

Non-infectious factors in the development of chronic prostatitis

Chemical factors

According to experts, the leading role in the development of chronic prostatitis belongs to the intraprostatic reflux of urine, when urine is thrown from the urethra into the gland, which leads to impaired emptying of the prostate and seminal vesicles.

With the disease develop vascular reactions leading to swelling of the organ, impaired nerve and humoral regulation of the tone of the smooth muscle tissues of the urethra, the activation of alpha_one-Adrenergic receptors cause the development of dynamic obstruction and contribute to the development of new intraprostatic refluxes.

Urates contained in urine with reflux lead to the development of a "chemical inflammatory response".

Hemodynamic disorders

They maintain chronic inflammation and circulatory disorders in the pelvic organs and scrotum. Congestion develops in people who lead a sedentary lifestyle, such as drivers, office workers and others. , With obesity, sexual abstinence, sexual dysmetry, frequent hypothermia, mental and physical overload. Intake of spicy and savory foods, alcohol and smoking, etc. Contribute to the maintenance of the inflammatory process.

Other factors

There are many other factors that support chronic inflammation of the prostate. They include:

• Hormonal.
• Biochemical.
• Impaired immune response.
• Autoimmune mechanisms.
• Infectious and allergic processes.
• Characteristics of the structure of the prostate glands, leading to difficulties in complete drainage.

Quite often it is not possible to determine the causes of chronic prostatitis.

Classification of prostatitis

According to the classification proposed in 1995 by the US National Institutes of Health, prostatitis is divided into:

• Acute (category I). E 5 - 10%.
• Chronic bacterial (category II). E 6 - 10%.
• Chronic nonbacterial inflammation (category IIIA). E 80 - 90%.
• Chronic non-bacterial non-inflammatory (category IIIB) or chronic pelvic pain syndrome.
• Chronic prostatitis diagnosed accidentally (category IV).

Signs and symptoms of chronic prostatitis

Chronic prostatitis is long but not monotonous. Periods of exacerbation are replaced by periods of relative calm, which occur after complex anti-inflammatory and antibacterial therapy.

The development of chronic bacterial prostatitis is often preceded by urethritis of bacterial or gonorrheal nature, non-bacterial - disorders of blood circulation in the pelvic organs and scrotum (hemorrhoids, varicocele, etc. ), sexual excesses.

Patients with chronic prostatitis have many complaints. They go to doctors for years, but are very rarely tested for prostate disease. About a quarter of patients do not complain or the disease has scanty clinical symptoms.

The complaints of patients with chronic prostatitis can be conditionally divided into several groups.

Urinary disorders associated with narrowing of the urethra:

• Difficulty starting to urinate.
• Weak urine flow.
• Intermittent urination or drop by drop.
• Feeling of incomplete emptying of the bladder.

Symptoms due to irritation of the nerve endings:

• Frequent urination.
• The urge to urinate is sharp and violent.
• Urination in small portions.
• Urinary incontinence during the urge to urinate.

Pain syndrome:

• The intensity and nature of the pain are different.
• Localization of pain: lower abdomen, perineum, rectum, groin and lower back, inner thighs.

Sexual dysfunction:

• Pain in the rectum and urethra during ejaculation.
• Slow erection.
• Loss of orgasm.
• Premature ejaculation, etc.

From the nervous system: neurotic disorders in the form of fixing patients' attention to their health.

Signs and symptoms of chronic nonbacterial prostatitis

Chronic pelvic pain syndrome in men (CPPS) is manifested by the usual symptoms of chronic prostatitis, but the bacteria are absent in the 3rd portion of urine and in the secretion of the prostate gland. CPPS can be simulated by chronic nonbacterial interstitial cystitis, rectal diseases, spastic pelvic myalgia syndrome, and functional prostate lesions caused by disturbances in organ innervation and hemodynamics.

If the neurovegetative function is impaired, atony and disturbance of the innervation of the gland are noted, which is manifested by the difficulty of rapid and complete closure of the lumen of the urethra. At the same time, urine after urination continues to be excreted for a long time drop by drop. In such patients, the study revealed instability and increased excitability, which is manifested by increased sweating and excitability of the heart, changes in dermographism.

Complications of the disease

The long course of chronic prostatitis is complicated by impaired sexual and reproductive functions, the development of diseases such as vesiculitis and epididymitis, as well as organ hardening. Organ sclerosis worsens local microcirculation and urodynamics, as well as the results of surgical interventions. Fibrosis of the periurethral tissues leads to the development of urinary disorders.

Diagnosis

Due to the fact that there are many reasons for the development of chronic prostatitis, a whole range of diagnostic tests are used to diagnose it. The success of treatment depends on the correct determination of the causes of the disease. The diagnosis of chronic prostatitis is based on the following data:

• The classic triad of symptoms.
• Set of physical methods (digital rectal examination of the prostate).
• Set of laboratory methods (analysis of urine and microscopy of prostate secretion, cultivation and determination of the sensitivity of the microflora to antibacterial drugs, general analysis of urine and blood)
• For detection of gonococci, bacterioscopy of cytosmear of the urethra, PCR and serological methods (for detection of ureaplasmas and chlamydia).
• Urofluometry.
• Prostate biopsy.
• Complex of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of neurological status.
• If the treatment is ineffective and there are suspicions of complications, computed tomography and magnetic resonance imaging, blood culture and others.

Palpation of the prostate

Of paramount importance in the diagnosis of the disease is the palpation of the prostate, which increases in the period of exacerbation and decreases during the period of attenuation of the inflammatory process. In chronic prostatitis during the exacerbation of iron, it is swollen and painful.

The density of the consistency of the organ can be different: the areas of softening and compaction are palpated, areas of dents are determined. On palpation it is possible to assess the shape of the gland, the condition of the seminal tubercles and the surrounding tissues.

The process of transrectal digital examination is combined with the collection of glandular secretion. Sometimes it becomes necessary to obtain the secret of each action separately.

Analysis of a sample of 3 cups of urine and prostate secretion

The "gold standard" in the diagnosis of chronic prostatitis are:

• Collect the first portion of urine.
• Collect the second portion of urine.
• Obtaining glandular secretion by massage.
• Collect the third portion of urine.

In addition, microscopic and bacteriological examination of the material is performed.

In inflammation of the prostate:

• The number of microbes (CFU) exceeds 10³/ ml (10^four/ ml for epidermal staphylococci), but do not neglect the small number of microbes of tens and hundreds.
• The presence of 10-15 leukocytes in the visual field, detected by microscopy, is a common criterion for the presence of an inflammatory process.

The secretion of the prostate and the 3rd portion of urine are subjected to microscopic and bacteriological examinations:

• In chronic bacterial prostatitis, an increase in the number of leukocytes in the secretion of the gland is observed and the third post-massage portion of urine, bacteria (mainly from the intestinal group) is released.
• In nonbacterial prostatitis there is an increase in the number of leukocytes in the secretion of the gland, but the microflora is not detected.
• In CPPS there is no increased number of leukocytes and microflora.

Normal rate of prostate secretion:

• Leukocytes below 10 in the visual field.
• There are many lecithin grains.
• There is no microflora.

In chronic prostatitis, the secretion of the prostate reveals:

• The number of leukocytes is large - more than 10-15 in the visual field.
• The amount of lecithin grains is reduced.
• The pH of the secretion shifts to the alkaline side.
• The acid phosphatase content is reduced.
• Lysozyme activity is increased.

Obtaining negative results from prostate secretion does not prove once the absence of an inflammatory process.

The value of the test for crystallization of prostate secretion is preserved. Usually during crystallization a characteristic pattern in the form of a fern leaf is formed. In case of violation of the aggregating properties of prostate secretion, such a pattern does not form, which occurs when the androgenic hormonal background changes.

Ultrasound procedure

If prostate disease is suspected, an ultrasound examination of the gland itself (optical is the transrectal ultrasound), the kidneys and the bladder is used, which makes it possible to determine:

• The volume and size of the gland.
• Availability of calculators.
• The size of the seminal vesicles.
• The condition of the walls of the bladder.
• The amount of residual urine.
• Scrotal structures.
• Another type of pathology.

Other methods of prostate examination

• The state of urodynamics (study of the flow rate of urine) is determined easily and simply with the help of a study such as uroflowmetry. With the help of this study, it is possible to detect signs of obstruction of the bladder outlet in a timely manner and to perform dynamic monitoring.
• Puncture biopsy is performed when an abscess, benign hyperplasia and prostate cancer are suspected.
• X-ray and endoscopic examinations are performed to clarify the reasons for the development of infravesicular obstruction.
• In long-term inflammatory process, urethrocystoscopy is recommended.

Differential diagnosis

Chronic prostatitis should be distinguished from vesiculoprostatosis, autonomic prostatopathy, congestive prostatitis, pelvic floor myalgia, neuropsychiatric disorders, pseudodysynergia, reflex sympathetic dystrophy, inflammatory diseases of other organs, interstitial cystic fibrosis, interstitial cystitisprostate and prostate urolithiasis, chronic epididymitis, inguinal hernia.

Treatment of chronic prostatitis

Treatment of chronic prostatitis should begin with a change in the patient's lifestyle and diet.

In the treatment of the disease are used simultaneously drugs that affect different parts of the pathogenesis.

The main directions of therapy:

• Elimination of pathogens of microorganisms.
• Anti-inflammatory therapy.
• Normalization of blood circulation in the prostate and pelvic organs.
• Normalization of adequate drainage of prostate acini.
• Normalization of the hormonal profile.
• Prevention of organ hardening.

Drugs from the following groups are used to treat chronic prostatitis:

• Antibacterial.
• Anticholinergic.
• Vasodilators.
• Alpha_one–Adrenergic blockers.
• 5 alpha reductase inhibitors.
• Cytokine inhibitors.
• Non-steroidal anti-inflammatory drugs.
• Angioprotectors.
• Immunomodulators.
• Drugs that affect urate metabolism.

Antibiotics in the treatment of chronic bacterial prostatitis

Antibiotic therapy should be performed taking into account the sensitivity of the identified microorganisms to antibiotics. If the pathogen is not identified, empirical antimicrobial treatment is used.

The selected drugs are fluoroquinolones of II-IV generation. They rapidly penetrate the tissues of the gland with the usual methods of application, are active against a large group of gram-negative microorganisms, as well as ureaplasma and chlamydia. In case of failure of antimicrobial treatment, the following should be taken:

• multidrug resistance of the microflora
• short (less than 4 weeks) courses of treatment,
• wrong choice of antibiotic and its dosage,
• changes in the type of pathogen,
• the presence of bacteria living in the ducts of the prostate covered with a protective extracellular membrane.

The duration of treatment should be at least 4 weeks with mandatory follow-up bacteriological control. If there is more than 10 bacteriuria in the 3rd portion of urine and prostate secretion³CFU / ml, a repeat course of antibiotic therapy is prescribed for a period of 2 to 4 weeks.

Cytokine inhibitors in the treatment of chronic prostatitis

Cytokines are glycoproteins that are secreted by immune and other cells in response to an inflammatory response and an immune response. They are actively involved in the development of the chronic inflammatory process.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs have anti-inflammatory action, relieve pain and fever. They are widely used in the treatment of chronic prostatitis in the form of tablets and suppositories. The most effective route is rectal administration.

Immunotherapy

In the treatment of bacterial chronic prostatitis, in addition to antibiotics and anti-inflammatory drugs, immunomodulatory agents are used. The most effective is the rectal route of their administration. An immunomodulator is widely used that increases the functional activity of phagocytes, which contributes to more efficient elimination of pathogens.

Alpha-blockers in the treatment of chronic prostatitis

Alpha-1 adrenergic blockers have been found to normalize the tone of the smooth muscles of the prostate urethra, seminal vesicles and prostate capsule, which makes drugs in this group very effective in treating the disease. Alpha-1 adrenergic blockers are used in patients with severe urinary incontinence in the absence of an active inflammatory process.

In CPPS, the duration of treatment is 1 to 6 months.

5α-reductase inhibitor in the treatment of abacterial prostatitis and CPPS

It has been found that under the influence of the 5α-reductase enzyme testosterone is converted into the prostate form 5α-dihydrotestosterone, whose activity in prostate cells is over 5 times higher than the activity of testosterone itself, which in the elderly leads to organ enlargement. due to epithelial and stromal components.

When taking a 5α-reductase inhibitor for 3 months, atrophy of the stromal tissue is noted, within 6 months - glandular, secretory function is inhibited, the severity of the pain syndrome and the volume of the gland decrease, tension and swelling of the organ decrease.

The role of antisclerotic drugs in the treatment of chronic prostatitis

Prolonged inflammation in the prostate gland develops fibrosis, which manifests itself with impaired microcirculation and urodynamics. Antisclerotic drugs are used to prevent the process of fibrosis.

Other drugs used to treat chronic prostatitis

Along with the drugs described above, the following are used to treat the disease:

• Antihistamines.
• Vasodilators and angioprotectors.
• Immunosuppressants.
• Drugs affecting the metabolism of urate and trisodium salt of citric acid.

Herbal products

Effective in the treatment of prostatitis is the use of a preparation in the form of suppositories containing a complex of biologically active peptides isolated from the prostate gland of cattle.

Under the influence of the drug occurs:

• Stimulation of metabolic processes in glandular tissues.
• Improving microcirculation.
• Reduction of edema, leukocyte infiltration, stagnation of secretion and pain.
• Prevention of thrombosis in the venules of the prostate gland.
• Increased activity of the secretory epithelium of acini.
• Improving sexual function (increasing libido, restoring erectile function and normalizing spermatogenesis).

Massage with fingers of the prostate gland

A number of researchers claim that finger massage should be used in chronic prostatitis, taking into account the known contraindications.

Physiotherapy

Today, the effectiveness of physiotherapy procedures in the treatment of prostatitis has not been proven, the mechanism of action has not been scientifically established and side effects have not been studied.

Prevention of chronic prostatitis

When you start to prevent the development of chronic prostatitis, you need to know:

• The risk of developing the disease increases with age.
• Representatives of the Negroid race are more prone to disease.
• A familial predisposition to the disease is not excluded.

People with a predisposition to develop chronic prostatitis should be more careful about their health.

Disease prevention tips:

• Drink plenty of fluids. Frequent urination promotes the extraction of microflora from the urethra.
• Prevention of diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods high in carbohydrates and saturated fats, which leads to weight gain.
• You should minimize the use of substances that irritate the urethra: spicy and spicy foods, smoked meats, sauces and spices, coffee and alcohol.
• Stop smoking. Nicotine adversely affects the condition of the vessel walls.
• Do not overcool.
• Do not delay emptying the bladder.
• Lead an active lifestyle, exercise. Exercise to strengthen the pelvic floor muscles, which can eliminate venous congestion, which in turn maintains normal prostate function.
• Have a regular sex life. Avoid prolonged abstinence. The gland must be released from the secretion immediately.
• Stay in a monogamous relationship. Indiscriminate sex increases the likelihood of acquiring sexually transmitted diseases.
• If you have urogenital complaints, contact your urologist immediately.