Chronic prostatitis

According to many experts, chronic prostatitis is an inflammatory disease caused by infection with the addition of autoimmune diseases characterized by parenchymatosis and damage to interstitial tissue. The disease has been known in medicine since 1850, but is still poorly understood and responds poorly 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 quality of life. The disease is mainly observed in young and middle-aged people and is often complicated by impaired copulative and generative functions (decreased capacity, infertility, etc. ). The disease occurs in 8-35% of cases in men between the ages of 20 and 40.

The cause of bacterial prostatitis is a pyogenic flora that penetrates the gland through the urethra or lymphogenic and hematogenous routes. The etiology and pathogenesis of chronic non-bacterial prostatitis are unknown. It mainly affects men over 50 years old.

Causes of the disease

Chronic prostatitis is currently considered a polyetiological disease. There is an opinion that the disease occurs as a result of penetration of the prostate infection and then continues without the involvement of the pathological process. This is due to a number of non-infectious factors.

Infectious factors in the development of chronic prostatitis

In 90% of cases, pathogens enter the pancreas through the urethra, resulting in acute or chronic prostatitis. There have been cases of asymptomatic transport. The course of the disease is affected by the protective state of the human body and the biological characteristics of the pathogen. The transition from acute to chronic prostatitis is thought to be due to loss of tissue elasticity due to excessive production of fibrous tissue.

The following pathogens are found in the causes of chronic prostatitis:

• In 90% of cases, the disease is Escherichia coli (E. coli), Enterococcus faecalis (fecal enterococci), a little less - Pseudomonas aeruginosa, Klebsiella spp. , Proteus spp. Detects gram-negative bacteria such as Pseudomonas aeruginogenes and Enterobacter. . Gram-positive bacteria such as enterococci, streptococci and staphylococci are rare.
• The role of coagulase-negative staphylococci, ureaplasma, chlamydia, Trichomonas, gardnerella, anaerobic bacteria, and fungi of the genus Candida is not fully understood.

The infection enters the prostate in several ways:

• As evidenced by the frequent combination of prostatitis and urethritis, an increasing pathway is most likely.
• Hematogenous prostatitis infection is associated with chronic tonsillitis, sinusitis, periodontitis, pneumonia, cholecystitis and cholangitis, purulent skin diseases, etc. It develops when it penetrates the gland with the blood flow observed in
• In contact, with chronic prostatitis, urethritis and narrowing of the urethra, the infection develops in the urinary tract, with purulent infections of the kidneys, during diagnostic and therapeutic urological manipulations, epipidymitis, deferentitis and funiculitis develops in a canalicular way (catheterization, urethral)being.
• Lymphogenic infection is associated with prostate proctitis, thrombophlebitis of hemorrhoidal vessels, etc.

Non-infectious factors in the development of chronic prostatitis

Chemical factors

According to experts, the leading role in the development of chronic prostatitis belongs to the intraprostatic urine flow, which leads to the emptying of the prostate and seminal vesicles when discharged from the urethra.

With the disease, vascular reactions develop, cause edema of the body, nervous and humoral regulation of the tone of the smooth muscle tissue of the urinary tract is disrupted, alpha is activated._a- Adrenergic receptors cause dynamic obstruction and promote the development of new intraprostatic reflux.

The flow of urine in the urine, along with reflux, causes the development of a "chemical inflammatory reaction. "

Hemodynamic diseases

They support chronic inflammation and circulatory disorders in the pelvic organs and scrotum. Congestion occurs in people who lead a sedentary lifestyle, such as drivers, office workers, and so on. It develops with obesity, sexual abstinence, sexual dysmetry, often hypothermia, mental and physical overload. Consumption of spicy and spicy foods, alcoholic beverages and smoking helps to protect the inflammatory process.

Other factors

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

• Hormonal.
• Biochemical.
• Impaired immune response.
• Autoimmune mechanisms.
• Infectious and allergic processes.
• Features of the structure of the prostate gland, difficulty in complete drainage.

It is impossible to determine the causes of the development of chronic prostatitis.

Classification of prostatitis

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

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

Signs and symptoms of chronic prostatitis

The course of chronic prostatitis is long, but not monotonous. Exacerbation periods are replaced by periods of relative calm that occur after complex anti-inflammatory and antibacterial therapy.

Before the development of chronic bacterial prostatitis often occurs bacterial or gonorrheal urethritis, non-bacterial - circulatory disorders in the pelvic organs and scrotum (hemorrhoids, varicocele, etc. ), sexual overdose.

There are many complaints in patients with chronic prostatitis. They have been seeing doctors for years, but very rarely are they diagnosed with prostate disease. About a quarter of patients have no complaints or the disease continues with few clinical symptoms.

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

Urinary diseases associated with narrowing of the urethra:

• Difficulty at the beginning of urination.
• Poor urine flow.
• Intermediate or drip urination.
• Feeling of incomplete emptying of the bladder.

Symptoms that irritate the nerve endings:

• Frequent urination.
• The urge to urinate is sharp and intense.
• Urinary excretion in small portions.
• Failure to urinate during urination.

Pain syndrome:

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

Sexual dysfunction:

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

By the nervous system: neurotic disorders in the form of focusing patients' attention on health conditions.

Signs and symptoms of chronic non-bacterial prostatitis

In men, chronic pelvic pain syndrome (CPPS) occurs with the usual symptoms of chronic prostatitis, but the bacteria are not present in the third part of the urine and in the secretion of the prostate gland. CPPS can be simulated with chronic non-bacterial interstitial cystitis, rectal diseases, spastic pelvic floor myalgia syndrome, and functional prostate lesions caused by disturbances in the body's innervation and hemodynamics.

If neurovegetative function is impaired, there is atony and impaired glandular innervation, resulting in difficulty in rapid and complete closure of the lumen of the urethra. At the same time, urine continues to drip for a long time after urination. In such patients, the study reveals instability and increased agitation, which is manifested by increased sweating and agitation of the heart, changes in dermography.

Complications of the disease

Prolonged chronic prostatitis is complicated by sexual and reproductive dysfunction, the development of diseases such as vesiculitis and epipidymitis, as well as hardening of the body. Sclerosis of the body worsens local microcirculation and urodynamics, as well as the consequences of surgical interventions. Periurethral tissue fibrosis leads to the development of urinary tract diseases.

Diagnostics

Because there are many causes for the development of chronic prostatitis, all diagnostic tests are used to make a diagnosis. The success of treatment depends on the correct identification of the causes of the disease. The diagnosis of chronic prostatitis is based on the following information:

• The classic trio of symptoms.
• A number of physical methods (digital rectal examination of the prostate).
• A set of laboratory methods (urinalysis and microscopy of prostate secretion, culture and determination of the sensitivity of the microflora to antibacterial drugs, general analysis of urine and blood).
• Bacterioscopy of a smear from the urethra for the detection of gonococci, PCR and serological methods (for the detection of ureaplasma and chlamydia).
• Urofluometry.
• Prostate biopsy.
• A set of instrumental methods (ultrasound).
• Determination of the patient's immune status.
• Determination of neurological status.
• If the treatment is ineffective and complications are suspected, calculated and magnetic resonance imaging, blood culture, etc. should be performed.

Palpation of the prostate

Prostate palpation is of great importance in the diagnosis of the disease, it increases during the period of exacerbation and decreases during the period of reduction of the inflammatory process. Inflammation of the iron causes swelling and pain in chronic prostatitis.

The density of body consistency can be different: areas of softening and compression are palpated, depressions are identified. During palpation, it is possible to assess the shape of the gland, the condition of the seminal tubules and surrounding tissues.

The process of digital rectal examination is combined with the collection of glandular secretions. Sometimes it is necessary to get the secret from each share separately.

Analysis of 3 cups of urine sample and prostate secretion

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

• Collection of the first part of urine.
• Collection of the second part of urine.
• Get glandular secretion by massage.
• Collection of a third of the urine.

In addition, 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 neglect dozens and hundreds of small numbers of microbes.
• The presence of 10-15 leukocytes detected under a microscope in the field of vision is a generally accepted criterion for the presence of an inflammatory process.

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

Normal prostate secretion:

• Less than 10 leukocytes in the visual field.
• There are many lecithin grains.
• No microflora.

Prostate secretion in chronic prostatitis shows the following:

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

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

The value of the crystallization test of prostate secretion is maintained. Normally, during crystallization, a characteristic pattern in the form of a fern leaf is formed. In the case of a violation of the merging properties of prostate secretion, such a form does not occur, which occurs when the androgenic hormonal background changes.

Ultrasound procedure

If you suspect a prostate disease, an ultrasound examination of the gland itself (transrectal ultrasound is optimal), kidneys and bladder are used:

• Diaper volume and size.
• Having a calculus.
• The size of the seminal vesicles.
• Condition of the walls of the bladder.
• Residual amount of urine.
• Scrotal structures.
• Another type of pathology.

Other methods of prostate examination

• The condition of urodynamics (study of the rate of urine flow) is easily and simply determined using a study such as uroflowmetry. With the help of this study, it is possible to detect the signs of bladder obstruction in a timely manner and conduct dynamic monitoring.
• Puncture biopsy is performed if abscess formation, benign hyperplasia and prostate cancer are suspected.
• X-ray and endoscopic examinations are performed to determine the causes of infravesicular obstruction.
• It is recommended to perform urethrocystoscopy with a long-term inflammatory process.

Differential diagnosis

Chronic prostatitis vesiculoprostatostasis, autonomic prostatopathy, congestive prostatitis, pelvic thoracic myalgia, neuropsychiatric disorders, pseudodysynergy, reflex sympathetic dystrophy, inflammatory diseases of other organs: interstitial cystitis, cervical urethral epithelial hysteresis, osteoarthritis hysteresis osteitis.

Treatment of chronic prostatitis

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

Drugs that affect various pathogenesis relationships are also used in the treatment of the disease.

The main directions of therapy:

• Eliminate the creating microorganisms.
• Anti-inflammatory therapy.
• Normalization of blood circulation in the prostate and pelvic organs.
• Normalization of adequate prostate bone drainage.
• Normalization of hormonal profile.
• Prevention of hardening of the body.

The following groups of drugs are used to treat chronic prostatitis:

• Antibacterial.
• Anticholinergic.
• Vasodilators.
• Alpha_a- 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 has not been identified, empirical antimicrobial therapy is used.

The drugs of choice are II-IV generation fluoroquinolones. They penetrate rapidly into the glandular tissues by conventional methods of application, are active against a large group of gram-negative microorganisms and ureaplasma and chlamydia. In case of failure of antimicrobial treatment, the following should be taken:

• multi-drug resistance of the microflora,
• short (less than 4 weeks) treatment courses,
• wrong choice and dosage of antibiotics,
• changes in the type of pathogen,
• the presence of bacteria living in the ducts of the prostate, which are covered by a membrane outside a protective cell.

The duration of treatment should be at least 4 weeks with subsequent mandatory bacteriological control. If there are more than 10 bacteriuria in the 3rd part of the urine and prostate secretion³CFU / ml, a repeated course of antibiotic treatment is prescribed between 2 and 4 weeks.

Cytokine inhibitors in the treatment of chronic prostatitis

Cytokines are glycoproteins secreted by the immune and other cells in response to the inflammatory response and immune response. They are actively involved in the development of chronic inflammatory processes.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs have anti-inflammatory effects, reduce pain and fever. It is widely used in the form of tablets and suppositories in the treatment of chronic prostatitis. The most effective way is rectal application.

Immunotherapy

In addition to antibiotics and anti-inflammatory drugs, immunomodulatory agents are used to treat bacterial chronic prostatitis. The most effective is the rectal route of their application. An immunomodulator that enhances the functional activity of phagocytes and helps to remove pathogens more efficiently is widely used.

Alpha-blockers in the treatment of chronic prostatitis

Alpha-1 adrenergic blockers have been found to normalize the smooth muscle tone of the prostate urethra, seminal vesicles and prostate capsule, which makes this group of drugs very effective in the treatment of the disease. Alpha-1 adrenergic blockers are used in patients with severe urinary incontinence in the absence of an active inflammatory process.

The duration of treatment with CPPS is between 1 and 6 months.

5a-reductase inhibitor in the treatment of abacterial prostatitis and CPPS

Under the influence of the enzyme 5a-reductase, the activity of testosterone in prostate cells was found to be 5a-dihydrotestosterone, a form of prostate that is 5 times higher than the activity of testosterone in older people. growth in the body due to epithelial and stromal components.

When 5a-reductase inhibitors are taken for 3 months, atrophy of stromal tissue is noted for 6 months - glandular, secretory function is inhibited, pain syndrome and gland volume are reduced, body tension and edema are reduced.

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

With long-term inflammation of the prostate gland, fibrosis develops, which manifests itself in the violation of microcirculation and urodynamics. Anti-sclerotic drugs are used to prevent the process of fibrosis.

Other drugs used in the treatment of chronic prostatitis

In addition to the drugs described above, the following are used to treat the disease:

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

Herbal products

Effective in the treatment of prostatitis is the use of a drug in the form of a suppository, a complex of biologically active peptides isolated from the prostate gland of cattle.

Occurs under the influence of the drug:

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

Finger massage of the prostate gland

A number of researchers claim that finger massage should be used for chronic prostatitis, given the 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.
• Negroes are more prone to disease.
• The predisposition of the family to the disease is not excluded.

People who are prone to developing chronic prostatitis should be more careful about their health.

Disease prevention recommendations:

• Drink plenty of fluids. Frequent urination helps to flush the microflora out of the urethra.
• Prevent diarrhea and constipation.
• Eat a balanced diet. Avoid foods that are high in carbohydrates and saturated fats, which can lead to weight gain.
• You should limit the use of substances that irritate the urinary tract as much as possible: spicy and spicy foods, smoked meats, sauces and condiments, coffee and alcohol.
• Stop smoking. Nicotine has a negative effect on the condition of the vascular walls.
• Do not overcool.
• Do not leave the bladder empty.
• Lead an active lifestyle, do sports. Exercise to strengthen the pelvic floor muscles, which can relieve venous congestion, which supports normal prostate function.
• Have a regular sex life. Do not hesitate for a long time. The cloth should be released immediately.
• Stay in a monogamous relationship. Separate sexual intercourse increases the risk of sexually transmitted diseases.
• If you have any complaints about the genitourinary system, contact your urologist immediately.