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Prostatitis

Prostatitis (prostatitis) is an inflammation of the prostate (an organ of the male reproductive and reproductive system) and an alteration in its physiological functions as a result of this process.

symptoms of prostatitis in men

To spread

According to various sources, prostatitis occurs in 35-40% and, according to some authors, in 70% of men aged between 18 and 50 years. The prostate, in terms of the prevalence of the disease and the resulting complex of problems, occupies a prominent place among urological pathologies.

Classification

There are many classifications of prostatitis, hence a very peculiar terminology. The most common is the classification of prostatitis, proposed by the US National Institutes of Health (NIH) in 1995:

Category Description
Category I Acute bacterial prostatitis
Category II Chronic bacterial prostatitis
Category III Chronic abacterial prostatitis
Category IIIA Inflammatory chronic pelvic pain syndrome
Category IIIB Non-inflammatory chronic pelvic pain syndrome (prostatodynia)
Category IV Asymptomatic inflammatory prostatitis

This classification of prostatitis is based on the clinical signs, presence or absence of leukocytes and microorganisms in the secretion of the prostate, ejaculation and urine.

Category I

Acute bacterial prostatitisIt is expressed by an acute infectious inflammation of the prostate with all the accompanying symptoms:

  • an increase in the number of leukocytes in the urine;
  • the presence of bacteria in the urine;
  • general signs of infection (fever, symptoms of intoxication).

Category II

Chronic bacterial prostatitis- accompanied by corresponding symptoms and an increase in the number of leukocytes and bacteria in the prostate secretions, ejaculation and urine obtained after prostate massage.

Category III

Chronic pelvic pain syndrome (CPPS)- the main clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of the prostate, ejaculation and urine obtained after prostate massage. The criterion for separation in III A and III B is the presence of an increased number of leukocytes.

Category III A

Chronic pelvic pain inflammatory syndrome- characterized by the presence of painful syndrome and symptoms of prostatitis, although there is an increase in the number of leukocytes in the secretion of the prostate, ejaculation and urine portion, after prostate massage, pathogenic microorganisms are not detected in these samples by standard methods.

Category III B

Non-inflammatory chronic pelvic pain syndrome- characterized by the presence of painful syndrome and symptoms of prostatitis, while there is no increase in the number of leukocytes and pathogenic microorganisms in prostate secretion, ejaculation and urine obtained after prostate massage are not detected by conventional methods.

Category IV

Asymptomatic inflammatory prostatitis- the absence of characteristic symptoms of prostatitis, the disease is detected by chance during a histological examination of prostate tissue samples obtained in connection with the diagnosis for other reasons (for example, a prostate biopsy due to an increase in the level of specificof the prostate antigen - PSA).

Diagnosis of prostatitis

The symptoms of prostatitis are extremely varied, but they can be grouped into several groups.

Pain Syndrome

As a result of insufficient blood supply, caused by inflammation or spasm of the vessels that feed the prostate, there is a lack of oxygen in the gland tissues, as a result of the formation of pathological oxidation by-products that affect the nerve endings of the prostate. Since prostate innervation is associated with innervation of the pelvic floor, penis, scrotum, testicles, rectum, the location of pain is variable. The following pain symptoms are the most common:

  • Discomfort or pain in the perineum - appears mainly after physical exertion, sexual intercourse, alcohol ingestion in the form of transient seizures;
  • Hot potato sensation in the rectum;
  • Pain (discomfort) in the testicles - patients describe it as "pain", "torsion", are also associated with several provocative factors;
  • Discomfort, cramps and pain in the urethra are mainly associated with a change in the pH of the secretion from the prostate to the acidic side. Acid secretion from the prostate irritates the urethral mucosa, so painful sensations, most often in the form of "burning", occur after urination or intercourse, when part of the secretion is squeezed into the lumen of the urethra during contraction of the muscles of the urethragland and pelvis.

Urinary disorder syndrome

Associated with the narrow innervation of the prostate and bladder, as well as the involvement of the prostate muscles in the act of urination. Dysuria can be accompanied by the following manifestations:

  • Frequent urination - frequent urination (up to 3 times per hour) with a sharp and sudden need (impossible to tolerate) and very small portions;
  • Sensation of incomplete emptying of the bladder - after urination, there is a feeling that the urine remains in the bladder;
  • Weak or intermittent urine flow - it can also include the symptom of "last drop" - despite all the patient's efforts, after urinating, a drop of urine is still released from the canal.

Ejaculation and orgasm disturbance

It is associated with lesions in the seminal tubercle (colliculitis) during prostatatitis, on whose surface there are nerve receptors that send a signal to the structures of the brain, where the sensation of orgasm is formed. Prostatitis does not directly cause erectile dysfunction (blood filling of the penis with sexual arousal).

Main violations:

  • Premature ejaculation, or vice versa, excessively prolonged sexual intercourse - caused by inflammation of the seminal tubercle or its scar due to the inflammatory process;
  • Off orgasm - also associated with inflammation of the seminal tubercle;
  • Pain during ejaculation - associated with an inflammatory process in the excretory ducts of the prostate, through which sperm is released.

Impairment of fertility

When the properties of prostate secretion change due to inflammation, the following changes in sperm are observed, which reduces man's ability to fertilize (fertility):

  • A decrease in the pH of the sperm towards the acidic side - since with the inflammation of the prostate, acidic products of pathological oxidation begin to accumulate in secret. An acidic environment is extremely destructive to sperm, causing them to immobilize and even die;
  • Sperm agglutination - sperm bonding mainly by heads - is associated with a change in the physicochemical properties of the secret;
  • Asthenospermia - decreased sperm motility - is closely associated with a change in pH towards the acid side and a violation of the production of lecithin cells by the prostate, which guarantee the vital activity of sperm.

Urethroprostatitis

In some cases, prostatitis is combined with chronic urethritis, which is manifested by little mucopurulent discharge from the urethra (mainly after prolonged urinary retention).

Prostatitis and sexual disorders

The question "Does prostatitis cause impotence? " Has been a cause of professional controversy for decades.

Under the influence of sexual stimuli, with a complete saturation of the body with androgens in the formations of the cortical-subcortical region of the brain, a nervous signal appears, which is transmitted to the erection center located in the spinal cord, from where it goes to the smooth muscles of thesinusoidal formations of the corpora cavernosa of the penis, which relax (arteries and sinusoids) or narrow (veins). There is no role for the prostate in this process.

Ejaculation and orgasm occur with sufficient irritation of the special receptor cells, which are located in the region of the seminal tubercle where the excretory ducts of the prostate fall, these same receptors are responsible for sending a nervous impulse to the cerebral cortex where the sensation of orgasm occurs. It is formed.

An inflammatory process in the prostate (prostatitis) can lead to damage to the seminal tubercle and, as a result, both to violations of the man's potency, as well as to premature ejaculation and elimination of orgasm. Impotence in chronic prostatitis is pathogenetically associated with the degree of damage to the prostate's nervous system. This form of impotence (impotence of neuroreceptors) is a typical example of a phenomenon of repercussion, when the presence of pathological impulses from the organs affected by the inflammatory process leads to the irradiation of the excitation process to the centers that control sexual function, and to its disturbance. last. A certain role, although not a major one, in the pathogenesis of impotence of neuroreceptors is also played by some suppression of the androgenic activity of the testicles and sensitivity to androgens in the centers of the hypothalamus and pituitary gland.

At the same time, there is an opinion that in the Russian Federation there is an overdiagnosis of prostatitis and an overestimation of its role in the development of erectile dysfunction.

Diagnosis

The doctor's task is to detect the inflammatory process in the prostate, identify a possible causative agent of the disease and assess prostate dysfunction. In 1990, Stamey wrote that prostatitis is a "trash can of clinical ignorance" due to the variety of terms used, diagnostic methods and treatments. At the same time, several simple, clinical and laboratory tests allow a correct diagnosis, which allows the initiation of appropriate therapy.

Digital rectal examination of the prostate

A very informative way. The inflammatory process can be evaluated by evaluating the shape, contours, size of the gland, presence of foci of compaction and (or) softening, pain. The main signs of prostatitis: increase or decrease in size, heterogeneity of consistency, presence of foci of compaction and softening, pastyness, pain. The fact that 80% of pancreatic cancers are detected by rectal examination speaks for itself. We can safely say that this research method will always be used.

Microscopic examination of pancreatic secretion

It should be remembered that an increase in the number of leukocytes in a secret does not always indicate prostatitis, as methods of obtaining a secret during massage do not guarantee that the contents of the urethra and seminal vesicles do not enter it. At the same time, with obvious signs of prostatitis, the prostate secret can be normal. This is due to focal inflammation, the presence of part of the obliterated or closed excretory ducts.

Study of prostate secretion

The study of prostate secretion (Expressed prostatic secretions-EPS) allows to determine the presence of an inflammatory process in the prostate and, in part, its functional capacity. It is the main method of diagnosis and monitoring of the treatment of chronic prostatitis. The prostate secret can be examined using light microscopy without staining or using special staining methods. In addition, the prostate secretion can be subjected to bacteriological examination or research using the polymerase chain reaction method to detect infectious agents in it. Discover the secret through prostate massage. The secretion released from the urethra is collected in a sterile test tube or on a clean glass slide for examination. Sometimes, secretion from the prostate does not flow out of the urethra. In such cases, the patient is advised to get up immediately. If, however, the secret was not obtained, more often it means that it did not enter the urethra, but the bladder. In this case, the centrifuge of the washing fluid released from the bladder after the prostate massage is examined.

  • Lipoid grains (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate. It gives the secret a milky appearance. Usually, the secret is rich in lecithin grains. A decrease in their number, along with an increase in the number of leukocytes, indicates an inflammatory process, a tumor;
  • Amyloid bodies are layered (starchy) bodies that turn purple or blue with Lugol's solution, like starch;
  • The amyloid body is a thickened secretion from the gland, it has an oval shape and a layered structure, resembling the trunk of a tree. They do not normally occur, their detection indicates stagnation of secretions in the gland, which can be with adenomas, chronic inflammatory processes;
  • Erythrocytes can be unique. They enter the secret as a result of a vigorous prostate massage. An increased number of them are observed in inflammatory processes, neoplasms.
  • The peeling of the epithelium in large quantities is observed at the beginning of the inflammatory processes and in the tumors, while the peeling with protein and fatty degeneration of the epithelial cells frequently occurs. Macrophages can be seen with stagnation of secretions, a current inflammatory process of long duration;
  • Bettcher's crystals are long crystals formed when the mixed secretion of male gonads (prostatic juice mixed with sperm) from sperm and the phosphate salt is cooled and dried. With azoospermia and severe oligozoospermia, Bettcher's crystals are formed quickly and in large quantities;
  • Retention syndrome - stagnation syndrome is seen with adenoma of the gland. There are plenty of macrophages, there are multinucleated cells like foreign bodies and amyloid bodies;
  • Fern symptom - a symptom of crystallization of secretion - how the sodium chloride crystals precipitate depends on the physicochemical properties of the prostate secretion. The symptom study is performed by adding a drop of 0. 9% sodium chloride solution to the obtained prostatic secretion, with subsequent visualization after drying under an optical microscope. In healthy men of reproductive age, crystallization of prostate secretion is characterized by a phenomenon typical of the fern leaf (3+). Androgenic insufficiency or the presence of prostatitis give varying degrees of violation of the crystal structure until its absence.

Bacteriological studies of urine portions and pancreatic secretions

Urethral swab, including diagnosis of CRP

Serological diagnosis of agents (ELISA) that cause urinary tract infections

Direct and indirect immunofluorescence reaction (RIF)

Detection of antibodies to known antigens.

Determination of PSA (prostate specific antigen) from blood serum

The American Foundation for Urological Diseases recommends an annual rectal examination of the prostate, accompanied by PSA, for all men over 50 and in the presence of prostate cancer in blood relatives in the male line. There is still a discussion about obtaining PSA immediately after a digital prostate exam by the rectum. Recent studies have not been able to confirm the presence of a significant increase in PSA content immediately after the digital exam. Thus, the PSA level can be determined by obtaining reliable results and after examining the pancreas.

Four glass sample

To diagnose chronic prostatitis, a 4-glass test was proposed, based on a comparative bacteriological evaluation of approximately equal portions of urine received before and after prostate massage, as well as its secretion.

The diagnosis of prostatitis is established with a tenfold increase in the concentration of microorganisms in the secretion of the prostate in relation to its content in the urine (1, 2 and 3 portions) and an increase in the number of polymorphonuclear leukocytes >10-16 in the field of view of an optical microscope (magnification 200 times). Or an increase in the number of leukocytes more than 300x106 / l when counting them in the counting chamber. The lecithin bodies, which are the product of the normal secretion of the glandular epithelium of the prostate, must densely cover the microscope's field of view (5-10 million in 1 ml). Amyloid bodies in prostate secretion are found in significantly smaller quantities. In men of mature age, they can be found 1-2 in the field of view.

Biochemical blood test

Immune and hormonal profile (as indicated).

Ultrasound, TRUS

Ultrasonographic diagnosis of prostatitis with an abdominal and transrectal transducer (TRUS).

Urofluxometry

Treatment of prostatitis

Complex treatment of patients with chronic prostatitis should include:

  • adherence to the general regimen, diet, sexual hygiene, as well as the involvement of sexual partners in treatment in the presence of an infectious agent;
  • selection of effective drugs to suppress infection;
  • increase the general reactivity of the patient's body and the immunobiological tolerance of microorganisms to drugs;
  • increased secretion flow and activation of local repair processes in the focus of inflammation;
  • sanitation of foci of infection in Organs present and distant organs;
  • improvement of microcirculation in the prostate and pelvic organs;
  • the appointment of fortifying agents, enzymes and vitamins;
  • correction of hormonal disorders;
  • the appointment of antispasmodics;
  • the indication of analgesics and anti-inflammatory drugs;
  • taking sedatives and tranquilizers;
  • regulation of neurotrophic disorders with local analgesics;

Prostate massage

Prostate massageit is a medical procedure used to diagnose and sometimes treat chronic prostatitis. The first prostate massage was described by Posner in 1893 and, since 1936, it has been widely introduced in O'Conory's urological practice. However, in 1968, after Meares and Stamey described the landmark test for the diagnosis of prostatitis, views on the causes of this disease changed and massage as a therapeutic procedure was excluded from the measurement lists in many treatment manuals. of prostatitis in the developed world.

But, since the mid-90s of the 20th century, many doctors involved in the diagnosis and treatment of prostatitis began to notice the ineffectiveness in some cases of the proposed antibiotic therapy and the use of alpha-blockers, which led them to use this forgotten method in practice. .

Basically, prostate massage is currently used as a diagnostic procedure to obtain prostatic secretions (expressed prostatic secretions-EPS)- for your microscopic examination (cultural) and for pre and post-massage test (pre and post-massage test -PPMT). Prostate secretion perform your massage. Massage is a medical procedure and must be performed by a previously trained specialist. The massage is performed after urination and in the case of secretion of the urethra after its preliminary washing with isotonic sodium chloride solution, especially necessary in cases in which the bacteriological examination of the secretion is supposed. Prostate massage is performed through the anus, as the prostate is adjacent to the rectum ampoule and is only available for examination. Massage one first, then another lobe of the prostate with finger movements from the periphery to the central groove along the excretory ducts, trying not to touch the seminal vesicles. Finish the massage by pressing the area of the central groove over the top. The secretion released from the urethra is collected in a sterile test tube or on a clean glass slide for examination. Sometimes, secretion from the prostate does not flow out of the urethra. In these cases, the patient is instructed to get up immediately, if, however, the secret has not been obtained, it means that he did not enter the urethra, but the bladder. In this case, the centrifuge of the washing fluid released from the bladder after the prostate massage is examined.

Prostate massage for therapeutic purposes (repetitive prostate massage) is officially recommended by the Ministry of Health of the Russian Federation as a treatment procedure for chronic prostatitis. Prostate massage is widely used for the treatment of prostatitis in the countries of Southeast Asia, China and some European countries. Some American and Canadian urologists also recommend using massage in combination with antibiotic therapy to treat some forms of prostatitis. In fact, little has been done to assess the effectiveness or ineffectiveness of prostate massage. There are several conflicting studies, in one conducted by Egyptian doctors, no differences were found in the groups of patients, some of whom received massage in combination with antibiotic therapy and simply antibiotic therapy, in another conducted by American and Filipino researchers, on the contrary, in a group ofprostatitis patients who received massage in combination with antibiotic therapy showed a significant improvement.

Proponents of using massage for therapeutic purposes believe that the main effect of its use is to drain the prostate ducts - that is, freeing them from purulent and dead cells. Another effect is considered to increase blood flow in the prostate, which improves the penetration of antibiotics in it and activates the local protective immune processes.

There is little data in the world literature on complications associated with prostate massage. In 1990, Japanese doctors described genital gangrene (Fournier), and in 2003, German doctors described perioprostatic hemorrhage after prostate massage with the development of an embolic effusion (hemorrhage) in the lungs. There is a study that shows that after the massage the level of PSA (prostate specific antigen) increases temporarily. Massage is contraindicated in acute inflammation of the prostate (acute prostatitis), acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcifications and prostate adenoma. It is generally recommended to massage the prostate 2 or 3 times a week.

Physiotherapy procedures

Any physiotherapy procedures (prostate massage, heating, etc. ) are contraindicated for acute prostatitis.

The use of physiotherapeutic procedures in the complex treatment of prostatitis aims both at a direct effect on the prostate of physical agents to normalize the functional and pathological changes, as well as the electrophoretic administration of drugs in the prostate tissue.

The use of physical therapy methods in the context of drug therapy gives a much better result than with treatment alone. The following methods of influencing the prostate have spread and proved their effectiveness:

  • shockwave therapy;
  • electrostimulation of the pancreas with modulated currents of cutaneous or rectal electrodes;
  • thermotherapy in several versions (including high frequency thermotherapy);
  • magnetotherapy;
  • microwave therapy;
  • laser therapy.
  • transrectal ultrasound therapy and phonophoresis;
  • microclysters.