Chronic prostatitis is a chronic inflammation of the prostate gland (after which the abbreviation prostate may appear), and the etiology of the inflammatory process may be different in different patients.Therefore, the classification of prostatitis is constantly revised and updated.
According to its classification (NIH), chronic prostatitis includes the second type or chronic bacterial prostatitis (XBP), the third type (chronic non-bacterial prostatitis, CNP), the fourth type, asymptomatic inflammatory prostatitis.
The NIH classification of prostatitis (1999) suggests dividing 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 part of urine, seminal fluid)
- III B - non-inflammatory chronic pelvic pain syndrome (absence of leukocytes in the urine, seminal fluid)
- Type IV - asymptomatic prostatitis (the inflammatory process is determined by histology)
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 bacterial infection of the pancreas.The diagnosis is based on the study of pancreatic discharge, the clinic and the results of bacterial culture.
As a rule, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is initially carried out, even if there is no bacterial component of prostatitis.
There are no patient complaints with the fourth type of prostatitis.This type of prostatitis is accidentally diagnosed during a prostate biopsy to rule out another possible pathology (prostate cancer).
The fourth type of prostatitis is not determined by the patient's complaints about specific symptoms of prostatitis, but on the basis of a biopsy, examination of a surgical specimen or sperm analysis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by an increase in the level of PSA (prostate-specific antigen).Patients with long-term elevated PSA during antibacterial therapy are recommended to undergo periodic pancreatic biopsies.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by bacterial infection of the prostate gland (PG).CKD causes a characteristic clinical picture, in which repeated inflammation of the organs of the urinary system comes to the fore (in most cases, 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 the growth of pathogenic microorganisms in the culture of prostate secretions, semen, or part of the urine obtained after prostate 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.About half of men develop a clinical picture similar to prostatitis during their lifetime.
This set of symptoms accounts for 8% of all visits to the 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 chronic bacterial infection of the gland.Nevertheless, traditionally, antibacterial therapy is prescribed to patients with symptoms of prostatitis (50% of patients with symptoms of prostatitis receive antibiotic therapy, in only 5-10% of men these symptoms are caused by bacterial infection, and treatment is accompanied by patient treatment).
In most cases, antibacterial therapy leads to a positive dynamics of the disease due to the placebo effect or the anti-inflammatory effect of the antibiotic.
A factor that complicates the diagnosis of prostatitis is "fast" microorganisms (chlamydia, mycoplasma, ureaplasma) that can cause CKD, but do not grow well in the food environment.
In this case, the condition can be mistakenly interpreted as non-bacterial prostatitis.Subsequent examination of the patient using bacterial nucleic acid detection technologies shows a more frequent association of prostatitis symptoms with bacterial infection.
A possible link between prostatitis and pancreatic cancer is currently under investigation.The theory is that anti-inflammatory drugs that reduce the activity of the cyclooxygenase enzyme may reduce the incidence of pancreatic cancer.
Etiology
Due to its anatomical configuration, the pancreas can serve as a source of recurrent infections.The peripheral part of the gland consists of a system of communication channels with poor drainage capacity, which can lead to stagnation of the secretion of the gland.
With age, the pancreas enlarges, signs of obstruction of the urinary system develop, and reflux into the ducts of the urinary gland occurs.
Urinary reflux is also possible with the development of urethral stricture.Reflux of urine can cause even sterile (non-bacterial) chemical irritation and lead to tubular fibrosis and stone formation in the pancreatic ducts, which subsequently leads to intraductal obstruction and stasis of pancreatic secretions.
When stagnation occurs, bacterial flora can join the secretion, which leads to the formation of a chronic infection focus with periodic exacerbations.
Infection of the pancreas can develop as a result of an infection that rises against the background of urethritis or when it enters the ducts of the infected urinary gland.
Infection in the gland can last for a long time due to poor accumulation of antibacterial drugs in its tissues.Pancreatic cells do not have active mechanisms for the transfer of antibacterial drugs;the concentration of the drug in the cell depends on its passive diffusion through the membrane.
The most common causes of CKD are:
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Proteus species
- Staphylococcus species
- Enterococcal 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 prostate secretion (pH = 6.4), which is significantly lower than the plasma acidity (plasma pH = 7.4) and reduces the diffusion of highly acidic antibiotics into the prostatic secretion.
In CKD, infection with Escherichia coli (E. coli) occurs in 8 out of 10 patients.Other pathogens are 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 obtained, leading to false results.Therefore, treatment is prescribed to patients based on the second bacterial culture of the material.
Transmission of infection
In most cases, it is impossible to determine the exact source of infection of the pancreas.Increased urethral infection is a known source due to the frequent association of prostatitis with gonococcal flora in the urethra (gonococcal urethritis).
Among the most common ways of spreading the infection:
- Increased infection from the urethra.
- Backflow of urine containing pathogenic microorganisms into the pancreatic ducts.
- Migration of bacteria from the rectum or its lymphogenic spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients suffer from prostatitis-related symptoms.
About 5 out of 10 patients will develop symptoms similar to pancreatitis during their lifetime.Less than 5-10% of men with symptoms of pancreatitis 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 urological pathology in patients over 50 years of age.The frequency of prostatitis symptoms in men aged 20-74 is 10%.
Prognosis for CKD
When treated with a drug from the sulfonamide group, the recovery rate is 30-40%, with fluoroquinolones - 60-90%.
Illness
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 Crohn's disease).
Studies show that prostatitis causes changes in mental status comparable to the level of mental changes in patients with diabetes and chronic heart failure.
Retrospective studies show a relationship between the severity of CKD and the frequency of sexual dysfunction (erectile dysfunction, duration of intercourse, premature ejaculation) in men.The exact nature of the association of these diseases (psychogenic or somatic cause) is still unclear.
In one study, scientists compared the course of CKD during infection with C. trachomatis and during infection with the most common uropathogenic flora.
The quality of life of patients in the group infected with C. trachomatis was noted to be low;patients more often complain of premature ejaculation during intercourse.
In a study of 110 infertile men with CKD, 78 had a good result when a drug from the fluoroquinolone group was prescribed: 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 decreased.
In a control group of 37 healthy men, none of the listed indicators changed when the fluoroquinolone drug was prescribed.These indicators worsened in the group of patients who responded poorly to antibiotics.
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 patient interview are specific to inflammation of the pancreas and allow the doctor to narrow down the search for pathology.
Patients complain of pain in the perineum, head of the genital organ, testicles, rectum, lower abdomen and back.
Periods of exacerbation of infection in the pancreas are replaced by periods of asymptomatic disease.
Patients may develop symptoms of urinary tract obstruction or irritation: increased frequency of urination, passing urine in small portions, decreased flow pressure, nocturia (increased urination at night), urinary incontinence.
Often, patients with CKD complain of discharge from the urethra (can be colorless or milky), pain during ejaculation, blood in ejaculation, erectile dysfunction of the genital organ.
If CKD is suspected, the urologist makes a differential diagnosis with another common pathology from the following list:
- Acute prostatitis.A more pronounced clinical picture is accompanied by severe intoxication and severe pancreatic symptoms.If it is not treated in time or with an incorrect antibacterial therapy regimen, it can become a chronic infection of the pancreas and can be complicated by a gland abscess.
- Prostate stones.
- Obstruction of the urinary tract due to benign hyperplasia of the pancreas, narrowing of the urethra, dysfunction of the bladder neck.Accompanied by symptoms of slow flow.They are not accompanied by intoxication, bacterial growth in pancreatic secretions or 3rd part of urine.
- Pelvic floor tension myalgia.
- Cystitis.Bladder inflammation is accompanied by an increased urge to urinate, the patient urinates in small portions, intoxication, pain in the lower abdomen.
- Pancreatic abscess.Pancreatic abscess is a rare complication of acute prostatitis.It is accompanied by severe intoxication and severe pain in the perineum.In some cases, a pancreatic abscess can be palpated through the rectum (defined as the softening area of the pancreatic tissue), 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.In the diagnosis of urethritis, a scraping from the surface of the urethra is used, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
For an accurate diagnosis of CKD, it is necessary to conduct microscopy of pancreatic secretion, bacterial culture of urine sample after gland massage, and bacterial culture of sperm.
The spectrum of flora in CKD is similar to the causative agents of acute pancreatitis.Most cases of CKD are associated with a single pathogen, but it is not uncommon for several bacteria to combine as the source of prostatitis.
When examining the urine, it is important to compare the composition/concentration of bacteria in the three portions (CKD is characterized by a higher concentration of microbes in portion 3, at the end of the urine than in the beginning and middle of the urine).
During the microscopy of the material, the detection of more than 10 leukocytes in the field of view indicates the presence of a clear inflammatory syndrome.
Microscopic examination
Often, CKD is established on the basis of microscopy of pancreatic secretions and urine after transrectal pancreatic massage.If the patient has symptoms of acute genitourinary infection or fever during the examination, the doctor should avoid transrectal examination and prostate massage.
In this case, the patient is likely to have acute prostatitis, and the possibility of developing sepsis due to prostate massage increases.
CKD is characterized by an increase in the amount of leukocytes in the biomaterial under the microscope and positive results of the bacterial culture of the biomaterial.
Bacterial culture of prostatic discharge
Conducting this study facilitates the diagnosis of CKD.A part of the urine after transrectal massage of the pancreas is used for the study.
The obtained material is used for bacterial culture to determine the resistance of bacteria to antibiotics.
Prostate massage is performed until white discharge is obtained from the urethra;the whole procedure may take about a minute.Before conducting the research, it is necessary to inform the patient about the research methodology and its goals.
Sometimes as a result of massaging the pancreas, urine mixed with white feces is released from the urethra;in this case, the resulting fluid is subjected to bacterial culture.In the presence of infection in the pancreas, the acidity of the secretion changes from pH 6.5 to pH 8.0.
Prostate-specific antigen (PSA)
Routine PSA testing is not recommended for prostatitis.Most patients with proven CKD have a marked increase in PSA.
An increase in PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on an increase in PSA, it is not possible to distinguish between pancreatic cancer and inflammation within it;additional examination is required (TRUS, pancreatic biopsy).
In patients with CKD and elevated PSA levels, this marker should be rechecked 6-8 weeks after the end of prostatitis treatment.
When the prostatitis is cured, the marker level should return to normal values.If high PSA test results persist for a long time, a pancreatic biopsy is necessary to rule out other possible pathologies.
Three examples of glasses
This method has historically been the standard for diagnosing CKD.The technique was first described in 1968.Currently, doctors are increasingly turning to this research.
Instead of trying 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.If there are microorganisms in the bladder, the patient is prescribed an antimicrobial agent from the nitrofuran group, which leads to sterility of the urine in the bladder and allows for research.
Test technique:
- The first part of urine is 5-10 ml, collected in a separate bottle and contains microorganisms from the urethra.
- After collecting the first part, the patient urinates in the toilet;After passing 150-200 ml of urine, another 10-15 ml of urine is collected (the second part is in a separate bottle).The second part contains bladder microorganisms.
- The third part is a mixture of pancreatic secretion and urine, which is obtained after pancreatic massage and is about 5-10 ml, collected in a separate bottle.The third part is sent to bacterial culture.
Transrectal ultrasound
This study is only informative if there is 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 exacerbations of CKD, pancreatic stones can be a significant trigger for recurrent attacks.
The use of TRUS does not make it possible to make 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 may prompt the doctor to further examine the patient.
Pancreatic biopsy
The most informative study is a pancreatic biopsy.However, this procedure is rarely performed for CKD, as microscopy and bacterial culture of the biomaterial are sufficient for an accurate diagnosis.
Examination of the obtained biopsy sample under a microscope allows to determine the focal infiltration of the stroma of the pancreas with inflammatory cells.
A biopsy can be used to determine the bacterial culture and sensitivity of the flora to certain antibacterial drugs.
Contraindications to conducting a biopsy are severe intoxication of the patient, high fever, signs of acute inflammation in the pancreas (conducting a biopsy under these conditions can cause the spread of bacteria throughout the patient's body and the development of bacterial sepsis).
Type IV prostatitis is diagnosed only on the basis of pancreatic biopsy.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 perform this study, a radiopaque contrast agent is injected into the urethra and an X-ray is taken.If there is a stricture of the urethra, the image shows a narrowing of the contrast band in a limited area.
Chronic non-bacterial prostatitis (CNP)
CNP is a disease accompanied by chronic inflammation in the pancreas, symptoms of prostatitis and negative results of bacterial culture of biomaterial in food medium.
According to the modern classification, CNP refers to type III prostatitis and is divided into IIIA (chronic pelvic inflammatory syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs are used to treat CNP;the course of treatment is 30-40 days.According to modern studies, among group IIIA patients, it is more appropriate to use a short (2 weeks) antibacterial therapy, while in group IIIB, urologists try to avoid using antibiotics.
Epidemiology
CNP can develop in men of any age group.
- Most often, CNP develops at the age of 35-45.
- 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 gland tissue.
- 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 has yet to be determined.Scientists suggest that the possible etiology of CNP is a combination of several factors: 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.
Diagnostics
The diagnosis of CNP is based on symptoms, physical examination of the patient by a urologist, study of medical history and additional laboratory tests.
The following are used in the diagnosis of CNP:
- Digital rectal examination: the back surface of the pancreas is examined transrectally.During palpation, the pancreas may be noticeably painful, firm, and slightly enlarged.
- A general urine test shows an increase in leukocytes.
- Bacterial culture of urine and pancreatic secretions does not result in the growth of microorganisms.
- The bacterial seed of the sperm does not allow the growth of microorganisms.
Disease prevention
- Increasing the volume of fruits and vegetables in the daily diet (they contain a lot of antioxidants and help reduce inflammation in internal organs).
- Reducing wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- Increased consumption of polyunsaturated fatty acids.
- An increase in plant protein and a decrease in animal protein in the diet.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechins have anti-inflammatory activity.
- Drink your daily water intake.Sufficient hydration of the body prevents urinary tract infections and eventually prostatitis.
- Maintaining physical fitness and normal body weight.
- Avoid stressful situations.
- Observe personal hygiene.
- Use of barrier contraceptive methods.
- To prevent damage to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation there.
- Drink cranberry juice, juice, lingonberry decoction.These juices and decoctions have a clear uroseptic effect and can prevent the development of inflammation in the organs of the genitourinary system.
- Limit or refuse alcohol intake.
- Avoiding the use of spices.Spices can aggravate the symptoms of prostatitis.
- Reduce caffeine consumption.Caffeine irritates the pancreas and worsens prostatitis.