Chronic prostatitis is a chronic inflammation in the prostate gland (hereafter 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, 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 third part of urine, seminal fluid)
- III B - non-inflammatory chronic pelvic pain syndrome (no leukocytes in urine, seminal fluid)
- Type IV - asymptomatic prostatitis (inflammatory process 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 a bacterial infection of the pancreas.Diagnosis is based on the study of secretions from the pancreas, clinical and bacterial culture results.
As a rule, even without the presence of a bacterial component of prostatitis, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is initially carried out.
With the fourth type of prostatitis, there are no patient complaints.This type of prostatitis is diagnosed accidentally, during a prostate biopsy to exclude other possible pathologies (prostate cancer).
The fourth type of prostatitis is established based on biopsy, examination of surgical specimens, or analysis of semen taken not because of patient complaints about specific prostatitis symptoms.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated PSA (prostate-specific antigen) levels.With a prolonged rise in PSA during antibacterial therapy, patients are advised 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 inflammation of the organs of the urinary system comes to the fore (most often, exacerbation of inflammation is caused by the same microorganisms).
CKD is often confused with non-bacterial prostatitis, chronic pelvic pain syndrome (CPPS) and prostatodynia.
By definition, CKD is associated with the overgrowth of pathogenic microorganisms in cultures of prostate secretions, semen, or a portion of urine obtained after prostate massage.As a rule, microscopy of pancreatic secretions reveals 10 or more leukocytes and macrophages in one field of view.
Prostatitis symptom complex is very common.About half of men have a clinical picture during their lifetime similar to prostatitis.
This set of symptoms accounts for 8% of all visits to urologists.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 associated with 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 bacterial infection and treatment is accompanied by an antidote for 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 antibiotics.
A complicating factor in the diagnosis of prostatitis are "full" microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause CKD, but do not grow well in nutrient media.
In this case, the condition may be mistakenly interpreted as non-bacterial prostatitis.Further examination of patients using bacterial nucleic acid detection technology showed a more frequent association of prostatitis symptoms with bacterial infection.
Research is being conducted into the possible relationship 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, because of its anatomical configuration, 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 cause stagnation of glandular secretions.
With age, the pancreas increases, symptoms of obstruction of the urinary system develop, and urine reflux into the duct of the gland.
Urine reflux may also occur with the development of urethral stricture.Urine reflux, even if it is sterile (does not contain bacteria), can cause chemical irritation and initiate tubular fibrosis and stone formation in the pancreatic duct, which in turn leads to intraductal obstruction and stagnation of pancreatic secretions.
When stagnation occurs, bacterial flora can combine with secretions, which leads to the formation of chronic foci of infection with periodic exacerbations.
Pancreatic infection can develop as a result of ascending infection against the background of urethritis or when infected urine enters the duct of the gland.
Infections in the glands can last for a long time due to the accumulation of weak antibacterial drugs in their tissues.There is no active mechanism for the transfer of antibacterial drugs in pancreatic cells;the concentration of the drug in the cell depends on its passive diffusion through the membrane.
The most common causative agents 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 prostate secretions (pH = 6.4), which is much lower than plasma acidity (plasma pH = 7.4) and reduces the diffusion of antibiotics with high acidity into prostate secretions.
Escherichia coli (E. coli) infection in CKD 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 it is obtained, leading to incorrect conclusions.Therefore, treatment is prescribed to the patient based on the bacterial culture of the two substances.
Transmission of infection
In most cases, it is not possible to determine the exact source of pancreatic infection.Infection of the ascending urethra is a known source due to the frequent association of prostatitis with gonococcal flora in the urethra (gonococcal urethritis).
Among the most common routes of transmission of infection are:
- Infection ascending from the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic duct.
- Bacterial migration from the rectum or its lymphogenous spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients experience symptoms related to prostatitis.
About 5 out of 10 patients will experience symptoms similar to inflammation of the pancreas during their lifetime.Less than 5-10% of men with symptoms of pancreatic inflammation have bacterial prostatitis.
Symptoms of prostatitis most often develop in the age group of 36-50 years.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 prostatitis symptoms is 10% in the male age group from 20 to 74 years.
Prognosis for CKD
The cure rate when treated with drugs from the sulfonamide group is 30-40%, with fluoroquinolones - 60-90%.
Morbidity
Pancreatic inflammation has a significant impact on the patient's quality of life (the quality of life is reduced to the level of patients with coronary heart disease or patients with Crohn's disease).
Studies have shown that prostatitis leads to mental status changes comparable to the level of mental changes in patients with diabetes mellitus and chronic heart failure.
A retrospective study showed a relationship between the severity of CKD and the occurrence of sexual dysfunction in men (erectile dysfunction, duration of intercourse, premature ejaculation).The exact nature of this disease association (psychogenic or somatic cause) is still unclear.
In one study, scientists compared the course of CKD during C. trachomatis infection and during infection with the most common uropathogenic flora.
In the group infected with C. trachomatis, a lower quality of life of patients was noted;patients more often complain of early ejaculation during sex.
In a study of 110 infertile men with CKD, 78 had good results when prescribed drugs from the fluoroquinolone group: sperm motility increased significantly, 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 indicators changed when fluoroquinolone drugs were prescribed.In the group of patients with a poor response to antibiotics, this indicator worsened.
Clinical picture
CKD patients 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 pancreatic inflammation and allow the doctor to narrow down the pathologic search.
The patient complains of pain, which 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 experience symptoms of urinary tract obstruction or irritation: increased frequency of urination, urination in small portions, decreased flow pressure, nocturia (increased urination at night), urinary incontinence.
Often, CKD patients complain of discharge from the urethra (can be colorless or milky), pain during ejaculation, blood in ejaculation, and impaired erectile function of the penis.
If CKD is suspected, the urologist conducts a differential diagnosis with other common pathologies from the list below:
- Acute prostatitis.Accompanied by a more pronounced clinical picture, severe intoxication, and severe pancreatic symptoms.If not treated in time or with the wrong antibacterial therapy regimen, it can develop into a chronic infection of the pancreas and be complicated by glandular abscess.
- Prostate stones.
- Urinary tract obstruction due to benign pancreatic hyperplasia, urethral stricture, bladder neck dysfunction.Accompanied by slow flow symptoms.They are not accompanied by hangovers, increased bacteria in pancreatic secretions, or the third part of urine.
- Pelvic floor tension myalgia.
- Cystitis.Bladder inflammation is accompanied by an increased urge to urinate, the patient urinates in small portions, hangovers, and pain in the lower abdomen.
- Pancreatic abscess.Pancreatic abscess is a rare complication of acute prostatitis.Accompanied by severe hangover and severe pain in the perineum.In some cases, a pancreatic abscess can be palpated through the rectum (defined as an area of pancreatic tissue softening), through transrectal ultrasound, computed tomography of the pelvic organs.
- Urethritis.Urethritis is accompanied by mild hangover, pain at the beginning of urination, and discharge from the urethra.In the diagnosis of urethritis, scraping from the surface of the urethra is used, followed by microscopic and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
For an accurate diagnosis of CKD, it is necessary to carry out microscopy of pancreatic secretions, bacterial culture of urine samples after glandular massage, and bacterial culture of sperm.
The spectrum of flora in CKD is similar to the causative agent of acute pancreatic inflammation.Most cases of CKD are associated with a single pathogen, but the combination of several bacteria as the source of prostatitis is not unusual.
When examining the urine, it is important to compare the content/concentration of bacteria in the three parts (CKD is characterized by a higher concentration of microbes in the 3rd part, at the end of urination, compared to urine at the beginning and middle of urination).
The detection of more than 10 leukocytes in the field of view during material microscopy indicates the presence of a clear inflammatory syndrome.
Microscopic examination
Often, CKD is established based on microscopy of pancreatic secretions and urine after pancreatic transrectal massage.If the patient has symptoms of an acute urogenital infection or fever at the time of the examination, the doctor should refrain from performing a transrectal examination and prostate massage.
In this situation, there is a possibility that the patient has acute prostatitis and the possibility of getting sepsis increases due to prostate massage.
CKD is characterized by increased leukocyte content in the biomaterial under the microscope, and positive results of bacterial culture of the biomaterial.
Bacterial culture of prostate discharge
Conducting this study facilitates the diagnosis of CKD.For the study, part of the urine was used after the transrectal procedure of the pancreas.
The resulting material is used for bacterial culture to determine bacterial resistance to antibiotics.
Prostate massage is carried out until white discharge is obtained from the urethra;the entire procedure may take about a minute.Before conducting the study, it is necessary to inform the patient about the research methodology and its goals.
Sometimes, as a result of pancreatic massage, urine mixed with white stool is removed 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 shifts from pH 6.5 to pH 8.0.
Prostate-specific antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with CKD are shown to have a significant increase in PSA.
Elevated PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on the increase in PSA, it is impossible to distinguish between pancreatic cancer and inflammation in it;additional examination is required (TRUS, pancreatic biopsy).
In patients with CKD and high PSA levels, it is necessary to retest this marker 6-8 weeks after the end of prostatitis therapy.
Marker levels should return to normal values when prostatitis is cured.If high PSA test results persist for a long time, a pancreatic biopsy is needed to rule out other possible pathologies.
Sample three glasses
This method has historically been the standard for diagnosing CKD.This technique was originally described in 1968. Currently, doctors are increasingly using this study.
Instead of testing three glasses, the doctor conducted a culture study of microorganisms in the urine before and after the transrectal procedure of the pancreas.
This method is of greatest value when the urine in the bladder is sterile.If microorganisms are present in the bladder, the patient is prescribed an antimicrobial agent from the nitrofuran group, which leads to the sterility of the urine in the bladder and makes it possible for research.
Test technique:
- The first portion of urine is 5-10 ml, collected in a separate glass and contains microorganisms from the urethra.
- After collecting the first portion, the patient urinates into the toilet;after 150-200 ml of urine has passed, another 10-15 ml of urine is collected (the second part in a separate glass).The second part contains the microorganisms of the bladder.
- The third part is a mixture of pancreatic secretions and urine, obtained after pancreatic massage and about 5-10 ml, collected in a separate glass.The third part is sent for bacterial culture.
Transrectal ultrasonography
This study is informative only in the presence of pancreatic abscess.Pancreatic abscess is an unusual pathology that is accompanied by severe intoxication.
If TRUS is not possible and pancreatic abscess is suspected, computed tomography can be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent exacerbations of CKD, pancreatic stones may be an important trigger 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 doctor to examine additional patients.
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 biopsy specimens obtained under a microscope makes it possible to identify focal infiltration of the pancreatic stroma with inflammatory cells.
Biopsies can be used for bacterial culture and determination of flora sensitivity to certain antibacterial drugs.
Contraindications for performing a biopsy are the patient's severe intoxication, high fever, symptoms of acute inflammation in the pancreas (performing a biopsy under these conditions can lead to the spread of bacteria throughout the patient's body and the development of bacterial sepsis).
Type IV prostatitis is established 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.Persistently elevated PSA levels 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 carry out this study, a radiopaque contrast agent is injected into the urethra and X-rays are taken.If there is a stricture of the urethra, 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 biomaterial bacterial cultures on nutrient media.
CNP belongs to prostatitis type III according to the modern classification and is divided into IIIA (chronic pelvic pain inflammatory syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs are used in the treatment of CNP;the course of treatment is 30-40 days.According to modern studies, it is better to use a short antibacterial therapy (2 weeks) among group IIIA patients, while among 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 cause the development of inflammation in the gland tissue.
- Previous episode of pancreatic inflammation.
- Pressure.
- General hypothermia, perineal hypothermia during prolonged sitting on a cold surface.
- Disorders in the psycho-emotional state.
The exact cause of CNP is still unknown.Scientists suggest that the possible etiology of CNP lies in a combination of several factors: psycho-emotional characteristics of the patient, immune disorders, hormonal and nervous disorders.The combination of these factors leads to the development of prostatitis symptoms.
The clinical picture of CNP is very diverse and may not differ from the clinical picture of CKD.
Diagnostics
The diagnosis of CNP is established based on symptoms, physical examination of the patient by a urologist, medical history, and additional laboratory tests.
In the diagnosis of CNP the following are used:
- Digital rectal examination: the posterior surface of the pancreas is examined transrectally.On palpation, the pancreas may be painful, firm, and slightly enlarged.
- A general urine test reveals an increase in leukocytes.
- Bacterial cultures of urine and pancreatic secretions did not result in the growth of microorganisms.
- Bacterial inoculation of sperm does not allow the growth of microorganisms.
Disease prevention
- Increase the amount of fruits and vegetables in the daily diet (contain a large amount of antioxidants and help reduce inflammation in internal organs).
- Reduce wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- Increase the consumption of unsaturated fatty acids.
- Increase plant protein in the diet and reduce animal protein.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechins have expressed anti-inflammatory activity.
- Drink your daily water intake.Adequate body hydration helps prevent urinary tract infections and, as a result, prostatitis.
- Maintain physical fitness and normal weight.
- Avoid stressful situations.
- Maintain personal hygiene.
- Use of barrier contraceptive methods.
- Avoid injury to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation in it.
- 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 to drink alcohol.
- Avoid the use of spices.Spices can worsen prostatitis symptoms.
- Reduce caffeine consumption.Caffeine leads to pancreatic irritation and worsens prostatitis.