Chronic prostatitis

chronic prostatitis symptoms

If the situation with infectious (or rather bacterial) prostatitis is more or less clear, then chronic non-bacterial prostatitis is still a serious urological problem with many unclear issues. Perhaps, under the guise of a disease called chronic prostatitis, there is a whole range of diseases and pathological conditions characterized by various organic changes in tissues and functional disorders of the activity of not only the prostate gland, the organs of the male reproductive system and the lower urinary tract , but also other organs and systems in general.

ICD-10 Codes

  • N41. 1 Chronic prostatitis.
  • N41. 8 Other inflammatory diseases of the prostate.
  • N41. 9 Inflammatory prostate disease, unspecified.

Epidemiology of chronic prostatitis

Chronic prostatitis ranks first in prevalence among inflammatory diseases of the male reproductive system and one of the first among male diseases in general. This is the most common urological disease in men under 50 years of age. The average age of patients suffering from a chronic inflammatory process in the prostate is 43 years. By the age of 80, up to 30% of men suffer from chronic or acute prostatitis.

The prevalence of chronic prostatitis in the general population is 9%. In our country, chronic prostatitis, according to the most approximate estimates, in 35% of cases makes men of working age consult a urologist. In 7-36% of patients it is complicated by vesiculitis, epididymitis, urinary disorders, reproductive and sexual functions.

What causes chronic prostatitis?

Modern medical science considers chronic prostatitis a polyetiological disease. The occurrence and recurrence of chronic prostatitis, in addition to the action of infectious factors, are caused by neurovegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmune (exposure to endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical processes (urine reflux into the prostate ducts) and biochemical (possible role of citrates), as well as aberrations of peptide growth factors. Risk factors for developing chronic prostatitis include:

  • Lifestyle characteristics that cause infection of the genitourinary system (promiscuous sexual intercourse without protection and personal hygiene, presence of an inflammatory process and/or infections of the urinary and genital organs in the sexual partner):
  • carrying out transurethral manipulations (including TURP of the prostate) without prophylactic antibiotic therapy:
  • presence of a permanent urethral catheter:
  • chronic hypothermia;
  • sedentary lifestyle;
  • irregular sex life.

Among the etiopathogenetic risk factors for chronic prostatitis, immunological disorders are important, in particular the imbalance between several immunocompetent factors. First of all, this applies to cytokines - low molecular weight compounds of a polypeptide nature that are synthesized by lymphoid and non-lymphoid cells and have a direct effect on the functional activity of immunocompetent cells.

Chronic prostatitis symptoms

The symptoms of chronic prostatitis are: pain or discomfort, urinary problems and sexual dysfunction. The main symptom of chronic prostatitis is pain or discomfort in the pelvic region that lasts for 3 months. and more. The most common site of pain is the perineum, but a sensation of discomfort may occur in the suprapubic region, groin, anus and other areas of the pelvis, on the inner thighs, as well as in the scrotum and lumbosacral region. Unilateral testicular pain is usually not a sign of prostatitis. Pain during and after ejaculation is more specific to chronic prostatitis.

Sexual function is impaired, including suppression of libido and deterioration in the quality of spontaneous and/or adequate erections, although most patients do not develop severe impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE), however, in more advanced stages of the disease, ejaculation may be slow. There may be a change ("erasure") of the emotional coloring of the orgasm.

Urinary disorders are more frequently manifested by irritative symptoms and less frequently by IVO symptoms.

In the case of chronic prostatitis, quantitative and qualitative ejaculation disorders can also be detected, which are rarely a cause of infertility.

The disease of chronic prostatitis is wave-like in nature, periodically intensifying and weakening. In general, the symptoms of chronic prostatitis correspond to the phases of the inflammatory process.

The exudative phase is characterized by pain in the scrotum, groin and suprapubic region, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful erections.

In the alternative phase, the patient may feel pain (unpleasant sensations) in the suprapubic region, less commonly in the scrotum, groin region and sacrum. Urination, as a rule, is not impaired (or increased). Against the background of accelerated and painless ejaculation, a normal erection is observed.

The proliferative phase of the inflammatory process can be manifested by a weakening of the intensity of the urinary stream and increased urination (with exacerbations of the inflammatory process). Ejaculation at this stage is not impaired or slightly delayed, the intensity of adequate erections is normal or moderately reduced.

In the phase of cicatricial changes and prostate sclerosis, patients are concerned about heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total urinary frequency), slow and intermittent stream of urine and an urgent need to urinate. Ejaculation is delayed (up to its absence), adequate and sometimes spontaneous erections are weakened. Often, at this stage, attention is drawn to the "erasure" of the orgasm.

The impact of chronic prostatitis on quality of life, according to the unified quality of life assessment scale, is comparable to the impact of myocardial infarction. angina or Crohn's disease.

Diagnosis of chronic prostatitis

Diagnosing the manifestation of chronic prostatitis is not difficult and is based on the classic triad of symptoms. Considering that the disease is often asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including determining the immunological and neurological status.

In assessing the subjective manifestations of the disease, questionnaires are of great importance. Many questionnaires have been developed that are filled out by the patient and the doctor wants to have an idea of the frequency and intensity of pain, urinary disorders and sexual disorders, the patient's attitude towards these clinical manifestations of chronic prostatitis, as well as how to assess the state of psycho-emotional sphere of the patient. The most popular currently is the Chronic Prostatitis Symptom Scale (NIH-CPS) questionnaire. The questionnaire was developed by the US National Institutes of Health and represents an effective tool for identifying the 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 allows you to diagnose "chronic prostatitis" (since in 1961, Farman and McDonald established the "gold standard" in the diagnosis of prostate inflammation - 10-15 leukocytes in the field of view) and make a diagnosis difference between its bacterial and non-bacterial forms.

A microscopic examination of the discharged urethra determines the number of leukocytes, mucus, epithelium, as well as trichomonas, gonococci and nonspecific flora.

When examining a scraping from the urethral mucosa using the PCR method, the presence of microorganisms that cause sexually transmitted diseases is determined.

Microscopic examination of prostate secretion determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallement bodies and macrophages.

A bacteriological examination of prostate secretion or urine obtained after massage is carried out. Based on the results of these studies, the nature of the disease (bacterial or abacterial prostatitis) is determined. Prostatitis can cause an increase in PSA concentration. Blood sampling to determine serum PSA concentration should not be performed earlier than 10 days after the digital rectal examination. Despite this, when the PSA concentration is above 4. 0 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is indicated to exclude prostate cancer.

Of great importance in the laboratory diagnosis of chronic prostatitis is the study of the immunological status (state of humoral and cellular immunity) and the level of nonspecific antibodies (IgA, IgG and IgM) in prostate secretion. Immunological research helps to determine the stage of the process and monitor the effectiveness of treatment.

Instrumental diagnosis of chronic prostatitis

TRUS of the prostate for chronic prostatitis has high sensitivity but low specificity. The study allows not only to make differential diagnoses, but also to determine the form and stage of the disease with subsequent monitoring throughout the treatment. Ultrasonography makes it possible to assess the size and volume of the prostate, echostructure (cysts, stones, fibrosclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), size, degree of expansion, density and echo-homogeneity of the contents of the seminal vesicles.

UDI (UFM, urethral pressure profile determination, pressure/flow study, cystometry) and pelvic floor muscle myography provide additional information if neurogenic voiding disorders and pelvic floor muscle dysfunction are suspected. as well as IVO, which often accompanies chronic prostatitis.

Radiographic examination should be carried out in patients with diagnosed BOO in order to clarify the cause of its occurrence and determine further treatment tactics.

Computed tomography and MRI of the pelvic organs are performed for differential diagnosis with prostate cancer, as well as if a non-inflammatory form of abacterial prostatitis is suspected, when it is necessary to exclude pathological changes in the spine and pelvic organs.

What needs to be examined?

Prostate (prostate)

How to examine?

  • Prostate ultrasound
  • prostate biopsy

What tests are needed?

  • Analysis of prostate (prostate) secretion
  • Prostate-specific antigen in the blood

Who to contact?

  • Urologist
  • Andrologist

Treatment of chronic prostatitis

The treatment of chronic prostatitis, as with any chronic disease, must be carried out respecting the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's lifestyle, his thinking and his psychology. Eliminating the influence of various harmful factors, such as a sedentary lifestyle, alcohol, chronic hypothermia and others. By doing so, we not only prevent the progression of the disease, but also promote recovery. This, as well as the normalization of sex life, diet and much more, is a preparatory stage of treatment. This is followed by the main, basic course, which involves the use of various medications. This step-by-step approach to treating the disease makes it possible to monitor its effectiveness at each stage, making the necessary changes, and also combat the disease according to the same principle by which it developed. - predisposing factors for producers.

Indications for hospitalization

Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of chronic persistent prostatitis, complex therapy carried out in a hospital setting is more effective than outpatient treatment.

Drug treatment of chronic prostatitis

It is necessary to simultaneously use several drugs and methods that act on different parts of the pathogenesis in order to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), adequate drainage of prostatic acini, especially in the peripheral zones, normalize the level of essential hormones and immunological reactions. Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators, as well as prostate massage can be recommended for use in chronic prostatitis. In recent years, the treatment of chronic prostatitis has been carried out with drugs that were not previously used for this purpose: alpha1 blockers, 5-a-reductase inhibitors, cytokine inhibitors, immunosuppressants, drugs that affect the metabolism of urates and citrates.

In the case of chronic bacterial prostatitis and chronic pelvic pain inflammatory syndrome (in the case when the pathogen was not identified as a result of the use of microscopic, bacteriological and immunological diagnostic methods), empirical antibacterial treatment of chronic prostatitis with a course can be carried out short and, if clinically effective, continued. The effectiveness of empirical antimicrobial therapy in patients with bacterial and abacterial prostatitis is about 40%. This indicates the undetectability of bacterial flora or the positive role of other microbial agents (chlamydia, mycoplasmas, ureaplasmas, fungal flora, Trichomonas, viruses) in the development of the infectious inflammatory process, which is currently not confirmed. Flora that is not detected by standard microscopic or bacteriological examination of prostate secretions can, in some cases, be detected by histological examination of prostate biopsies or other subtle methods.

In chronic non-inflammatory pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is controversial. The duration of antibacterial therapy should be no more than 2 to 4 weeks, after which, if the results are positive, it is continued for up to 4 to 6 weeks. If there is no effect, it is possible to stop antibiotics and prescribe drugs from other groups (for example, alpha1 blockers, plant extracts from Serenoa repens).

The drugs of choice for the empirical treatment of chronic prostatitis are fluoroquinolones, as they have high bioavailability and penetrate well into the glandular tissue (the concentration of some of them in the secretion exceeds that in the blood serum). Another advantage of drugs in this group is their activity against most gram-negative microorganisms, as well as against chlamydia and ureaplasma. The results of chronic prostatitis treatment do not depend on the use of any specific medication from the fluoroquinolone group.

If fluoroquinolones are ineffective, combined antibacterial therapy should be prescribed. Tetracyclines have not lost their importance, especially when chlamydia infection is suspected.

Recent studies have proven that clarithromycin penetrates prostate tissue well and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.

It is also recommended to prescribe antibacterial medications to prevent relapses of bacterial prostatitis.

If relapses occur, the previous course of antibacterial medications in lower single, daily doses may be prescribed. The ineffectiveness of antibiotic therapy is generally due to the wrong choice of medication, its dosage and frequency, or to the presence of bacteria that persist in the ducts, acini or calcifications and are covered by a protective extracellular membrane.

Pain and irritative symptoms are indications for prescribing NPS, which are used both in complex therapy and as an isolated alpha-blocker if antibacterial therapy is ineffective (diclofenac dose 50-100 mg/day).

Some studies demonstrate the effectiveness of herbal medicine, but this information has not been confirmed by multicenter placebo-controlled studies.

If clinical symptoms of the disease (pain, dysuria) persist after use of antibiotics, α-blockers and NSAIDs, subsequent treatment should be aimed at relieving pain, or resolving problems with urination, or correcting both. above symptoms.

For pain, tricyclic antidepressants have an analgesic effect due to blocking histamine H1 receptors and anticholinesterase action. The most commonly prescribed medications are amitriptyline and imipramine. However, they must be taken with caution. Side effects - drowsiness, dry mouth. In extremely rare cases, narcotic painkillers (tramadol and other medications) may be used to relieve pain.

If dysuria predominates in the clinical picture of the disease, ultrasound (UFM) should be performed before starting drug therapy and, if possible, a videourodynamic study. Additional treatment is prescribed depending on the results obtained. In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as with interstitial cystitis, prescribing amitriptyline, antihistamines and instillation of antiseptic solutions into the bladder. For detrusor hyperreflexia, anticholinesterase medications are prescribed. For hypertonicity of the external sphincter of the bladder, benzodiazepines are prescribed, and if drug therapy is ineffective, physiotherapy (relief of spasms), neuromodulation (for example, sacral stimulation).

Based on the neuromuscular theory of the etiopathogenesis of chronic bacterial prostatitis, antispasmodics and muscle relaxants can be prescribed.

In recent years, based on the theory of the participation of cytokines in the development of a chronic inflammatory process, the possibility of using cytokine inhibitors has emerged, such as monoclonal antibodies to tumor necrosis factor, leukotriene inhibitors (belonging to a new class of NSAIDs ) and tumor necrosis factor inhibitors, is being considered for chronic prostatitis.

Non-drug treatment of chronic prostatitis

Currently, great importance is attached to the local use of physical methods, which make it possible not to exceed the average therapeutic dose of antibacterial drugs due to the stimulation of microcirculation and, consequently, an increase in the accumulation of drugs in the prostate.

The most effective physical methods for treating chronic prostatitis:

  • transrectal microwave hyperthermia;
  • physiotherapy (laser therapy, mud therapy, phonotherapy and electrophoresis).

Depending on the nature of changes in prostate tissue, the presence or absence of congestive and proliferative changes, as well as concomitant prostatic adenoma, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 "The main effects of electromagnetic radiation of the microwave range, in addition to the above, are anticongestive and bacteriostatic effects, as well as the activation of the cellular immune system. At a temperature of 40-45 ° C, they prevail the sclerosing and neuroanalgesic effects, and the analgesic effect is due to the inhibition of sensory nerve endings.

Low-energy magnetic laser therapy has an effect on the prostate close to microwave hyperthermia at 39-40 ° C, that is, it stimulates microcirculation, has an anticogestive effect, promotes the accumulation of drugs in prostate tissue and activation of the cellular immune system. Furthermore, laser therapy has a biostimulating effect. This method is most effective when congestive-infiltrative changes predominate in the organs of the reproductive system and is therefore used for the treatment of acute and chronic prostatovesiculitis and orchiepididymitis. In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value. Sanatorium treatment and rational psychotherapy are successfully used in the treatment of chronic prostatitis.

Surgical treatment of chronic prostatitis

Despite its prevalence and known difficulties in diagnosis and treatment, chronic prostatitis is not considered a potentially fatal disease. This is proven by cases of long-term and often ineffective therapy, making the treatment process a purely commercial enterprise with minimal risk to the patient's life. A much more serious danger is represented by its complications, which not only disrupt the urination process and negatively affect the reproductive function of men, but also lead to serious anatomical and functional changes in the bladder - sclerosis of the prostate and bladder neck.

Unfortunately, these complications often occur in young and middle-aged patients. This is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly important. In the case of severe organic BOO, caused by bladder neck sclerosis and prostate sclerosis, a transurethral incision is performed at 5, 7 and 12 o'clock on the conventional dial, or economical electrical resection of the prostate is performed. In cases where the result of chronic prostatitis is prostatic sclerosis with severe symptoms that are not amenable to conservative therapy. perform the most radical transurethral electroresection of the prostate. Transurethral electroresection of the prostate can also be used for common calculous prostatitis. Calcifications. located in the central and transitional zones, they disrupt tissue trophism and increase congestion in isolated groups of acini, leading to the development of pain that is difficult to treat conservatively. In these cases, electrical resection should be performed until the calcifications are removed as completely as possible. In some clinics, TRUS is used to monitor resection of calcifications in these patients.

Another indication for endoscopic surgery is sclerosis of the seminal tubercle, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate.

If during transurethral intervention an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the prostatic sinuses) is diagnosed, the operation must be completed with the removal of the entire remaining gland. The prostate is removed by electroresection, followed by punctual coagulation of the hemorrhagic vessels with a spherical electrode and installation of a cystostomy with a trocar to reduce intravesical pressure and prevent reabsorption of infected urine into the prostatic ducts.