Chronic prostatitis is a prolonged inflammation of the prostate gland, leading to a violation of the morphology and functioning of the prostate. It is manifested by a prostatic triad: pain in the pelvis and genitals, urination disorders, sexual disorders. Diagnostics includes palpation of the gland, examination of prostate secretions, ultrasound, uroflowmetry, urethroscopy, puncture biopsy of the prostate gland. Complex medical, physiotherapeutic treatment, prostate massage, instillation of the posterior urethra are shown. Surgical intervention is advisable for complicated forms of chronic prostatitis.
ICD 10
N41.1 Chronic prostatitis
Meaning
Chronic prostatitis is the most common male disease: about 50% of men suffer from some form of prostate inflammation. Chronic prostatitis more often affects men aged 20 to 40 years, who are in the period of the greatest sexual, reproductive and labor activity. In this regard, the detection and treatment of chronic prostatitis acquires in modern andrology not only a medical, but also a socially significant aspect.
Causes
Causes of infectious prostatitis
The etiology and pathogenesis of chronic bacterial prostatitis are associated with infection in the prostate gland in the following ways: ascending (through the urethra), descending (when throwing infected urine from the bladder), hematogenic or lymphogenic. More often, the uropathogens are E. coli, Klebsiella, proteus, Staphylococcus, Enterococcus, Corynebacteria, fungal, parasitic and viral pathogens. Along with non-specific flora, pathogens of specific urethritis (chlamydia, mycoplasma, gonococci, trichomonas, gardnerella) can participate in the development of chronic prostatitis.
However, for the development of chronic prostatitis, it is not so much the presence and activity of microorganisms that is important, as the condition of the pelvic organs and blood circulation in them, the presence of concomitant diseases, the level of protective mechanisms. Therefore, a number of factors can contribute to the occurrence of chronic prostatitis:
- urological diseases: pyelonephritis, cystitis, urethritis, urethral stricture, incurable acute prostatitis, orchitis, epididymitis, etc.;
- the presence of distant foci of infection: sinusitis, tonsillitis, caries, chronic bronchitis, pneumonia, pyoderma, etc. ;
- local and general hypothermia, overheating, staying in a humid environment;
- fatigue;
- malnutrition;
- rare urination, etc.
Causes of non-infectious prostatitis
Non-bacterial chronic prostatitis is usually associated with congestive (stagnant) phenomena in the prostate gland caused by stasis of venous circulation in the pelvic organs and impaired drainage of prostate acinuses. Local congestion leads to overflow of the prostate vessels with blood, edema, its incomplete emptying of secretions, violation of the barrier, secretory, motor, contractile function of the gland. Stagnant changes are usually caused by behavioral factors:
- prolonged sexual deprivation;
- the practice of interrupted or prolonged sexual acts;
- excessive sexual activity;
- hypodynamia;
- chronic intoxication;
- occupational hazards (vibration).
Pathology of pelvic organs and nervous structures that carry out their innervation (for example, spinal cord injuries), prostate adenoma, hemorrhoids, constipation, androgen deficiency, etc. causes predispose to the development of non-bacterial inflammation.
Classification
According to the modern classification of prostatitis, developed in 1995, there are 4 categories of the disease:
- I. Acute prostatitis.
- II. Chronic prostatitis of bacterial origin.
- III. Inflammation of non–bacterial genesis / pelvic pain syndrome is a symptom complex that is not associated with obvious signs of infection and lasts from 3 months or more.
- III A. A chronic process with the presence of an inflammatory component (detection of leukocytes and infectious agents in the secret of the prostate);
- III B. Chronic pathology with the absence of an inflammatory component (leukocytes and pathogens in the secret of the prostate).
- IV. Asymptomatic chronic prostatitis (absence of complaints when detecting leukocytes in the prostatic secret).
In the presence of an infectious component, they speak of bacterial (infectious) chronic prostatitis; in the absence of microbial pathogens, non–bacterial (non-infectious). It is believed that in 90-95% of all cases there is non-bacterial inflammation and only in 10-5% – bacterial.
Chronic prostatitis symptoms
The disease is manifested by local and general symptoms. Local manifestations include the prostatic triad, characterized by pain, dysuria and impaired sexual function. The pains are of a constant aching nature, localized in the perineum, genitals, above the pubis, in the groin. The pain syndrome increases at the beginning and end of urination, while the pain radiates into the head of the penis, scrotum, sacrum, rectum.
Pain may increase after sexual intercourse or in connection with prolonged abstinence; weaken or intensify after orgasm, become more intense immediately at the moment of ejaculation. The intensity of the pain syndrome varies from discomfort to pronounced manifestations that disrupt sleep and performance. Pain with limited localization in the sacrum is often regarded as osteochondrosis or sciatica, and therefore the patient can be treated independently for a long time without resorting to the help of a doctor.
Urination is frequent and painful. At the same time, there may be difficulty in starting the injection, weakening or intermittent urine flow, a feeling of incomplete emptying of the bladder, frequent nocturnal urges, burning in the urethra. In the urine, the presence of floating threads can be detected. After defecation or physical exertion, secretions (prostatorrhea) appear from the urethra due to a decrease in prostate tone. There may be the appearance of itching, a feeling of cold or excessive sweating in the perineum, local changes in skin color associated with stagnation of blood circulation.
Chronic prostatitis is accompanied by severe violations of sexual function. The phenomena of dispotence can be expressed in deterioration, soreness of erection, prolonged and frequent nocturnal erections, difficulty or early ejaculation, loss of libido (decreased libido), erased orgasms, hemospermia, infertility. Sexual disorders are always hard experienced by a man, lead to psycho-emotional disorders, up to neurosis and depression, further impairing sexual function.
Exacerbations are accompanied by a slight increase in body temperature and deterioration of well-being. The general condition is characterized by increased irritability, lethargy, anxiety, fatigue, loss of appetite, sleep disorders, decreased ability to work, creative and physical activity. Almost a quarter of patients have no symptoms of the disease for a long time, which leads to late treatment by an andrologist.
Complications
The long-term course of chronic prostatitis can be complicated by impotence, vesiculitis, epididymoorchitis, male infertility, urinary incontinence, the formation of stones and cysts of the prostate gland, prostate sclerosis, the development of adenoma and prostate cancer.
Diagnostics
The information necessary for the diagnosis of chronic prostatitis is obtained using a comprehensive laboratory and instrumental examination.
- Initial examination. It includes finding out the anamnesis and complaints, conducting an external examination of the genitals for secretions, rashes, irritations, finger rectal examination of the prostate in order to determine the contours, boundaries, consistency, tenderness of the gland.
- Prostate ultrasound. To determine the structural and functional changes of the prostate gland, prostate ultrasound (TRU) is indicated.
- Detection of infectious pathogens. A study of the general analysis of urine, a bacteriological examination of a smear from the urethra and urine, a 3-cup urine sample, PCR and RIF examination of scraping for pathogens of sexual infections is carried out. Clinically significant is the detection of pathogens of chlamydia, mycoplasmosis, herpes, cytomegalovirus, trichomoniasis, gonorrhea, candidiasis, as well as non-specific bacterial flora in the analyses. Bacteriological culture of urine allows to reveal the degree and nature of bacteriuria.
- Sampling and examination of prostate secretions. Prostate juice is taken after urination and prostate massage. Signs of the disease are an increase in the number of leukocytes in the field of vision, a decrease in the number of lecithin grains, the presence of pathogenic microflora. In the general analysis of urine, leukocyturia, pyuria, erythrocyturia can be detected.
- Urodynamic examination. The degree and causes of urination disorders help to determine urodynamic studies (uroflowmetry, cystometry, profilometry, electromyography). With the help of these studies, chronic prostatitis can be differentiated from stress urinary incontinence, neurogenic bladder, etc.
- Urinary tract endoscopy. With hematuria, hemospermia, obstructive urination, endoscopic examination is indicated – urethroscopy, cystoscopy.
- Other research. To exclude adenoma and prostate cancer, PSA determination is required, in some cases, prostate biopsy with morphological examination of tissues. In case of reproductive disorders, a study of a spermogram and a MAP test is shown.
Chronic prostatitis treatment
Conservative therapy
The disease is not easy to cure, but it should be remembered that recovery is still possible and largely depends on the mood of the patient, the timeliness of his treatment to a specialist, the clarity of compliance with all the prescriptions of the urologist.
The basis of the treatment of bacterial inflammatory process is antimicrobial therapy in accordance with an antibioticogram lasting at least 2 weeks. NSAIDs (diclofenac, ibuprofen, naproxen, piroxicam) are prescribed to reduce pain and inflammation; a-blockers (tamsulosin, alfuzosin) are indicated to relax the muscles of the prostate, restore urodynamics and outflow of prostatic secretions.
In order to improve the drainage of the prostate gland, local microcirculation and muscle tone, a course of therapeutic prostate massage is carried out. A prostate massage session should end with the release of at least 4 drops of prostate secretions. Prostate massage is contraindicated in acute bacterial prostatitis, prostate abscess, hemorrhoids, prostate stones, rectal cracks, hyperplasia and prostate cancer.
To relieve the pain syndrome, paraprostatic blockades, acupuncture can be recommended. Physiotherapy with the appointment of medicinal electrophoresis, ultrasound, ultraphonophoresis, magnetotherapy, laser magnetotherapy, inductometry, mud therapy, SMT, hot sedentary baths with a temperature of 40 – 45 ° C, enemas with hydrogen sulfide and mineral waters, instillations into the urethra is of great importance in the treatment.
Surgical treatment
With the development of complications, surgical treatment is indicated: elimination of urethral strictures; prostate TUR or prostatectomy for prostate sclerosis; transurethral resection of the bladder for sclerosis of its neck, puncture and drainage of prostate cysts and abscesses; circumcision for phimosis caused by recurrent urinary tract infections, etc.
Prognosis and prevention
The prognosis is determined by the timeliness and adequacy of treatment, the age of the patient, the presence of concomitant pathologies. Prevention of the disease requires compliance with sexual hygiene, timely therapy of urogenital and extragenital infections, normalization of the regularity of sexual life, sufficient physical activity, prevention of constipation, timely emptying of the bladder. To exclude relapses, dynamic examinations of an andrologist (urologist) are necessary; preventive courses of physiotherapy, multivitamins, immunomodulators; exclusion of hypothermia, overheating, stress, bad habits.