Chronic prostatitis is a chronic inflammation of the prostate gland (hereinafter the abbreviation prostate may appear), and the etiology of the inflammatory process may be different in different patients.That is why the classification of prostatitis is constantly revised and updated.
According to the classification (NIH), chronic prostatitis includes the second type or chronic bacterial prostatitis (CKD), the third type (chronic non-bacterial prostatitis, CNP), the fourth type of asymptomatic inflammatory prostatitis.
The NIH classification of prostatitis (1999) suggests the division of prostatitis into the following groups and types:
- Type I – acute bacterial prostatitis
- Type II – chronic bacterial prostatitis
- Type III – Chronic Pelvic Pain Syndrome (CPPS):
- III A – inflammatory syndrome of chronic pelvic pain (leukocytes in the 3rd portion of urine, seminal fluid)
- III B – non-inflammatory syndrome of chronic pelvic pain (absence of leukocytes in urine, seminal fluid)
- Type IV – asymptomatic prostatitis (the inflammatory process is determined histologically)
The third type of prostatitis is associated with chronic pelvic pain syndrome (CPPS) and is divided into inflammatory CPPS and non-inflammatory CPPS.
This type of prostatitis is not accompanied by a bacterial infection of the pancreas.The diagnosis is based on the examination of the secretion from the pancreas, the clinic and the results of the bacterial culture.
As a rule, even in the absence of a bacterial component of prostatitis, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is initially carried out.
In the fourth type of prostatitis, there are no complaints from the patient.This type of prostatitis is diagnosed incidentally, during a biopsy of the prostate to rule out another possible pathology (prostate cancer).
The fourth type of prostatitis is established on the basis of a biopsy, examination of a surgical preparation or analysis of semen, taken not because of the patient's complaints about specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated PSA (prostate specific antigen) levels.In case of persistently elevated PSA during antibacterial therapy, the patient is recommended to undergo periodic pancreatic biopsies.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by a bacterial infection of the prostate gland (PG).CKD causes a characteristic clinical picture, in which repeated inflammations of the organs of the excretory system come to the fore (most often, exacerbation of inflammation is caused by the same microorganism).
CKD is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatodynia.
By definition, CKD is associated with an overgrowth of pathogenic microorganisms in a culture of prostatic secretions, semen, or a portion of urine obtained after prostatic massage.As a rule, microscopy of pancreatic secretion reveals 10 or more leukocytes and macrophages in one field of view.
The symptom complex of prostatitis is very common.Approximately half of men develop a clinical picture similar to that of prostatitis during their lifetime.
This set of symptoms accounts for 8% of all visits to a urologist.Patients with symptoms of prostatitis are more likely to seek specialist advice than patients with pancreatic hyperplasia or pancreatic cancer.
Often the symptoms of prostatitis are not related to a chronic bacterial infection of the gland.Despite this fact, traditionally patients with symptoms of prostatitis are prescribed antibacterial therapy (50% of patients with symptoms of prostatitis receive antibiotic therapy, only in 5-10% of men these symptoms are caused by a bacterial infection and the treatment is accompanied by a cure of the patient).
In most cases, antibacterial therapy leads to positive dynamics of the disease due to the placebo effect or the anti-inflammatory effect of the antibiotic.
A complicating factor in the diagnosis of prostatitis are "picky" microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause CKD, but do not grow well in food environments.
In this case, the situation may be mistaken for non-bacterial prostatitis.Further examination of the patient using bacterial nucleic acid detection technologies showed a more frequent association of prostatitis symptoms with bacterial infection.
Research is currently underway into the possible link between prostatitis and pancreatic cancer.The theory is that anti-inflammatory drugs that reduce the activity of the enzyme cyclooxygenase may lead to a reduction in the incidence of pancreatic cancer.
Etiology
The pancreas, due to its anatomical configuration, can serve as a source of recurrent infections.The peripheral part of the gland consists of a system of communicating ducts with poor drainage, which can lead to stagnation of gland secretion.
With age, the pancreas increases, symptoms of obstruction of the excretory system and reflux of urine in the ducts of the gland develop.
Urine reflux is also possible with the development of a urethral stricture.Backflow of urine, even sterile (bacteria-free), can cause chemical irritation and initiate tubular fibrosis and stone formation in the pancreatic ducts, subsequently leading to intraductal obstruction and stagnation of pancreatic secretions.
When stagnation occurs, the bacterial flora can join the secretion, which leads to the formation of a chronic focus of infection with periodic exacerbations.
Infection of the pancreas can develop as a result of an ascending infection against the background of urethritis or when infected urine enters the ducts of the gland.
The infection in the gland can last for a long time due to the poor accumulation of antibacterial drugs in its tissues.There are no active mechanisms for transferring antibacterial drugs into pancreatic cells;the concentration of the drug in the cell depends on its passive diffusion across the membrane.
The most common causes of CKD:
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Proteus species
- Staphylococcus species
- Enterococcus species
- Trichomonas species
- Candida species
- Chlamydia trachomatis
- Ureaplasma urealyticum
- Mycoplasma hominis
Another factor that reduces the effect of antibacterial drugs is the acidity of the prostatic secretion (pH = 6.4), which is significantly lower than the plasma acidity (plasma pH = 7.4) and reduces the diffusion of antibiotics with high acidity in the prostatic secretion.
Escherichia coli (E. coli) infection in CKD occurs in 8 out of 10 patients.Other pathogens are much less common.The role of gram-positive flora (Staphylococcus epidermidis and S. saprophyticus) in the development of CKD is controversial.
These microorganisms usually inhabit the anterior urethra and can "contaminate" the material when it is obtained, leading to false conclusions.Therefore, treatment is prescribed to patients based on the second bacterial culture of the material.
Transmission of infection
In most cases, it is not possible to determine the exact source of infection of the pancreas.Ascending urethral infection is a known source because of the frequent association of prostatitis with gonococcal flora in the urethra (gonococcal urethritis).
Among the most common routes of transmission of the infection are:
- An ascending infection from the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic ducts.
- Migration of bacteria from the rectum or their lymphogenic spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients suffer from prostatitis-related symptoms.
Approximately 5 out of 10 patients will develop symptoms similar to those of pancreatitis during their lifetime.Less than 5-10% of men with symptoms of pancreatic inflammation have bacterial prostatitis.
Symptoms of prostatitis develop most often in the 36-50 age group.Prostatitis is the most common urological problem in patients under 50 years of age and the 3rd most common urological pathology in patients over 50 years of age.The frequency of symptoms of prostatitis is 10% in the age group of men from 20 to 74 years.
Prognosis for CKD
The cure rate when treated with a drug from the sulfonamide group is 30-40%, with fluoroquinolones - 60-90%.
morbidity
Inflammation of the pancreas significantly affects the patient's quality of life (the quality of life is reduced to the level of a patient with coronary heart disease or a patient with Crohn's disease).
Studies have shown that prostatitis leads to changes in mental status comparable to the level of mental changes in patients with diabetes mellitus and chronic heart failure.
Retrospective studies have shown an association between the severity of CKD and the incidence of sexual dysfunction in men (erectile dysfunction, duration of intercourse, premature ejaculation).The exact nature of the association of these diseases (psychogenic or somatic cause) is still not clear.
In one study, scientists compared the course of CKD during infection with C. trachomatis and during infection with the most common uropathogenic flora.
In the group infected with C. trachomatis, a lower patient quality of life was observed;patients more often complain of premature ejaculation during sex.
In a study of 110 infertile men with CKD, 78 had a good result when they were prescribed a drug from the fluoroquinolone group: sperm motility significantly increased, the number of leukocytes in the seminal fluid decreased, the viscosity of the seminal fluid decreased, the content of free radicals, IL-6 and TNF-alpha decreased.
In a control group of 37 healthy men, none of the listed parameters changed when a fluoroquinolone drug was prescribed.In the group of patients with a poor response to antibiotics, these indicators worsened.
Clinical picture
Patients with CKD often come to the doctor with a list of subjective complaints.Only a small part of the complaints described during the interview with the patient are specific to inflammation of the pancreas and allow the doctor to narrow the search for pathology.
Patients complain of pain that can be observed in the perineum, head of the penis, testicles, rectum, lower abdomen and back.
Periods of exacerbation of infection in the pancreas alternate with periods of asymptomatic disease.
Patients may develop symptoms of urinary tract obstruction or irritation: increased frequency of urination, urination in small portions, decreased stream pressure, nocturia (frequent urination at night), urinary incontinence.
Often, patients with CKD complain of urethral discharge (can be colorless or milky), pain during ejaculation, blood in the ejaculate and impaired erectile function of the penis.
When CKD is suspected, the urologist conducts a differential diagnosis with another common pathology from the list below:
- Acute prostatitis.Accompanied by a more pronounced clinical picture, severe intoxication and severe pancreatic symptoms.With untimely treatment or with an incorrect regimen of antibacterial therapy, a chronic infection of the pancreas can develop and be complicated by an abscess of the gland.
- Stones in the prostate.
- Urinary tract obstruction as a result of benign pancreatic hyperplasia, urethral stricture, bladder neck dysfunction.Accompanied by symptoms of slow flow.They are not accompanied by intoxication, an increase in bacteria in the pancreatic secretion or the 3rd portion of urine.
- Pelvic floor tension myalgia.
- cystitis.Bladder inflammation is accompanied by an increased urge to urinate, the patient urinates in small portions, intoxication and pain in the lower abdomen.
- Pancreatic abscess.Pancreatic abscess is a rare complication of acute prostatitis.Accompanied by severe intoxication and severe pain in the perineum.In some cases, the pancreatic abscess can be palpated through the rectum (defined as the area of softening of the pancreatic tissue), by transrectal ultrasound, computed tomography of the pelvic organs.
- Urethritis.Urethritis is accompanied by mild intoxication, pain at the beginning of urination and discharge from the urethra.A scraping from the surface of the urethra, followed by microscopy and nucleic acid analysis, is used in the diagnosis of urethritis.
- Tuberculous prostatitis.
Diagnosis
Accurate diagnosis of CKD requires microscopy of pancreatic secretions, bacterial culture of urine sample after glandular massage, and bacterial culture of semen.
The spectrum of flora in CKD is similar to the causative agents of acute inflammation of the pancreas.Most cases of CKD are associated with a single pathogen, but the combination of several bacteria as the source of prostatitis is not uncommon.
When examining urine, it is important to compare the content/concentration of bacteria in three portions (CKD is characterized by a higher concentration of microbes in the 3rd portion, at the end of urination, compared to urine at the beginning and in the middle of urination).
The detection of more than 10 leukocytes in the field of view during microscopy of the material indicates the presence of a pronounced inflammatory syndrome.
Microscopic examination
Most often, CKD is diagnosed on the basis of microscopic examination of pancreatic secretions and urine after transrectal massage of the pancreas.If the patient has symptoms of an acute urogenital infection or fever during the examination, the doctor should refrain from performing a transrectal examination and massage of the prostate.
In this situation, the patient is likely to have acute prostatitis, and the possibility of developing sepsis increases due to prostate massage.
CKD is characterized by an increased content of leukocytes in the biomaterial on microscopic examination and positive results of the bacterial culture of the biomaterial.
Bacterial culture of prostate secretion
Conducting this test facilitates the diagnosis of CKD.A part of the urine after a transrectal massage of the pancreas is used for the study.
The resulting material is used for bacterial culture to determine the resistance of bacteria to antibiotics.
Prostate massage is performed until a white discharge is obtained from the urethra;the entire procedure may take about one minute.Before conducting the research, it is necessary to inform the patient about the methodology of the research and its goals.
Sometimes, as a result of pancreatic massage, urine mixed with white excrement is released from the urethra;in this case, the resulting liquid is subjected to bacterial culture.In the presence of infection in the pancreas, the acidity of the secretion shifts from pH 6.5 to pH 8.0.
Prostate-specific antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with proven CKD experience a significant rise in PSA.
Elevated PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on an increase in PSA, it is impossible to distinguish between pancreatic cancer and inflammation in it;additional investigation (TRUS, pancreatic biopsy) is required.
In patients with CKD and elevated PSA levels, re-examination of this marker is necessary 6-8 weeks after the end of prostatitis treatment.
The level of the marker should return to normal values when the prostatitis is cured.If elevated PSA test results persist for a long time, a pancreatic biopsy is required to rule out other possible pathologies.
A sample of three glasses
This method has historically been the standard for diagnosing CKD.The technique was originally described in 1968. Currently, doctors are increasingly resorting to this study.
Instead of testing three glasses, doctors conduct a study of cultures of microorganisms in the urine before and after transrectal massage of the pancreas.
This method is of greatest value when the urine in the bladder is sterile.In the presence of microorganisms in the bladder, the patient is prescribed an antimicrobial agent from the group of nitrofurans, which leads to sterility of the urine in the bladder and allows for examination.
Test technique:
- The first portion of urine is 5-10 ml, collected in a separate cup and contains microorganisms from the urethra.
- After taking the first portion, the patient urinates in the toilet;after the release of 150-200 ml of urine, another 10-15 ml of urine is collected (the second portion in a separate glass).The second part contains microorganisms from the bladder.
- The third portion is a mixture of pancreatic secretion and urine obtained after pancreatic massage and is about 5-10 ml, collected in a separate cup.The third part is sent for bacterial culture.
Transrectal ultrasound
This study is informative only in the presence of a pancreatic abscess.Pancreatic abscess is an unusual pathology accompanied by severe intoxication.
If TRUS is not possible and a pancreatic abscess is suspected, computed tomography may be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent CKD exacerbations, pancreatic stones can be a significant precipitating factor for recurrent attacks.
The use of TRUS does not make it possible to establish a diagnosis of CKD, although the presence of hypoechoic inclusions and calcifications in the stroma of the gland may indicate the presence of infection and chronic inflammation and prompt the physician to further examine the patient.
Biopsy of the pancreas
The most informative study is a biopsy of the pancreas.However, this procedure is rarely performed in CKD, as microscopy and bacterial culture of the biomaterial are sufficient for an accurate diagnosis.
Examining the obtained biopsy under a microscope allows identifying focal infiltration of the pancreatic stroma with inflammatory cells.
The biopsy can be used for bacterial culture and determining the sensitivity of the flora to certain antibacterial drugs.
Contraindications for performing a biopsy are severe intoxication of the patient, high fever, symptoms of acute inflammation of the pancreas (performing a biopsy under these conditions can lead to the spread of bacteria in the patient's body and the development of bacterial sepsis).
Prostatitis type IV is diagnosed only on the basis of a biopsy of the pancreas.This category of prostatitis is characterized by asymptomatic inflammation in the stroma of the gland and an increase in PSA.A persistently elevated PSA level may require a pancreatic biopsy to rule out pancreatic cancer.
Retrograde urethrography
Retrograde urethrography is used in the differential diagnosis of CKD and urethral stricture.To conduct this examination, a radiopaque contrast agent is injected into the urethra and an X-ray is taken.If there is a urethral stricture, the image shows narrowing of the contrast band in a limited area.
Chronic nonbacterial prostatitis (CNP)
CNP is a disease accompanied by chronic inflammation of the pancreas, symptoms of prostatitis and negative results of bacterial culture of biomaterial on nutrient media.
CNP belongs to type III prostatitis according to the modern classification and is divided into IIIA (inflammatory chronic pelvic pain syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs have been used in the treatment of CNP;the course of treatment is 30-40 days.According to modern studies, it is preferable to use a short (2 weeks) antibacterial therapy in group IIIA patients, while in group IIIB urologists try to avoid the use of antibiotics.
Epidemiology
CNP can develop in men of any age group.
- Most often, CNP develops at the age of 35-45 years.
- CNP is equally common among different ethnic groups.
Risk factors for CNP:
- Damage (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation in the tissue of the gland.
- Previous episodes of inflammation of the pancreas.
- stress.
- General hypothermia, hypothermia of the perineum during prolonged sitting on cold surfaces.
- Disturbances in the psycho-emotional state.
The exact cause of CNP is not yet known.Scientists suggest that the possible etiology of CNP lies in a combination of several factors: the psycho-emotional characteristics of the patient, immune disorders, hormonal and neurological disorders.The combination of these factors leads to the development of symptoms of prostatitis.
The clinical picture of CNP is very diverse and may not differ from the clinical picture of CKD.
Diagnosis
The diagnosis of CNP is made on the basis of symptoms, a physical examination of the patient by a urologist, a study of the medical history and additional laboratory tests.
The following are used in the diagnosis of CNP:
- Digital rectal examination: the posterior surface of the pancreas is examined transrectally.On palpation, the pancreas can be markedly painful, firm and slightly enlarged.
- The general urine test shows an increase in leukocytes.
- Bacterial culture of urine and pancreatic secretion does not lead to the development of microorganisms.
- Bacterial inoculation of sperm does not allow the growth of microorganisms.
Disease prevention
- Increasing the volume of fruits and vegetables in the daily diet (they contain a large amount of antioxidants and help reduce inflammation in the internal organs).
- Reduction of wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- Increased consumption of polyunsaturated fatty acids.
- Increase vegetable protein in the diet and decrease animal protein.
- Drinking green tea.Green tea contains catechins, which are good antioxidants.Catechins have pronounced anti-inflammatory activity.
- Drink your daily intake of water.Adequate hydration of the body helps prevent urinary tract infections and, as a result, prostatitis.
- Maintaining physical fitness and normal body weight.
- Avoiding stressful situations.
- Maintain personal hygiene.
- Use of barrier methods of contraception.
- Avoiding injuries to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation in it.
- Drink cranberry juice, juice, cranberry decoction.These juices and decoctions have a pronounced uroseptic effect and can prevent the development of inflammation in the organs of the genitourinary system.
- Limiting or refusing the use of alcohol.
- Avoiding the use of spices.Spices can make prostatitis symptoms worse.
- Reduce your caffeine consumption.Caffeine irritates the pancreas and worsens prostatitis.