If infectious (or rather bacterial) prostatitis is more or less clear-cut, chronic bacterial prostatitis remains a serious urological problem with many unclear questions.Perhaps, under the guise of a disease called chronic prostatitis, there is a series of diseases and pathological conditions that are characterized by various organic changes in tissues and functional disorders in the functioning of not only the prostate, organs of the male reproductive system and the lower urinary tract, but also other organs and systems in general.
ICD-10 code
- N41.1 Chronic prostatitis.
- N41.8 Other inflammatory diseases of the prostate.
- N41.9 Prostatitis, unspecified.
Epidemiology of chronic prostatitis
Chronic prostatitis ranks first in the incidence of inflammatory diseases of the male reproductive system and takes one of the first positions among male diseases in general.This is the most common urinary disease in men under 50 years old.The average age of patients with chronic inflammation of the prostate is 43 years old.By age 80, up to 30% of men have 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, in 35% of cases causes men of working age to consult a urologist.In 7-36% of patients, this condition is complicated by vesicular inflammation, epididymitis, disorders of urination, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medicine considers chronic prostatitis to be a multifactorial disease.The emergence and recurrence of chronic prostatitis, in addition to the impact of infectious factors, is also due to autonomic and hemodynamic disorders, accompanied by a weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (urine reflux into the prostatic duct) and biochemical processes (possible presence of citrate), as well as aberrant peptide growth factors.Risk factors for developing chronic prostatitis include:
- Lifestyle characteristics that cause infections of the genitourinary system (promiscuous sex without protection and personal hygiene, presence of inflammatory processes and/or infections of urinary and genital organs in partners):
- perform transurethral manipulations (including TURP of the prostate) without prophylactic antibiotic treatment:
- Presence of an indwelling urethral catheter:
- chronic hypothermia;
- sedentary lifestyle;
- Irregular sex life.
Among the risk factors for the pathogenesis of chronic prostatitis, immune disorders are important, especially imbalances between different immunocompetent factors.First of all, this applies to cytokines - low molecular compounds of 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, urinary problems, and sexual dysfunction.The main symptom of chronic prostatitis is pain or discomfort in the pelvic area that lasts 3 months.and more.The most common location of pain is the perineum, but discomfort can occur in the suprapubic region, groin, anus and other areas of the pelvis, in the inner 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 decreased sexual desire and impaired quality of spontaneous and/or adequate erections, although most patients do not suffer from severe impotence.Chronic prostatitis is one of the causes of premature ejaculation (PE), however, in the later stages of the disease, ejaculation may be delayed.There may be a change (“erasing”) of the emotional color of orgasm.
Urinary disorders are often manifested by symptoms of irritation, less commonly by symptoms of IVO.
In cases of chronic prostatitis, disorders in the quantity and quality of ejaculation can also be detected, which are rarely the cause of infertility.
Chronic prostatitis has an undulating nature, gradually increasing and weakening in cycles.In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.
The ejaculatory phase is characterized by pain in the scrotum, in the groin and the suprapubic area, frequent urination and discomfort at the end of urination, rapid ejaculation, pain at the end or after ejaculation, increased erection and pain.
At the replacement stage, the patient may feel pain (discomfort) in the suprapubic area, less often in the scrotum, groin area and sacrum.As a rule, urination is not impaired (or increased).Against the background of rapid, painless ejaculation, a normal erection is observed.
The proliferative phase of the inflammatory process can be manifested by a weakening of the intensity of the urinary stream and frequent urination (during the exacerbation of the inflammatory process).Ejaculation at this stage is not impaired or slightly slowed down, the intensity of erection is normal or moderately reduced.
In the stage of scarring changes and prostate sclerosis, patients worry about the severity of the suprapubic area, the sacrum area, frequent urination all day and night (total urine volume), slow and intermittent urine flow and urge to urinate.The ejaculation process is delayed (even to the point of no ejaculation), the ability to have a full and sometimes spontaneous erection is impaired.Usually at this stage, people pay attention to "eliminating" orgasm.
The impact of chronic prostatitis on quality of life, according to the Unified Quality of Life Scale, is comparable to the impact of myocardial infarction.angina or Crohn's disease.
Diagnosis of chronic prostatitis
Diagnosis of chronic prostatitis is not difficult and is based on the classic triad of symptoms.Because the disease is often asymptomatic, a variety of physical methods, tests, and complex instruments are needed, including determining the immune and neurological status.
When evaluating subjective manifestations of the disease, questionnaires are of great importance.Many questionnaires have been developed for the patient to fill out, and the doctor wants to know about 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 assess the patient's psycho-emotional state.The most popular today is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire.Questionnaire developed by the US National Institutes of Health;it represents an effective tool to identify the symptoms of chronic prostatitis and determine its impact on quality of life.
Laboratory diagnosis of chronic prostatitis
Laboratory diagnosis of chronic prostatitis allows us to diagnose “chronic prostatitis” (since 1961, Farman and McDonald established the “gold standard” in the diagnosis of prostatitis - 10-15 leukocytes per field of view) and make a differential diagnosis between bacterial and non-bacterial forms.
Microscopic examination of the discharged urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and nonspecific flora.
When examining scratches of the urethral mucosa by PCR, the presence of microorganisms that cause sexually transmitted diseases is determined.
Microscopic examination of prostatic secretions determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallement bodies, and macrophages.
Bacteriological examination of prostatic secretions 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 increase PSA levels.Blood sampling to determine serum PSA levels should be performed no earlier than 10 days after digital rectal examination.Despite this fact, when PSA levels are 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 nonspecific antibodies (IgA, IgG and IgM) in prostatic secretions.Immunological studies help determine the stage of the process and monitor the effectiveness of treatment.
Instrument for diagnosing chronic prostatitis
TRUS of the prostate in the treatment of chronic prostatitis has high sensitivity but low specificity.This study allows not only to perform differential diagnosis, but also to determine the form and stage of the disease with subsequent monitoring throughout the treatment process.Ultrasound can evaluate the size and volume of the prostate, acoustic structures (cysts, stones, sclerotic changes in the organ, abscesses, hypoechoic areas in the periphery of the prostate), size, degree of dilatation, density and echo homogeneity of the contents of the seminal vesicles.
UDI (UFM, urethral pressure profiling, pressure/flow studies, cystometry) and pelvic floor myography provide additional information if neurogenic micturition disorders and pelvic floor muscle dysfunction are suspected.as well as IVO, which is often accompanied by chronic prostatitis.
X-ray examination should be performed in patients diagnosed with BOO to clarify the cause of its appearance 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 bacterial prostatitis is suspected, when it is necessary to exclude pathological changes in the spine and pelvic organs.
What needs to be checked?
Prostate (prostate)
How to check?
- Prostate ultrasound
- Prostate biopsy
What tests are needed?
- Analysis of prostatic secretion (prostate gland)
- Prostate-specific antigen in the blood
Who should I contact?
- Urologist
- andrology doctor
Treatment of chronic prostatitis
Treatment of chronic prostatitis, like any chronic disease, must be carried out following consistent principles and an integrated approach.First of all, it is necessary to change the patient's lifestyle, thinking, and psychology.By eliminating the effects of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others.By doing so, we not only prevent further progression of the disease but also promote recovery.This, as well as the normalization of sex life, diet and much more, is the preparatory phase in treatment.Next comes the basic, main course, which includes the use of various drugs.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 on which it developed.- from favorable factors to productive factors.
Indications for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization.In severe cases of persistent chronic prostatitis, complex therapy performed in a hospital is more effective than outpatient treatment.
Drugs to treat chronic prostatitis
It is necessary to use several drugs and methods acting on different parts of the pathogenesis simultaneously to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), adequately drain the prostate acini, especially in the periphery, normalize the level of essential hormones and immune reactions.Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, vasoprotectors and vasodilators, as well as prostate massage may 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, drugs that affect urate and citrate metabolism.
In the case of chronic bacterial prostatitis and chronic pelvic inflammatory pain syndrome (in cases where the pathogen has not been identified due to the use of bacterial, bacteriological and immunological diagnostic methods), empiric antibacterial treatment for chronic prostatitis can be administered with a short course and, if clinically effective, continued.The effectiveness of empiric antibiotic therapy in both bacterial and bacterial prostatitis patients is approximately 40%.This suggests an undetectable bacterial flora or an active role of other microbial agents (chlamydia, mycoplasmas, ureaplasmas, fungal flora, Trichomonas, viruses) in the development of the inflammatory process, which is currently unconfirmed.In some cases, flora not detected by standard bacteriological or microscopic examination of prostatic secretions may be detected by histological examination of prostate biopsies or other refined methods.
In chronic noninflammatory pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibiotic treatment is controversial.The duration of antibacterial treatment should not exceed 2-4 weeks, then, if the result is positive, continue for up to 4-6 weeks.If there is no effect, the antibiotic can be stopped and a drug of another class (eg, alpha1 blockers, plant extract of Serenoa repens) prescribed.
The drugs of choice for the empirical treatment of chronic prostatitis are fluoroquinolones, because they have high bioavailability and penetrate well into glandular tissue (the concentration of some drugs in secretions exceeds the concentration in serum).Another advantage of drugs in this group is 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 any specific drug of the fluoroquinolones group.
If fluoroquinolones are ineffective, combination antibacterial therapy should be prescribed.Tetracycline has not lost its importance, especially when chlamydia infection is suspected.
Recent studies have demonstrated that clarithromycin penetrates well into prostate tissue and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.
Antibacterial drugs are also recommended to prevent recurrence of bacterial prostatitis.
If relapse occurs, previous antibacterial drugs can be prescribed in single and lower daily doses.Ineffectiveness of antibacterial therapy is often due to incorrect choice of drug, dosage and frequency of use or the presence of bacteria existing in the ducts, acini or calcifications and covered by a protective extracellular membrane.
Symptoms of pain and irritation are indications for the prescription of NPS, which is used both in complex therapy and also as a simple alpha-blocker if antibacterial therapy is ineffective (dose of diclofenac 50-100 mg/day).
Several studies demonstrate the effectiveness of herbal medicines, 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 at relieving pain or resolving urination problems or correcting both of the above symptoms.
For pain, tricyclic antidepressants provide analgesia through histamine H1 receptor blocking and anticholinesterase effects.The most commonly prescribed drugs are amitriptyline and imipramine.However, they must be done with caution.Side effects - drowsiness, dry mouth.In extremely rare cases, narcotic pain relievers (tramadol and others) may be used to relieve pain.
If the clinical picture of the disease is dominated by dysuria, before starting drug therapy, ultrasound (UFM) should be performed and, if possible, videodynamic studies.Further treatment is prescribed depending on the results obtained.In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as for interstitial cystitis, prescribing amitriptyline, antihistamines and instilling antiseptic solutions into the bladder.For smooth muscle hyperreflexia, anticholinesterase drugs are prescribed.For hypertonicity of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug treatment is ineffective, physiotherapy (reducing spasticity), neuromodulation (for example, sacral stimulation).
Based on the neuromuscular theory of the cause of chronic bacterial prostatitis, antispasmodics and muscle relaxants may 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 such as monoclonal antibodies against tumor necrosis factor, leukotriene inhibitors (belonging to the new class of NSAIDs) and tumor necrosis factor inhibitors are being considered for the treatment of chronic prostatitis.
Treatment of chronic prostatitis without medication
Currently, great importance is attached to the use of local physical methods, which help not to exceed the average therapeutic dose of antibacterial drugs due to stimulation of microcirculation and, as a result, increased accumulation of drugs in the prostate.
The most effective physical methods for treating chronic prostatitis:
- Transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonophoresis and electrophoresis).
Depending on the nature of changes in prostate tissue, the presence or absence of hyperemic 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 effect of electromagnetic radiation in the microwave range, in addition to the above effects, also has an anti-congestive and bacteriostatic effect, as well as activation of the cellular immune system. At a temperature of 40-45 ° C, the sclerosing and neuropathic analgesic effects prevail, the analgesic effect is due to the inhibition of sensitive nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate almost like microwave hyperthermia at 39-40 ° C, i.e. stimulates microcirculation, has an anticoagulant effect, promotes drug accumulation in prostate tissue and activates the cellular immune system.In addition, laser therapy also has a biological stimulation effect.This method is most effective when congestive infiltrative changes in the organs of the reproductive system prevail and is therefore used to treat acute and chronic prostatitis and epididymo-orchitis.In the absence of contraindications (prostate stones, adenoma), prostate massage does not lose its therapeutic value.Sanatorium treatment and rational psychotherapy are successfully used in the treatment of chronic prostatitis.
Surgical treatment of chronic prostatitis
Despite its incidence and difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease.This is proven by cases of long and often ineffective treatment, turning the treatment process into a purely commercial activity with minimal risk to the patient's life.A much more serious danger is that its complications not only disrupt the urination process and negatively affect the reproductive function of men, but also lead to serious changes in the anatomy and function of the bladder - sclerosis of the prostate and bladder neck.
Unfortunately, these complications often occur in young and middle-aged patients.That's why the use of transurethral electrosurgery (as a minimally invasive surgery) is becoming increasingly important.In severe organic BOO, due to bladder neck sclerosis and prostatic sclerosis, perform transurethral incisions at 5, 7 and 12 o'clock according to the usual dial or perform economical electroprostatectomy.In cases where chronic prostatitis results, prostatic sclerosis with severe symptoms cannot be treated with conservative therapy.perform the most radical transurethral prostatectomy.Transurethral electroprostatectomy can also be used for common stone-induced prostatitis.Calcification.Centrally localized and transient, they disrupt tissue nutrition and increase congestion in isolated groups of acini, leading to the development of pain that is difficult to treat conservatively.In such cases, electroablation must be performed until the calcification is removed as completely as possible.In some clinics, TRUS is used to monitor calcification removal in these patients.
Another indication for laparoscopic surgery is tuberous sclerosis, accompanied by obstruction of the ejaculatory and excretory ducts of the prostate.
If an exacerbation of a chronic inflammatory process (purulent or serous discharge from the prostatic sinus) is diagnosed during transurethral intervention, surgery must be completed by excision of the entire remaining gland.The prostate is removed by electrosurgery, followed by precise coagulation of the blood vessels with balloon electrodes and installation of a bladder trocar to relieve pressure in the bladder and prevent reabsorption of infected urine into the prostatic duct.