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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 between 18 and 50 years of age. The prostate gland, in terms of the prevalence of the disease and the complex of problems derived from it, occupies a prominent 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 Chronic inflammatory pelvic pain syndrome
Category IIIB Chronic non-inflammatory pelvic pain syndrome (prostatodynia)
Category IV Asymptomatic inflammatory prostatitis

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

Category I

Acute bacterial prostatitisIt is expressed by an 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 the corresponding symptoms and an increase in the number of leukocytes and bacteria in the secretions of the prostate, ejaculation and urine obtained after massage of the prostate.

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 the prostate, ejaculation and urine obtained 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 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, ejaculation and urine portion, after prostate massage, pathogenic microorganisms are not detectedin these samples by standard methods.

Category III B

Chronic non-inflammatory 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, ejaculation and urine obtained after prostate massage are not detected withstandard 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 ofprostate specific antigen - PSA).

Prostatitis diagnosis

The symptoms of prostatitis are extremely varied, but 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 pathological oxidation by-products are formed, affecting the endingsnerve cells of the prostate. Since the innervation of the prostate is associated with the innervation of the pelvic floor, penis, scrotum, testicles, rectum, the location of pain is variable. The following pain symptoms are the most common:

  • Discomfort or pain in the perineum - appears mainly after physical exertion, sexual intercourse, alcohol intake in the form of temporary seizures;
  • Sensation of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles: patients describe as "pains", "torsions", they are also associated with various provoking factors;
  • Discomfort, cramps and pain in the urethra are mainly associated with a change in the pH of the prostate secretion towards the acidic side. Acidic discharge from the prostate irritates the mucous urethra, therefore, painful sensations, most often in the form of "burning", occur after the act of urination or sexual intercourse, when part of the discharge is squeezed into the lumenof the urethra during contraction of the muscles of the gland and pelvis.

Urinary disorder syndrome

Associated with the close innervation of the prostate and the bladder, as well as with the participation 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 an 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, there is a sensation that urine remains in the bladder;
  • Weak or intermittent urine stream - this may also include the "last drop" symptom - despite all 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 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 of the penis with sexual arousal).

Major Violations:

  • Premature ejaculation, or vice versa, excessively prolonged sexual 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 are released.

Impaired fertility

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

  • A decrease in the pH of sperm to the acidic side, since with inflammation of the prostate, the acidic products of pathological oxidation begin to accumulate secretly. An acidic environment is extremely destructive to sperm, causing them to become immobilized and even die;
  • Sperm agglutination (sticking of sperm 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 change in pH towards the acidic side and with a violation of the production of lecithin cells by the prostate, which ensure the vital activity of spermatozoa.

Urethroprostatitis

In some cases, prostatitis is combined with chronic urethritis, manifested by scant mucopurulent discharge from the urethra (mainly after prolonged urinary retention).

Prostatitis and sexual disorders

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

Under the influence of sexual stimuli, with a total 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 erection center located in the spinal cord, from where it is directedto the smooth muscles of the sinusoids of the formations of the corpora cavernosa of the penis, which relax (arteries and sinusoids) or narrow (veins). The prostate has no role in this process.

Ejaculation and orgasm occur with sufficient irritation of the special receptor cells, which are located in the region of the seminal tubercle in which the excretory ducts of the prostate gland fall, these same receptors are responsible for sending a nerve impulse tothe 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 violations of a man's potency and 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 the irradiation of the arousal process to the centers that control sexual function, and the disorder. of the last. A certain, although not major, role in the pathogenesis of neuroreceptor impotence is also played by some suppression of the androgen activity of the testes and androgen sensitivity in the hypothalamus and pituitary gland centers.

At the same time, there is an opinion that in the Russian Federation there is an overdiagnosis of prostatitis and an overestimation of its role in the development of erectile dysfunction.

Diagnostics

The task of the doctor is to detect the inflammatory process in the prostate, identify a possible causative agent of the disease and evaluate 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, diagnostic methods, and treatments. At the same time, several simple and clinical and laboratory tests make it possible to correctly diagnose, allowing the initiation of appropriate therapy.

Digital rectal exam of the prostate

A very informative way. The inflammatory process can be judged by evaluating 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, presence of foci of compaction and softening, pastiness, pain. The fact that 80% of pancreatic cancers are detected by rectal exam 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 do not get into it. 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.

Study of the secretion of the prostate gland.

The study of the secretion of the prostate gland (Expressed prostate secretions-EPS) allows to determine the presence of an inflammatory process in the prostate gland and, in part, its functional capacity. It is the main method of diagnosing and monitoring the treatment of chronic prostatitis. The secret of the prostate can be examined with light microscopy without staining or with special staining methods. Also, the secrecy of the prostate gland can be subjected to bacteriological examination or investigation by the polymerase chain reaction method 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 discharge from the prostate does not come out of the urethra. In such cases, the patient is advised to stand up immediately. However, if the secret could not be obtained, more often this means that it did not enter the urethra, but the bladder. In this case, the centrifugation of the washing liquid released 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 appearance. Normally, the secret is rich in lecithin grains. A decrease in their number, together 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;
  • Amyloid body is a thick secretion from the gland, it has an oval shape and a layered structure, resembling the trunk of a tree. 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 unique. They enter the secret as a result of a vigorous massage of the prostate gland. A greater number of them are 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, desquamation often occurs with protein and fat degeneration of epithelial cells. Macrophages can be seen with stagnant secretions, a current long-term inflammatory process;
  • Bettcher crystals are long crystals that form when the male gonad's mixed secretion (prostate juice mixed with sperm) of spermine and phosphate salt cools and dries. With azoospermia and severe oligozoospermia, Bettcher crystals form rapidly 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 way sodium chloride crystals precipitate 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 prostate secretion obtained with subsequent visualization after drying under an optical microscope. In healthy men of reproductive age, crystallization of prostate secretion is characterized by a typical fern leaf phenomenon (3+). Androgen insufficiency or the presence of prostatitis give various degrees of violation of the crystal structure until its absence.

Bacteriological studies of urine portions and pancreatic secretions.

Urethral swab, including PCR diagnostics

Serological diagnosis of agents (ELISA) that cause urinary tract infections

Direct and indirect immunofluorescence reaction (RIF)

Detection of antibodies against 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 gland, accompanied by PSA, for all men over 50 years of age and in the presence of prostate cancer in blood relatives of the male line. There is still a discussion about obtaining PSA immediately after a digital rectal prostate gland exam. Recent studies have not been able to confirm the presence of a significant increase in PSA content immediately after digital examination. Therefore, the PSA level can be determined by obtaining reliable results and after examination of the pancreas.

Sample of four glasses

To diagnose chronic prostatitis, a 4-vessel test was proposed, based on a comparative bacteriological evaluation 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 ten-fold increase in the concentration of microorganisms in the secretion of the prostate compared to its 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 an optical 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 the normal secretion of the glandular epithelium of the prostate gland, should thickly 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 men of mature age, 1-2 can be found in the field of vision.

Biochemical blood test

Immunological and hormonal profile (according to indications).

Ultrasound, TRUS

Ultrasound diagnosis of prostatitis with 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 participation of sexual partners in treatment in the presence of an infectious agent;
  • selection of effective drugs to suppress infection;
  • increase the general reactivity of the patient's body and the immunobiological tolerance of microorganisms to drugs;
  • increased secretion flow and activation of local repair processes in the focus of inflammation;
  • sanitation of foci of infection in present 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-inflammatories;
  • take sedatives and tranquilizers;
  • 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 since 1936 it has been widely introduced into O'Conory's urological practice. However, in 1968, after Meares and Stamey described the historical test for the diagnosis of prostatitis, opinions on the causes of this disease changed and massage as a therapeutic procedure was removed from the lists of measures in many manuals for 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 notice 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 prostate secretions-EPS) - for microscopic (cultural) examination and for testingpre and post massage (pre and post massage test -PPMT). secretion perform your massage. Massage is a medical procedure and must be performed by a previously trained specialist. Massage is carried out 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 a bacteriological examination of the discharge is supposed. Prostate massage is done through the anus, as the prostate gland is adjacent to the bleb of the rectum and is only available there for examination. Massage first one, then another lobe of the prostate with finger movements from the periphery to the central sulcus along the excretory ducts, trying not to touch the seminal vesicles. Finish the massage by pressing on the central groove area 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 discharge from the prostate does not come out of the urethra. In such cases, the patient is advised to stand up immediately, but if, nevertheless, the secret could not be obtained, this means that it did not enter the urethra, but the bladder. In this case, the centrifugation of the washing liquid released from the bladder after massaging the prostate gland 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 procedure for chronic prostatitis. Prostate massage is widely used for the treatment of prostatitis in Southeast Asian countries, 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 contradictory studies, in one conducted by Egyptian doctors, no differences were found in the groups of patients, some of whom received massages in combination with antibiotic therapy and simply antibiotic therapy, in another conducted by American and Filipino researchers, on the contrary, in a group of prostatitis patients who received massages 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 to drain the ducts of the prostate, that is, freeing them of 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 bleeding after prostate massage with the development of an embolic stroke (hemorrhage) of the lungs. There is a study that after massage temporarily increases the level of PSA (prostate specific antigen). Massage is contraindicated in acute inflammation of the prostate gland (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcifications and prostate adenoma, it is generally recommended to massage the prostate 2 or 3 times a week.

Physiotherapy procedures

Any physiotherapy procedure (prostate massage, warm-up, etc. ) is contraindicated for acute prostatitis.

The use of physiotherapeutic procedures in the complex treatment of prostatitis aims both a direct effect on the prostate gland of physical agents to normalize functional and pathological changes, as well as the electrophoretic administration of drugs in the prostate tissue.

The use of physiotherapeutic methods in the context of drug therapy gives a much better result than with treatment alone. The following methods of influencing the prostate gland have become widespread and proven effective:

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