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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

Propagation

According to various sources, prostatitis occurs in 35-40%, and according to some authors, in 70% of men between the ages of 18 and 50. The prostate gland, in terms of the prevalence of the disease and the ensuing complex of problems, occupies a prominent place in urological pathology.

Classification

There are many classifications of prostatitis, therefore a very particular 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 bacterial 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 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 associated symptoms:

  • an increase in the 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 the prostate, ejaculate and urine obtained after prostate massage. The criterion for separation in 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 increase in the number of leukocytes in the secretion of the prostate gland, ejaculate and urine portion, after prostate massage, pathogenic microorganisms are not detected inthese samples with 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, ejaculate and urine obtained after prostate massage 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 prostate tissue samples obtained in connection with the diagnosis for other reasons (for example, a prostate biopsy due to an increase in the level of specific prostateantigen - PSA).

Prostatitis diagnostics

Symptoms of prostatitis are extremely varied, but they can be grouped into several groups.

Pain syndrome

Due to insufficient blood supply, caused by inflammation or spasm of the vessels supplying the prostate, oxygen starvation is noted in the tissues of the gland, as a result of which pathological oxidation byproducts are formed, affecting 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 the most common:

  • Discomfort or pain in the perineum - appears mainly after physical exertion, sexual intercourse, alcohol intake in the form of transient convulsions;
  • Sensation of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles - patients describe as "aches", "twists", 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 prostatic secretion to the acid side. Acid secretion from the prostate irritates the mucous urethra, so painful sensations, more often in the form of "burning" occur after the act of urination or sexual intercourse, when part of the secretion is squeezed into the lumen of the urethra during contractionof the muscles of the gland and pelvis.

Urinary Disorder Syndrome

Associated with the tight innervation of the prostate and bladder, as well as the involvement of the prostate muscles 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;
  • Sensation of incomplete emptying of the bladder - after the act of urination, there is a feeling that urine remains in the bladder;
  • Weak or intermittent urine flow - this can also include the symptom of the "last drop" - despite all the patient's best efforts, after the act of urination, a drop of urine is still released from the canal.

Disorders of ejaculation and orgasm

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 sensation of orgasm is formed. Prostatitis does not directly cause erectile dysfunction (blood filling of the penis with sexual arousal).

Main violations:

  • Premature ejaculation, or vice versa, 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.

Impaired fertility

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

  • A decrease in the pH of the sperm towards the acid side - since with inflammation of the prostate, the acid products of pathological oxidation begin to accumulate in the secret. An acidic environment is extremely destructive to spermatozoa, causing them to immobilize and even die;
  • Agglutination of spermatozoa - the gluing of spermatozoa mainly from the head - is associated with a change in the physicochemical properties of the secret;
  • Astenospermia - a decrease in sperm motility - is closely associated with a shift in pH to the acid 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 poor mucopurulent secretion from the urethra (mainly after prolonged urinary retention).

Prostatitis and sexual disorders

The question "Does prostatitis cause impotence? " Has been a source of professional controversy 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 occurs, which is transmitted to the erection center located in the spinal cord, from where it goes to the smooth musclesof the sinusoids of the corpora cavernosa formations of the penis, which relax (arteries and sinusoids) or narrow (veins). There is no role for the prostate in this process.

Ejaculation and orgasm occur with sufficient irritation of special receptor cells, which are located in the region of the seminal tubercle where the excretory ducts of the prostate gland fall, these same receptors are responsible for sending a nerve impulse to thecerebral 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, and to premature ejaculation and cancellation of orgasm. Impotence in chronic prostatitis is pathogenetically associated with the degree of damage to the nervous system of the prostate gland. This form of impotence (impotence of neuroreceptors) is a typical example of 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 to the disturbance ofthe latter. A certain, although not decisive, role in the pathogenesis of neuroreceptor impotence is also played by a certain suppression of the androgenic activity of the testes and sensitivity to androgens in the hypothalamus and pituitary gland centers.

At the same time, it is believed 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 "clinical ignorance bin" 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, which allows the initiation of 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 compaction foci 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, because the methods of obtaining a secret during massage do not guarantee that the contents of the urethra and seminal vesicles do not penetrate into it. At the same time, with obvious signs of prostatitis, the prostate secret can be normal. This is due to focal inflammation, the presence of a part of the excretory ducts obliterated or closed.

Study of the secretion of the prostate gland

The study of the secretion of the prostate gland (Expressed prostatic secretions-EPS) allows to determine the presence of an inflammatory process in the prostate gland and, in part, its functional capacity. It is the primary method of diagnosing and monitoring the treatment of chronic prostatitis. The secret of the prostate can be examined by light microscopy without staining or by using special staining methods. In addition, the secret of the prostate gland can be subjected to bacteriological examination or research by the method of the polymerase chain reaction for the detection of infectious agents contained in it. Get the secret through prostate massage. The secretion released from the urethra is collected in a sterile tube or on a clean slide for examination. Sometimes the secretion of the prostate gland does not come out of the urethra. In these cases, the patient is advised to immediately stand up. If, however, it was not possible to obtain the secret, more often it means that it did not enter the urethra, but into the bladder. In this case, the centrifuged washing liquid 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 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;
  • The amyloid body is a thickened secretion of the gland, has an oval shape and a layered structure, similar to 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. A larger 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 squamation often occurs 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 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 gland adenoma. There is an abundance of macrophages, there are multinucleated cells such as foreign bodies and amyloid bodies;
  • Symptom of fern - a symptom of crystallization of the secretion - the form of precipitation of sodium chloride crystals 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 prostatic secretion obtained with further observation after drying under a light microscope. In healthy men of reproductive age, the crystallization of prostatic secretion is characterized by a typical phenomenon of fern leaves (3+). Androgenic insufficiency or the presence of prostatitis give varying degrees of violation of the crystal structure up to their absence.

Bacteriological studies of portions of urine 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) 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 for the 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 by obtaining reliable results and after examination of the pancreas.

Four glass sample

To diagnose chronic prostatitis, a 4-glass 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 relative to their content in the urine (portions 1, 2 and 3) and an increase in the number of polymorphonuclear leukocytes >10-16 in the field of view of an optical microscope (200 times magnification). Or an increase in the number of leukocytes greater 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 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, 1-2 can be found in the visual field.

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 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 outflow of secretion and activation of local reparative processes in the focus of inflammation;
  • hygiene 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 in O'Conory's urological practice. However, in 1968, after Meares and Stamey described the fundamental test for the diagnosis of prostatitis, opinions 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 United States. developed world.

But since the mid-90s of the twentieth 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 usethis forgotten method. practically.

Basically, prostate massage is currently used as a diagnostic procedure for obtaining prostatic secretions (expressed prostatic secretions-EPS) - for its microscopic (cultural) examination and for pre-testing. and post-massage (pre and post-massage test -PPMT). secretionperform its 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 an isotonic solution of sodium chloride, which is especially necessary in cases where bacteriological examination of the secretion is supposed. Prostate massage is performed through the anus, as the prostate gland is adjacent to the ampulla of the rectum and is only available 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 sulcus area from above. The secretion released from the urethra is collected in a sterile tube or on a clean slide for examination. Sometimes the secretion of the prostate gland does not come out of the urethra. In such cases, the patient is advised to immediately stand up, but if, nevertheless, it was not possible to obtain the secret, it means that he did not enter the urethra, but the bladder. In this case, the centrifuged washing liquid released from the bladder after massage of 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 conflicting studies, in one conducted by Egyptian doctors, no differences were found in patient groups, some of whom received massage in combination with antibiotic therapy and simply antibiotic therapy, in another conducted by American and Filipino researchers, alconversely, in a group of prostatitis patients who received massage 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, eg. freeing them from purulent and dead cells. Another effect is believed 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 the level of PSA (prostate specific antigen) increases temporarily. Massage is contraindicated in acute inflammation of the prostate (acute prostatitis), 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 procedure (prostate massage, warm-up, etc. ) is contraindicated for acute prostatitis.

The use of physiotherapeutic procedures in the complex treatment of prostatitis is aimed both at a direct effect on the prostate gland of physical agents in order 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 gives a much better result than just treatment. The following methods of influencing the prostate gland have spread and proved their effectiveness:

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