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 the prostate, but also the organs of the male reproductive system. and from the bottom. 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, 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 50 years of age. The average age of patients suffering from a chronic inflammatory process of the prostate is 43 years. By age 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 forces men of working age to consult a urologist. In 7-36% of patients it is complicated by vesiculitis, epididymitis, disorders of urination and reproductive and sexual functions.
What causes chronic prostatitis?
Modern medical science considers chronic prostatitis as a polyetiological disease. The appearance and recurrence of chronic prostatitis, in addition to the action of infectious factors, is caused by neurovegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators: cytokines and leukotrienes), hormonal. , chemical processes (reflux of urine 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 infection of the genitourinary system (promiscuous sexual relations without protection and personal hygiene, presence of an inflammatory process and/or infections of the urinary organs and genitals 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 sexual life.
Among the etiopathogenetic risk factors for chronic prostatitis, immunological disorders are important, in particular the imbalance between 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 3 months. and more. The most common location of pain is the perineum, but a feeling of discomfort may occur in the suprapubic area, groin, anus and other areas of the pelvis, on the inner thighs, as well as in the scrotum and the lumbosacral. Unilateral testicular pain is not usually a sign of prostatitis. Pain during and after ejaculation is more specific to chronic prostatitis.
Sexual function is affected, 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 ("erasing") of the emotional color of the orgasm.
Urinary disorders are most often manifested by irritative symptoms, less often by IVO symptoms.
In case of chronic prostatitis, quantitative and qualitative alterations of the ejaculate can also be detected, which are rarely a cause of infertility.
The disease of 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 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, increased and painful erections.
In the alternative stage, the patient may experience pain (unpleasant sensations) in the suprapubic region, less often in the scrotum, groin and sacrum. Urination, as a rule, is not disturbed (or 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 urine stream and increased urination (with exacerbations of the inflammatory process). Ejaculation at this stage is not disturbed or slightly slowed down, the intensity of proper erections is normal or moderately reduced.
At the stage of cicatricial changes and sclerosis of the prostate, patients are worried about heaviness in the suprapubic region, in the sacrum, frequent urination during the day and night (total urinary frequency), a slow intermittent stream of urine and an urgent need to urinate. Ejaculation slows down (even to the point of its absence), proper and sometimes spontaneous erections weaken. Often at this stage, attention is drawn to the "erasure" 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. Taking into account that the disease is usually asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including determination of the immunological and neurological status.
When evaluating the subjective manifestations of the disease, questionnaires are of great importance. Numerous questionnaires have been developed that the patient fills out and the doctor wants to get an idea of the frequency and intensity of pain, urinary and sexual disorders, the patient's attitude towards these clinical manifestations of chronic prostatitis, as well as 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 and 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 in 1961 Farman and McDonald established the "gold standard" in the diagnosis of prostate inflammation: 10-15 leukocytes in the field of vision) and perform a differential diagnosis between its bacterial and non-bacterial forms.
Microscopic examination of the discharged urethra determines the amount 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 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 is performed on the prostate secretion or urine obtained after massage. 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 levels. 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 greater than 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 immunological status (state of humoral and cellular immunity) and the level of nonspecific antibodies (IgA, IgG and IgM) in the prostate 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 a differential diagnosis, but also to determine the form and stage of the disease, followed by monitoring throughout the 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 zone of the prostate), size, degree of expansion, density and echohomogeneity. 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 if neurogenic voiding disorders and pelvic floor muscle dysfunction are suspected. as well as IVO, which often accompanies chronic prostatitis.
An X-ray examination should be performed in patients with diagnosed BOO to clarify the cause of its occurrence and determine additional treatment tactics.
Computed tomography 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 examine?
- prostate ultrasound
- prostate biopsy
What tests are needed?
- Analysis of prostate secretion (prostate gland)
- Prostate-specific antigen in the blood.
Who to contact?
- Urologist
- andrologist
Treatment of chronic prostatitis.
The treatment of chronic prostatitis, like any chronic disease, must be carried out respecting the principles of coherence and an integrated approach. First of all, it is necessary to change the patient's lifestyle, thinking and psychology. Eliminating the influence of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others. By doing so, we not only stop further progression of the disease, but also promote recovery. This, in addition to the normalization of sexual life, diet and much more, is a preparatory stage of treatment. This is followed by the main and basic 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 was developed. - from predisposing factors to producers.
Indications for hospitalization.
Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy carried out in a 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 to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), proper drainage of the prostatic acini, especially in peripheral areas, they normalize the level of essential hormones and immune reactions. Based on this, the use of 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 with 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 event that the pathogen has not been identified as a result of the use of microscopic, bacteriological and immunological diagnostic methods), empirical antibacterial treatment of prostatitis can be carried out chronicle. with a short course and, if clinically effective, continued. The effectiveness of empiric 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, mycoplasmas, ureaplasmas, fungal flora, Trichomonas, viruses) in the development of the infectious inflammatory process, something that 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 other subtle methods.
In chronic non-inflammatory pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial treatment is controversial. The duration of antibacterial therapy should be no more than 2 to 4 weeks, after which, if the results are positive, it continues for up to 4 to 6 weeks. If no effect occurs, it is possible to stop antibiotics and prescribe drugs from other groups (for example, alpha1 blockers, extracts of Serenoa repens plants).
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 of the blood serum). Another advantage of drugs in this group is their activity against most gram-negative microorganisms, as well as against chlamydia and ureaplasma. The results of the treatment of chronic prostatitis do not depend on the use of any specific drug from the fluoroquinolone group.
If fluoroquinolones are not effective, combined antibacterial therapy should be prescribed. Tetracyclines have not lost their importance, especially when 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 medications to prevent relapses of bacterial prostatitis.
If relapses occur, the previous course of antibacterial medications may be prescribed in lower single daily doses. The ineffectiveness of antibacterial therapy is usually due to a poor choice of drug, its dose and 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 therapies and also as alpha-blockers alone, if antibacterial therapy is ineffective (diclofenac doses of 50 to 100 mg/day).
Some studies demonstrate the effectiveness of herbal medicines, 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, alpha-blockers and NSAIDs, subsequent treatment should be aimed at relieving pain, resolving problems with urination, or correcting both of the above symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to blockade of histamine H1 receptors and anticholinesterase action. The most prescribed drugs are amitriptyline and imipramine. However, they must 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 predominates in the clinical picture of the disease, an ultrasound (UFM) should be performed before starting pharmacological treatment and, if possible, a videourodynamic study. Additional 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, amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder are prescribed. For detrusor hyperreflexia, anticholinesterase medications are prescribed. For hypertonicity of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (relief of spasms), neuromodulation (for example, sacral stimulation).
According to 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 the chronic inflammatory process, the possibility of using cytokine inhibitors has emerged, such as monoclonal antibodies against tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs) and tumor necrosis factor inhibitors are being considered for chronic prostatitis.
Non-pharmacological 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 consequence, increased accumulation of drugs in the prostate.
The most effective physical methods to treat chronic prostatitis:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonotherapy 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 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 of 40-45 ° C , sclerosing and neuroanalgesic effects predominate, 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 anticogestive 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 most effective when congestive-infiltrative changes in the organs of the reproductive system predominate, and therefore it is used for the treatment of acute and chronic prostatovesiculitis and epididymoorchitis. 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 the known difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. This is demonstrated by cases of prolonged 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 posed by its complications, which not only disrupt the urination process and negatively affect the reproductive function of men, but also cause serious anatomical and functional changes in the bladder: sclerosis of the prostate and neck of the bladder. bladder.
Unfortunately, these complications often occur in young and middle-aged patients. That is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly important. In case 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 hours of the conventional dial, or an economical electrical resection of the prostate is performed. In cases where the result 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 zones, they alter 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 resection should be performed until the calcifications are eliminated 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 during the transurethral intervention an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the prostatic sinuses) is diagnosed, the operation should be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by spot coagulation of the 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.