If the situation of infectious (or rather bacterial) prostatitis is more or less clear, chronic abacterial prostatitis still remains a serious urological problem with many unclear questions. Perhaps, under the guise of a disease called chronic prostatitis, there is a whole series 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 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 is first in prevalence 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 50 years of age. The average age of patients suffering from chronic inflammatory process of the prostate is 43 years, while at 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, according to the most approximate estimates, chronic prostatitis leads 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 are the causes of chronic prostatitis?
Modern medical science considers chronic prostatitis as a polyetiological disease. The onset 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 to endogenous immunomodulators - cytokines and leukotrienes) , hormonal, chemical processes (urine reflux into the prostatic ducts) and biochemical processes (possible role of citrates), as well as aberrations of peptide growth factors. Risk factors for developing chronic prostatitis include:
- lifestyle characteristics that cause infections of the genitourinary system (promiscuous sexual 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 prostate TURP) without prophylactic antibiotic therapy:
- presence of an indwelling urethral catheter:
- chronic hypothermia;
- sedentary lifestyle;
- irregular sexual life.
Among the etiopathogenetic risk factors of chronic prostatitis, immunological disorders are important, in particular the imbalance between the various immunocompetent factors. First of all, this applies to cytokines: low molecular weight 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
The 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 for 3 months. and more. The most common site of pain is the perineum, but a feeling of discomfort can occur in the suprapubic area, inguinal area, anus and other areas of the pelvis, inside 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 more specific to 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 advanced stages of the disease, ejaculation may be slow. There may be a change ("erasure") of the emotional coloring of the orgasm.
Urinary disorders manifest themselves more often with irritative symptoms, less often with symptoms of BOI.
In case of chronic prostatitis, quantitative and qualitative disorders of the ejaculate can also be found, which rarely cause infertility.
The disease chronic prostatitis has a wavy nature, periodically intensifying and weakening. In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.
The exudative phase is characterized by pain in the scrotum, inguinal and suprapubic area, 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 phase, the patient may experience pain (unpleasant sensations) in the suprapubic region, less commonly in the scrotum, inguinal area and sacrum. Urination, as a rule, is not impaired (or increased). Against the background of accelerated and painless ejaculation, a normal erection is observed.
The proliferative phase of the inflammatory process can be manifested by a weakening of the intensity of urine flow and increased urination (with exacerbations of the inflammatory process). Ejaculation in this phase is not impaired or slightly slowed down, the intensity of adequate erections is normal or moderately reduced.
In the stage of scar changes and sclerosis of the prostate, patients are concerned about heaviness in the suprapubic region, sacrum, frequent urination day and night (total pollakiuria), slow and intermittent urine flow and an imperative urge to urinate. Ejaculation is slowed down (to the point of disappearing), adequate and sometimes spontaneous erections are weakened. Often in this phase attention is drawn to the "cancellation" 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
The diagnosis of manifest chronic prostatitis is not difficult and is based on the classic triad of symptoms. Considering that the disease is often asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including determination of immune and neurological status.
When evaluating subjective manifestations of the disease, questionnaires are of great importance. Numerous questionnaires have been developed that are filled out by the patient and with which the doctor wants to get an idea of the frequency and intensity of pain, urination disorders and sexual disorders, the patient's attitude towards these clinical manifestations of chronic prostatitis, as well as how to evaluate 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; represents an effective tool for identifying the symptoms of chronic prostatitis and determining their impact on quality of life.
Laboratory diagnosis of chronic prostatitis
It is the laboratory diagnosis of chronic prostatitis that allows you to diagnose "chronic prostatitis" (since 1961 Farman and McDonald established the "gold standard" in the diagnosis of inflammation of the prostate - 10-15 leukocytes in the field of vision) and make a differential diagnosis between its bacterial and non-bacterial forms.
A microscopic examination of the unloaded urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and nonspecific flora.
When examining a scraping of the urethral mucosa using the PCR method, the presence of microorganisms causing sexually transmitted diseases is determined.
Microscopic examination of prostatic secretion determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallement bodies, and macrophages.
A bacteriological examination of the prostate secretion or urine obtained after its massage is carried out. 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 serum PSA concentration should be performed 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.
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 secretion. Immunological research helps determine the stage of the process and monitor the effectiveness of treatment.
Instrumental diagnosis of chronic prostatitis
TRUS of the prostate for chronic prostatitis has high sensitivity but low specificity. The study allows not only to make differential diagnoses, but also to determine the form and stage of the disease with subsequent monitoring during the course of treatment. Ultrasound allows you to evaluate the size and volume of the prostate, echostructure (cysts, stones, fibrosclerotic alterations of the organ, abscesses, hypoechoic areas in the peripheral area of the prostate), dimensions, degree of expansion, density and echo-homogeneity of the contents of the vesicles seminal.
UDI (UFM, urethral pressure profile determination, pressure/flow study, cystometry) and pelvic floor muscle myography provide additional information if neurogenic micturition disorders and pelvic floor muscle dysfunction are suspected. as well as BOI, which often accompanies chronic prostatitis.
Radiographic examination should be carried out in patients diagnosed with BOO 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 exclude pathological changes in the spine and pelvic organs.
What needs to be examined?
Prostate gland (prostate)
How to test?
- Ultrasound of the prostate
- Prostate biopsy
What tests are necessary?
- Analysis of prostatic secretion (prostate gland)
- 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 lifestyle, his thinking and psychology. Eliminating the influence of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others. In this way we not only stop the further progression of the disease, but also promote healing. This, as well as the normalization of sexual life, diet and much more, is a preparatory stage of treatment. This is followed by the main, basic course, which involves the use of various drugs. This step-by-step approach to treating the disease allows you to monitor its effectiveness at each stage, making the necessary adjustments, and also fight the disease according to the same principle by which it developed. - from predisposing to producing factors.
Indications for hospital admission
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy carried out in hospital is more effective than outpatient treatment.
Pharmacological 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 the prostatic acini, especially in the area peripheral areas, normalize 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 in chronic prostatitis. In recent years, the treatment of chronic prostatitis has been carried out using drugs previously not used for this purpose: alpha1-blockers, 5-α-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs that affect the metabolism of urate and citrate.
In case of chronic abacterial prostatitis and chronic pelvic pain inflammatory syndrome (in case the pathogen has not been identified as a result of the use of microscopic, bacteriological and immune diagnostic methods), empirical antibacterial treatment of prostatitis can be carried out chronic with a short and, if clinically effective, continuous cycle. The effectiveness of empiric antimicrobial therapy in both bacterial and abacterial prostatitis patients is approximately 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 the 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 prostatic biopsies or other subtle methods.
In chronic non-inflammatory pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is controversial. The duration of antibacterial therapy must not exceed 2-4 weeks, after which, if the results are positive, it is continued for up to 4-6 weeks. If there is no effect, you can discontinue antibiotics and prescribe drugs from other groups (for example, alpha1-blockers, plant extracts of Serenoa repens).
The drugs of choice for the empirical treatment of chronic prostatitis are fluoroquinolones, since they have high bioavailability and penetrate well into the glandular tissue (the concentration of some of them in the secretion exceeds that in the blood serum). Another advantage of drugs from this group is their activity against most gram-negative microorganisms, as well as against chlamydia and ureaplasma. The results of 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 a chlamydial infection is suspected.
Recent studies have shown that clarithromycin penetrates well into prostatic tissue and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.
It is also advisable to prescribe antibacterial drugs to prevent recurrences of bacterial prostatitis.
If relapses occur, the previous course of antibacterial drugs in single, lower daily doses may be prescribed. The ineffectiveness of antibacterial therapy is usually due to the wrong choice of the drug, its dosage and its frequency, or to 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 and also as an alpha-blocker alone if antibacterial therapy 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 the clinical symptoms of the disease (pain, dysuria) persist after the use of antibiotics, α-blockers and NSAIDs, subsequent treatment should be aimed at relieving pain, solving problems with urination or correcting both symptoms mentioned above.
Regarding pain, tricyclic antidepressants have an analgesic effect due to the blockade 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) may be used to relieve pain.
If dysuria prevails in the clinical picture of the disease, before starting drug therapy it is advisable to perform an ultrasound (UFM) and, if possible, a videourodynamic study. 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, prescribe amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder. 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 has opened up, such as monoclonal antibodies against tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs) and tumor necrosis factor inhibitors, is being considered for chronic prostatitis.
Non-pharmacological 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, an increase in the accumulation of drugs in the prostate.
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 the activation of the cellular immune system. At a temperature of 40-45 ° C, they prevail the sclerosing and neuroanalgesic effects and the analgesic effect is due to the inhibition of sensory nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate close to microwave hyperthermia at 39-40 ° C, that is, it stimulates microcirculation, has an anti-gestive effect, promotes the accumulation of drugs in the prostate tissue and the activation of the immune system mobile phone. Furthermore, laser therapy has a biostimulating effect. This method is most effective when congestive-infiltrative changes in the organs of the reproductive system predominate and is therefore used for the treatment of acute and chronic prostatovesiculitis and epididymo-orchitis. 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 life-threatening disease. This is demonstrated by cases of long-term and often ineffective therapies, which turn the treatment process into a purely commercial enterprise with minimal risk to the patient's life. A much more serious danger is represented by its complications, which not only interrupt 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 bladder neck.
Unfortunately, these complications often occur in young and middle-aged patients. This is why the use of transurethral electrosurgery (as a minimally invasive procedure) is becoming increasingly important. In case of severe organic BOO, caused by sclerosis of the bladder neck and sclerosis of the prostate, the transurethral incision is performed at the 5, 7 and 12 o'clock positions of the conventional quadrant or the economical electrical resection of the prostate is performed. In cases where the outcome of chronic prostatitis is prostatic sclerosis with severe 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 stone prostatitis. Calcifications. located in the central and transitional areas, they alter the trophism of the tissues and increase the congestion of isolated groups of grapes, determining the development of pain that is difficult to treat conservatively. In these cases it is necessary to perform electrical resection until the calcifications are removed as completely as possible. In some clinics, TRUS is used to monitor resection of calcifications in such 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 during the transurethral surgery an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the prostatic sinuses) is diagnosed, the surgery must be completed with the removal of the entire residual gland. The prostate is removed by electroresection, followed by spot coagulation of bleeding vessels with a ball electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent reabsorption of infected urine into the prostatic ducts.