chronic prostatitis

If the situation with infectious (or rather, bacterial) prostatitis is more or less clear, nonbacterial chronic prostatitis remains a serious urological problem with many unclear issues. Perhaps, under the guise of a disease called chronic prostatitis, there is a spectrum of diseases and pathological conditions characterized by various organic changes in the tissues and activities of the prostate, male reproductive system organs and lower reproductive systemdisfunction. urinary tract, but also other general organs and systems.

ICD-10 code

• N41. 1 Chronic prostatitis.
• N41. 8 Other inflammatory diseases of the prostate.
• N41. 9 Unspecified inflammatory disease of the prostate.

Epidemiology of chronic prostatitis

Chronic prostatitis ranks first among the inflammatory diseases of the male reproductive system and is also the first among male diseases. It is the most common urinary tract disorder in men under 50 years of age. The average age of patients with chronic inflammation of the prostate is 43 years old. By the age of 80, up to 30% of men have chronic or acute prostatitis.The prevalence of chronic prostatitis in the general population is 9%. In our country, according to the nearest estimate, 35% of cases of chronic prostatitis lead to a visit to a urologist in men of working age. 7-36% of patients are complicated by seminal vesiculitis, epididymitis, urinary disorders, reproductive and sexual dysfunction.

What causes chronic prostatitis?

Modern medicine believes that chronic prostatitis is a disease with multiple causes. The occurrence and recurrence of chronic prostatitis, in addition to the role of infectious factors, are also caused by autonomic nerve and hemodynamic disorders, and are accompanied by local and systemic immunity, autoimmunity (exposure to endogenous immune modulators -Cytokines and leukotrienes), hormone weakening. , chemical (reflux of urine into the prostatic duct) and biochemical (probably the action of citrate) processes, as well as aberrations of peptide growth factors. Risk factors for developing chronic prostatitis include:

• Lifestyle characteristics leading to genitourinary infections (promiscuous intercourse without protection and personal hygiene, inflammatory processes in the sexual partner and/or infections of the urinary and reproductive organs):
• Transurethral surgery (including prostate TURP) without prophylactic antibiotic therapy:
• Presence of indwelling urinary catheter:
• chronic hypothermia;
• Sedentary lifestyle;
• Irregular sex life.

Among the risk factors for chronic prostatitis, immune disorders are important, especially the imbalance between various immune active factors. First of all, this applies to cytokines - low-molecular compounds of polypeptide nature synthesized by lymphoid and non-lymphoid cells that have a direct influence on the functional activity of immunocompetent cells.

Symptoms of chronic prostatitis

Symptoms of chronic prostatitis include pain or discomfort, urinary problems, and sexual dysfunction. The main symptom of chronic prostatitis is pain or discomfort in the pelvic area that lasts for 3 months. and more. The most common site of pain is the perineum, but discomfort can also occur in the suprapubic area, groin, anus, and other areas of the pelvis, inner thighs, and scrotum and lumbosacral areas. Unilateral testicular pain is usually not a sign of prostatitis. Pain during and after ejaculation is the most characteristic symptom of chronic prostatitis.Impaired sexual function, including suppression of libido and reduced quality of spontaneous and/or full erections, although most patients do not experience severe impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE), but in the later stages of the disease, ejaculation may be slow. The emotional color of orgasm may change ("eliminate").Urological disorders more commonly present with irritative symptoms and less frequently with IVO symptoms.In case of chronic prostatitis, disturbances in the quantity and quality of ejaculation can also be detected, which are rarely the cause of infertility.Chronic prostatitis is a disease that occurs in waves, with periodic increases and decreases. In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.The effusion phase is characterized by pain in the scrotum, groin and suprapubic area, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful erections.During the replacement phase, patients may experience pain (an unpleasant sensation) in the suprapubic area, but less commonly in the scrotum, inguinal area, and sacrum. Generally, urination is not impaired (or increased). Normal erections are observed against the background of accelerated, painless ejaculation.The proliferative phase of the inflammatory process can be manifested by a decrease in the intensity of the urine stream and increased urination (exacerbation of the inflammatory process). Ejaculation during this stage is unimpaired or slightly slowed, and the intensity of a full erection is normal or moderately diminished.During the stages of scarring and sclerosis of the prostate, patients are concerned about the suprapubic area, heaviness of the sacrum, frequent urination during the day and night (complete urinary frequency), slow, intermittent, and urgent need to urinate. Ejaculation is slowed (even to the point of no ejaculation), full and sometimes spontaneous erections are weakened. Often at this stage, attention is drawn to the "killing" of orgasm. The impact of chronic prostatitis on quality of life, according to the Unified Quality of Life Assessment Scale, is comparable to that of myocardial infarction. Angina or Crohn's disease.

Diagnosis of chronic prostatitis

The diagnosis of chronic prostatitis is not difficult and is based on the typical triad of symptoms. Considering that the disease is often asymptomatic, a combination of physical, laboratory, and instrumental methods is necessary, including determination of immune status and neurological status.Questionnaires are very important when assessing subjective manifestations of disease. A number of questionnaires have been developed that are filled out by patients in which physicians wish to know the frequency and intensity of pain, urinary disturbances and sexual dysfunction, the patient's attitude towards these clinical manifestations of chronic prostatitis, as well as to assess the patient's status in the psycho-emotional domain. The most popular currently is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire. This questionnaire was developed by the National Institutes of Health; it is an effective tool for identifying symptoms of chronic prostatitis and determining their impact on quality of life.

Laboratory diagnosis of chronic prostatitis

It is the laboratory diagnosis of chronic prostatitis that makes the diagnosis of "chronic prostatitis" possible (since 1961, Farman and McDonald established the "gold standard" for the diagnosis of prostatic inflammation - 10-15 white blood cells in the field of view) and theDifferential diagnosis of its bacterial and nonbacterial forms.Microscopic examination of the draining urethra is performed to determine the number of leukocytes, mucus, epithelium, and trichomonas, gonococci, and nonspecific bacterial flora.When urethral mucosal scrapings are examined using the PCR method, the presence of microorganisms that cause sexually transmitted diseases can be determined.Microscopic examination of prostatic secretions determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallement bodies, and macrophages.Bacteriological examination of prostate secretions or urine obtained after massage. Based on the results of these studies, the nature of the disease (bacterial or nonbacterial prostatitis) is determined. Prostatitis can cause elevated PSA concentrations. Blood should be collected within 10 days of the digital rectal examination to measure serum PSA concentration. Nonetheless, when PSA concentrations are above 4. 0 ng/ml, other diagnostic methods, including prostate biopsy, are needed to rule out prostate cancer.Very important in the laboratory diagnosis of chronic prostatitis is the study of the immune status (humoral and cellular immune status) and the levels of non-specific antibodies (IgA, IgG and IgM) in prostate secretions. Immunological studies help determine the stages of the process and monitor the effectiveness of treatment.

Instrumental diagnosis of chronic prostatitis

Prostate TRUS examination has high sensitivity but low specificity for chronic prostatitis. The study allows not only differential diagnosis but also identification of the form and stage of the disease and subsequent monitoring throughout treatment. Ultrasound can assess the size and volume of the prostate, echogenic structures (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the periprostatic region), size, degree of distension, density and echogenicity of the contents of the seminal vesicles.If neurogenic voiding disorder and pelvic floor muscle dysfunction are suspected, UDI (UFM, urethral manometry, pressure/flow studies, cystometry) and pelvic floor muscle electromyography can provide additional information. and IVO, which often accompanies chronic prostatitis.Patients diagnosed with BOO should undergo X-ray examination to clarify the cause of its occurrence and determine further treatment strategies.When it is necessary to exclude pathological changes of the spine and pelvic organs, CT and MRI of the pelvic organs are performed for the differential diagnosis of prostate cancer, as well as for suspicion of non-inflammatory non-bacterial prostatitis.

What needs to be checked?

prostate (prostate)

How to check?

• Prostate ultrasound
• prostate biopsy

What tests are needed?

• Prostate secretion analysis (prostate)
• prostate specific antigen in blood

Who to contact?

• urologist
• Andrologist

Treatment of chronic prostatitis

Treatment of chronic prostatitis, like any chronic disease, should follow the principles of consistency and a comprehensive approach. First, the patient's lifestyle, thoughts and psychology must be changed. By eliminating the effects of many harmful factors such as physical inactivity, alcohol, chronic hypothermia, etc. By doing this, we not only prevent further progression of the disease but also promote recovery. This, along with normalization of sex life, diet, etc. , is the preparatory stage for treatment. Next comes the main basic course, which involves the use of various medications. This step-by-step approach to treating a disease allows you to monitor its effectiveness at each stage, make necessary changes, and fight the disease according to the same principles as it develops. - From predisposing factors to producing factors.

Indications for hospitalization

Generally speaking, chronic prostatitis does not require hospitalization. For severe cases of persistent chronic prostatitis, comprehensive treatment in the hospital is more effective than outpatient treatment.

Drug treatment of chronic prostatitis

It is necessary to use a variety of drugs and methods that act on different parts of the pathogenesis at the same time to eliminate infectious factors, normalize the blood circulation of the pelvic organs (including improving the microcirculation of the prostate), and fully drain the prostate acini, especially the prostate acini. surrounding areas, normalizing levels of essential hormones and immune responses. Based on this, antibacterial and anticholinergic drugs, immunomodulators, nonsteroidal anti-inflammatory drugs, vasoprotectants and vasodilators, and prostate massage can be recommended for the treatment of chronic prostatitis. In recent years, chronic prostatitis has been treated with drugs that were not previously used for this purpose: α1-blockers, 5-α-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs affecting urate and citric acidDrugs that metabolize salt.For chronic non-bacterial prostatitis and chronic pelvic pain inflammatory syndrome (when the pathogen cannot be detected using microscopy, bacteriology, and immunodiagnostic methods), chronic prostatitis can be treated with empiric antibiotics for a short course, and if clinically effective, it can be continuedtreat. Empirical antimicrobial therapy is approximately 40% effective in patients with bacterial and nonbacterial prostatitis. This suggests an undetectable bacterial flora, or an active role of other microbial pathogens (Chlamydia, Mycoplasma, Ureaplasma, fungal flora, Trichomonas, viruses) in the development of the infectious inflammatory process, which is currently unproven. In some cases, flora not detectable by standard microscopic or bacteriological examination of prostate secretions can be detected by histological examination of prostate biopsies or other subtle methods.The need for antimicrobial therapy in non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis is controversial. The duration of antimicrobial treatment should not exceed 2-4 weeks, followed by a maximum of 4-6 weeks if the result is positive. If that doesn't work, the antibiotic may be discontinued and another medication may be prescribed (e. g. , alpha-1 blockers, saw palmetto plant extract).The drugs of choice for empiric treatment of chronic prostatitis are fluoroquinolones because they are highly bioavailable and penetrate well into glandular tissue (some of them are present in greater concentrations in secretions than in serum). Another advantage of this group of drugs is that they are active against most Gram-negative microorganisms as well as Chlamydia and Ureaplasma urealyticum. The outcome of chronic prostatitis treatment does not depend on the use of any specific drug in the fluoroquinolone class.If fluoroquinolones are ineffective, combination antimicrobial therapy should be used. Tetracyclines have not lost their importance, especially when chlamydial infection is suspected.Recent studies have demonstrated that clarithromycin penetrates well into prostate tissue and is effective against intracellular pathogens of chronic prostatitis, including Ureaplasma urealyticum and Chlamydia.Antimicrobial medications are also recommended to prevent recurrence of bacterial prostatitis.If relapse occurs, lower single and daily doses of antimicrobials from the previous course may be prescribed. Ineffective antimicrobial therapy is often due to errors in drug selection, dosage, and frequency, or the persistence of bacteria in ducts, acini, or calcifications, covered by a protective extracellular membrane.Painful and irritating symptoms are indications for prescription of NPS, either for complex treatment or as an alpha-blocker alone (diclofenac dose 50-100 mg/day) when antimicrobial therapy is ineffective.Some studies have demonstrated the effectiveness of herbal medicines, but this information has not been confirmed by multicenter, placebo-controlled studies.If clinical symptoms of disease (pain, dysuria) persist despite the use of antibiotics, alpha-blockers, and NSAIDs, subsequent treatment should be aimed at relieving pain, resolving the urinary problem, or correcting both. symptoms.For pain, tricyclic antidepressants have analgesic effects by blocking histamine H1 receptors and anticholinesterase effects. The most commonly prescribed drugs are amitriptyline and imipramine. However, caution must be exercised. Side Effects - Drowsiness, dry mouth. In rare cases, narcotic analgesics (tramadol and other drugs) may be used to relieve pain.If dysuria predominates in the clinical manifestations of the disease, ultrasonography (UFM) and, if possible, videourodynamic studies should be performed before starting medical therapy. Further treatment is carried out based on the results obtained. If the bladder neck has increased sensitivity (hyperactivity), it is treated as if it were interstitial cystitis and they would prescribe amitriptyline, antihistamines, and instill an antiseptic solution into the bladder. For detrusor hyperreflexia, anticholinesterase drugs may be used. For external bladder sphincter hypertonia, benzodiazepines may be used, and if medical treatment is ineffective, physical therapy (to relieve spasm), neuromodulation (such as sacral stimulation) may be used. According to the neuromuscular theory of the pathogenesis of chronic nonbacterial prostatitis, antispasmodics and muscle relaxants may be prescribed.In recent years, based on the theory that cytokines are involved in the development of chronic inflammatory processes, the possibility of using cytokine inhibitors, such as tumor necrosis factor monoclonal antibodies, leukotriene inhibitors (belonging to a new class of NSAIDs) and tumor necrosis factor inhibitors, is being considered for the treatment of chronic prostatitis.

Non-drug treatment of chronic prostatitis

At present, great emphasis is placed on the local use of physical methods, which can not exceed the average therapeutic dose of antimicrobial drugs due to the stimulation of microcirculation, thereby increasing the accumulation of drugs in the prostate.The most effective physical method to treat chronic prostatitis:

• transrectal microwave hyperthermia;
• Physiotherapy (laser therapy, mud therapy, sound wave therapy and electrophoresis therapy).

Different microwave hyperthermia temperature regimens are used depending on the nature of the changes in the prostate tissue, the presence of hyperemic and proliferative changes, and accompanying prostate adenomas. At a temperature of 39-40 ° C, the main effects of electromagnetic radiation in the microwave range, in addition to the above, are anti-congestive and bacteriostatic effects, as well as activation of the cellular immune system. At temperatures of 40-45°C, sclerosing and neural analgesic effects dominate, with the analgesic effect being due to the inhibition of sensory nerve endings.The effect of low-energy magnetic laser therapy on the prostate is close to that of microwave hyperthermia at 39-40°C, which stimulates microcirculation, has anti-digestive effects, promotes the accumulation of drugs in prostate tissue and activates the cellular immune system. Additionally, laser therapy has a biostimulating effect. This method is most effective when hyperemic and infiltrative changes predominate in the organs of the reproductive system and is therefore used in the treatment of acute and chronic prostatic seminal vesiculitis and epididymo-orchitis. In the absence of contraindications (prostate stones, adenomas), prostate massage does not lose its therapeutic value. Convalescent therapy and rational psychotherapy are successfully used in the treatment of chronic prostatitis.

Surgical treatment of chronic prostatitis

Despite its prevalence and difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. Cases of long-term and often ineffective treatments bear this out, transforming the treatment process into a purely commercial enterprise with minimal risk to the patient's life. Its complications pose a more serious danger, not only disrupting the urinary process and negatively affecting male reproductive function, but also causing severe anatomical and functional changes in the bladder - sclerosis of the prostate and bladder neck.Unfortunately, these complications often occur in young adult patients. This is why the use of transurethral electrosurgery, as a minimally invasive procedure, is becoming increasingly important. If it is severe organic BOO caused by bladder neck sclerosis and prostate sclerosis, transurethral incisions are made at the 5, 7 and 12 o'clock positions of the conventional dial, or economical resection of the prostate is performed. In cases where chronic prostatitis results in prostate sclerosis and severe symptoms that are not suitable for conservative treatment. Perform the most radical resection of the prostate. Transurethral resection of the prostate can also be used for common calculous prostatitis. Calcification. They are located in central and transient areas, disrupting tissue nutrition and increasing congestion of isolated acinar groups, causing pain that is difficult to treat conservatively. In this case, electrical resection must be performed until the calcification is removed as completely as possible. In some clinics, TRUS is used to monitor calcification removal in such patients.Another indication for endoscopic surgery is sclerosis of the spermatozoa with associated obliteration of the prostatic ejaculatory and excretory ducts.If an exacerbation of the chronic inflammatory process (suppuration of the prostatic sinus or seropuppurative discharge) is diagnosed during transurethral intervention, the operation must be completed by resection of the entire remaining gland. The prostate is removed by electroresection, followed by precise coagulation of bleeding vessels with a ball electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent reabsorption of infected urine into the prostatic duct.