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Prostatitis

Prostatitis (prostatitis) is an 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

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According to various sources, prostatitis affects 35 to 40%, and according to some authors, 70% of men aged 18 to 50 years. The prostate, in terms of the prevalence of the disease and all the problems that arise from it, occupies a prominent place among urological pathology.

Classification

There are many classifications of prostatitis, hence very specific terminology. The most common is the classification of prostatitis, proposed by the National Institutes of Health (NIH) of the United States in 1995:

Category The 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 clinical signs, the presence or absence of leukocytes and microorganisms in the secretion of the prostate, ejaculate and urine.

Category I

Acute bacterial prostatitisIt results 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 the pain syndrome of 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 increase in the number of leukocytes in the secretion of the prostate, ejaculate and urine, after massage of theprostate, pathogenic microorganisms are not detected in 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, ejaculate and lUrine obtained after prostate massage is 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 aincrease in the level of prostate specific antigen - PSA).

Diagnosis of prostatitis

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 that supply the prostate, oxygen deprivation of the tissues of the gland is noted, which leads to the formation of pathological oxidation byproducts thataffect the nerve endings of the prostate. The innervation of the prostate being associated with the innervation of the pelvic floor, penis, scrotum, testes, 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 consumption in the form of transient seizures;
  • Sensation of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles - which patients describe as "stiffness", "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 prostatic secretion to the acidic 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 intercourse, when part of the secretion is squeezed into the lumen of the prostate. urethra during contraction of the muscles of the gland and pelvis.

Urinary disorder syndrome

Associated with the narrow 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 strong and sudden urge (impossible to tolerate) and rather small portions;
  • Feeling of incomplete emptying of the bladder - after the act of urination, there is a feeling that the urine remains in the bladder;
  • Weak or intermittent urine flow - this can also include the symptom of the "last drop" - despite the patient's best efforts, after the act of urination, a drop of urine is still released from the duct.

Ejaculation and orgasm disorders

It is associated with lesions of 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).

Major 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 semen is released.

Impaired fertility

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

  • A decrease in the pH of semen towards the acidic side - because with inflammation of the prostate, the acid products of pathological oxidation begin to accumulate in secret. An acidic environment is extremely destructive to sperm, causing them to immobilize and even die;
  • The agglutination of the spermatozoa - sticking of the spermatozoa mainly by the heads - is associated with a modification of 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 a violation of the production of lecithin cells by the prostate, which provides vital sperm activity.

Urethroprostatitis

In some cases, prostatitis is associated with chronic urethritis, which manifests as scant 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, with complete saturation of the body with androgens in the formations of the cortico-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 muscles of the sinusoids of the formations of the cavernous bodies 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 into which the excretory ducts of the prostate fall, these same receptors are responsible for sending an impulsenerve to the cerebral cortex where the sensation of orgasm is formed.

An inflammatory process in the prostate (prostatitis) can lead to lesions of the seminal tubercle and, as a result, both violations of the potency of a man, as well as premature ejaculation and erasure of orgasm. Impotence in chronic prostatitis is pathogenic associated with the degree of damage to the nervous system of the prostate. 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 excitation process to the centers that control the function. sexual and disorder. of the last. Some role, although not critical, in the pathogenesis of neuroreceptor impotence is also played by some suppression of androgenic activity of the testes and androgen sensitivity in the hypothalamus and pituitary centers. .

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.

Diagnostic

The task of the doctor is to detect the inflammatory process in the prostate, to identify a possible causative agent of the disease and to assess the dysfunction of the prostate. In 1990, Stamey wrote that prostatitis is a "dumpster of clinical ignorance" because of 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 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, the presence of foci of compaction and softening, grazing, pain. The fact that 80% of pancreatic cancers are detected by rectal examination speaks for itself. We can say with certainty 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, since the methods of obtaining a secret during massage do not ensure that the contents of the urethra and seminal vesicles do notwill not enter 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 prostate secretion

The study of the secretion of the prostate (Expressed prostatic secretions-EPS) makes it possible to determine the presence of an inflammatory process in the prostate and, in part, its functional capacity. It is the main method of diagnosing and monitoring treatment for chronic prostatitis. The secret of the prostate can be examined using light microscopy without staining or using special staining methods. In addition, the secret of the prostate can be subjected to bacteriological examination or research by the polymerase chain reaction method for the detection of infectious agents. 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 from the prostate does not flow from the urethra. In such cases, the patient is advised to get up immediately. If, nevertheless, the secret could not be obtained, then most often it means that it did not enter the urethra, but the bladder. In this case, the centrifugate of the washing fluid released from the bladder after the prostate massage is examined.

  • Lipoid grains (body of lecithin) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate. Gives the secret a milky appearance. Normally the secret is rich in lecithin grains. A decrease in their number, associated 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 unique. They enter the secret following a vigorous massage of the prostate. An increased number of them is observed in inflammatory processes, neoplasms.
  • Dequamation of the epithelium in a large amount 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 observed with stagnation of secretions, a current long-term inflammatory process;
  • Bettcher crystals are long crystals formed when the mixed secretion of male gonads (prostatic juice mixed with sperm) of spermine and phosphate salt is cooled and dried. With severe azoospermia and 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;
  • Symptom of fern - a symptom of crystallization of the secretion - the form of precipitating crystals of sodium chloride depends on the physicochemical properties of the secretion of the prostate. The study of the symptom is carried out by adding a drop of 0. 9% sodium chloride solution to the prostate secretion obtained with further examination after drying under an optical microscope. In healthy men of childbearing age, crystallization of the secretion of the prostate is characterized by a phenomenon typical of fern leaves (3+). Androgenic insufficiency or the presence of prostatitis gives varying degrees of violation of the structure of crystals until their absence.

Bacteriological studies of urine portions and pancreatic secretions

Urethral swab, including PCR diagnostics

Serologic Diagnosis of Agents (ELISA) Causing Urinary Tract Infections

Direct and indirect immunofluorescence reaction (RIF)

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

Sample of four glasses

In order to diagnose chronic prostatitis, a 4-glass test has been proposed, based on a comparative bacteriological evaluation of approximately equal portions of urine received before and after prostate massage, 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 an optical microscope (magnification 200 times). Or an increase in the number of leukocytes of more than 300x106 / l when they are counted in the counting chamber. Lecithin bodies, which are the product of the normal secretion of the glandular epithelium of the prostate, 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 amounts. In mature men, they can be found 1-2 in the field of view.

Biochemical blood test

Immunological and hormonal profile (as indicated).

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 diet, diet, sexual hygiene, as well as the involvement of sexual partners in the 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 and activation of local repair processes at the center of inflammation;
  • sanitation of foci of infection in presenting and distant organs;
  • improvement of microcirculation in the prostate 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;
  • 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 milestone 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. numerous manuals for the treatment of prostatitis in the developed world.

But since the mid-90s of the 20th century, many physicians 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 to obtain prostatic secretions (expressed prostatic secretions - EPS) - for its microscopic examination(cultural) and for the pre- and post-massage test (pre- and post-massage -PPMT test). Prostate secretion perform its massage. Massage is a medical procedure and should 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 secretion is assumed. Prostate massage is performed through the anus, as the prostate is adjacent to the bulb of the rectum and is only available there for examination. Massage first one, then another prostate lobe 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 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 from the prostate does not flow from the urethra. In such cases, the patient is advised to get back on their feet immediately. If, however, the secret could not be obtained, it means that it did not enter the urethra, but the bladder. In this case, the centrifugate of the washing fluid released from the bladder after the prostate massage 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 antibiotics in the treatment of certain forms of prostatitis. In fact, little has been done to assess the effectiveness or ineffectiveness of prostate massage. There are several conflicting studies, in one conducted by Egyptian doctors no difference was found in the groups of patients, some of whom received massage in combination with antibiotic therapy and just antibiotic therapy, in another conducted by researchersAmericans and Filipinos, on the contrary. , in a group of patients with prostatitis 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 - ie. i. e. freeing them from purulent and dead cells. Another effect is considered to increase blood flow in the prostate, 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 massage of the prostate with the development of a stroke (hemorrhage) of the lungs. According to a study, after massage, the level of PSA (prostate specific antigen) increases temporarily. Massage is contraindicated in acute inflammation of the prostate (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcifications and prostatic adenoma, it is generally recommended to massage the prostate 2-3 times per week.

Physiotherapy procedures

Any physiotherapy intervention (prostate massage, warming 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 of physical agents in order to normalize functional and pathological changes, and the electrophoretic delivery of drugs to 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 have become widespread and have proven to be effective:

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