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Prostatitis

Prostatitis (prostatitis) is inflammation of the prostate (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

Spread

According to various sources, prostatitis occurs in 35-40% and, according to some authors, in 70% of men aged 18 to 50 years. occupies a leading place in urological pathology.

classification

There are many classifications of prostatitis, hence a very peculiar terminology. 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 bacterial 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 clinical symptoms, the presence or absence of leukocytes and microorganisms in the secretion of the prostate, ejaculate and urine.

Category I.

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

  • an 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 main clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of prostate, ejaculate and urine after prostate massage. The criterion for the separation into III A and III B is the presence of an increased number of leukocytes.

Category III A.

Chronic Pelvic Inflammatory Pain 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, ejaculate and urine. After a prostate massage, no pathogenic microorganisms are detected in these samples using standard methods.

Category III B.

Non-inflammatory chronic pelvic pain syndrome- characterized by the presence of a pain syndrome and symptoms of prostatitis, while the number of leukocytes and pathogenic microorganisms in the process of secretion of the prostate, ejaculate and urine obtained after massaging the prostate does not increase, are not detected using standard methods.

Category IV

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

Diagnosis of prostatitis

The symptoms of prostatitis vary widely, but they can be divided into several groups.

Pain syndrome

As a result of insufficient blood supply caused by inflammation or spasm of the vessels supplying the prostate, a lack of oxygen in the glandular tissues is noted, as a result of which by-products of pathological oxidation are formed that affect the nerve endings of the prostate. Since the innervation of the prostate is linked to the innervation of the pelvic floor, penis, scrotum, testicles and rectum, the localization of the pain is variable. The following pain symptoms are the most common:

  • Discomfort or pain in the perineum - occurs mainly after physical exertion, sexual intercourse and alcohol consumption in the form of transient seizures;
  • Feeling of hot potatoes in rectum;
  • Pain (discomfort) in the testicles - patients called "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 the prostate secretion to the acidic side. The acidic secretion of the prostate irritates the mucous membrane of the urethra, therefore, painful sensations, more often in the form of "burning", occur after urination or intercourse, when part of the secretion is pressed into the lumen of the urethra during the contraction of the urethra muscles of theGland and pelvis.

Urinary disorder syndrome

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

  • Frequent urination - frequent urination (up to 3 times an hour) with a sharp and sudden urge (impossible to tolerate) and rather small portions;
  • Feeling of incomplete emptying of the bladder - after urination there is a feeling that the urine is left in the bladder;
  • Weak or intermittent flow of urine - this can also be the "last drop" symptom - despite the patient's best efforts, a drop of urine is still released from the canal after urinating.

Ejaculation and orgasm disorder

It is associated with damage to the seminal tubercle (colliculitis) during prostatitis, on the surface of which 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 the penis with sexual arousal).

Serious violations:

  • Premature ejaculation or, conversely, excessively prolonged sexual intercourse - caused by inflammation of the seminal tubercle or its scarring due to the inflammatory process;
  • Extinguished 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 are released.

Impairment of fertility

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

  • A decrease in the pH of the sperm in the direction of the acidic side - since with inflammation of the prostate, acidic products of pathological oxidation accumulate in secret. An acidic environment is extremely destructive to sperm, causing them to immobilize and even die.
  • The agglutination of the sperm - the sticking together of the sperm mainly by the heads - is associated with a change in the physicochemical properties of the secret.
  • Asthenospermia - a decrease in sperm motility - is closely linked to a shift in pH to the acidic side and a violation of the production of lecithin cells by the prostate, which ensure the vital activity of the sperm.

Urethroprostatitis

In some cases, prostatitis is associated with chronic urethritis, which manifests itself in a scanty mucopurulent discharge from the urethra (mainly after prolonged urinary retention).

Prostatitis and sexual disorders

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

Under the influence of sexual stimuli, when the body is completely saturated with androgens, a nerve signal is generated in the formations of the cortical-subcortical region of the brain, which is transmitted from there to the erection center located in the spinal cord, it goes to the smooth muscles of the sinusoids of the formations of the cavernous bodiesof the penis, which either relax (arteries and sinusoids) or narrow (veins). The prostate does not play a role.

Ejaculation and orgasm occur with sufficient stimulation of special receptor cells located in the area of the seminal tubercle, into which the excretory ducts of the prostate fall. The same receptors are responsible for sending a nerve impulse to the cerebral cortex, where the sensation of orgasm occurs.

An inflammatory process in the prostate (prostatitis) can lead to damage to the seminal tubercle and, as a result, both violations of a man's potency and premature ejaculation and extinction of orgasm. Impotence in chronic prostatitis is pathogenetically linked to the degree of damage to the nervous apparatus of the prostate. This form of impotence (neuroreceptor impotence) is a typical example of a reaction phenomenon, when the presence of pathological impulses from the organs affected by the inflammatory process leads to the irradiation of the arousal process to the centers that control sexual function and literally to the disorder. A certain, though not leading role in the pathogenesis of neuroreceptor impotence also plays 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 an overdiagnosis of prostatitis and an overestimation of its role in the development of erectile dysfunction.

diagnosis

The doctor's task is to identify the inflammatory process in the prostate, identify a possible causative agent of the disease and assess the dysfunction of the prostate. In 1990, Stamey wrote that prostatitis is a "garbage can of clinical ignorance" because of the multitude of terms, diagnostic methods, and treatments used. At the same time, several simple as well as clinical and laboratory tests enable a correct diagnosis, which enables the initiation of an appropriate therapy.

Digital rectal exam of the prostate

A 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 compression and softening, pies, pain. The fact that 80% of pancreatic cancers are detected by rectal examination speaks for itself. We can safely say that this research method is always 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, because methods of obtaining a secret during massage do not guarantee that the contents of the urethra and seminal vesicles will not penetrate them. At the same time, with obvious signs of prostatitis, the secret of the prostate can be normal. This is due to focal inflammation, the presence of part of the obliterated or closed excretory ducts.

Examination of the secretion of the prostate

The study of the secretion of the prostate (Expressed Prostatic Secretions-EPS) allows you to determine the presence of an inflammatory process in the prostate and, in part, its functionality. It is the main method used to diagnose and monitor the treatment of chronic prostatitis. The secret of the prostate can be examined with light microscopy without staining or with special staining methods. The secret of the prostate can also be subjected to bacteriological examination or research by the method of polymerase chain reaction for the detection of infectious agents in it. Get the secret through prostate massage. The secretion released from the urethra is collected for examination in a sterile test tube or on a clean slide. Sometimes the secretion from the prostate does not flow from the urethra. In such cases, the patient is advised to get up on his feet immediately. More often, if the secret could not be obtained, it means that it did not get into the urethra, but into the bladder. In this case, the centrifugate of the irrigation fluid released from the bladder after massaging the prostate is examined.

  • Lipoid grains (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate. Gives the secret a milky look. 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 of the gland, it has an oval shape and a layered structure that resembles a tree trunk. Usually they do not appear, their detection indicates stagnation of secretions in the gland, which may be accompanied by adenomas or chronic inflammatory processes;
  • Erythrocytes can be single. You enter the secret through a vigorous massage of the prostate. An increased number of them is observed with inflammatory processes, neoplasms.
  • Desquamation of the epithelium in large quantities is observed at the beginning of inflammatory processes and in tumors, while desquamation often occurs at the same time with protein and fat degeneration of epithelial cells. Macrophages can be seen with stagnation of secretions, a long-term current inflammatory process;
  • Bettcher crystals are long crystals that are formed when the mixed secretion of the male gonads (prostate juice mixed with semen) of spermine and phosphate salt is cooled and dried. In azoospermia and severe oligozoospermia, Bettcher crystals form quickly and in large quantities;
  • Retention syndrome - stagnation syndrome is observed with adenoma of the gland. There is an abundance of macrophages, there are multinucleated cells such as foreign bodies and amyloid bodies;
  • Fern symptom - a symptom of secretion crystallization - the shape of the precipitating sodium chloride crystals depends on the physicochemical properties of the secretion of the prostate. The examination of the symptom is carried out by adding a drop of 0. 9% sodium chloride solution to the prostate secretion obtained, further observation being made under a light microscope after drying. In healthy men of childbearing age, the crystallization of prostate secretion is characterized by a typical fern leaf phenomenon (3+). Androgenic insufficiency or the presence of prostatitis lead to various degrees of damage to the structure of crystals up to their absence.

Bacteriological examinations of urine and pancreatic secretions

Urethral swab, including PCR diagnostics

Serological diagnosis of active substances (ELISA) that cause urinary tract infections

Immunofluorescence Reaction (RIF) direct and indirect

Detection of antibodies against 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 with PSA for all men over the age of 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 exam of the prostate per rectum. Recent studies could not confirm the presence of a significant increase in PSA levels immediately after the digital examination. Thus, the PSA level can be determined with reliable results and after examination of the pancreas.

Four-glass sample

A 4-glass test based on a comparative bacteriological assessment of approximately equal parts of the urine obtained before and after massaging the prostate and its secretion has been proposed for the diagnosis of chronic prostatitis.

The diagnosis of prostatitis is made with a ten-fold increase in the concentration of microorganisms in the secretion of the prostate compared to their content in the urine (1, 2 and 3 servings) and an increase in the number of polymorphonuclear leukocytes >placed 10-16 in the field of view of a light microscope (200x magnification). Or an increase in the number of leukocytes by more than 300 x 106 / l if they are counted in the counting chamber. Lecithin bodies, which are the product of normal secretion of the glandular epithelium of the prostate, 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 lower amounts. In mature men, they can be found in field of vision 1-2.

Biochemical blood test

Immunological and hormonal profile (according to indications).

Ultrasound, TRUS

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

Uroflowmetry

Treatment of prostatitis

Complex treatment of patients with chronic prostatitis should include:

  • Compliance with the general regime, diet, sexual hygiene, as well as the participation of sexual partners in treatment in the presence of an infectious agent;
  • Choosing effective drugs to suppress infections;
  • Increasing the general reactivity of the patient's body and immunobiological tolerance of microorganisms to drugs;
  • increased secretion outflow and activation of local repair processes in the focus of the inflammation;
  • Hygiene of foci of infection in the presenting and distant organs;
  • Improvement of microcirculation in the prostate and pelvic organs;
  • the appointment of enrichment agents, enzymes and vitamins;
  • Correction of hormonal disorders;
  • the appointment of anticonvulsants;
  • the appointment of analgesics and anti-inflammatory drugs;
  • Taking sedatives and sedatives;
  • Regulation of neurotrophic disorders with local analgesics;

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 has been widely used in O'Conory's urological practice since 1936. However, after Meares and Stamey described the milestone test for diagnosing prostatitis in 1968, views about the causes of this disease changed and massage as a therapeutic method was removed from the lists of measures in many manuals for the treatment of prostatitis in the developed world.

Since the mid-1990s, many doctors involved in the diagnosis and treatment of prostatitis noticed the ineffectiveness of the proposed antibiotic therapy and the use of alpha blockers in some cases, leading them to use this forgotten method inpractice.

Basically, prostate massage is currently used as a diagnostic method for obtaining prostate secretions (expressed prostate secretions-EPS) - for their microscopic (cultural) examination and for the test before and after the massage (test before and after the massage -PPMT). Prostate SecretionPerform your massage. The massage is amedical intervention and must be performed by a previously trained specialist. Massage is carried out after urination and, in the case of a discharge from the urethra, after preliminary washing with isotonic sodium chloride solution, which is necessary especially in cases where a bacteriological examination of the secretion is assumed. The prostate is massaged through the anus, as the prostate is adjacent to the ampulla of the rectum and is only available there for examination. Massage first one, then another flap of the prostate with finger movements from the periphery to the central groove along the excretory canals, trying not to touch the seminal vesicles. End the massage by pressing on the central sulcus area from above. The secretion released from the urethra is collected for examination in a sterile test tube or on a clean slide. Sometimes the secretion from the prostate does not flow from the urethra. In such cases, the patient is advised to get on their feet immediately. If, nevertheless, the secret could not be obtained, it means that it did not get into the urethra, but into the bladder. In this case, the centrifugate of the irrigation fluid released from the bladder after massaging the prostate 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 method for chronic prostatitis. Prostate massage is widely used to treat prostatitis in the countries of Southeast Asia, China and some European countries. Some North American and Canadian urologists also recommend using massage in combination with antibiotic therapy in treating some forms of prostatitis. In fact, little has been done to evaluate the effectiveness or ineffectiveness of prostate massage. There are several conflicting studies, in one carried out by Egyptian doctors, no differences were found in the groups of patients, some of whom received a massage combined with antibiotic therapy and simply antibiotic therapy, in another by American and Filipino researchers on the contrarya group of patients with prostatitis who received massage in combination with antibiotic therapy showed a significant improvement.

Proponents of the use of massage for therapeutic purposes believe that the main effect of its use is to drain the ducts of the prostate - i. H. Liberation of purulent and dead cells. It is believed that another effect increases blood flow to the prostate, which improves the penetration of antibiotics into the prostate and activates local immunological protective processes.

There is little data in the world literature on complications related to prostate massage. In 1990, Japanese doctors described genital burn (Fournier), and in 2003, German doctors described perioprostatic bleeding after prostate massage with the development of an embolic stroke (bleeding) of the lungs. There is a study that shows that PSA (prostate-specific antigen) levels temporarily rise after massage. Massage is contraindicated in acute inflammation of the prostate (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for calcifications of the prostate and prostate adenoma. It is usually recommended to massage the prostate two or three times a week.

Physiotherapy procedure

Physiotherapeutic interventions (prostate massage, warming up, etc. ) are contraindicated in acute prostatitis.

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

The use of physiotherapeutic methods against the background of drug therapy leads to a much better result than with treatment alone. The following methods of influencing the prostate are widely used and have proven to be effective:

  • Shock wave therapy;
  • Electrical stimulation of the pancreas with modulated currents from skin or rectal electrodes;
  • Thermotherapy in different versions (including high frequency thermotherapy);
  • Magnetotherapy;
  • Microwave microwave therapy;
  • Laser therapy.
  • transrectal ultrasound therapy and phonophoresis;
  • Microclysters.