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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

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

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 clinical signs, the 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:

  • 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 leading clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of the prostate, ejaculate and urine obtained after massage of the prostate. The criterion for separation into 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 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 pain syndrome and symptoms of prostatitis, while there is no increase in the number of leukocytes and pathogenic microorganisms in the secretion of the prostate, ejaculate and urine obtained after massage of the prostate are not detected by standard methods.

Category IV

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

Diagnostics of the 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 gland 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 associated with the innervation of the pelvic floor, penis, scrotum, testicles, rectum - the localization of pain is variable. The following pain symptoms are most common:

  • Discomfort or pain in the perineum - mainly appears after physical exertion, intercourse, alcohol intake in the form of passing seizures;
  • Sensation of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles - patients describe as "aches", "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 urethra, therefore 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 contraction of the muscles of the gland and pelvis.

Urinary Disorder Syndrome

It is associated with the close innervation of the prostate and bladder, as well as the involvement of the muscles of the prostate 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 urge (impossible to tolerate) and rather small portions;
  • A feeling of incomplete emptying of the bladder - after the act of urination, there is a feeling that urine remains in the bladder;
  • Weak or intermittent stream of urine - this can also include the symptom of the "last drop" - despite all the efforts of the patient, after the act of urination, a drop of urine is still released from the canal.

Ejaculation and orgasm disturbance

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

Major violations:

  • Premature ejaculation or, on the contrary, excessively prolonged intercourse - caused by inflammation of the seminal tubercle or its scarring due to the inflammatory process;
  • Erased 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.

Fertility impairment

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

Urethroprostatitis

In some cases, prostatitis is combined with chronic urethritis, which is manifested by 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 controversy among specialists for decades.

Under the influence of sexual stimuli, with a full saturation of the body with androgens in the formations of the cortical-subcortical region of the brain, a nerve signal arises, which is transmitted to the center of erection located in the spinal cord, from where it goes to the smooth muscles of the sinusoids of the formations of the cavernous bodies of the penis, which either relax (arteriesand sinusoids) or narrow (veins). There is no role for the prostate in this process.

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

An inflammatory process in the prostate gland (prostatitis) can lead to damage to the seminal tubercle and, as a result, both to violations of the potency of a man, as well as premature ejaculation and erasure of orgasm. Impotence in chronic prostatitis is pathogenetically associated with the degree of damage to the nervous apparatus 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 excitation 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 some suppression of 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 both an overdiagnosis of prostatitis and an overestimation of its role in the development of erectile dysfunction.

Diagnostics

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

Digital rectal examination of the prostate

A very informative way. The inflammatory process can be judged 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 compaction and softening, pastiness, soreness. 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, becausemethods of obtaining a secret during massage do not guarantee that the contents of the urethra and seminal vesicles will not get into it. At the same time, with obvious signs of prostatitis, the secret of the prostate may be normal. This is due to the focal inflammation, the presence of part of the obliterated, or closed, excretory ducts.

Study of the secretion of the prostate gland

The study of the secretion of the prostate gland (Expressed prostatic secretions-EPS) allows you to determine the presence of an inflammatory process in the prostate gland and, in part, its functional ability. It is the main method for diagnosing and monitoring the treatment of chronic prostatitis. The secret of the prostate can be examined using light microscopy without staining or using special staining methods. Also, the secret of the prostate gland can 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 in a sterile test tube or on a clean glass slide for examination. Sometimes the secretion of the prostate gland does not flow out of the urethra. In such cases, the patient is advised to get to his feet immediately. If, nevertheless, the secret could not be obtained, more often this means that it did not get into the urethra, but into the bladder. In this case, the centrifugate of the lavage fluid released from the bladder after massage of 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. Normally, 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, resembling a tree trunk. Normally, they do not occur, their detection indicates stagnation of secretions in the gland, which can be with adenomas, chronic inflammatory processes;
  • Erythrocytes can be single. They enter the secret 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, at the same time disquamation often occurs with protein and fatty degeneration of epithelial cells. Macrophages can be seen with stagnation of secretions, a long-term inflammatory process;
  • Bettcher crystals are long crystals formed when the mixed secretion of the male gonads (prostatic juice mixed with sperm) from spermine and phosphate salt is cooled and dried. With azoospermia and severe oligozoospermia, Bettcher crystals are formed 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 form of precipitating crystals of sodium chloride depends on the physicochemical properties of the secretion of the prostate gland. The study of the symptom is carried out 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, crystallization of prostate secretion is characterized by the typical fern leaf phenomenon (3+). Androgenic insufficiency or the presence of prostatitis give various degrees of violation of the structure of crystals up to their absence.

Bacteriological studies of urine portions and pancreatic secretions

Urethral swab, including PCR diagnostics

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) of blood serum

The American Foundation for Urological Diseases recommends an annual rectal examination of the prostate gland, accompanied by 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 examination of the prostate gland per rectum. Recent studies have not been able to confirm the presence of a significant increase in PSA content immediately after digital examination. Thus, the PSA level can be determined with obtaining reliable results and after examination of the pancreas.

Four-glass sample

In order to diagnose chronic prostatitis, a 4-glass test was proposed, based on a comparative bacteriological assessment of approximately equal portions of urine received before and after massage of the prostate gland, 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 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 more than 300x106 / l when counting them in the counting chamber. Lecithin bodies, which are the product of normal secretion of the glandular epithelium of the prostate gland, should densely 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 men of mature age, they can be found 1-2 in the field of view.

Biochemical blood test

Immunological and hormonal profile (according to indications).

Ultrasound, TRUS

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

Uroflowmetry

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 the treatment in the presence of an infectious agent;
  • selection of effective medicines to suppress infection;
  • increasing the general 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;
  • sanitation of foci of infection in the presenting and distant organs;
  • improvement of microcirculation in the prostate gland and pelvic organs;
  • the appointment of fortifying 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 the urological practice of O'Conory. However, in 1968, after Meares and Stamey described a milestone test for diagnosing prostatitis, the views on the causes of this disease changed and massage as a therapeutic procedure was deleted from the lists of measures in many manuals for the treatment 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 note 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 for obtaining prostate secretions (expressed prostatic secretions-EPS) - for its microscopic (cultural) examination and for pre- and post-massage test (pre- and postmassage test -PPMT). prostate secretionperform her massage. Massage is a medical procedure and must be performed by a previously trained specialist. Massage is performed after urination, and in case of discharge from the urethra after its preliminary washing with isotonic sodium chloride solution, which is especially necessary in cases where bacteriological examination of the secretion is supposed. Massage of the prostate is performed through the anus, since the prostate gland is adjacent to the ampulla of the rectum 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 excretory ducts, trying not to touch the seminal vesicles. Finish the massage by pressing on the area of the central sulcus from above. The secretion released from the urethra is collected in a sterile test tube or on a clean glass slide for examination. Sometimes the secretion of the prostate gland does not flow out of the urethra. In such cases, the patient is advised to immediately get to his feet. If, nevertheless, the secret could not be obtained, this means that it did not get into the urethra, but into the bladder. In this case, the centrifugate of the lavage fluid released from the bladder after massage of the prostate gland is examined.

Prostate massage for therapeutic purposes (Repetitive prostatic massage) is officially recommended by the Ministry of Health of the Russian Federation as a treatment procedure for chronic prostatitis. Massage of the prostate is widely used for the treatment of prostatitis in the countries of 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 evaluate 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 of patients with prostatitis who receivedmassage 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. e. freeing them from purulent and dead cells. Another effect is considered to increase blood flow in the prostate gland, which improves the penetration of antibiotics into it and activates local protective immunological 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 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), 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 2 or 3 times a week.

Physiotherapy procedures

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

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

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

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