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 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, 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 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 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 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 a weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (reflux of urine into the prostatic ducts) and biochemical (possiblethe role of citrates) processes, as well as aberrations of peptide growth factors. Risk factors for the development of chronic prostatitis include:
- lifestyle features that cause infection of the genitourinary system (promiscuous 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):
- carrying out 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, in particular 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 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, on 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 specific for 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 ("erasing") of the emotional coloring of orgasm.
Urinary disorders are more often manifested by irritative symptoms, less often by symptoms of IVO.
In case of chronic prostatitis, quantitative and qualitative disorders of the ejaculate can also be detected, which are rarely the cause of 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 stage is characterized by pain in the scrotum, in the 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 commonly in the scrotum, groin area and sacrum. Urination, as a rule, is not impaired (or increased). Against the background of accelerated, 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 impaired or slightly slowed down, the intensity of adequate erections is normal or moderately reduced.
At the stage of scar changes and sclerosis of the prostate, patients are worried about heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total pollakiuria), a sluggish, intermittent stream of urine and an imperative urge to urinate. Ejaculation is slowed down (even to the point of absence), adequate and sometimes spontaneous erections are weakened. 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
Diagnosis of manifesting 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 determining the state of the immune and neurological status.
When assessing the subjective manifestations of the disease, questionnaires are of great importance. Many questionnaires have been developed that are filled out by the patient and that the doctor wants to get an idea of the frequency and intensity of pain, urination disorders and sexual disorders, the patient’s attitude to these clinical manifestations of chronic prostatitis, as well as 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 the symptoms of chronic prostatitis and determining its impact on the 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 view) and make a differential diagnosis between its bacterial andnonbacterial forms.
A microscopic examination of the discharged 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 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 prostate secretion or urine obtained after its massage is carried out. Based on the results of these studies, 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 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 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 carry out 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 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 echo-homogeneity of the contents of the seminal vesicles.
UDI (UFM, determination of urethral pressure profile, pressure/flow study, cystometry) and myography of the pelvic floor muscles provide additional information if neurogenic urination disorders and dysfunction of the pelvic floor muscles are suspected. as well as IVO, which often accompanies chronic prostatitis.
X-ray examination should be carried out in patients with diagnosed 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 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?
- Urologist
- Andrologist
Treatment of chronic prostatitis
Treatment of chronic prostatitis, like any chronic disease, should be carried out in compliance 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. By 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, as well as normalization of sex life, diet and much more, is a preparatory stage in treatment. This is followed by the main, 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, making the necessary changes, and also fight the disease according to the same principle by which it developed. - from predisposing factors to producing ones.
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 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 pathogenesis in order to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), adequate drainage of prostatic acini, especially in the peripheral zones, normalize the level of essentialhormones 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, 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), 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 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 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 be no more than 2-4 weeks, after which, if the results are positive, it continues for up to 4-6 weeks. If there is no effect, it is possible to discontinue antibiotics and prescribe drugs of other groups (for example, alpha1-blockers, plant extracts of Serenoa repens).
The drugs of choice for empirical treatment of chronic prostatitis are fluoroquinolones, since they have high bioavailability and penetrate well into the gland tissue (the concentration of some of them in the secretion exceeds that 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 treatment of chronic prostatitis do not depend on the use of any specific drug from the group of fluoroquinolones.
If fluoroquinolones are ineffective, combination antibacterial therapy should be prescribed. Tetracyclines have not lost their importance, especially when a chlamydial 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 relapses of bacterial prostatitis.
If relapses occur, the previous course of antibacterial drugs in lower single and daily doses may be prescribed. The ineffectiveness of antibacterial therapy is usually due to the wrong choice of drug, its dosage and frequency, or the presence of bacteria that persist in the ducts, acini or calcifications and are covered with 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 either relieving pain, or solving problems with urination, or correcting both of the above symptoms.
For pain, tricyclic antidepressants have an analgesic effect due to blocking 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 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) should be performed before starting drug therapy, and, if possible, a video urodynamic 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, they prescribe amitriptyline, antihistamines, and instillation of antiseptic solutions 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 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 a chronic inflammatory process, 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 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 for treating 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 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 prevail, and the analgesic effect is due to the inhibition of sensory nervesendings.
Low-energy magnetic laser therapy has an effect on the prostate that is close to microwave hyperthermia at 39-40 ° C, i. e. stimulates microcirculation, has an anticogestive effect, promotes the accumulation of drugs in prostate tissue and 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 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 proven 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 danger is posed by its complications, which not only disrupt 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. 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, transurethral incision is performed at 5, 7 and 12 o'clock of the conventional dial, or economical electrical resection of the prostate is performed. In cases where the outcome of chronic prostatitis is prostate 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 calculous prostatitis. Calcifications. localized in the central and transient zones, 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 must be carried out until the calcifications are removed as completely as possible. In some clinics, TRUS is used to monitor the 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 an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the prostatic sinuses) is diagnosed during transurethral intervention, the operation must be completed by removing the entire remaining gland. The prostate is removed by electroresection, followed by pinpoint coagulation of bleeding vessels with a ball electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.