Prostatitis (prostatitis) is an inflammation of the prostate (organs of the male reproductive and reproductive system) and changes in its 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 aged 18 to 50 years. The prostate, given the prevalence of the disease and the complex of problems that arise from it, occupies a leading place among urological pathology.
Classification
There are many classifications of prostatitis, hence the very unusual terminology. The most common classification of prostatitis, proposed by the US National Institutes of Health (NIH) in 1995:
| Category | Description |
| Category I | Acute bacterial prostatitis |
| Category II | Chronic bacterial prostatitis |
| Category III | Chronic abacterial prostatitis |
| Category IIIA | Inflammatory syndrome of chronic pelvic pain |
| Category IIIB | Non-inflammatory syndrome of chronic pelvic pain (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 prostate, ejaculate and urine.
Category I
Acute bacterial prostatitisIt is expressed by acute infectious inflammation of the prostate with all the accompanying symptoms:
- increased number of leukocytes in urine;
- the presence of bacteria in the urine;
- general signs of infection (fever, symptoms of intoxication).
Category II
Chronic bacterial prostatitis- accompanied by appropriate 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 leading clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of prostate, ejaculate and urine obtained after prostate massage. The criterion for separation in III A and III B is the presence of an increased number of leukocytes.
Category III A
Chronic inflammatory pelvic pain syndrome- characterized by the presence of pain syndrome and symptoms of prostatitis, while there is an increased number of leukocytes in the secretion of the prostate, ejaculate and part of the urine, after prostate massage pathogenic microorganisms in these samples were not detected by standard methods.
Category III B
Non-inflammatory syndrome of chronic pelvic pain- 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 urine obtained after prostate massage were not detected by standard methods.
Category IV
Asymptomatic inflammatory prostatitis- absence of symptoms characteristic of prostatitis, the disease is accidentally detected during histological examination of prostate tissue samples obtained in connection with the diagnosis for other reasons (for example, prostate biopsy due to increased levels of prostate-specific antigen - PSA).
Diagnosis of prostatitis
The symptoms of prostatitis are extremely diverse, but can be classified into several groups.
Pain syndrome
As a result of insufficient blood supply, caused by inflammation or spasm of the vessels that supply the prostate, starvation of the glandular tissue with oxygen is observed, resulting in by-products of pathological oxidation affecting the nerve endings of the prostate. Because the innervation of the prostate is associated with the innervation of the bottom of the pelvis, penis, scrotum, testis, rectum, the localization of pain is variable. The following symptoms of pain are the most common:
- Discomfort or pain in the perineum - usually appear after physical exertion, intercourse, alcohol consumption in the form of transient seizures;
- Feeling of hot potatoes in the rectum;
- Pain (discomfort) in the testicles - patients describe as "pain", "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 prostate secretion to the acidic side. Acidic secretion of the prostate irritates the mucous membrane of the urine, 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 urethral lumen during contraction of the glands and pelvis.
Urinary disorder syndrome
It is associated with close innervation of the prostate and bladder, as well as the participation of 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 sharp and sudden urge (impossible to tolerate) and fairly small portions;
- Feeling of incomplete emptying of the bladder - after the act of urinating there is a feeling that urine remains in the bladder;
- Weak or intermittent flow of urine - this may also include the symptom of the "last drop" - despite all the patient's efforts, after the act of urination, a drop of urine still comes out of the canal.
Disorder of ejaculation and orgasm
It is associated with damage to the seminal tubercle (coliculitis) during prostatitis, on the surface of which there are nerve receptors that send a signal to the structures of the brain, where the feeling of orgasm is created. Prostatitis does not directly cause erectile dysfunction (filling the blood of the penis with sexual arousal).
Main violations:
- Premature ejaculation, or vice versa, excessively prolonged intercourse - caused by inflammation of the seminal tubercle or its scars due to the inflammatory process;
- Deleted 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 sperm is released.
Impaired fertility
When the properties of prostate secretion change due to inflammation, the following changes in sperm are observed, which reduce a man's ability to fertilize (fertility):
- Decrease in the pH of sperm towards the acidic side - because with inflammation of the prostate, acidic products of pathological oxidation begin to accumulate in secret. The acidic environment is extremely destructive to sperm, causing them to immobilize and even die;
- Sperm agglutination - the sticking of sperm mainly to the heads - is associated with a change in the physicochemical properties of the secretion;
- Asthenospermia - a decrease in sperm motility - is closely linked to a shift in pH to the acidic side and a violation of the production of lecithin cells in the prostate, which ensure the vital activity of sperm.
Urethroprostatitis
In some cases, prostatitis is combined with chronic urethritis, manifested by scanty mucopurulent discharge from the urethra (mostly 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 cortical-subcortical region of the brain, a nerve signal is transmitted to the erection center located in the spinal cord, from where it goes to the smooth muscles of the sinusoids. sinusoids) or narrow (veins). The prostate has no role in this process.
Ejaculation and orgasm occur with sufficient irritation of special receptor cells, which are located in the area of the seminal tubercle into which the excretory ducts of the prostate fall, these same receptors are responsible for sending a nerve impulse to the cerebral cortex where the sensation occurs. orgasm is formed.
The inflammatory process in the prostate (prostatitis) can lead to damage to the seminal tuber and, as a result, to a violation of a man's potency, as well as premature ejaculation and erasure of orgasm. Impotence in chronic prostatitis is pathogenetically related to the degree of damage to the nervous system of the prostate. This form of impotence (neuroreceptor impotence) is a typical example of repercussion, when the presence of pathological impulses from organs affected by the inflammatory process leads to radiation of the excitation process to the centers that control sexual function and to disorders of the latter. A certain, although not leading role, in the pathogenesis of neuroreceptor impotence has a certain suppression of androgenic activity of the testes and sensitivity to androgens in the centers of the hypothalamus and pituitary gland.
At the same time, there is an opinion that in the Russian Federation there is an over-diagnosis of prostatitis and overestimation of its role in the development of erectile dysfunction.
Diagnosis
The task of the doctor is to detect the inflammatory process in the prostate, identify a possible cause of the disease and assess prostate dysfunction. In 1990, Stamey wrote that prostatitis was a "bucket of clinical ignorance" because of the different terms used, diagnostic methods, and treatments. At the same time, several simple clinical and laboratory tests enable the correct diagnosis, which enables the initiation of appropriate therapy.
Digital rectal examination of the prostate
Very informative way. The inflammatory process can be judged by assessing 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, pastiness, soreness. The fact that rectal examination reveals 80% of pancreatic cancers speaks for itself. We can say with certainty that this research method will always be used.
Microscopic examination of pancreatic secretion
It should be borne in mind that the increase in the number of leukocytes in the secretion does not always indicate prostatitis, because the methods of obtaining secretions during massage do not guarantee that the contents of the urethra and seminal vesicles will not enter it. At the same time, with obvious signs of prostatitis, prostate secretion may 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 prostate secretion (Pronounced prostate secretion-EPS) allows to determine the presence of an inflammatory process in the prostate and partially its functional capacity. It is the main method for diagnosing and monitoring the treatment of chronic prostatitis. The secretion of the prostate can be examined by light microscopy without staining or by special staining methods. Also, the secretion of the prostate can be subjected to bacteriological examination or research by the method of polymerase chain reaction in order to detect infectious agents in it. Get to the secret of prostate massage. The secretion released from the urethra is collected in a sterile tube or on a clean glass object for examination. Sometimes prostate secretion does not come out of the urethra. In such cases, the patient is advised to get up immediately. If, however, the secretion could not be obtained, it more often means that it did not enter the urethra, but the bladder. In this case, the centrifuge of the rinsing fluid that is released from the bladder after the prostate massage is examined.
- Lipoid grains (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate. Gives a secret milky look. The secret is usually rich in lecithin grains. A decrease in their number, together 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 condensed glandular secretion, has an oval shape and a layered structure, resembling a tree trunk. They do not usually occur, their detection indicates stagnation of secretions in the gland, which may be in adenomas, chronic inflammatory processes;
- Erythrocytes may be single. They enter the secret as a result of a strong prostate massage. An increased number of them is observed in inflammatory processes, neoplasms.
- Desquamation of the epithelium in large quantities is observed at the beginning of inflammatory processes and in tumors, at the same time disquamation often occurs in proteins and fatty degeneration of epithelial cells. Macrophages can be seen with stagnation of secretions, a long-lasting current inflammatory process;
- Bettcher crystals are long crystals that form when the mixed secretion of the male gonads (prostate juice mixed with sperm) from the salt of spermine and phosphate is cooled and dried. With azoospermia and severe oligozoospermia, Bettcher crystals form rapidly and in large quantities;
- Retention syndrome - with glandular adenoma, stagnation syndrome is observed. Macrophages abound, there are multinucleated cells like foreign bodies and amyloid bodies;
- The symptom of ferns - the symptom of crystallization of secretions - the form of deposition of sodium chloride crystals depends on the physicochemical properties of prostate secretion. The study of symptoms is performed by adding drops of 0, 9% sodium chloride solution to the obtained prostate secretion with further viewing after drying under a light microscope. In healthy men of reproductive age, crystallization of prostate secretion is characterized by the typical phenomenon of fern leaves (3+). Androgen insufficiency or the presence of prostatitis give different degrees of disruption of the crystal structure until their absence.
Bacteriological examination of parts of urine and pancreatic secretions
Urethral swab, including PCR diagnostics
Serological diagnosis of agents (ELISA) that cause urinary tract infections
Immunofluorescence reaction (RIF), direct and indirect
Detection of antibodies to known antigens.
Determination of PSA (prostate-specific antigen) of blood serum
The American Foundation for Urological Diseases recommends an annual rectal examination of the prostate, accompanied by PSA, for all men older than 50 and in the presence of prostate cancer in blood relatives in the male line. There is still debate about getting PSA immediately after a digital prostate examination by rectum. Recent studies have failed to confirm the presence of a significant increase in PSA content immediately after digital review. Thus, PSA levels can be determined by obtaining reliable results even after examination of the pancreas.
A sample of four glasses
In order to diagnose chronic prostatitis, a 4-glass test was proposed, based on a comparative bacteriological assessment of approximately equal parts of urine received before and after prostate massage, as well as its secretion.
The diagnosis of prostatitis is determined by a tenfold increase in the concentration of microorganisms in the secretion of the prostate in relation 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 a light microscope (magnification 200 times). Or an increase in the number of leukocytes more than 300x106 / l when 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 prostate secretion are found in much smaller amounts. In mature men 1-2 can be found in the field of view.
Biochemical blood test
Immune and hormonal profile (according to indications).
Ultrasound, TRUS
Ultrasound diagnosis of prostatitis by abdominal and transrectal transducer (TRUS).
Uroflowmetry
Treatment of prostatitis
Complex treatment of patients with chronic prostatitis should include:
- adherence to the general regime, diet, sexual hygiene, as well as the participation of sexual partners in treatment in the presence of an infectious agent;
- selection of effective drugs to control infection;
- increasing the general reactivity of the patient's body and the immunobiological tolerance of microorganisms to drugs;
- increased outflow of secretion and activation of local reparative processes in the focus of inflammation;
- remediation of foci of infection in present and distant organs;
- improving microcirculation in the prostate and pelvic organs;
- naming tonics, enzymes and vitamins;
- correction of hormonal disorders;
- naming antispasmodics;
- naming analgesics and anti-inflammatory drugs;
- taking sedatives and tranquilizers;
- regulation of neurotrophic disorders by 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 from 1936 it was widely introduced into O'Conory's urological practice. However, in 1968, after Meares and Stamey described a turning point for the diagnosis of prostatitis, views on the causes of the disease changed and massage as a therapeutic procedure was deleted from the list of measures in many manuals for the treatment of prostatitis in the developed world.
But since the mid-1990s, many physicians involved in the diagnosis and treatment of prostatitis have begun to notice the ineffectiveness in some cases of proposed antibiotic therapy and the use of alpha-blockers, prompting them to use this forgotten method in practice.
Basically, prostate massage is currently used as a diagnostic procedure for obtaining prostate secretion (pronounced prostate secretion) - for its microscopic (cultural) examination and for the test before and after the massage (test before and after the massage - PPMT). secretionperform her massage. Massage is a medical procedure and must be performed by a previously trained specialist. The massage is performed after urination, and in case of discharge from the urethra after its previous rinsing with isotonic sodium chloride solution, which is especially necessary in cases when bacteriological examination of secretions is assumed. Prostate massage is performed through the anus, because the prostate is near the ampoule of the rectum and is only available for examination there. First massage one, then the other lobe of the prostate with finger movements from the periphery to the central groove along the outlet ducts, trying not to touch the seminal vesicles. Finish the massage by pressing on the area of the central furrow from above. The secretion released from the urethra is collected in a sterile tube or on a clean glass object for examination. Sometimes prostate secretion does not come out of the urethra. In such cases, the patient is advised to get to his feet immediately. If, however, the secretion failed to come, it means that it did not enter the urethra, but the bladder. In this case, the centrifuge of the rinsing fluid that is 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 procedure for the treatment of chronic prostatitis. Prostate massage is widely used to treat prostatitis in Southeast Asian countries, China and some European countries. Some urologists from North America and Canada also recommend the use of massage in combination with antibiotic therapy in the treatment of some 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 physicians, no differences were found in groups of patients, some of whom received massage in combination with antibiotic therapy and simple antibiotic therapy, and in the other conducted by American and Philippine researchers, on the contrary, in the group. 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 the drying of the prostate canal - ie. freeing them of purulent and dead cells. The second effect is believed to increase blood flow to the prostate, which improves the penetration of antibiotics into it and activates local protective immune processes.
There is little data in the world literature on the complications associated with prostate massage. In 1990, Japanese doctors described genital gangrene (Fournier), and Germans in 2003 described perioprostatic hemorrhage 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 (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcification and prostate adenoma, and prostate massage is usually recommended 2 or 3 times a week.
Physiotherapy procedures
Any physiotherapy procedures (prostate massage, warm-up, etc. ) are contraindicated for acute prostatitis.
The use of physiotherapeutic procedures in the complex treatment of prostatitis is aimed both at the direct effect of physical agents on the prostate to normalize functional and pathological changes, and at the electrophoretic application of drugs into prostate tissue.
The use of physiotherapeutic methods in the background of drug therapy gives a much better result than just treatment. The following methods of affecting the prostate have become widespread and have proven their effectiveness:
- shock wave therapy;
- electrostimulation of the pancreas by modulated currents of skin or rectal electrodes;
- thermotherapy in various versions (including high frequency thermotherapy);
- magnetotherapy;
- microwave microwave therapy;
- laser therapy.
- transrectal ultrasound therapy and phonophoresis;
- microclysters.