chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by an infection with the possible addition of autoimmune diseases, characterized by damage to the parenchymal and interstitial tissue of the organ. The disease has been known to medicine since 1850, but still today it remains little known and not very sensitive 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 registered in men in 8 - 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 by lymphogenic and hematogenous pathways. The etiology of chronic non-bacterial prostatitis and its pathogenesis remain unknown. It mainly affects men over the age of 50.

The reasons for the development of the disease

Chronic prostatitis is currently considered a polyetiological disease. There is an opinion that the disease occurs due to the penetration of the infection into the prostate, and therefore 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, causing acute or chronic prostatitis. There have been cases of asymptomatic transport. The course of the disease is affected by the state of the defenses of the human body and the biological properties of the pathogen. It is assumed that the transition from acute to chronic prostatitis occurs due to the loss of elasticity of the tissues due to the excessive production of fibrous tissue.

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

• 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.

Infection enters the prostate in several ways:

• An ascending path is most likely, as evidenced by the frequent combination of prostatitis and urethritis.
• Hematogenic prostatitis develops when the infection enters 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 ascending gland with urinary flow, with purulent infections of the kidneys, canalicularly for epipidymitis, deferentitis and funiculitis, during diagnostic and therapeutic urological manipulations (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 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, which 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 refluxes.

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 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 spicy and spicy foods, alcohol and smoking, etc. , They contribute to the maintenance of the inflammatory process.

Other factors

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

• Hormonal.
• Biochemistry.
• 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, it is not possible to establish the reasons for the development of chronic prostatitis.

Prostatitis classification

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

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

Chronic Prostatitis Signs and Symptoms

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 nature or gonorrhea, non-bacterial circulatory disorders in the pelvic organs and scrotum (hemorrhoids, chicken pox, etc. ), sexual excesses.

Patients with chronic prostatitis have many complaints. They have been going to doctors for years, but very rarely are they examined for prostate disease. About a quarter of patients do not have any complaints or the disease proceeds 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 or drip urination.
• Feeling of incomplete emptying of the bladder.

Symptoms due to irritation of the nerve endings:

• Frequent urination.
• The urge to urinate is acute and violent.
• Urination in small portions.
• Urinary incontinence 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 the rectum and urethra during ejaculation.
• 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 non-bacterial prostatitis

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

If the autonomic function is impaired, atony and 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 heart 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 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 prostatic 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 ureaplasm and chlamydia).
• Urofluometry.
• Prostate biopsy.
• Complex of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of the neurological status.
• If treatment is ineffective and complications are suspected, MRI and computerized resonance imaging, blood culture, etc.

Palpation of the prostate

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

Analysis of a urine sample of 3 glasses and prostatic secretion

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

• Collection of the first portion of urine.
• Collection of the second portion of urine.
• Obtain 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 microbial count (CFU) exceeds 10³/ ml (10^four/ ml for epidermal staphylococci), but do not overlook the small number of microbes in the tens and hundreds.
• The presence of 10-15 leukocytes in the visual field, detected under a microscope, 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 visual field.
• There are many lecithin grains.
• Microflora is absent.

In chronic prostatitis, secretion from the prostate reveals:

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

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

The value of the prostatic secretion crystallization test is maintained. Normally, during crystallization, a characteristic pattern is formed in the form of a fern leaf. In case of 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 (transrectal ultrasound is optimal), kidneys and bladder is used, which allows you to determine:

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

Other methods of prostate examination

• The state of urodynamics (a study of urine flow rate) 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 obstruction of the bladder outlet and perform dynamic observation.
• Puncture biopsy is done 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, urethrocystoscopy is recommended to be performed.

Differential diagnosis

Chronic prostatitis must be distinguished from vesiculoprostatostasis, autonomic prostatopathy, congestive prostatitis, pelvic floor myalgia, neuropsychiatric disorders, pseudodysynergy, reflex sympathetic dystrophy, inflammatory diseases of other organs: interstitial cystitis, osteitis of the vesicular joint, hyperthyroidism and bladder, 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 that affect different links of pathogenesis are used simultaneously.

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 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 that affect 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 II-IV generation 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:

• multi-resistance of microflora,
• short treatment courses (less than 4 weeks),
• 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 must be at least 4 weeks with subsequent mandatory bacteriological control. If more than 10 bacteriuria are present in the third portion of urinary and prostatic 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 secreted by immune cells 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 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 smooth muscle tone of the prostatic urethra, seminal vesicles and prostate capsule, which makes 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 enzyme 5a-reductase, testosterone is converted into the prostatic form 5a-dihydrotestosterone, the activity of which in the cells of the prostate is more than 5 times higher than the activity of testosterone itself, which in the elderly brings 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 noted, within 6 months - glandular, secretory function is inhibited, the severity of the pain syndrome and the volume of the gland decrease, 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 impaired microcirculation and urodynamics. In order to prevent the fibrosis process, antisclerotic drugs are used.

Other drugs used to treat chronic prostatitis

Together 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 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.
• Improvement of microcirculation.
• Reduction of edema, leukocyte infiltration, stagnation of secretion and pain.
• Prevention of thrombosis in the venules of the prostate gland.
• 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

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

Disease prevention tips:

• Drink lots of fluids. Frequent urination promotes the leaching of microflora from the urethra.
• Preventing diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods rich in carbohydrates and saturated fats, which lead 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.
• Don't get too cold.
• Do not hold back the 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.
• Having 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 contracting sexually transmitted diseases.
• If you have complaints from the genitourinary organs, contact your urologist immediately.