Prostate sclerosis is a progressive condition, the final stage of inflammatory diseases of the prostate, characterized by excessive accumulation of collagen with compaction of the organ tissue. The main manifestations are obstructive symptoms of the lower urinary tract due to narrowing of the urethra, impaired sexual function. Ultrasound, cystourethrography, prostate MRI, and biopsy are used for diagnosis. Conservative treatment is justified before or after surgery: absorbable drugs, medications that improve blood supply, antibiotics, NSAIDs, alpha-blockers are prescribed.
N42.8 Other specified prostate diseases
The Greek term “sklerosis” – “hard, hard” – means compaction of the organ structure. Prostate sclerosis is more often the outcome of chronic inflammation, which is experienced by about 13% of men aged 40-50 years. Also, sclerotic changes of the gland are typical for patients with benign prostatic hyperplasia (BPH). In 24% of cases, symptoms of infravesical obstruction in older men are caused by prostate sclerosis, which also prevents the response to treatment of BPH. Until recently, the process was considered irreversible, but now drugs are being developed that stop the development of sclerosis in the prostate.
The main reason is chronic inflammatory reactions caused by any stimulus: persistent infection, autoimmune processes, allergies. Any destructive process can act as a trigger for prostate sclerosis — abscess, tumor, prostatolithiasis due to urine reflux. Conditions after operations on the pelvic organs, iatrogenic injuries after medical manipulations and diagnostic procedures, radiation therapy also imply the formation of a wound-healing response with increased fibroblast function, but the mechanism of collagen hyperproduction has not been fully studied. Predisposing factors include:
- Violation of blood supply. Generalized atherosclerosis of blood vessels, congestive phenomena against the background of irregular sexual activity, lack of physical activity, metabolic syndrome, varicose veins of the pelvis lead to disruption of metabolic processes in cells. Due to circulatory disorders, ischemia develops, which supports inflammation.
- Age. Numerous studies show that aging and related fibrous changes in prostate tissue lead to increased symptoms of obstruction and dysfunction of the bladder. The state of hypoandrogenism against the background of male menopause contributes to sclerotic processes. A certain role probably belongs to the violation of testosterone metabolism in the gland tissues.
- Some pathological conditions. Genetic predisposition to fibrosing processes, autoimmune diseases with deposition of fibrous elements (psoriasis, rheumatoid arthritis, systemic lupus erythematosus, etc.), allergic reactions and toxic lesions affect all organs of the body, including the prostate gland. The main genetic pathologies that induce the fibrous process are neurofibromatosis, cystic fibrosis.
Sclerosis (fibrosis) is determined by the proliferation, scarring and compaction of the prostate and is explained by the excessive accumulation of extracellular matrix components, including collagen. The main collagen-forming cell is myofibroblast, which is activated by various mechanisms: paracrine signals from lymphocytes and macrophages, autocrine factors and pathogen-associated molecular structures interacting with pattern recognition receptors on fibroblasts. Other fibrosis regulators (cytokines, chemokines, growth factors, etc.) also take part in the deposition of collagen. Unlike acute inflammatory reactions characterized by rapidly resolving vascular changes, edema and neutrophilic inflammation, sclerosis usually occurs as a result of a chronic inflammatory process. In fact, it is an immune response that persists for several months. Why the recovery process acquires a perverse course is unknown, but there is an assumption that this is due to a violation of myofibroblast apoptosis.
According to the etiology and pathogenesis, sclerosis can be the outcome of inflammation, prostatolithiasis, natural aging. Replacement sclerosis is spoken of in case of atrophy of tissue structures against the background of circulatory disorders, metabolic processes, exposure to toxic and chemical factors. A scar can form when damage heals. There are 4 stages in the development of prostate sclerosis, based on functional changes in the process of urination:
- Stage 1. There are no urinary disorders, pathological changes at the histological level are established with a transrectal biopsy performed for another reason, for example, to exclude prostate cancer.
- Stage 2. The first signs of obstruction of the lower urinary tract appear: the need to strain to start urinating, a change in the quality of the urine stream, incomplete emptying, etc. At the same time, sexual dysfunction manifests itself, but unpleasant symptoms are transient.
- Stage 3. Pronounced changes from the bladder (trabecularity, increased volume), kidneys (recurrent infections, hydronephrotic transformation with gradual loss of function) are recorded. Sexual life is disrupted, the quality of the ejaculate suffers, since the sclerotic compression of the vas deferens generates an obturation mechanism of infertility.
- Stage 4. For this stage, in addition to total organ sclerosis, secondary lesions of the parenchymal tissue of the kidneys, ureters, bladder and vas deferens are typical.
For a more accurate diagnosis in urology, histological classification is used. It is based on morphological features, which are judged by the results of a biopsy. Possible options: focal changes, nodular hyperplasia of adenomatous nature, sclerosis with parenchymal atrophy, sclerosis with cystic changes.
In prostate sclerosis, clinical manifestations are diverse and depend on the stage of the process. The main symptoms are a violation of urination: pain, sluggish jet, a feeling of incomplete emptying, in the advanced stage – the discharge of urine by drops, frequent urge with a small amount of urine. When the sclerosing process spreads to the vesicles, blood (hemospermia) may appear in the sperm. Pain sensations and their localization are variable: intense or aching pain may be in the perineum, testicles, lower abdomen, rectum.
Typical manifestations of sexual dysfunction are: weakening of erection, ejaculation disorders, changes in orgasmic sensations (erasure of orgasm or the appearance of pain after ejaculation, decreased sexual desire). A characteristic sign of the loss of prostate functions is a decrease in the amount of ejaculate during ejaculation, since connective tissue cannot produce a secret. Background psychoemotional disorders correlate with the characteristics of the psychotype and are represented by depressed mood, irritability, sleep disorders, depression.
In the absence of timely therapy, chronic urinary retention may join, constant stagnation of urine contributes to the activation of microbial flora with frequent recurrent urinary tract infections. Residual urine leads to the formation of reflux — with the reverse flow of urine into the kidneys, the internal cavities of the organ expand (hydronephrotic transformation of the kidney). In the future, the death of nephrons is complicated by chronic renal failure. Violation of the passage of urine in prostate sclerosis is one of the causes of urolithiasis, stones can form in the bladder, kidneys. Concretions aggravate pain (CPPS) and support inflammation. When the mouths of the ejaculatory ducts are sclerosed, the number of spermatozoa in the ejaculate is reduced, with bilateral obturation, azoospermia develops.
Pathology can be verified by biopsy, but this invasive manipulation is not performed in all patients. The presumptive diagnosis is established on the basis of complaints, data from a finger rectal examination of the prostate gland. When palpated, it is compacted, moderately painful; its size is variable, depends on morphological changes – background atrophy or hyperplasia. If a dense area (local fibrosis) is detected, it is impossible to determine the nature of the formation without additional diagnostic methods. The following instrumental and laboratory tests may be useful:
- Visualization techniques. TRU, ultrasound of the kidneys, bladder with the control of residual urine allow you to determine the severity of the pathological process. The degree of obstruction of the prostatic urethra can be assessed using ascending or descending urethrography, urethroscopy, uroflowmetry.
- Laboratory diagnostics. There are no pathognomonic tests to confirm prostate sclerosis, laboratory tests are prescribed to identify a possible cause. The diagnostic algorithm includes prostate secretion analysis, STI tests, culture seeding, general urine analysis — these studies are aimed at identifying concomitant inflammation.
As additional methods, excretory urography and scintigraphy are performed, which show the preservation of kidney functions. If a bladder pathology is suspected, a cystoscopy is performed. Prostate MRI is a non-invasive examination, which is more often carried out to exclude the tumor process. In each case, the diagnostic measures plan is developed individually. Differential diagnosis is carried out with prostate cancer, BPH, genitourinary tuberculosis. Elevated PSA levels, lack of response to therapy with alpha-blockers with 5-ARI inhibitors require clarification of the diagnosis with possible morphological examination.
Treatment is mainly surgical, its purpose is to eliminate the pathological focus, restore normal passage of urine, and prevent potential complications. Conservative treatment can be used in the initial stages of fibrosis, with pronounced gland densification, it is ineffective. To resolve the issue of management tactics for sexual dysfunction, an andrologist’s consultation is indicated. The latest drugs are at various stages of clinical trials and have not yet been introduced into extensive practice. At this stage , the following are used:
- Surgical interventions. Transurethral resection, open or laparoscopic (robotic) prostatectomy help to normalize urination. Minimally invasive techniques include vaporization, ablation, incision of the prostate. In case of serious extragenital pathology associated with a high risk of mortality, urethral stenting or epicystostomy can be performed as a palliative. If, with further conservative therapy, the patient’s condition normalizes, it is possible to remove the affected prostate gland.
- Conservative therapy. Antibacterial drugs are mainly prescribed to suppress microbial flora or prevent secondary infection. Their effect can be enhanced by the use of NSAIDs, which also have an analgesic effect. In prostatitis, it is considered reasonable to use absorbents that promote the dissolution of hyaluronic acid. If prostate sclerosis has not taken a diffuse character, alpha-blockers and inhibitors of 5 ARI will help to relax the muscle structures of the neck of the bladder, gland, prostatic urethra and strengthen the urine stream. Additionally, hormones, vitamins, and means to improve microcirculation can be prescribed. In young men with confirmed hypoandrogenism, testosterone is prescribed.
- Local impact. With loose forming scars, improvement of well-being can occur as a result of massage, mud therapy, phonophoresis, short-wave inductothermy, laser exposure. Pain syndrome is reduced when using microclysters with decoctions of anti-inflammatory herbs with the addition of drugs that break down hyaluronic acid, antiseptic solutions, lidocaine hydrochloride, hormones. Suppositories with hyaluronidase, prostatilene, sea buckthorn, ichthyol, propolis are prescribed as an auxiliary link in general therapy.
Prognosis and prevention
The prognosis for prostate sclerosis depends on the prevalence of the process, the timeliness of treatment: at stage 1-2, it is favorable. In the terminal stage, when the organs of the urogenital tract are affected, without performing surgery, the prognosis for life is serious. Prevention consists in early diagnosis of the inflammatory process with the adoption of preventive measures to prevent the development of sclerosis. The probability of encountering pathology is less if you adhere to a number of rules: avoid casual sexual intercourse without a condom, lead a regular sexual life with full ejaculation, monitor daily bowel movements, exercise. Studies have shown that a certain role belongs to proper nutrition in prostatitis, especially during the period of exacerbation. It is worth limiting spicy, sour, salty dishes, products containing extractive substances, and giving up alcohol.