If the situation with infectious (or rather, bacterial) prostatitis is more or less clear, then abacterial chronic prostatitis is still a serious urological problem with many unclear questions. Perhaps, under the name of the disease called chronic prostatitis, there are many types 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 reproductive system and the lower part. 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 one of the first among male diseases in general. This is the most common urological disease in men under the age of 50. The average age of patients with chronic inflammatory processes in the prostate is 43 years. By the age of 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 it is complicated by vesiculitis, epididymitis, urinary disorders, reproductive and sexual function.
What causes chronic prostatitis?
Modern medical science considers chronic prostatitis as a polyetiological disease. The occurrence and recurrence of chronic prostatitis, in addition to the action of infectious factors, is caused by neurovegetative and hemodynamic disorders, which are accompanied by weakness of local and general immunity, autoimmunity (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormones. , chemical (urine reflux into the prostate duct) and biochemical (possible role of citrate) processes, as well as peptide growth factor deviations. Risk factors for the development of chronic prostatitis include:
- lifestyle characteristics that cause infections of the genitourinary system (promiscuous sexual intercourse without protection and personal hygiene, the presence of inflammatory processes and/or infections in the urinary and genital organs in sexual partners):
- carrying out transurethral manipulation (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 various 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 many more. The most common location of pain is the perineum, but discomfort can occur in the suprapubic, groin, anus and other areas of the pelvis, in the inner thighs, as well as in the scrotal and lumbosacral areas. Unilateral testicular pain is usually not a sign of prostatitis. Pain during and after ejaculation is most 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 experience severe impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE), however, in the late stages of the disease, ejaculation may be slow. There may be a change ("erasure") of the emotional color of orgasm.
Urinary disorders are more often shown by irritating symptoms, less often by IVO symptoms.
In the case of chronic prostatitis, quantitative and qualitative disorders of ejaculation can also be detected, which are rarely the cause of infertility.
Chronic prostatitis disease has a wavy nature, periodically intensifying and weakening. In general, the symptoms of chronic prostatitis correspond to the stage of the inflammatory process.
The exudative stage is characterized by pain in the scrotum, in the groin and suprapubic area, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful erection.
At the alternative stage, the patient may experience pain (unpleasant sensation) in the suprapubic area, less commonly in the scrotum, groin area and sacrum. Urine, as a rule, is not affected (or increased). Against the background of accelerated ejaculation, painless, normal erection is observed.
The proliferative level of the inflammatory process can be shown by weakening the intensity of urine flow and increased urination (with exacerbation of the inflammatory process). Ejaculation at this stage is not affected or slightly slow, sufficient intensity of erection is normal or moderately reduced.
At the stage of scarring and sclerosis of the prostate, the patient is concerned about heaviness in the suprapubic area, in the sacrum, frequent urination day and night (total pollakiuria), wet and intermittent urine flow and the urge to urinate. Ejaculation is slowed down (even to the point of absence), sufficient and sometimes spontaneous erections become weak. Often at this stage, attention is paid to the "erasure" of the orgasm.
The impact of chronic prostatitis on quality of life, according to the unified quality of life rating 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 triad of classic symptoms. Since the disease is often asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including determining the condition of the immune and neurological status.
When assessing the subjective manifestations of the disease, questionnaires are very important. Many questionnaires have been developed that are filled in by patients and doctors who want to get an idea about the frequency and intensity of pain, urinary disorders and sexual disorders, the patient's attitude towards the clinical manifestations of chronic prostatitis, as well as to assess the state of the patient's psycho-emotional sphere. The most popular at the moment 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 to identify the symptoms of chronic prostatitis and determine 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 established the "gold standard" in the diagnosis of prostate inflammation - 10-15 leukocytes in the field of view) and to make a differential diagnosis between bacterial and non-bacterial formsbacteria.
Microscopic examination of the discharged urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and non-specific flora.
When examining scrapings of the urethral mucosa using the PCR method, the presence of microorganisms that cause sexually transmitted diseases is determined.
Microscopic examination of prostate secretions determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.
Bacteriological examination of prostate secretions or urine obtained after the procedure. Based on the results of this study, the nature of the disease is determined (bacterial or abacterial prostatitis). Prostatitis can cause an increase in PSA concentration. Blood sampling to determine serum PSA concentration should be carried out no earlier than 10 days after a digital rectal examination. Despite this fact, when the PSA concentration exceeds 4. 0 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is indicated to exclude prostate cancer.
Very important 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 prostate secretions. 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. This 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 treatment. Ultrasound makes it possible 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 of expansion, density and homogeneity of the echo of the contents of the seminal vesicles.
UDI (UFM, urethral pressure profiling, pressure/flow studies, cystometry) and pelvic floor muscle myography provide additional information if neurogenic urinary disorders and pelvic floor muscle dysfunction are suspected. as well as IVO, which often accompanies chronic prostatitis.
X-ray examination should be carried out in patients with diagnosed BOO 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 non-inflammatory forms of abacterial prostatitis are suspected, when necessary to exclude pathological changes in the spine and pelvic organs.
What needs to be researched?
Prostate gland (prostate)
How to check?
- Ultrasound of the prostate
- Prostate biopsy
What tests are required?
- Analysis of prostate secretions (prostate gland)
- Prostate-specific antigens 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, thoughts 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, as well as the normalization of sex life, diet and more, is a preparatory stage in treatment. This is followed by the main basic course, which involves the use of various drugs. A 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 principles by which it develops. - from predisposing factors to those that produce.
Indications for hospitalization
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of chronic prostatitis, complex therapy carried out in a hospital 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 to eliminate infectious factors, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), adequate drainage of prostate acini, especially in the peripheral zone, normalize the levelimportant hormones and immune responses. 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 urate and citrate.
In the case of chronic abacterial prostatitis and chronic pelvic pain inflammatory syndrome (in cases when the pathogen has not been identified due to the use of microscopic, bacteriological and immune diagnostic methods), empirical antibacterial treatment of chronic prostatitis can be carried out. with a short course and, if clinically effective, continued. The effectiveness of empirical antimicrobial therapy in both patients with bacterial and abacterial prostatitis is approximately 40%. This indicates the undetectable 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 not detected by standard microscopic or bacteriological examination of prostate secretions can, in some cases, be detected by histological examination of prostate biopsy or other subtle methods.
In non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is controversial. The duration of antibacterial therapy should not exceed 2-4 weeks, after which, if the result is positive, it continues for 4-6 weeks. If there is no effect, it is possible to stop the antibiotic and prescribe another group of drugs (for example, alpha1 blockers, Serenoa repens plant extract).
The drug of choice for the empiric treatment of chronic prostatitis is fluoroquinolones, because they have high bioavailability and penetrate well into the tissue of the gland (the concentration of some of them in the secretion exceeds the concentration in 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. Tetracycline does not lose its 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.
Antibacterial drugs are also recommended to be prescribed to prevent recurrence of bacterial prostatitis.
If a relapse occurs, a previous course of antibacterial drugs in single and lower daily doses can be prescribed. The ineffectiveness of antibacterial therapy is usually caused by the wrong choice of drugs, their dose and frequency, or the persistent presence of bacteria in the ducts, acini or calcifications and covered with a protective extracellular membrane.
Pain and symptoms of irritation are indications for the prescription of NPS, which is used in complex therapy, and also as an alpha blocker alone if antibacterial therapy is ineffective (diclofenac dose 50-100 mg/day).
Some studies show the effectiveness of herbal remedies, 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 next treatment should be aimed either at relieving the pain, or solving the urinary problem, or correcting both of the above symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to blocking of histamine H1 receptors and anticholinesterase action. The most commonly prescribed drugs are amitriptyline and imipramine. However, they must be taken with caution. Side effects - drowsiness, dry mouth. In very rare cases, narcotic analgesics (tramadol and other drugs) can be used to relieve pain.
If dysuria predominates in the clinical picture of the disease, ultrasonography (UFM) should be performed before starting drug therapy, and, if possible, a video urodynamic study. Further treatment is prescribed depending on the results obtained. In the case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as for interstitial cystitis, they prescribe amitriptyline, antihistamines, and inhalation of an antiseptic solution into the bladder. For detrusor hyperreflexia, anticholinesterase drugs are prescribed. 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 chronic abacterial prostatitis etiopathogenesis, antispasmodics and muscle relaxants can be prescribed.
In recent years, based on the theory of cytokine participation in the development of chronic inflammatory processes, the possibility of using cytokine inhibitors, such as monoclonal antibodies to tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs) and tumor necrosis factor inhibitors, is being considered for chronic prostatitis.
Non-drug treatment for 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 drug accumulation in the prostate.
The most effective physical methods to treat chronic prostatitis:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono- and electrophoresis).
Depending on the nature of changes in prostate tissue, the presence or absence of congestive and proliferative changes, as well as concomitant prostate adenomas, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 "The main effect of electromagnetic radiation of the microwave range, in addition to the above, is an anticongestive and bacteriostatic effect, as well as activation of the cellular immune system. At a temperature of 40-45 ° C, sclerosing and neuroanalgesic effects occur, and analgesic effectsis caused by inhibition of sensory nerve endings.
Low-energy magnetic laser therapy has an effect on the prostate near hyperthermia microwaves at 39-40 ° C, i. e. stimulates microcirculation, has an anticogestive effect, promotes drug accumulation in prostate tissue and activation of the cellular immune system. In addition, laser therapy has a biostimulation effect. This method is most effective when congestive-infiltrative changes in the organs of the reproductive system dominate and is therefore used for the treatment of acute and chronic prostatovesiculitis and epididymo-orchitis. If there are no contraindications (prostate stones, adenomas), prostate massage does not lose its therapeutic value. Sanatorium-resort treatment and rational psychotherapy are successfully used in the treatment of chronic prostatitis.
Surgical treatment of chronic prostatitis
Despite the prevalence and known difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. This is proven by cases of long-term and often ineffective therapy, making the treatment process a purely commercial enterprise with minimal risk to the patient's life. A more serious danger is posed by its complications, which not only disrupt the urination process and negatively affect the male reproductive function, but also lead to serious anatomical and functional changes in the bladder - sclerosis of the prostate and bladder neck.
Unfortunately, this complication often occurs in young and middle-aged patients. That is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly important. In cases of severe organic BOO, due to bladder neck sclerosis and prostate sclerosis, transurethral incisions are performed at 5, 7 and 12 o'clock of the conventional dial, or economic electrical cutting of the prostate is performed. In cases where the result of chronic prostatitis is prostate sclerosis with severe symptoms that are not amenable to conservative therapy. performed the most radical transurethral electroresection of the prostate. Transurethral electroresection of the prostate can also be used for common calculous prostatitis. Calcification. localized in the middle and temporal zones, they disrupt tissue trophism and increase congestion in isolated groups of acini, which leads to the development of pain that is difficult to treat conservatively. In such cases, electrical cutting must be carried out until the calcification is completely removed. In some clinics, TRUS is used to monitor resection of calcifications in these patients.
Another indication for endoscopic surgery is sclerosis of the seminal tubercles, accompanied by obstruction of the ejaculatory ducts and prostatic excretion.
If an exacerbation of the chronic inflammatory process (purulent or serous-purulent discharge from the prostate sinus) is diagnosed during transurethral intervention, the operation must be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by direct coagulation of the bleeding vessel with a ball electrode and installation of a cystostomy trocar to reduce intravesical pressure and prevent absorption of infected urine into the prostatic duct.