Prostatitis (Prostatitis) is an inflammation of the prostate gland (an organ of the male sex and genital system) and a change in physiological functions as a result of this process.
Spread
According to various sources, prostatitis occurs in 35-40%, and according to some authors, in 70% of men between the ages of 18-50. urology is a leader among pathologists.
Classification
There are many classifications of prostatitis, so there is a very specific terminology. The most common classification of prostatitis proposed by the US National Institutes of Health (NIH) in 1995 is:
| category | Description |
| Category I | Acute bacterial prostatitis |
| Category II | Chronic bacterial prostatitis |
| Category III | Chronic abacterial prostatitis |
| Category IIIA | Inflammatory chronic pelvic pain syndrome |
| Category IIIB | Non-inflammatory chronic pelvic pain syndrome (prostatodinia) |
| Category IV | Asymptomatic inflammatory prostatitis |
This classification of prostatitis is based on clinical signs, the presence of leukocytes and microorganisms in the prostate, ejaculation and urinary excretion.
Category I
Acute bacterial prostatitisWith all the accompanying symptoms is expressed by acute infectious inflammation of the prostate gland:
- increased number of leukocytes in the urine;
- presence of bacteria in the urine;
- general symptoms of infection (fever, signs of intoxication).
Category II
Chronic bacterial prostatitis- is accompanied by an increase in the number of leukocytes and bacteria in the prostate, discharge and urinary secretions obtained after appropriate symptoms and prostate massage.
Category III
Chronic pelvic pain syndrome (CPPS)- The leading clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the prostate, ejaculation and urinary excretion after prostate massage. The criterion for the separation of I III A and III B is the presence of an increase in the number of leukocytes.
Category III A
Chronic pelvic pain inflammatory syndrome- characterized by the presence of symptoms of pain syndrome and prostatitis, an increase in the number of leukocytes in the prostate gland, discharge and urinary secretions, no pathogenic microorganisms are detected in these samples by standard methods after prostate massage.
Category III B
Non-inflammatory chronic pelvic pain syndrome- is characterized by pain syndrome and symptoms of prostatitis, in the absence of an increase in the number of leukocytes and pathogenic microorganisms in the prostate secretion, the discharge and urine obtained after prostate massage is not detected by standard methods.
Category IV
Asymptomatic inflammatory prostatitis- Absence of symptoms characteristic of prostatitis, the disease is detected accidentally during histological examination of prostate tissue samples taken in connection with the diagnosis of other causes (eg, prostate biopsy due to an increase in prostate-specific levels) antigen - PSA).
Diagnosis of prostatitis
The symptoms of prostatitis are extremely different, but can be grouped into several groups.
Pain syndrome
Inadequate blood supply due to inflammation or spasm of the vessels that feed the prostate results in oxygen starvation of the glandular tissues, resulting in products that affect the lateral nerve endings of pathological oxidation. 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 most common:
- Anxiety or pain in the perineum - mainly seen after alcohol intake in the form of physical exertion, communication, transient seizures;
- Hot potato sensation in rectum;
- Pain in the testicles (anxiety) - patients describe it as "pain", "twisting", which is also associated with various stimuli;
- Anxiety, cramps, and pain in the urethra are mainly associated with an acidic pH of prostate secretion. The acidic secretion of the prostate irritates the mucous urethra, so painful sensations, more often in the form of "burning" after urination or sexual intercourse, occur when part of the secretion is squeezed into the lumen of the urethra. glands and pelvic muscles.
Urinary incontinence syndrome
It is associated with close innervation of the prostate and bladder, as well as the involvement of prostate muscles in urinary excretion. Dysuria may be accompanied by the following manifestations:
- Frequent urination - a sharp and sudden urge (unbearable) and frequent urination in very small portions (up to 3 times an hour);
- Feeling of incomplete emptying of the bladder - a feeling of staying in the bladder after urination;
- Poor or intermittent urination - which can include a "last drop" symptom - despite all the patient's efforts, a drop comes out of the urethra after urination.
Ejaculation and orgasm anxiety
Prostatitis is associated with damage to the seminal tubercle (colliculitis), the surface of which contains nerve receptors that send signals to the brain structures where the sensation of orgasm occurs. Prostatitis does not directly cause erectile dysfunction (filling the penis with blood due to sexual arousal).
The main violations:
- Premature ejaculation or, conversely, excessive prolonged contact - occurs as a result of scarring due to inflammation of the seminal tubercle or inflammatory process;
- Deleted orgasm - also associated with inflammation of the seminal tubercle;
- Pain during ejaculation is associated with an inflammatory process in which sperm are released in the secretory ducts of the prostate.
Productivity disorder
When the properties of prostate secretion change due to inflammation, the following changes are observed in the sperm, which reduces a man's ability to fertilize (fertility):
- A decrease in the pH of the sperm to the acidic side - with inflammation of the prostate, the acidic products of pathological oxidation begin to accumulate in the secretion. An acidic environment is extremely destructive to spermatozoa, causing them to become immobile and even die;
- Sperm agglutination - the adhesion of sperm mainly by the heads - is associated with changes in the physical and chemical properties of the secretion;
- Asthenospermia - a decrease in sperm motility - is closely associated with the transition of the pH to the acidic side and disruption of the production of lecithin cells by the prostate, which provides the vital activity of sperm.
Urethroprostatitis
In some cases, prostatitis is combined with chronic urethritis, which manifests itself with a small amount of mucopurulent discharge from the urethra (mainly after prolonged urinary retention).
Prostatitis and sexual disorders
"Does prostatitis cause impotence? " Has been the subject of professional debate for decades.
Under the influence of sexual stimuli, in the formations of the cortical-subcortical region of the brain, when the body is fully saturated with androgens, a nerve signal is generated, which is transmitted to the erection center, where the spinal cord is located. the sinusoids in the formation of the cavernous bodies of the penis go to either the relaxing (arteries and sinusoids) or the narrow (veins) smooth muscles. There is no role for the prostate during this period.
Ejaculation and orgasm occur with sufficient stimulation of specific receptor cells located in the seminal vesicles of the prostate gland, where the same receptors are responsible for sending a nerve impulse to the sensory cortex. orgasm occurs.
An inflammatory process in the prostate gland (prostatitis) can damage the seminal tubercle, resulting in both male dysfunction and premature ejaculation and 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 (neuroreceptor impotence) is a typical example of the phenomenon of adverse reactions when the presence of pathological impulses in the organs affected by the inflammatory process, the excitation process radiates to the centers that control sexual function and disrupts. of the latter. Although certain, not leading, in the pathogenesis of neuroreceptor impotence, a slight suppression of the androgenic activity of the testes and their sensitivity to androgens in the centers of the hypothalamus and pituitary gland also play a role.
At the same time, there is an opinion in the Russian Federation that both the overdiagnosis of prostatitis and its role in the development of erectile dysfunction are highly valued.
Diagnostics
The doctor's task is to detect the inflammatory process in the prostate, determine the probable cause of the disease and assess the dysfunction of the prostate gland. In 1990, Stamey wrote that prostatitis was a "clinical ignorance trash can" in terms of the various terms, diagnostic methods, and treatments used. At the same time, a few simple and clinical and laboratory tests allow to make a correct diagnosis, which allows you to start appropriate therapy.
Digital rectal examination of the prostate
In a very informative way. The inflammatory process can be judged by assessing the shape, contours, size, compression and (or) softening of the gland, the presence of foci of pain. The main symptoms of prostatitis: increase or decrease in size, heterogeneity of consistency, compression and softening, tenderness, the presence of pain centers. The fact that 80% of pancreatic cancers are detected by rectal examination speaks for itself. We can say with confidence that this research method will always be used.
Microscopic examination of pancreatic secretion
We must not forget that an increase in the number of leukocytes in the secretion does not always indicate prostatitis, because the methods of obtaining a secretion during massage do not guarantee that it will not enter the urethra and seminal vesicles. At the same time, with obvious signs of prostatitis, the secretion of the prostate may be normal. This is due to focal inflammation, the presence of part of the destroyed or closed secretory ducts.
Study of prostate secretion
Examination of prostate secretion (EPS) allows to determine the presence of an inflammatory process in the prostate gland and its partial functional capacity. It is the main method for monitoring the diagnosis and treatment of chronic prostatitis. The secretion of the prostate can be examined by light microscopy without staining or using special staining methods. In addition, the secretion of the prostate gland can be subjected to bacteriological examination for the detection of infectious substances in it or by polymerase chain reaction. Get it with a secret prostate massage. Secretions from the urethra are collected in a sterile test tube or on a clean glass slide for examination. Sometimes the secretion of the prostate gland does not flow from the urethra. In such cases, it is recommended that the patient stand up immediately. However, if the secretion cannot be obtained, it means that it falls into the bladder rather than into the urethra. In this case, the centrifuge of the lavage fluid released from the bladder after the prostate massage is examined.
- Lipoid granules (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate gland. Gives a hidden milky lookNormally, cannabis is rich in lecithin grains. A decrease in their number, along 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, such as starch;
- The amyloid trunk is a thickened secretion of the gland, oval in shape and has a layered structure similar to a tree trunk. Normally they do not occur, the detection of which indicates the stagnation of secretions in the gland, which may be accompanied by adenomas, chronic inflammatory processes;
- Erythrocytes may be solitary. They enter the secretion as a result of a strong massage of the prostate gland. An increase in their number is observed in inflammatory processes, neoplasms.
- Excessive desquamation of the epithelium is observed at the beginning of inflammatory processes and tumors, while disqualification often occurs with protein and fat degeneration of epithelial cells. Macrophages, stagnation of secretions, can be seen with a long-term current inflammatory process;
- Bettcher crystals are long crystals formed when a mixed secretion of sperm and phosphate salts from the male sex glands (prostate juice mixed with sperm) is cooled and dried. With azospermia and severe oligozoospermia, Bettcher crystals form rapidly and in large quantities;
- Retention syndrome - stagnation syndrome, observed with glandular adenoma. There is an abundance of macrophages, there are multinucleated cells like foreign bodies and amyloid bodies;
- Fern's symptom - a sign of crystallization of the secretion - the form of precipitating crystals of sodium chloride depends on the physicochemical properties of the secretion of the prostate gland. Examination of the symptom is performed by adding 0. 9% sodium chloride solution to the obtained prostate secretion and further examining it after drying under a light microscope. Crystallization of prostate secretion in healthy men of reproductive age is characterized by a typical fern leaf phenomenon (3+). Androgenic deficiency or the presence of prostatitis vary in structure until there are no crystals.
Bacteriological studies of urinary tract and pancreatic secretions
Urethral gland, including PCR diagnostics
Serological diagnosis of agents that cause urinary tract infections (ELISA)
Immunofluorescence reaction (RIF) direct and indirect
Detection of antibodies to known antigens.
Determination of blood serum PSA (prostate specific antigen)
The American Urological Diseases Foundation recommends rectal examination of the prostate gland, accompanied by PSA, for all men over the age of 50 per year and for prostate cancer in male blood relatives. There is still discussion about taking PSA immediately after a digital examination of the prostate gland per rectum. Recent studies have not been able to confirm a significant increase in PSA levels immediately after digital examination. Thus, PSA levels can be determined by obtaining reliable results and after examination of the pancreas.
Sample of four bottles
To diagnose chronic prostatitis, 4 vial tests were proposed based on a comparative bacteriological evaluation of equal parts of urine and its excretion taken before and after prostate massage.
Diagnosis of prostatitis is a tenfold increase in the concentration of microorganisms in the prostate secretion in the urine (1, 2 and 3 of them) and >is determined by an increase in the number of polymorphonuclear leukocytes. 10-16 in the field of view of the light microscope (200 magnification). Or when the number of leukocytes in the counting chamber is more than 300x106 / l. Lecithin bodies, which are the product of normal secretion of the glandular epithelium of the prostate gland, should closely cover the field of view of the microscope (5-10 million per 1 ml). It is less common than amyloid bodies in prostate secretion. In adult men, 1-2 are found in the visual field.
Biochemical blood test
Immunological and hormonal profile (according to indicators).
Ultrasound, TRUS
Ultrasound diagnosis of prostatitis with abdominal and transrectal transducer (TRUS).
Uroflowmetry
Treatment of prostatitis
Comprehensive treatment of patients with chronic prostatitis should include:
- adherence to the general regime, diet, sexual hygiene, as well as the involvement of sexual partners in treatment with an infectious agent;
- selection of effective drugs to suppress the infection;
- increase the general reactivity of the patient's body and immunobiological tolerance of microorganisms to drugs;
- increased secretion in the center of inflammation and activation of local regenerative processes;
- sanitation of foci of infection in present and distant organs;
- improving microcirculation in the prostate gland and pelvic organs;
- determination of strengthening agents, enzymes and vitamins;
- correction of hormonal disorders;
- appointment of antispasmodics;
- prescribing analgesics and anti-inflammatory drugs;
- taking sedatives and diluents;
- regulation of neurotrophic diseases 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 has been widely used in O'Conory's urological practice since 1936. However, after Meares and Stamey described a stage test for the diagnosis of prostatitis in 1968, opinions about the causes of the disease changed, and massage as a therapeutic procedure was removed from the list of measures in many books for the treatment of prostatitis. developed world.
However, since the mid-1990s, many doctors diagnosing and treating prostatitis have begun to note the ineffectiveness of the proposed antibiotic therapy and the use of alpha-blockers in some cases, which has led them to use this forgotten method in practice.
Basically, prostate massage is currently used as a diagnostic procedure for obtaining prostate secretions (expressed prostate secretions-EPS) - microscopic (cultural) examination and massageprostate for pre- and post-test (pre-massage and post-test -PPMT). massage the secretion. Massage is a medical procedure and should be performed by a previously trained professional. Massage is performed after urination and in case of discharge from the urethra after pre-washing with isotonic sodium chloride solution, which is especially important in cases where bacteriological examination of secretions is provided. Because the prostate gland is adjacent to the ampulla of the rectum and is only there for examination, the prostate is massaged through the anus. Massage one, then another lobe of the prostate gland with finger movements along the secretory ducts from the periphery to the central groove, trying not to touch the seminal vesicles. Finish the massage by pressing on the central sulcus area from above. Secretions from the urethra are collected in a sterile test tube or on a clean glass slide for examination. Sometimes the secretion of the prostate gland does not flow from the urethra. In such cases, the patient is advised to get up immediately, however, if the secret is not available, then it has fallen into the bladder, not the urethra. In this case, the centrifuge of the lavage fluid released from the bladder after the prostate massage is examined.
Prostate massage for therapeutic purposes (Repeated 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 to treat prostatitis in Southeast Asia, China and some European countries. Some North American and Canadian urologists also recommend the use of massage in combination with antibiotic therapy to treat some types of prostatitis. In fact, little has been done to evaluate the effectiveness or ineffectiveness of prostate massage. There are several conflicting studies conducted by Egyptian physicians, but in another study by American and Filipino researchers, no difference was found in groups of patients, some of whom were massaged with antibiotic therapy and simply antibiotic therapy. , showed a significant improvement in a group of prostatitis patients receiving massage in combination with antibiotic therapy.
Proponents of the use of massage for therapeutic purposes believe that the main effect of its use is to loosen the prostate ducts - that is. to free them from pus and dead cells. Another effect is an increase in blood flow to the prostate gland, which improves the penetration of antibiotics and activates local protective immune processes.
There is little information in the world literature about 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 embolic stroke (bleeding) of the lungs. There is a study that temporarily increases the level of PSA (prostate-specific antigen) after massage. Massage is contraindicated in acute inflammation of the prostate gland (acute prostatitis), acute urethritis, orchitis, prostate cancer. Massage is not recommended for calcification of the prostate and prostate adenoma. It is recommended to massage the post 2 or 3 times a week.
Physiotherapy procedures
Any physiotherapy procedure (prostate massage, warming, etc. ) is contraindicated for acute prostatitis.
The use of physiotherapeutic procedures in the complex treatment of prostatitis is aimed at both the direct effect of physical substances on the prostate gland to normalize functional and pathological changes, as well as the electrophoretic application of drugs to prostate tissue.
The use of physiotherapeutic methods in the background of drug therapy gives better results than treatment alone. The following methods that affect the prostate gland are widespread and have proven effective:
- shock wave therapy;
- electrostimulation of the pancreas with modulated currents of skin or rectal electrodes;
- thermotherapy in different versions (including high-frequency thermotherapy);
- magnetotherapy;
- microwave microwave therapy;
- laser therapy.
- transrectal ultrasound treatment and phonophoresis;
- microclysters.