Chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by 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 does not respond 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 occurs mainly in young and middle-aged people and is often complicated by alterations in copulatory and generative functions (decreased potency, infertility, etc. ). The disease occurs in men in 8 to 35% of cases between the ages of 20 and 40.

The cause of bacterial prostatitis is the pyogenic flora, which enters the gland from the urethra, or through the lymphogenic and hematogenous routes. The etiology of chronic nonbacterial prostatitis and its pathogenesis are unknown. It mainly affects men over 50 years of age.

The reasons for the development of the disease

Chronic prostatitis is currently considered a polyetiological disease. There is an opinion that the disease arises as a result of the penetration of the infection into the prostate, and then the pathological process continues without its participation. Several 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. The transition from acute to chronic prostatitis is assumed to occur due to loss of tissue elasticity due to excessive production of fibrous tissue.

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

• In 90% of cases, the disease reveals gram-negative bacteria such as Escherichia coli (E. coli), Enterococcus faecalis (fecal enterococcus), somewhat less often: Pseudomonas aeruginosa, Klebsiella spp. , Proteus spp. , Pseudomonas aeruginogenes and Enterobacter. . Gram-positive bacterial 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 fully elucidated.

The infection enters the prostate in several ways:

• It is most likely an upward path, as evidenced by the frequent combination of prostatitis and urethritis.
• Hematogenous prostatitis develops when the infection penetrates the gland with the bloodstream, which is observed in chronic tonsillitis, sinusitis, periodontitis, pneumonia, cholecystitis and cholangitis, purulent skin diseases, etc.
• By contact, chronic prostatitis develops with urethritis and stricture of the urethra, when the infection enters the gland ascending with urine flow, with purulent infections of the kidneys, via the canalicular route for epipidymitis, vas deferens and funiculitis, during diagnostic urological manipulations and therapeutic (catheterization, urethralization), including transurethral.
• Lymphogenic infection penetrates the prostate with proctitis, thrombophlebitis of the hemorrhoidal veins, etc.

Non-infectious factors in the development of chronic prostatitis.

Chemical factors

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

With the disease, vascular reactions develop that lead 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 cause the development of dynamic obstruction and contribute to the development of new intraprostatic reflux.

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

Hemodynamic disorders

They support chronic inflammation and circulatory disorders in the pelvic organs and scrotum. Congestion develops in people who lead a sedentary lifestyle, for example drivers, office workers, etc. , with obesity, sexual abstinence, sexual dysmetria, frequent hypothermia, mental and physical overload. The intake of hot 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 inflammation of the prostate. These include:

• Hormonal.
• Biochemical.
• Impaired immune response.
• Autoimmune mechanisms.
• Infectious and allergic processes.
• Features of the structure of the prostate glands, which makes complete drainage difficult.

Very often, it is not possible to establish the reasons for the development of chronic prostatitis.

Classification of prostatitis

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

• Acute (category I). It is 5 to 10%.
• Chronic bacterial (category II). It is 6 to 10%.
• Chronic non-bacterial inflammatory (category IIIA). It is 80 - 90%.
• Chronic non-bacterial non-inflammatory (category IIIB) or chronic pelvic pain syndrome.
• Chronic prostatitis, diagnosed at random (category IV).

Signs and symptoms of chronic prostatitis.

The course of chronic prostatitis is long, but not monotonous. 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 see doctors for years, but are seldom screened for prostate disease. Approximately a quarter of patients have no complaints or the disease progresses with few 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 urination or drip.
• Feeling of incomplete emptying of the bladder.

Symptoms due to irritation of nerve endings:

• Frequent urination
• The urge to urinate is sharp and violent.
• Urination in small portions.
• Urine incontinence during the urge to urinate.

Pain syndrome:

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

Sexual dysfunction:

• Pain in the rectum and urethra when ejaculating.
• Slow 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

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

If the neurovegetative function is disturbed, 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 drop by drop for a long time. 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. Organ sclerosis 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 wide range of diagnostic studies are used to diagnose it. The success of the 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 exam of the prostate).
• A set of laboratory methods (urinalysis 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 urethral smear, PCR and serological methods (for the detection of ureaplasmas and chlamydia).
• Urofluometry.
• Prostate biopsy.
• Instrumental method complex (ultrasound).
• Determination of the immunological status of the patient.
• Determination of neurological status.
• If treatment is ineffective and complications are suspected, MRI and computerized resonances, blood culture, etc. are performed.

Palpation of the prostate

Of utmost 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 iron exacerbation, it is edematous and painful.

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

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

Analysis of a 3-vessel urine sample and prostate discharge

The "gold standard" in diagnosing 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.

In addition, 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 do not neglect the small number of microbes in the tens and hundreds.
• The presence of 10-15 leukocytes in the field of vision, detected by microscopy, is a generally accepted criterion for the presence of an inflammatory process.

The secret of the prostate and the third 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 in the third portion of urine after massage, bacteria are released (mainly from the intestinal group).
• With non-bacterial prostatitis, there is an increase in the number of leukocytes in the gland's secretion, but the microflora is not detected.
• With CPPS, there is no increase in the number of leukocytes and microflora.

Normal prostate secretion rate:

• Leukocytes less than 10 in the field of vision.
• There are many grains of lecithin.
• The microflora is absent.

In chronic prostatitis, discharge from the prostate reveals:

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

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

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

Ultrasound procedure

If prostate disease is suspected, an ultrasound of the gland itself (transrectal ultrasound is optimal), kidneys, and bladder is used to determine:

• The volume and size of the gland.
• Presence of stones.
• The size of the seminal vesicles.
• The state of the bladder walls.
• The amount of residual urine.
• Structures of the scrotum.
• Another type of pathology.

Other methods of examining the prostate.

• Urodynamic status (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 detect early signs of bladder outlet obstruction and perform dynamic observation.
• A needle biopsy is performed if abscess formation, benign hyperplasia, and prostate cancer are suspected.
• 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 perform urethrocystoscopy.

Differential diagnosis

Chronic prostatitis must be distinguished from vesiculoprostatostasis, autonomic prostate disease, congestive prostatitis, pelvic floor myalgia, neuropsychiatric disorders, pseudodysynergia, reflex sympathetic dystrophy, inflammatory diseases of other organs: interstitial cystitis, osteitis of the gallbladder joint, hyperthyroidism, urolithiastais cancer , chronic epipidymitis, inguinal hernia.

Treatment of chronic prostatitis

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

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

The main directions of therapy:

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

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.
• Nonsteroidal anti-inflammatory.
• Angioprotectors.
• Immunomodulators.
• Drugs that affect urate metabolism.

Antibiotics in the treatment of chronic bacterial prostatitis.

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

The drugs of choice are generation II-IV fluoroquinolones. They quickly penetrate 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, it should be assumed:

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

The duration of treatment must be at least 4 weeks with mandatory subsequent bacteriological control. If there are more than 10 bacteriuria in the third portion of urine secretion and prostate³CFU / ml, a repeated course of antibiotic therapy is prescribed for a period of 2-4 weeks.

Cytokine inhibitors in the treatment of chronic prostatitis.

Cytokines are glycoproteins that are secreted by immune cells and others in response to an inflammatory response and an immune response. They actively participate in the development of the chronic inflammatory process.

Non-steroidal anti-inflammatory drugs

Nonsteroidal 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 chronic bacterial prostatitis, in addition to antibiotics and anti-inflammatory drugs, immunomodulatory agents are used. The most effective is the rectal route of 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.

Alpha-1 adrenergic blockers have been established to normalize smooth muscle tone in the prostatic urethra, seminal vesicles, and prostate capsule, making drugs in this group highly 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 bacterial prostatitis and CPPS

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

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

The role of antisclerotic drugs in the treatment of chronic prostatitis.

With prolonged inflammation in the prostate gland, fibrosis develops, which is manifested by disturbances of microcirculation and urodynamics. To prevent the fibrosis process, antisclerotic drugs are used.

Other medicines used to treat chronic prostatitis.

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

• Antihistamines.
• Vasodilators and angioprotectors.
• Immunosuppressants.
• Drugs that affect the metabolism of urate and the 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 gland tissues.
• Improved microcirculation.
• Reduction of edema, leukocyte infiltration, secretion stagnation and pain.
• Prevention of thrombosis in the venules of the prostate.
• Increased activity of the secretory epithelium of the acini.
• Improvement of sexual function (increased libido, restoration of erectile function and normalization of spermatogenesis).

Finger massage of the prostate gland.

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

Physiotherapy

The efficacy of physiotherapeutic procedures in the treatment of prostatitis has not been demonstrated at present, 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 likely to get sick.
• A family predisposition to the disease is not excluded.

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

Tips for disease prevention:

• Drink much liquid. Frequent urination promotes leaching of the microflora of the urethra.
• Prevents diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods that are high in carbohydrates and saturated fat, which leads to weight gain.
• You should limit the use of substances that irritate the urethra as much as possible: hot and spicy foods, smoked meats, sauces and condiments, coffee and alcohol.
• Stop smoking. Nicotine adversely affects the condition of the vascular walls.
• Do not get too cold.
• Don't hold back emptying your bladder.
• Lead an active lifestyle, exercise. Exercise to strengthen your 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 quickly free itself from the secret.
• Be in a monogamous relationship. Indiscriminate sex increases the likelihood of contracting sexually transmitted diseases.
• If you have complaints about the genitourinary organs, immediately contact your urologist.