Chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by an infection with possible addition of autoimmune disorders, characterized by damage to the parenchymal and interstitial tissue of the organ. The disease has been known to medicine since 1850, but even today it remains poorly understood and poorly responsive to treatment. Chronic bacterial (6-10%) and non-bacterial (80-90%) prostatitis are the most common and socially significant inflammatory diseases in men, significantly reducing their quality of life. The disease is recorded mainly in young and middle-aged people and is often complicated by impaired copulatory and generative functions (decreased potency, infertility, etc. ). The disease is recorded in men in 8 - 35% of cases between the ages of 20 and 40.

The cause of bacterial prostatitis is the pyogenic flora, which penetrates into the gland from the urethra, or by the lymphogenous and hematogenous pathways. The etiology of chronic nonbacterial prostatitis and its pathogenesis remain unknown. It affects mainly men over the age of 50.

The reasons for the development of the disease

Chronic prostatitis is currently considered a polietiologic disease. There is an opinion that the disease arises as a result of the penetration of infection into the prostate, and then the pathological process proceeds without its participation. A number of non-infectious factors contribute to this.

Infectious factors in the development of chronic prostatitis

In 90% of cases, pathogens enter the gland from the urethra, resulting in acute or chronic prostatitis. There have been cases of asymptomatic carriage. The course of the disease is influenced by the state of the human body's defenses and the biological properties of the pathogen. It is assumed that the transition from acute to chronic prostatitis occurs due to loss of tissue elasticity due to excessive production of fibrous tissue.

Among the causative agents of chronic prostatitis, the following pathogens are found:

• In 90% of cases, the disease reveals such gram-negative bacteria as Escherichia coli (E. coli), Enterococcus faecalis (fecal enterococcus), somewhat less often - Pseudomonas aeruginosa, Klebsiella spp. , Proteus spp. , Pseudomonas aeruginogenes, and Enterobacter. Gram-positive bacteria enterococci, streptococci, and staphylococci are rare.
• The role of coagulase-negative staphylococci, ureaplasma, chlamydia, Trichomonas, gardnerella, anaerobic bacteria and fungi of the genus Candida has not been completely elucidated.

Infection enters the prostate in several ways:

• An ascending path is most likely, as evidenced by the frequent combination of prostatitis and urethritis.
• Hematogenous prostatitis develops when the infection penetrates into the gland with the blood stream, which is observed in chronic tonsillitis, sinusitis, periodontitis, pneumonia, cholecystitis and cholangitis, purulent diseases of the skin, etc.
• By contact, chronic prostatitis develops with urethritis and strictures of the urethra, when the infection enters the gland ascending with the urine stream, with purulent kidney infections, canalicular way with epipidymitis, deferentitis and funiculitis, during diagnostic and therapeutic urological manipulations (catheterization, urethralization), including transurethral.
• Lymphogenous infection penetrates the prostate with proctitis, thrombophlebitis of hemorrhoidal veins, etc.

Non-infectious factors in the development of chronic prostatitis

Chemical factors

According to experts, the leading role in the development of chronic prostatitis belongs to intraprostatic reflux of urine, when urine is thrown from the urethra into the gland, which leads to impaired emptying of the prostate and seminal vesicles.

With the disease, vascular reactions develop, leading to edema of the organ, the nervous and humoral regulation of the tone of the smooth muscle tissues of the urethra is disturbed, the activation of alpha_one–Adrenergic receptors causes the development of dynamic obstruction and contributes to the development of new intraprostatic refluxes.

The urates contained in urine, during reflux, lead to the development of a "chemical inflammatory response".

Hemodynamic disorders

They support chronic inflammation and circulatory disorders in the pelvic organs and scrotum. Congestion develops in persons leading a sedentary lifestyle, for example, drivers, office workers, etc. , with obesity, sexual abstinence, sexual dysmetria, frequent hypothermia, mental and physical overload. The intake of spicy and spicy foods, alcohol and smoking, etc. , contribute to the maintenance of the inflammatory process.

Other factors

There are many other factors that support chronic prostate inflammation. These include:

• Hormonal.
• Biochemical.
• Impaired immune response.
• Autoimmune mechanisms.
• Infectious and allergic processes.
• Features of the structure of the glands of the prostate, leading to difficulty in full drainage.

Quite often, the reasons for the development of chronic prostatitis are not possible to establish.

Classification of prostatitis

According to the classification proposed in 1995 by the US National Institutes of Health, prostatitis is divided into:

• Acute (category I). Is 5 - 10%.
• Chronic bacterial (category II). Is 6 - 10%.
• Chronic non-bacterial inflammatory (category IIIA). Is 80 - 90%.
• Chronic non-bacterial non-inflammatory (category IIIB) or chronic pelvic pain syndrome.
• Chronic prostatitis, diagnosed by chance (category IV).

Signs and symptoms of chronic prostatitis

The course of chronic prostatitis is long, but not monotonous. The periods of exacerbation are replaced by periods of relative calm, which occur after complex anti-inflammatory and antibacterial therapy.

The development of chronic bacterial prostatitis is often preceded by urethritis of a bacterial or gonorrheal nature, non-bacterial - circulatory disorders in the pelvic organs and scrotum (hemorrhoids, varicocella, etc. ), sexual excesses.

Patients with chronic prostatitis have many complaints. They go to doctors for years, but very rarely are examined for prostate disease. About a quarter of patients do not present any complaints, or the disease proceeds with scant clinical symptoms.

Complaints of patients with chronic prostatitis can be conditionally divided into several groups.

Urinary disorders associated with narrowing of the urethra:

• Difficulty at the beginning of urination.
• Weak urine stream.
• Intermittent or drop-by-drop urination.
• Feeling of incomplete emptying of the bladder.

Symptoms due to irritation of the nerve endings:

• Frequent urination.
• The urge to urinate is sharp and violent.
• Urination in small portions.
• Incontinence of urine during the urge to urinate.

Pain syndrome:

• The intensity and nature of the pain are different.
• Localization of pain: lower abdomen, perineum, rectum, groin and lower back, inner thighs.

Sexual dysfunction:

• Pain in rectum and urethra on ejaculation.
• Sluggish erection.
• Loss of orgasm.
• Premature ejaculation, etc.

On the part of the nervous system: neurotic disorders in the form of fixing the attention of patients on their state of health.

Signs and symptoms of chronic nonbacterial prostatitis

The syndrome of chronic pelvic pain in men (CPPS) proceeds with the usual symptoms for chronic prostatitis, but bacteria are absent in the 3rd portion of urine and in the secretion of the prostate. CPPS can be simulated by chronic non-bacterial interstitial cystitis, rectal diseases, spastic pelvic floor myalgia syndrome and functional prostate lesions caused by disorders of the innervation of the organ and its hemodynamics.

If the neurovegetative function is impaired, atony and a violation of the innervation of the gland are noted, which is manifested by the difficulty of quickly and completely closing the lumen of the urethra. At the same time, urine after urination continues to be excreted for a long time drop by drop. In such patients, the study reveals instability and increased excitability, which is manifested by increased sweating and excitability of cardiac activity, changes in dermographism.

Complications of the disease

The long course of chronic prostatitis is complicated by impaired sexual and reproductive functions, the development of diseases such as vesiculitis and epipidymitis, as well as hardening of the organ. Sclerosis of the organ worsens local microcirculation and urodynamics, as well as the results of surgical interventions. Fibrosis of the periurethral tissues leads to the development of urinary disorders.

Diagnostics

Due to the fact that there are many reasons for the development of chronic prostatitis, a whole range of diagnostic studies is used to diagnose it. The success of treatment depends on the correct determination of the causes of the disease. The diagnosis of chronic prostatitis is based on the following data:

• The classic triad of symptoms.
• A set of physical methods (digital rectal examination of the prostate).
• A set of laboratory methods (urine analysis and microscopy of prostate secretion, culture and determination of the sensitivity of microflora to antibacterial drugs, general analysis of urine and blood).
• For the detection of gonococci, bacterioscopy of a smear from the urethra, PCR and serological methods (for the detection of ureaplasmas and chlamydia).
• Urofluometry.
• Prostate biopsy.
• A set of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of neurological status.
• If treatment is ineffective and complications are suspected, computed and magnetic resonance imaging, blood culture, etc.

Palpation of the prostate

Of paramount importance in the diagnosis of the disease is palpation of the prostate, which increases during the period of exacerbation and decreases during the period of abatement of the inflammatory process. In chronic prostatitis during an exacerbation of iron, it is edematous and painful.

The density of the organ's consistency can be different: areas of softening and compaction are palpated, zones of depressions are determined. On palpation, it is possible to assess the shape of the gland, the condition of the seminal tubercles and surrounding tissues.

The process of transrectal digital examination is combined with the collection of the secretion of the gland. Sometimes it becomes necessary to obtain the secret from each share separately.

Analysis of a 3-glass urine sample and prostate secretion

The "gold standard" in the diagnosis of chronic prostatitis are:

• Collection of the first portion of urine.
• Collection of the second portion of urine.
• Obtaining the secretion of the gland by massage.
• Collection of the third portion of urine.

Further, a microscopic and bacteriological examination of the material is carried out.

With inflammation of the prostate:

• Microbial count (CFU) exceeds 10³/ ml (10^four/ ml for epidermal staphylococci), but one should not neglect the small number of microbes in the tens and hundreds.
• The presence of 10-15 leukocytes in the field of view, detected by microscopy, is a generally accepted criterion for the presence of an inflammatory process.

The secret of the prostate and the 3rd portion of urine are subjected to microscopic and bacteriological examinations:

• In chronic bacterial prostatitis, there is an increase in the number of leukocytes in the secretion of the gland and the third post-massage portion of urine, bacteria (mainly of the intestinal group) are released.
• With non-bacterial prostatitis, there is an increase in the number of leukocytes in the secretion of the gland, but the microflora is not detected.
• With CPPS, there is no increased number of leukocytes and microflora.

Normal rate of prostate secretion:

• Leukocytes less than 10 in the field of view.
• There are a lot of lecithin grains.
• Microflora is absent.

In chronic prostatitis, the secretion of the prostate reveals:

• The number of leukocytes is large - more than 10-15 in the field of view.
• The amount of lecithin grains is reduced.
• The pH of the secretion shifts to the alkaline side.
• The content of acid phosphatase is reduced.
• The activity of lysozyme is increased.

Obtaining negative results of prostate secretion does not prove once the absence of an inflammatory process.

The value of the prostate secretion crystallization test is retained. Normally, during crystallization, a characteristic pattern is formed in the form of a fern leaf. In the case of a violation of the aggregation properties of the prostatic secretion, such a pattern does not form, which occurs when the androgenic hormonal background changes.

Ultrasound procedure

If a prostate disease is suspected, an ultrasound examination of the gland itself is used (transrectal ultrasound is optimal), the kidneys and the bladder, which makes it possible to determine:

• The volume and size of the gland.
• Presence of calculi.
• The size of the seminal vesicles.
• The condition of the walls of the bladder.
• The amount of residual urine.
• Scrotum structures.
• Another type of pathology.

Other methods of examining the prostate

• The state of urodynamics (a study of the flow rate of urine) is easily and simply determined using a study such as uroflowmetry. With the help of this study, it is possible to timely detect signs of bladder outlet obstruction and carry out dynamic observation.
• Puncture biopsy is performed if abscess formation, benign hyperplasia and prostate cancer are suspected.
• In order to clarify the reasons for the development of infravesicular obstruction, X-ray and endoscopic studies are performed.
• With a long-term inflammatory process, it is recommended to carry out urethrocystoscopy.

Differential diagnosis

Chronic prostatitis should be distinguished from vesiculoprostatostasis, autonomic prostatopathy, congestive prostatitis, pelvic floor myalgia, neuropsychiatric disorders, pseudodyssynergy, reflex sympathetic dystrophy, inflammatory diseases of other organs: interstitial cystitis, osteitis of the vesicular articulation, cervical hyperthyroidism, prostate and bladder cancer, urolithiasis, chronic epipidymitis, inguinal hernia.

Chronic prostatitis treatment

Treatment of chronic prostatitis should begin with changing the lifestyle and diet of the patient.

In the treatment of the disease, drugs are simultaneously used that affect different links of pathogenesis.

The main directions of therapy:

• Elimination of causative microorganisms.
• Anti-inflammatory therapy.
• Normalization of blood circulation in the prostate and pelvic organs.
• Normalization of adequate drainage of the prostatic acini.
• Normalization of the hormonal profile.
• Prevention of hardening of the organ.

For the treatment of chronic prostatitis, drugs of the following groups are used:

• Antibacterial.
• Anticholinergic.
• Vasodilators.
• Alpha_one–Adrenergic blockers.
• 5 alpha reductase inhibitors.
• Cytokine inhibitors.
• Non-steroidal anti-inflammatory.
• Angioprotectors.
• Immunomodulators.
• Drugs affecting urate metabolism.

Antibiotics in the treatment of chronic bacterial prostatitis

Antibiotic therapy should be carried out taking into account the sensitivity of the identified microorganisms to antibiotics. If the pathogen is not identified, empirical antimicrobial treatment is used.

The drugs of choice are fluoroquinolones of the II-IV generation. They quickly penetrate into the tissues of the gland with the usual methods of application, are active against a large group of gram-negative microorganisms, as well as ureaplasma and chlamydia. In case of failure of antimicrobial treatment, one should assume:

• multidrug resistance of microflora,
• short (less than 4 weeks) courses of treatment,
• the wrong choice of antibiotic and its dosage,
• changes in the type of pathogen,
• the presence of bacteria living in the ducts of the prostate, covered with a protective extracellular membrane.

The duration of treatment should be at least 4 weeks with mandatory subsequent bacteriological control. If there is more than 10 bacteriuria in the 3rd portion of urine and prostate secretion³CFU / ml, a repeated course of antibiotic therapy is prescribed for a period of 2 to 4 weeks.

Cytokine inhibitors in the treatment of chronic prostatitis

Cytokines are glycoproteins that are secreted by immune and other cells in response to an inflammatory response and an immune response. They take an active part in the development of the chronic inflammatory process.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs have anti-inflammatory effects, relieve pain and fever. They are widely used in the treatment of chronic prostatitis in the form of tablets and suppositories. The most effective route is rectal administration.

Immunotherapy

In the treatment of bacterial chronic prostatitis, in addition to antibiotics and anti-inflammatory drugs, immunomodulatory agents are used. The most effective is the rectal route of their administration. An immunomodulator is widely used, which increases the functional activity of phagocytes, which contributes to a more efficient elimination of pathogens.

Alpha-blockers in the treatment of chronic prostatitis

It has been found that alpha-1 adrenergic blockers normalize the smooth muscle tone of the prostatic urethra, seminal vesicles and prostate capsule, which makes the drugs of this group very effective in treating the disease. Alpha-1 adrenergic blockers are used in patients with severe urinary disorders in the absence of an active inflammatory process.

With CPPS, the duration of treatment is 1 to 6 months.

5a-reductase inhibitor in the treatment of abacterial prostatitis and CPPS

It was found that under the influence of the 5a-reductase enzyme, testosterone is converted into the prostatic form 5a-dihydrotestosterone, the activity of which in prostate cells is more than 5 times higher than the activity of testosterone itself, which in elderly people leads to an increase in the organ due to epithelial and stromal components.

When a 5a-reductase inhibitor is taken for 3 months, atrophy of the stromal tissue is noted, within 6 months - glandular, the secretory function is inhibited, the severity of pain syndrome and the volume of the gland decreases, the tension and edema of the organ decrease.

The role of anti-sclerotic drugs in the treatment of chronic prostatitis

With prolonged inflammation in the prostate gland, fibrosis develops, which is manifested by impaired microcirculation and urodynamics. In order to prevent the process of fibrosis, anti-sclerotic drugs are used.

Other drugs used to treat chronic prostatitis

Along with the above-described drugs, the following are used to treat the disease:

• Antihistamines.
• Vasodilators and angioprotectors.
• Immunosuppressants.
• Drugs affecting the metabolism of urate and trisodium salt of citric acid.

Herbal products

Effective in the treatment of prostatitis is the use of a preparation in the form of suppositories containing a complex of biologically active peptides isolated from the prostate gland of cattle.

Under the influence of the drug occurs:

• Stimulation of metabolic processes in the tissues of the gland.
• Improving microcirculation.
• Reduction of edema, leukocyte infiltration, secretion stagnation and pain.
• Prevention of thrombosis in the venules of the prostate gland.
• Increased activity of the secretory epithelium of the acini.
• Improving sexual function (increasing libido, restoring erectile function and normalizing spermatogenesis).

Finger massage of the prostate gland

A number of researchers argue that finger massage should be used for chronic prostatitis, taking into account known contraindications.

Physiotherapy

The effectiveness of physiotherapeutic procedures in the treatment of prostatitis has not been proven today, the mechanism of action has not been scientifically established, and adverse reactions have not been studied.

Prevention of chronic prostatitis

When starting to prevent the development of chronic prostatitis, you should know:

• The risk of developing the disease increases over the years.
• Representatives of the Negroid race are more prone to illness.
• A family predisposition to the disease is not excluded.

Persons with a predisposition to the development of chronic prostatitis should be more attentive to their state of health.

Disease prevention tips:

• Drink plenty of fluids. Frequent urination promotes leaching of microflora from the urethra.
• Prevent diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods that are high in carbohydrates and saturated fats, which leads to weight gain.
• You should limit the use of substances that irritate the urethra as much as possible: spicy and spicy foods, smoked meats, sauces and seasonings, coffee and alcohol.
• Stop smoking. Nicotine adversely affects the condition of the vascular walls.
• Don't overcool.
• Do not hold emptying of the bladder.
• Lead an active lifestyle, exercise. Exercise to strengthen the pelvic floor muscles, which can eliminate venous congestion, which in turn supports normal prostate function.
• Have a regular sex life. Avoid prolonged abstinence. The gland must be promptly released from the secret.
• Stay in a monogamous relationship. Indiscriminate sex increases the likelihood of acquiring sexually transmitted diseases.
• If you have complaints from the genitourinary organs, immediately contact your urologist.