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 organ's parenchymal and interstitial tissue. The disease has been known to medicine since 1850, but even today it is poorly understood and unresponsive 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 mostly registered in young and middle-aged people and is often complicated by impaired copulatory and generative functions (decreased potency, infertility, etc. ). The disease is reported in men in 8 - 35% of cases between the ages of 20 and 40 years.

The cause of bacterial prostatitis is the pyogenic flora, which enters the gland from the urethra, or through the lymphogenic and hematogenous pathways. The etiology of chronic nonbacterial prostatitis and its pathogenesis remain 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 proceeds 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 through the urethra, resulting in acute or chronic prostatitis. There were cases of asymptomatic carriers. 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 gram-negative bacteria such as Escherichia coli (E. coli), Enterococcus faecalis (fecal enterococci), a little less frequently - 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 Candida genus fungi has not been fully elucidated.

The infection enters the prostate in several ways:

• An upward path is more 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 seen in chronic tonsillitis, sinusitis, periodontitis, pneumonia, cholecystitis and cholangitis, purulent skin diseases, etc.
• By contact, chronic prostatitis develops with urethritis and urethral narrowing, when the infection enters the gland ascending with urinary flow, with purulent kidney infections, via the canalicular route to epididymitis, deferentitis and funiculitis, during diagnostic and therapeutic urological manipulations (catheterization , urethralization), including transurethral.
• Lymphogenic infection enters 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 urine reflux, when urine is released from the urethra into the gland, which leads to emptying of the prostate and the damaged seminal vesicles.

With the disease, vascular reactions occur, leading to organ edema, nervous and humoral regulation of the smooth muscle tissue tone of the urethra is disturbed, alpha activation₁–Adrenergic receptors cause the development of dynamic obstruction and contribute to the development of new intraprostatic reflux.

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

hemodynamic disorders

They support chronic inflammation and circulatory disorders in Organs pelvic organs and scrotum. Congestion develops in people who lead a sedentary lifestyle, eg drivers, office workers, etc. , with obesity, sexual abstinence, sexual dysmetria, frequent hypothermia, mental and physical overload. Ingestion of spicy and spicy foods, alcohol and tobacco, etc. , 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.
• Characteristics of the structure of the prostate glands, making full drainage difficult.

It is often 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's 5 - 10%.
• Chronic bacteria (category II). It's 6 - 10%.
• Chronic non-bacterial inflammatory (category IIIA). It's 80 to 90%.
• Chronic nonbacterial (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 that follow complex anti-inflammatory and antibacterial therapy.

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

Patients with chronic prostatitis have many complaints. They go to the doctor for years, but are very rarely screened for prostate disease. About a quarter of patients have no complaints or the disease evolves with few clinical symptoms.

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

Urinary disorders associated with urethral narrowing:

• Difficulty starting urination.
• Weak urine stream.
• Intermittent urination or dripping.
• Feeling of incomplete emptying of the bladder.

Symptoms due to irritation of nerve endings:

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

Pain Syndrome:

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

Sexual dysfunction:

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

On the part of the nervous system: neurotic disorders in the way of fixing the patient's attention to his state of health.

Signs and symptoms of chronic nonbacterial prostatitis

Chronic Pelvic Pain Syndrome in Men (CPPS) occurs with the usual symptoms of chronic prostatitis, but the bacteria are absent in the 3rd portion of the urine and in the secretion of the prostate. CPPS can be simulated by chronic nonbacterial 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 neurovegetative function is impaired, there is atony and violation of the gland's innervation, which is manifested by the difficulty in quickly and completely closing the urethral lumen. At the same time, urine after urination continues to be excreted drop by drop for a long time. In these patients, the study reveals instability and increased excitability, which is manifested by increased sweating and excitability of cardiac activity, changes in dermographism.

Disease complications

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

Diagnosis

Because there are many reasons for the development of chronic prostatitis, a whole range of diagnostic studies are used to diagnose it. Successful treatment depends on correctly determining 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 (urine analysis and microscopy of prostate secretion, culture and determination of microflora sensitivity to antibacterial drugs, general analysis of urine and blood).
• For the detection of gonococci, urethral smear bacterioscopy, PCR and serological methods (for detection of ureaplasma and chlamydia).
• Urofluometry.
• Prostate biopsy.
• Complex of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of neurological status.
• If treatment is ineffective and complications are suspected, computerized and magnetic resonance imaging, blood cultures, etc.

Prostate palpation

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

The density of organ consistency may 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 state of the seminal tubercles and 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-glass urine sample and prostate secretion

The "gold standard" in diagnosing chronic prostatitis are:

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

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

With prostate inflammation:

• The microbial count (CFU) exceeds 10³/ ml (10^four/ ml for epidermal staphylococci), but don't 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 gland secretion and in the third portion of urine after massage, bacteria (mainly from the intestinal group) are released.
• In 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 with less than 10 in the field of view.
• There are many grains of lecithin.
• Microflora is absent.

In chronic prostatitis, the secretion of the prostate reveals:

• The number of white blood cells 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 acid phosphatase content is reduced.
• Lysozyme activity is increased.

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

The value of the prostate secretion crystallization test is maintained. Typically, during crystallization, a characteristic pattern is formed in the shape of a fern leaf. In the case of violation of the aggregation properties of the prostatic secretion, this 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 ideal), the kidneys, and the bladder, which makes it possible to determine:

• The volume and size of the gland.
• Presence of calculations.
• 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 examining the prostate

• The status of urodynamics (a study of the 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 bladder outlet obstruction and carry out dynamic observation.
• Puncture biopsy is performed if abscess formation, benign hyperplasia, and prostate cancer are suspected.
• To clarify the reasons for the development of infravesicular obstruction, radiographic and endoscopic studies are performed.
• With a long-lasting inflammatory process, urethrocystoscopy is recommended.

Differential diagnosis

Chronic prostatitis must be differentiated from vesiculoprostatitis, autonomic prostatitis, congestive prostatitis, pelvic floor myalgia, neuropsychiatric disorders, pseudodyssynergia, reflex sympathetic dystrophy, inflammatory diseases of other organs: interstitial cystitis, osteitis of the vesicular joint and bladder cancer, hyperthyroidism cervical, prostate cancer, urolithiasis, chronic epididymitis, inguinal hernia.

Chronic Prostatitis Treatment

Treatment of chronic prostatitis should begin with a change in the patient's lifestyle and diet.

In the treatment of the disease, drugs that affect different links of the pathogenesis 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 adequate drainage of prostatic acini.
• Normalization of the hormonal profile.
• Prevention of organ hardening.

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

• Anti-bacterial.
• Anticholinergic.
• Vasodilators.
• Alpha₁–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 performed 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 generation II-IV fluoroquinolones. They quickly penetrate gland tissues with the usual application methods, are active against a large group of gram-negative microorganisms as well as ureaplasma and chlamydia. In case of antimicrobial treatment failure, it must be assumed:

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

Duration of treatment should be at least 4 weeks with subsequent obligatory bacteriological control. If there are 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 secreted by immune cells and other cells 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 pills 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, immunomodulators 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

It is established that alpha-1 adrenergic blockers normalize the smooth muscle tone of the prostatic urethra, seminal vesicles and prostatic capsule, which makes the drugs in 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 bacterial prostatitis and CPPS

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

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

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

With prolonged inflammation in the prostate, fibrosis develops, manifested by impaired microcirculation and urodynamics. To prevent the fibrosis process, anti-sclerotic drugs are used.

Other Medications Used to Treat Chronic Prostatitis

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

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

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 bovine prostate.

Under the influence of the drug occurs:

• Stimulation of metabolic processes in gland tissues.
• Improving microcirculation.
• Reduction of edema, leukocyte infiltration, secretion stagnation and pain.
• Prevention of thrombosis in prostate venules.
• Increased activity of the acini-secreting epithelium.
• Improve sexual function (increase libido, restore erectile function and normalize spermatogenesis).

Prostate Finger Massage

Several 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 yet been proven, the mechanism of action has not been scientifically established, and adverse reactions have not been studied.

Prevention of chronic prostatitis

As you begin to prevent the development of chronic prostatitis, you should know:

• The risk of developing the disease increases over the years.
• Black representatives are more prone to illness.
• 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 status.

Disease Prevention Tips:

• Drink lots of fluids. Frequent urination promotes the leaching of the microflora from the urethra.
• Prevent diarrhea and constipation.
• Eat a balanced diet. Avoid eating foods high in carbohydrates and saturated fats, which lead to weight gain.
• The use of substances that irritate the urethra should be limited as much as possible: spicy and spicy foods, smoked meats, sauces and seasonings, coffee and alcohol.
• Stop smoking. Nicotine negatively affects the condition of vascular walls.
• Don't get too cold.
• Do not hold the bladder emptying.
• Lead an active lifestyle, exercise. Exercises 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 released from the secrecy immediately.
• Maintain a monogamous relationship. Indiscriminate sex increases the likelihood of acquiring sexually transmitted diseases.
• If you have complaints from Organs genitourinary organs, contact your urologist immediately.