Chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by infection with the 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 it is still poorly understood today and not very responsive to treatment. Chronic bacterial (6-10%) and non-bacterial (80-90%) prostatitis are the most common and socially significant inflammatory diseases in men, drastically reducing their quality of life. The disease is registered mainly in young and middle-aged people and is often complicated by impaired copulatory and generative functions (decrease in potency, infertility, etc. ). The disease is registered in men in 8-35% of cases between 20 and 40 years.

The cause of bacterial prostatitis is the pyogenic flora, which enters the gland through the urethra, or through the lymphogenous and hematogenous routes. The etiology of chronic non-bacterial prostatitis and its pathogenesis remain unknown. It mainly affects men over 50.

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The reasons for the development of the disease

Chronic prostatitis is currently considered a polietiological disease. There is an opinion that the disease occurs as a result of the penetration of infection into the prostate, 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 through 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 believed that the transition from acute prostatitis to chronic prostatitis occurs due to loss of tissue elasticity due to excessive production of fibrous tissue.

Among the causative agents of chronic prostatitis 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 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:

• An ascending path is most likely, as evidenced by the frequent combination of prostatitis and urethritis.
• Hematogenous prostatitis develops when the infection enters the gland with the bloodstream, 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 ascending gland with the urinary flow, with purulent infections of the kidneys, through the canalicular route for epipidymitis, deferentitisand funiculitis, during diagnostic and therapeutic urological manipulations (catheterization, urethralization), including transurethral.
• Lymphogenic infection enters the prostate with proctitis, thrombophlebitis of 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 intraprostatic reflux of urine, when urine is discharged from the urethra into the gland, which leads to impaired emptying of the prostate andseminal vesicles.

With the disease, vascular reactions develop, resulting in edema of the organ, the nervous and humoral regulation of the tone of smooth muscle tissues of the urethra is disturbed, the activation of alpha_a–Adrenergic receptors cause the development of a dynamic obstruction and contribute to the development of new intraprostatic reflux.

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

Hemodynamic disorders

They support chronic inflammation and circulatory disorders of the pelvic organs and scrotum. Congestion develops in people leading a sedentary lifestyle, for example, drivers, office workers, etc. , suffering from obesity, sexual abstinence, sexual dysmetria, frequent hypothermia, mental and physical overload. Consumption of spicy and spicy foods, alcohol and tobacco, etc. , contributes to the maintenance of the inflammatory process.

Other factors

There are many other factors that promote 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, leading to difficulties in complete 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 National Institutes of Health of the United States, prostatitis is divided into:

• Treble (category I). Is 5 to 10%.
• Chronic bacterial (category II). Is 6 - 10%.
• Chronic non-bacterial inflammation (category IIIA). Is 80 to 90%.
• Chronic non-bacterial (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. 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 gonorrheic nature, non-bacterial circulatory disorders in the pelvic organs and scrotum (hemorrhoids, chickenpox, etc. ), sexual excess.

Patients with chronic prostatitis have many complaints. They see doctors for years, but are very rarely seen for prostate disease. About a quarter of patients have no complaints, or the disease progresses with rare clinical symptoms.

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

Urinary disorders associated with stricture of the urethra:

• Difficulty at the onset of urination.
• Weak urine stream.
• Intermittent or drip urination.
• Sensation of incomplete emptying of the bladder.

Symptoms due to irritation of the nerve endings:

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

Pain syndrome:

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

Sexual dysfunction:

• Pain in the rectum and urethra during ejaculation.
• Slow erection.
• Loss of orgasm.
• Premature ejaculation, etc.

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

Signs and symptoms of chronic non-bacterial prostatitis

Male chronic pelvic pain syndrome (CPPS) presents with the usual symptoms of 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 myalgia syndrome of the pelvic floor, and functional lesions of the prostate caused by disturbances in the innervation of the organ and its hemodynamics.

If the vegetative function is impaired, atony and a violation of the innervation of the gland is 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 drip for a long time. In these patients, the study reveals increased instability and 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 periurethral tissues leads to the development of urinary disorders.

Diagnostic

Due to the fact that there are many reasons for the development of chronic prostatitis, a whole range of diagnostic studies are 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 (urinalysis and microscopy of the secretion of the prostate, culture and determination of the sensitivity of the 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.
• Complex of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of neurological state.
• If treatment is ineffective and complications are suspected, magnetic and calculated resonance imaging, blood culture, etc.

Prostate palpation

Palpation of the prostate is of primary importance in the diagnosis of the disease, which increases during the period of exacerbation and decreases during the period of reduction of the inflammatory process. In chronic prostatitis during iron exacerbation, it is edematous and painful.

The consistency density of the organ can be different: areas of softening and compaction are palpated, areas 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 digital transrectal examination is combined with the collection of secretion from the gland. Sometimes it becomes necessary to obtain the secret of each share separately.

Analysis of a 3-cup urine sample and prostatic secretions

The "gold standards" 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.

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

With inflammation of the prostate:

• The number of microbes (CFU) exceeds 10³/ ml (10^four/ ml for epidermal staphylococci), but let us not overlook 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 portion of post-massage urine, bacteria (mainly from 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 increase in the number of leukocytes and microflora.

Normal rate of prostatic secretion:

• Leukocytes less than 10 in the field of view.
• There are a lot of grains of lecithin.
• The 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 changes to the alkaline side.
• The content of acid phosphatase is reduced.
• The activity of lysozyme is increased.

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

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

Ultrasound procedure

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

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

Other methods of examining the prostate

• Urodynamic state (a study of urine flow) is easily and simply determined using a study such as urine flow. With the help of this study, it is possible to detect signs of bladder obstruction in time and conduct dynamic observation.
• A puncture biopsy is performed if there is a suspicion of abscess formation, benign hyperplasia and prostate cancer.
• In order to clarify the reasons for the development of subvesicular obstruction, radiographic and endoscopic studies are performed.
• With a long-term inflammatory process, it is recommended to perform 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: cystitisinterstitial, osteitis of the vesicular joint, cervical hyperthyroidism, prostate and bladder cancer, urolithiasis, chronic epipidymitis, inguinal hernia.

Treatment of chronic prostatitis

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

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

The main directions of therapy:

• Elimination of responsible microorganisms.
• Anti-inflammatory therapy.
• Normalization of blood circulation in the prostate and pelvic organs.
• Normalization of adequate drainage of 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_a- Adrenergic blockers.
• 5 alpha reductase inhibitors.
• Cytokine inhibitors.
• Non-steroidal anti-inflammatory drug.
• Angioprotectors.
• Immunomodulators.
• Drugs affecting urate metabolism.

Antibiotics for 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, empiric antimicrobial therapy is used.

The drugs of choice are the 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 against ureaplasma and chlamydia. If antimicrobial treatment has failed, it should be assumed:

• multidrug resistance of the microflora,
• short courses (less than 4 weeks),
• wrong choice of antibiotic and 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 are more than 10 bacteriuria in the 3rd portion of urinary and prostatic secretions³UFC / ml, repeated antibiotic therapy is prescribed for a period of 2 to 4 weeks.

Cytokine inhibitors for 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.

Nonsteroidal 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 their administration. An immunomodulator is widely used, which increases the functional activity of phagocytes, which contributes to more efficient elimination of pathogens.

Alpha-blockers in the treatment of chronic prostatitis

It has been established that alpha-1 adrenergic blockers normalize the tone of smooth muscles of the prostatic urethra, seminal vesicles and prostate capsule, making drugs of this group very effective in the treatment of 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.

5α-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, the activity of which in prostate cells is more than 5 times greater than the activity oftestosterone itself, which in the elderly leads to an increase in the organ due to epithelial and stromal components.

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

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

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

Other medicines used to treat chronic prostatitis

In addition to the drugs described above, the following drugs 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

The use of a preparation in the form of suppositories containing a complex of biologically active peptides isolated from the prostate of bovine animals is effective in the treatment of prostatitis.

Under the influence of the drug occurs:

• Stimulation of metabolic processes in the tissues of the gland.
• Improve microcirculation.
• Reduction of edema, leukocyte infiltration, stagnation of secretions and pain.
• Prevention of thrombosis in the venules of the prostate.
• Increased activity of the secretory epithelium of acini.
• Improvement of sexual function (increased libido, restoration of erectile function and normalization of spermatogenesis).

Prostate finger massage

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 side effects have not been studied.

Prevention of chronic prostatitis

When you start 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 diseases.
• A familial predisposition to the disease is not excluded.

People predisposed to developing chronic prostatitis should pay more attention to their condition.

Disease prevention tips:

• Drink lots of fluids. Frequent urination promotes leaching of the microflora from the urethra.
• Prevent diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods high in carbohydrates and saturated fat, which leads to weight gain.
• You should limit the use of substances irritating to the urethra as much as possible: spicy and spicy foods, smoked meats, sauces and seasonings, coffee and alcohol.
• Stop smoking. Nicotine negatively affects the state of the vascular walls.
• Do not overcool.
• Do not hold back the emptying of the bladder.
• Lead an active lifestyle, exercise. Exercise to strengthen the muscles of the pelvic floor, which can clear venous congestion, which in turn supports normal prostate function.
• Have a regular sex life. Avoid prolonged abstinence. The gland must be promptly released from secrecy.
• Stay in a monogamous relationship. Sex without discrimination increases the likelihood of contracting sexually transmitted diseases.
• If you have any complaints from the genitourinary organs, contact your urologist immediately.