If the situation with infectious (or rather, bacterial) prostatitis is more or less clear, then chronic abacterial prostatitis is still 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 characterized by various organic changes in tissues and functional disorders of the activity of not only the prostate, the organs of the male and lower reproductive system. 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 ranks first in prevalence among inflammatory diseases of the male reproductive system and among the first among men's 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 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, in 35% of cases causes men of working age to consult a urologist. In 7-36% of patients it is complicated by vesiculitis, epididymitis, urination disorders, reproductive and sexual functions.
What causes chronic prostatitis?
Modern medical science considers chronic prostatitis as a polyetiological disease. The appearance and reappearance of chronic prostatitis, in addition to the action of infectious factors, is caused by neurovegetative and hemodynamic disorders, which are accompanied by weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal. , chemical (urine reflux in prostatic ducts) and biochemical (possible role of citrates) processes, as well as deviations of peptide growth factors. Risk factors for developing chronic prostatitis include:
- lifestyle features that cause infection of the genitourinary system (irregular 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):
- performing 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, especially the imbalance between different immunocompetent factors. First of all, this applies to cytokines - low-molecular 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 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 location of pain is the perineum, but a feeling of discomfort can occur in the suprapubic, groin, anus and other areas of the pelvis, in the inner thighs, as well as in the scrotum and in the 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 the 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 with irritative symptoms, less often with symptoms of IVO.
In the case of chronic prostatitis, quantitative and qualitative ejaculate disorders can also be detected, which are rarely the cause of infertility.
The disease of chronic prostatitis has a wave nature, intensifying and weakening periodically. 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, groin and suprapubic areas, 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 often in the scrotum, groin area and sacrum. Urination, as a rule, is not impaired (or increased). Against the background of accelerated ejaculation, without pain, a normal erection is observed.
The proliferative phase of the inflammatory process can be manifested by a weakening of the intensity of the urine flow and increased urination (with exacerbations of the inflammatory process). Ejaculation at this stage is not damaged or slightly slowed down, the intensity of adequate erections is normal or moderately reduced.
In the stage of changes of scarring and sclerosis of the prostate, patients are concerned about heaviness in the suprapubic region, in the sacrum, frequent urination during the day and at night (total pollakiuria), a slow, intermittent flow of urine and an imperative urge to urinate. Ejaculation slows down (even to the point of absence), adequate and sometimes spontaneous erections weaken. Often at this stage, attention is drawn to the "erasing" of the orgasm.
The impact of chronic prostatitis on the 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 the manifestation of 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.
When evaluating the subjective manifestations of the disease, questionnaires are of great importance. Many questionnaires have been designed that are completed by the patient and that the doctor wants to get an idea 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. how to assess 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, it represents an effective tool for identifying 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 1961, Farman and McDonald set the "gold standard" in the diagnosis of prostate inflammation - 10-15 leukocytes in the field of vision) and makea differential diagnosis between its bacterial and nonbacterial forms.
A microscopic examination of the discharged urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and non-specific flora.
When examining an itch of 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 secretion of the prostate or urine obtained after its massage is performed. 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 serum PSA concentration should be performed no earlier than 10 days after digital rectal examination. Despite this fact, 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 non-specific antibodies (IgA, IgG and IgM) in the secretion of the prostate. Immunological research helps to 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 perform 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 evaluate the size and volume of the prostate, echostructure (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral area of the prostate), size, degree of expansion, density and echo-homogeneity. of 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.
X-ray examination should be performed in patients with diagnosed BOO 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 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 should be examined?
Prostate gland (prostate)
How to examine?
- Ultrasound of the prostate
- Prostate biopsy
What tests are needed?
- Analysis of prostate secretion (prostate gland)
- Prostate-specific antigen in the blood
Who to contact?
- urology
- 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, 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 further progression of the disease, but also promote healing. This, as well as the normalization of sex life, diet and much more, is a preparatory stage in treatment. This is followed by the main, basic course, which includes the use of various medications. This step-by-step approach to the treatment of the disease allows you to monitor its effectiveness at each stage, making the necessary changes and also fight the disease according to the same principle with which it was developed. - from predisposing factors to productive ones.
Indications for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy performed in the hospital is more effective than treatment on an outpatient basis.
Drug treatment of chronic prostatitis
It is necessary to simultaneously use several medications and methods that act on different parts of the pathogenesis to eliminate the infectious factor, to normalize blood circulation in the pelvic organs (including the improvement of microcirculation in the prostate), adequate drainage of prostate acini, especially in 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 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 the metabolism of urates and citrates.
In case of chronic abacterial prostatitis and inflammatory syndrome of chronic pelvic pain (in the case when the pathogen has not been identified as a result of the use of microscopic, bacteriological and immune diagnostic methods), empiric antibacterial treatment of chronic prostatitis can be carried out. with a short course and, if clinically effective, continues. The effectiveness of empiric antimicrobial therapy in both patients with bacterial and bacterial 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 the infectious inflammatory process, which is currently not confirmed. Flora that is not detected by standard microscopic or bacteriological examination of prostate secretions can, in some cases, be detected by histological examination of prostate biopsies or by other subtle methods.
In the syndrome of chronic non-inflammatory pelvic pain and chronic asymptomatic prostatitis, the need for antibacterial therapy is debatable. The duration of antibacterial therapy should be no more than 2-4 weeks, after which, if the results are positive, it continues up to 4-6 weeks. If there is no effect, it is possible to stop antibiotics and prescribe drugs of other groups (for example, alpha1-blockers, herbal extracts of Serenoa repens).
The drugs of choice for empiric treatment of chronic prostatitis are fluoroquinolones, as they have high bioavailability and penetrate well into the tissue of the glands (the concentration of some of them in the secret passes it into the blood serum). Another advantage of drugs in 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 any specific drug from the group of fluoroquinolones.
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 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 the return 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 the wrong choice of the drug, its dose and frequency, or the presence of bacteria that persist in the channels, acini or calcifications and are covered with an extracellular protective membrane.
Pain and irritating symptoms are indications for prescribing NPS, which are used both in complex therapy and as a single alpha-blocker 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, the subsequent treatment should aim either to relieve pain, or to resolve problems with urination, or to correct both of the above symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to the blocking of histamine H1 receptors and the action of anticholinesterase. The most commonly prescribed drugs are amitriptyline and imipramine. However, they should be treated 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 ultrasonography (UFM) and, if possible, a video urodynamic 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, the treatment is carried out as for interstitial cystitis, they prescribe amitriptyline, antihistamines and the introduction of antiseptic solutions into the bladder. Anticholinesterase drugs are prescribed for detrusor hyperreflexia. For 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 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 against tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs-ve) and tumor necrosis factor inhibitors are being considered for 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 the stimulation of microcirculation and, as a consequence, the increase in the 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 the accompanying prostate adenoma, different microwave hyperthermia temperature regimes 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 of 40-45 ° C, sclerosing and neuroanalgesic effects prevail, andthe analgesic effect is due to inhibition of sensory nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate that is close to microwave hyperthermia at 39-40 ° C, d. m. th. 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 more effective when the congestive-infiltrative changes in the organs of the reproductive system prevail and is therefore used for the treatment of acute and chronic prostatovesiculitis and epididymo-orchitis. In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value. Sanatorium-resort 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 evidenced by cases of long-term and often ineffective therapy, turning the treatment process into a purely commercial enterprise with minimal risk to the patient's life. A much more serious risk is presented by its complications, which not only disrupt the urination process and negatively affect the reproductive function of men, but also bring serious anatomical and functional changes to 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 surgery) is becoming increasingly important. In the case of severe organic BOO, caused by bladder neck sclerosis and prostate sclerosis, transurethral incision is made at 5, 7 and 12 o'clock of the conventional dial or economic electrical resection of the prostate is performed. In cases where the result of chronic prostatitis is prostate sclerosis with severe symptoms that are not suitable for conservative therapy. perform the most radical transurethral electroresection of the prostate. Transurethral electrosection of the prostate can also be used for common calculous prostatitis. Calcifications. located in the central and transitional areas, they disrupt tissue trophism and increase congestion in 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 resection of calcifications in such patients.
Another indication for endoscopic surgery is the sclerosis of seminal tuberculosis, accompanied by closure 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 the transurethral intervention, the operation must be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by precise coagulation of the bleeding vessels with a topical electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.