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Prostatitis

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

symptoms of prostatitis in men

Distribution

According to various sources, prostatitis occurs in 35-40%, and according to some authors in 70% of men aged 18 to 50 years. The prostate gland, in terms of the spread of the disease and the complex of problems arising from it, occupies a leading positionplace among urological pathology.

Classification

There are many classifications of prostatitis, hence very specific 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 syndrome of chronic pelvic pain
Category IIIB Non-inflammatory chronic pelvic pain syndrome (prostatodynia)
Category IV Asymptomatic inflammatory prostatitis

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

Category I

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

  • increased 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 secretions of the prostate, ejaculate and urine obtained after prostate massage.

Category III

Chronic Pelvic Pain Syndrome (CPPS)- The leading clinical symptom is the pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of the prostate, ejaculate and urine obtained after prostate massage. The criterion for separating 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 pain syndrome and symptoms of prostatitis, while there is an increased number of leukocytes in the secretion of the prostate gland, ejaculate and part of the urine, after prostate massage, pathogenic microorganisms are not detected in these samples by standard methods.

Category III B

Non-inflammatory syndrome of chronic pelvic pain- characterized by the presence of pain syndrome and symptoms of prostatitis, as long as there is no increase in the number of leukocytes and pathogens in the secretion of the prostate, ejaculate and urine obtained after prostate massage are not detected by standard methods.

Category IV

Asymptomatic inflammatory prostatitis- the absence of symptoms characteristic of prostatitis, the disease is detected accidentally during histological examination of prostate tissue samples obtained in connection with the diagnosis for other reasons (for example, prostate biopsy due to elevated 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, oxygen starvation of the glandular tissues is noted, resulting in the formation of by-products of pathological oxidation that affect the nerve endings of the prostate. Because the innervation of the prostate is related to the innervation of the pelvic floor, penis, scrotum, testicles, rectum, the location of the pain is variable. The following symptoms of pain are most common:

  • Discomfort or pain in the perineum - mainly occurs after exercise, sexual intercourse, alcohol intake in the form of transient seizures;
  • Feeling of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles - patients describe as "pain", "twisting", are also associated with various provoking factors;
  • Discomfort, cramps and pain in the urethra are mainly associated with a shift in the pH of prostate secretion to the acid side. Acid secretion of the prostate irritates the lining of the urethra, which is why painful sensations, more often in the form of "burning" occur after the act of urination or intercourse, when part of the secretion is squeezed into the lumen of the urethra during muscle contraction. gland 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 may be accompanied by the following manifestations:

  • Frequent urination - frequent urination (up to 3 times per hour) with a sharp and sudden urge (impossible to tolerate) and quite small portions;
  • Feeling of incomplete emptying of the bladder - after the act of urination it is felt that the urine remains in the bladder;
  • A weak or intermittent stream of urine - this may include the symptom of the "last drop" - despite all the patient's efforts, after the act of urination a drop of urine is still excreted from the canal.

Disorder of ejaculation and orgasm

It is associated with damage to the seminal tubercle (coliculitis) during prostatitis, on the surface of which there are nerve receptors that send a signal to the brain structures, where the feeling of orgasm is formed. Prostatitis does not directly cause erectile dysfunction (blood supply to the penis with sexual arousal).

Main violations:

  • Premature ejaculation, or vice versa, excessive sexual intercourse - caused by inflammation of the seminal tubercle or its scars due to the inflammatory process;
  • Deleted orgasm - also associated with inflammation of the seminal tubercle;
  • Pain during ejaculation - associated with an inflammatory process in the secretory ducts of the prostate, through which sperm are released.

Impaired fertility

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

  • Decrease in the pH of the sperm to the acidic side - because in inflammation of the prostate in the secretion begin to accumulate acidic products of pathological oxidation. The acidic environment is extremely destructive to sperm, causing them to become immobile and even die;
  • Sperm agglutination - the adhesion of sperm mainly to the heads - is associated with a change in the physicochemical properties of the secretion;
  • Asthenospermia - a decrease in sperm motility - is closely linked to a shift in pH to the acidic side and a disruption in the production of lecithin cells by the prostate, which ensures the vital activity of sperm.

Urethroprostatitis

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

Prostatitis and sexual disorders

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

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

Ejaculation and orgasm occur when enough stimulation of special receptor cells, which are located in the area of the seminal tubercle, into which the secretory ducts of the prostate gland, these same receptors are responsible for sending a nerve impulse to the cerebral cortex, where the sensation of orgasmforms.

Inflammatory process in the prostate gland (prostatitis) can lead to damage to the seminal tubercle and as a result to disorders of male potency, as well as premature ejaculation and orgasm. Impotence in chronic prostatitis is pathogenetically related to the degree of damage to the nervous system of the prostate gland. This form of impotence (neuroreceptor impotence) is a typical example of a repercussion phenomenon when the presence of pathological impulses from the organs affected by the inflammatory process leads to irradiation of the excitatory process to the centers that control sexual function and to the disorder of the latter. A certain, although not leading, role in the pathogenesis of neuroreceptor impotence is also played by a certain suppression of the androgenic activity of the testes and the 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 both overdiagnosis of prostatitis and overestimation of its role in the development of erectile dysfunction.

Diagnosis

The doctor's task is to detect the inflammatory process in the prostate, to identify the possible cause of the disease and to assess the dysfunction of the prostate gland. In 1990, Stamy wrote that prostatitis was a "basket of clinical ignorance" because of the variety of terms used, diagnostic methods and treatments. At the same time, several simple clinical and laboratory tests allow for proper diagnosis, allowing appropriate therapy to be initiated.

Digital rectal examination of the prostate

Very informative way. The inflammatory process can be assessed by assessing the shape, contours, size of the gland, the presence of foci of compaction and (or) softening, pain. The main signs of prostatitis: increase or decrease in size, heterogeneity of consistency, the presence of foci of thickening and softening, pasty, painful. The fact that 80% of cases of pancreatic cancer 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 the increase in the number of leukocytes in the secretion does not always indicate prostatitis, as the methods of obtaining secretion during massage do not guarantee that the contents of the urethra and seminal vesicles will not fall into it. At the same time, with obvious signs of prostatitis, the secretion of the prostate may be normal. This is due to focal inflammation, the presence of part of the deleted or closed secretory ducts.

Examination of the secretion of the prostate gland

Examination of the secretion of the prostate gland (Expressed prostate secretion-EPS) allows you to determine the presence of an inflammatory process in the prostate gland and partly its functional capacity. This is the main method for diagnosing and monitoring the treatment of chronic prostatitis. The secretion of the prostate can be examined with the help of light microscopy without staining or with the help of special staining methods. Also, the secretion of the prostate gland may be subjected to bacteriological examination or examination by the method of polymerase chain reaction for the detection of infectious agents in it. Get the secret by massaging the prostate. The secretion secreted from the urethra is collected in a sterile tube or on a clean glass object for examination. Sometimes the secretion of the prostate gland does not flow from the urethra. In such cases, the patient is advised to get to his feet immediately. If, however, the secretion cannot be obtained, more often it means that it has not entered the urethra, but the bladder. In this case, the centrifuge of the lavage fluid secreted from the bladder after massaging the prostate gland is examined.

  • Lipoid grains (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate gland. Gives the secret a milky look. The secret is usually rich in lecithin grains. The decrease in their number, together with the 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 of the gland, has an oval shape and a layered structure resembling a tree trunk. Usually they do not appear, their detection shows stagnation of secretions in the gland, which may be with adenomas, chronic inflammatory processes;
  • Erythrocytes can be single. They enter the secretion as a result of vigorous massage of the prostate gland. An increased number of them is observed in inflammatory processes, neoplasms.
  • Desquamation of the epithelium in large quantities is observed at the beginning of inflammatory processes and in tumors, while at the same time disquamation with protein and fat degeneration of epithelial cells often occurs. Macrophages can be seen with stagnation of secretions, long-term ongoing inflammatory process;
  • Bettcher crystals are long crystals formed when the mixed secretion of the male gonads (prostate juice mixed with semen) from spermine and phosphate salt is cooled and dried. In azoospermia and severe oligozoospermia, Bettcher crystals form rapidly and in large quantities;
  • Retention syndrome - a syndrome of stagnation is observed in gland adenoma. There is an abundance of macrophages, there are multinucleated cells such as foreign bodies and amyloid bodies;
  • Symptom of fern - symptom of crystallization of secretion - the form of precipitating crystals of sodium chloride depends on the physicochemical properties of the secretion of the prostate gland. Examination of the symptom is performed by adding a drop of 0, 9% sodium chloride solution to the obtained prostate secretion with further viewing after drying under a light microscope. In healthy men of reproductive age, the crystallization of prostate secretion is characterized by a typical phenomenon of fern leaves (3+). Androgen deficiency or the presence of prostatitis give varying degrees of disruption of the structure of the crystals to their absence.

Bacteriological examination of portions of urine and pancreatic secretion

Urethral swab, including PCR diagnosis

Serological diagnosis of agents (ELISA) causing urinary tract infections

Immunofluorescence reaction (RIF) direct and indirect

Detection of antibodies to known antigens.

Determination of PSA (prostate specific antigen) in blood serum

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

Sample of four cups

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

The diagnosis of prostatitis is established by a tenfold increase in the concentration of microorganisms in the secretion of the prostate compared to their 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 a light microscope (magnification 200 times). Or an increase in the number of leukocytes above 300x106 / l when counting them in the counting chamber. Lecithin bodies, which are a product of the normal secretion of the glandular epithelium of the prostate gland, should tightly cover the field of view of the microscope (5-10 million in 1 ml). Amyloid bodies in the secretion of the prostate are found in significantly smaller quantities. In adult men, they can be detected 1-2 in the field of view.

Biochemical blood test

Immunological and hormonal profile (according to the indications).

Ultrasound, TRUS

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

Uroflowmetry

Treatment of prostatitis

Comprehensive treatment of patients with chronic prostatitis should include:

  • observance of the general regime, diet, sexual hygiene, as well as the participation of sexual partners in the treatment in the presence of an infectious agent;
  • selection of effective drugs to suppress the infection;
  • increasing the overall reactivity of the patient's body and the immunobiological tolerance of microorganisms to drugs;
  • increased outflow of secretion and activation of local reparative processes in the focus of inflammation;
  • remediation of foci of infection in the representing and distant organs;
  • improving microcirculation in the prostate gland and pelvic organs;
  • the appointment of strengthening agents, enzymes and vitamins;
  • correction of hormonal disorders;
  • the appointment of antispasmodics;
  • the appointment of analgesics and anti-inflammatory drugs;
  • taking sedatives and tranquilizers;
  • regulation of neurotrophic disorders with local analgesic drugs;

Prostate massage

Prostate massageis 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 into O'Conory's urological practice. However, in 1968, after Meares and Stamey described a milestone test to diagnose prostatitis, views on the causes of the disease changed and massage as a therapeutic procedure was removed from the lists of measures in many guidelines for the treatment of prostatitis in the developed world. .

But since the mid-1990s, many doctors involved in the diagnosis and treatment of prostatitis have begun to note the ineffectiveness in some cases of the proposed antibiotic therapy and the use of alpha-blockers, which has led them to use this forgottenmethod in practice.

In general, prostate massage is currently used as a diagnostic procedure for obtaining prostate secretions (expressed prostate secretions-EPS) - for its microscopic (cultural) examination and for a test before and after massage (test before and after massage -PPMT). secretionperform her massage. Massage is a medical procedureand must be performed by a pre-trained professional. The massage is performed after urination, and in case of separation from the urethra after its preliminary washing with isotonic sodium chloride solution, which is especially necessary in cases when bacteriological examination of the secretion is assumed. The prostate massage is performed through the anus, as the prostate gland is adjacent to the rectal ampoule and is only available there for examination. Massage first one, then another lobe of the prostate gland with finger movements from the periphery to the central groove along the secretory ducts, trying not to touch the seminal vesicles. Finish the massage by pressing the area of the central groove from above. The secretion secreted from the urethra is collected in a sterile tube or on a clean glass object for examination. Sometimes the secretion of the prostate gland does not flow from the urethra. In such cases, the patient is advised to get to his feet immediately. If, however, the secretion cannot be obtained, it means that it has not entered the urethra, but the bladder. In this case, the centrifuge of the lavage fluid secreted from the bladder after massaging the prostate gland is examined.

Prostate massage for therapeutic purposes (repeated prostate massage) is officially recommended by the Ministry of Health of the Russian Federation as a procedure for the treatment of chronic prostatitis. Prostate massage is widely used to treat prostatitis in Southeast Asia, China and some European countries. Some North American and Canadian urologists also recommend the use of massage in combination with antibiotic therapy in the treatment of some forms of prostatitis. In fact, little has been done to assess the effectiveness or ineffectiveness of prostate massage. There are several contradictory 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 simple antibiotic therapy, in another conducted by American and Philippine researchers, on the contrary, in a group of patients. with prostatitis, received massage in combination with antibiotic therapy, showed significant improvement.

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

There is little evidence in the world literature of 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 embolic stroke (hemorrhage) of the lungs. There is a study that after massage the level of PSA (prostate-specific antigen) temporarily increases. Massage is contraindicated in acute inflammation of the prostate gland (acute prostatitis), acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcification and prostate adenoma. Prostate massage 2 or 3 times a week is usually recommended.

Physiotherapeutic procedures

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

The use of physiotherapeutic procedures in the complex treatment of prostatitis is aimed both at the direct effect on the prostate gland of physical agents in order to normalize the functional and pathological changes, and at the electrophoretic administration of drugs in the prostate tissue.

The use of physiotherapeutic methods against the background of drug therapy gives a much better result than just treatment. The following methods of action on the prostate gland have become widespread and have proven their effectiveness:

  • shock wave therapy;
  • electrical stimulation of the pancreas with modulated currents of skin or rectal electrodes;
  • thermotherapy in various versions (including high-frequency thermotherapy);
  • magnetic therapy;
  • microwave microwave therapy;
  • laser therapy.
  • transrectal ultrasound therapy and phonophoresis;
  • microclysters.