If the situation with infectious (or rather bacterial) prostatitis is more or less clear, then chronic abacterial prostatitis remains 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 functional disorders of the activity of not only theprostate, organs of the male reproductive system and 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 disease of the prostate, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis occupies the first place in terms of prevalence among inflammatory diseases of the male reproductive system and one of the first 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 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, chronic prostatitis, according to the most approximate estimates, leads men of working age to consult a urologist in 35% of cases. In 7 to 36% of patients, it is complicated by vesiculitis, epididymitis, urination disorders, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medical science considers chronic prostatitis a polyetiological disease. The appearance 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, autoimmune immunity (exposure toendogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (reflux of urine into the prostate ducts) and biochemical (possible role of citrates), as well as aberrations of peptide growth factors. Risk factors for developing chronic prostatitis include:
- lifestyle features that provoke 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 a 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, in particular the imbalance between different immunocompetent factors. First of all, this applies to cytokines - low molecular weight compounds of a 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 include: pain or discomfort, urinary problems, 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 location of pain is the perineum, but a feeling of discomfort can occur in the suprapubic area, groin, anus and other areas of the pelvis, insidethighs, 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 more specific to chronic prostatitis.
Sexual function is impaired, including suppression of libido and deterioration in the 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 later stages of the disease, ejaculation may be slow. There may be a change ("erasure") of the emotional coloring of the orgasm.
Urinary disorders are more often manifested by irritative symptoms, less often by symptoms of IVO.
In cases of chronic prostatitis, quantitative and qualitative disorders of the ejaculate can also be detected, rarely causing infertility.
The disease of chronic prostatitis has a wavy character, periodically intensifying and weakening. 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, enlarged and painful erections.
In the alternative stage, the patient may experience pain (unpleasant sensations) in the suprapubic region, more rarely in the scrotum, groin and sacrum. As a rule, urination is not impaired (nor increased). Against the background of accelerated and 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 urinary stream and an increase in urination (with exacerbations of the inflammatory process). Ejaculation at this stage is neither impaired nor slightly slowed down, the intensity of adequate erections is normal or moderately reduced.
At the stage of scar changes and sclerosis of the prostate, patients worry about heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total pollakiuria), a stream ofslow and intermittent urination and an imperative urge to urinate. Ejaculation is slowed down (to its absence), adequate and sometimes spontaneous erections are weakened. Often at this stage, attention is drawn to the "fading" of the orgasm.
The impact of chronic prostatitis on quality of life, according to the unified quality of life assessment scale, is comparable to the impact of myocardial infarction. angina or Crohn's disease.
Diagnosis of chronic prostatitis
Diagnosis of manifesting chronic prostatitis is not difficult and is based on the classic triad of symptoms. Since the disease is often asymptomatic, it is necessary to use a set of physical, laboratory and instrumental methods, including determining the immune and neurological state.
When assessing subjective manifestations of the disease, questionnaires are of great importance. Many questionnaires have been developed which are completed by the patient and which the doctor wishes to have an idea of the frequency and intensity of pain, urination disorders and sexual disorders, of the patient's attitude towards theseclinical manifestations of chronic prostatitis, as well as assessing the state of the patient's psycho-emotional sphere. The most popular currently is the NIH-CPS (Chronic Prostatitis Symptom Scale) questionnaire. The questionnaire was developed by the US National Institutes of Health and represents an effective tool for identifying the symptoms of chronic prostatitis and determining its 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 in 1961, Farman and McDonald established the "gold standard" in the diagnosis of inflammation of the prostate - 10-15leukocytes in the field of vision) and make a differential diagnosis between its bacterial and non-bacterial forms.
A microscopic examination of the evacuated urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and nonspecific flora.
When examining a scraping from the urethral mucosa using the PCR method, 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.
A bacteriological examination of the prostate secretions or urine obtained after the massage is carried out. Based on the results of these studies, the nature of the disease is determined (bacterial or abacterial prostatitis). Prostatitis can cause an increase in PSA concentration. A blood sample to determine the serum PSA concentration should be taken no earlier than 10 days after the digital rectal examination. Despite this, when the PSA concentration is above 4. 0 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is indicated to exclude prostate cancer.
The study of the immune state (state of humoral and cellular immunity) and the level of nonspecific antibodies (IgA, IgG and IgM) in prostate secretion is of great importance in the laboratory diagnosis ofchronic prostatitis. Immunological research makes it possible to determine the stage of the process and monitor the effectiveness of treatment.
Instrumental diagnosis of chronic prostatitis
Prostate TRUS for 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 allows you 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 ofexpansion, density and echo-homogeneity. of the contents of the seminal vesicles.
UDI (UFM, urethral pressure profile determination, pressure/flow study, cystometry) and pelvic floor muscle myography provide additional information in cases of suspected neurogenic urination disorders and dysfunction of the pelvic floor muscles. pelvic floor. as well as IVO, which often accompanies chronic prostatitis.
An X-ray examination should be carried out in patients with diagnosed BOO in order to clarify the cause of its occurrence and determine further treatment tactics.
CT and MRI of the pelvic organs are carried out for the differential diagnosis of prostate cancer, as well as if a non-inflammatory form of abacterial prostatitis is suspected, when it is necessary to exclude pathological changes in the spine andpelvic organs.
What to look at?
Prostate gland (prostate)
How to examine?
- Prostate ultrasound
- Prostate biopsy
What tests are needed?
- Analysis of prostate secretion (prostatic gland)
- Prostate specific antigen in blood
Who to contact?
- Urologist
- Andrologist
Treatment of chronic prostatitis
Treatment of chronic prostatitis, like any chronic disease, must be carried out in compliance with the principles of consistency and 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. By doing so, we not only stop the progression of the disease, but also promote recovery. This, along with the normalization of sex life, diet and much more, is a preparatory stage for treatment. Next comes the basic main course, which involves the use of various medications. This step-by-step approach to treating the disease allows you to monitor its effectiveness at each stage, make the necessary changes, and also fight the disease according to the same principle by which it developed. - predisposing factors to producing factors.
Indications for hospitalization
Typically, chronic prostatitis does not require hospitalization. In severe cases of chronic persistent prostatitis, complex therapy carried out in a hospital setting 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), Adequate drainage of prostatic acini, especially in the peripheral areas, normalizes the level of essential hormones and immune reactions. Based on this, 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 using drugs that were not previously used for this purpose: alpha1-blockers, 5-a-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugswhich affect the metabolism of urates and citrates.
In cases of chronic abacterial prostatitis and chronic inflammatory pelvic pain syndrome (in the case when the pathogen has not been identified through the use of microscopic, bacteriological and immune diagnostic methods), empirical antibacterial treatment ofChronic prostatitis can be carried out with a short course and, if clinically effective, continued. The effectiveness of empirical antimicrobial therapy in patients with bacterial and abacterial prostatitis is approximately 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 that is not detected by standard microscopic or bacteriological examination of prostate secretions may, in some cases, be detected by histological examination of prostate biopsies or other subtle methods.
In chronic non-inflammatory pelvic pain syndrome and chronic asymptomatic prostatitis, the need for antibacterial treatment is controversial. The duration of antibacterial treatment should not exceed 2-4 weeks, after which, if the results are positive, it continues for 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 empirical treatment of chronic prostatitis are fluoroquinolones, since they have high bioavailability and penetrate well into glandular tissue (the concentration of some of them in the secretion exceeds that of 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 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 chlamydia infection is suspected.
Recent studies have proven 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.
In the event of a relapse, the previous antibacterial treatment at lower single and daily doses may be prescribed. The ineffectiveness of antibiotic therapy is usually due to the wrong choice of drug, its dosage and frequency, or the presence of bacteria that persist in the ducts, acini or calcifications and are covered by a protective extracellular membrane.
Pain and irritative symptoms are indications for the prescription of NPS, which are used both in complex therapy, but also as an alpha-blocker alone if antibacterial treatment is ineffective (diclofenac dose 50-100 mg/day).
Some studies demonstrate the effectiveness of herbal medicine, but this information has not been confirmed by multicenter, placebo-controlled studies.
If clinical symptoms of the disease (pain, dysuria) persist after the use of antibiotics, α-blockers and NSAIDs, further treatment should be aimed either at relieving pain or solving problems with urination, or to correct the two symptoms above.
Against pain, tricyclic antidepressants have an analgesic effect due to blocking histamine H1 receptors and anticholinesterase action. The most commonly prescribed medications are amitriptyline and imipramine. However, they must be taken with caution. Side effects - drowsiness, dry mouth. In extremely rare cases, narcotic pain relievers (tramadol and other medications) may be used to relieve pain.
If dysuria predominates in the clinical picture of the disease, an ultrasound scan (UFM) should be performed before starting drug treatment and, if possible, a video-urodynamic study. Additional treatment is prescribed depending on the results obtained. In case of hypersensitivity (hyperactivity) of the bladder neck, treatment is carried out as for interstitial cystitis, they prescribe amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder. For detrusor hyperreflexia, anticholinesterase drugs are prescribed. In case of hypertonia of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug treatment is ineffective, physiotherapy (relief of spasms), 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 participation of cytokines in the development of a chronic inflammatory process, the possibility of using cytokine inhibitors, such as monoclonal antibodies to tumor necrosis factor, inhibitors ofleukotrienes (belonging to a new class of NSAIDs) and tumor necrosis factor inhibitors, is being considered for the treatment of chronic prostatitis.
Non-drug treatment of chronic prostatitis
Currently, great importance is attached to the local use of physical methods, which 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 inprostate.
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 changes in the prostate tissue, the presence or absence of congestive and proliferative changes, as well as concomitant prostatic 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 anticongestive and bacteriostatic effects, as well as activation of the cellular immune system. At a temperature of40-45 ° 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 close to microwave hyperthermia at 39-40°C, i. e. stimulates microcirculation, has an anticogestive effect, promotes the accumulation of drugsin 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 predominate and therefore is used for the treatment of acute and chronic prostatovesiculitis and orchepididymitis. In the absence of contraindications (prostatic stones, adenoma), prostate massage has not lost its therapeutic value. Sanatorium treatment 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 potentially fatal disease. This is proven by cases of long-term and often ineffective therapies, transforming 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 disrupt the process of urination 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 cervix. bladder.
Unfortunately, these complications often occur in young and middle-aged patients. This is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly important. In cases 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 electric resection of the prostate is performed. In cases where the outcome of chronic prostatitis is prostate sclerosis accompanied by severe symptoms that are not amenable to conservative treatment. 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 central and transitional zones, they disrupt tissue trophism and increase congestion of isolated groups of acini, leading 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 these patients.
Another indication for endoscopic surgery is sclerosis of the seminal tubercle, 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 prostatic sinuses) is diagnosed during a transurethral intervention, the operation should be supplemented with removal of the entire remaining gland. The prostate is removed by electroresection, followed by precise coagulation of bleeding vessels with a ball electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostate ducts.