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Prostatitis

Prostatitis (Prostatitis) is an inflammation of the prostate gland (organ of the male reproductive and reproductive system) and changes in its physiological function as a result of this process.

symptoms of prostatitis in men

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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 gland, in terms of the prevalence of the disease and the complex of problems arising from this, occupies a leading place among urological pathologists.

Welding

There are many classifications of prostatitis, hence the very strange term. The most common is the prostatitis classification, proposed by the U. S. National Institutes of Health (NIH) in 1995:

Categories Description
Category I Acute bacterial prostatitis
Category II Chronic bacterial prostatitis
Category III Chronic abacterial prostatitis
Category IIIA Chronic Inflammatory Pelvic Pain Syndrome
Category IIIB Chronic non -inflammatory pelvic pain syndrome (prostatodynia)
Category IV Asymptomatic inflammatory prostatitis

This classification of prostatitis is based on clinical signs, the presence or absence of leukocytes and microorganisms in prostate secretions, ejaculation and urine.

Category I

Acute bacterial prostatitisIt is expressed by acute infectious inflammation of the prostate gland with all the accompanying symptoms:

  • increased number of leukocytes in the urine;
  • the presence of bacteria in the urine;
  • signs of general 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 prostate secretions, ejaculation and urine obtained after prostate massage.

Category III

Chronic pelvic pain syndrome (CPPS)- the main clinical symptom is pain syndrome for more than 3 months with the absence of pathogenic microorganisms in prostate secretions, ejaculation and urine obtained after prostate massage. The criterion for separation into 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 pain syndrome and symptoms of prostatitis, while there is an increase in the number of leukocytes in the secretions of the prostate gland, ejaculation and urinary tract, after prostate massage, pathogenic microorganisms are not detected in these samples by standard methods.

Category III B

Chronic non -inflammatory pelvic pain syndrome- is characterized by the presence of pain syndrome and symptoms of prostatitis, while no increase in the number of leukocytes and pathogenic microorganisms in prostate secretions, ejaculation and urine obtained after prostate massage is not detected by standard methods.

Category IV

Asymptomatic inflammatory prostatitis- the absence of characteristic symptoms of prostatitis, the disease is detected incidentally 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).

Diagnostics of prostatitis

The symptoms of prostatitis vary greatly, but can be grouped into several groups.

Pain syndrome

As a result of insufficient blood supply, due to inflammation or spasm of the ducts that feed the prostate, oxygen starvation of the glandular tissue is observed, as a result of which byproducts of pathological oxidation are formed that affect the nerve endings of the prostate. Because the preservation of the prostate is associated with the preservation of the base of the pelvis, penis, scrotum, testicles, rectum, the localization of pain varies. The following pain symptoms are the most common:

  • Discomfort or pain in the perineum - mainly appears after physical exercise, sexual intercourse, alcohol intake in the form of seizures;
  • Sensation of hot potatoes in the rectum;
  • Pain (discomfort) in the testicles - the patient is described as "sore", "twisted", also associated with various provoking factors;
  • Discomfort, cramping and pain in the urethra are mainly related to the shift of the pH of prostate secretions to the acidic side. Acid secretion in the prostate irritates the urethral mucosa, therefore a painful sensation, more often in the form of "burning" occurs after urination or sexual intercourse, when part of the secretion is squeezed into the lumen of the urethra during contraction of glandular and pelvic muscles.

Urinary Tract Syndrome

It is associated with the preservation of the prostate and nearby bladder, as well as the involvement of the prostate muscles in the action of urination. Dysuria may be accompanied by the following manifestations:

  • Frequent urination - frequent urination (up to 3 times per hour) with sharp and sudden urges (impossible to tolerate) and relatively small portions;
  • Feeling of incomplete emptying of the bladder - after urination, there is a feeling that the urine remains in the bladder;
  • Poor or intermittent urine flow - this can also include "last drop" symptoms - despite all the patient’s efforts, after urinating, a drop of urine is still expelled from the duct.

Disorders of ejaculation and orgasm

It is associated with damage to the seminal tuberculosis (coliculitis) during prostatitis, on its surface there are nerve receptors that send signals to brain structures, where the feeling of orgasm is formed. Prostatitis does not directly cause erectile dysfunction (blood filling of the penis with sexual arousal).

Major violations:

  • Premature ejaculation, or conversely, prolonged sexual intercourse - caused by inflammation of the seminal tubules or scarring as a result of inflammatory processes;
  • Erased orgasm - also associated with inflammation of the seminal tubercle;
  • Pain during ejaculation - is associated with inflammatory processes in the excretory tract of the prostate where sperm are released.

Fertility decline

When the nature of prostate secretions changes due to inflammation, the following sperm changes are observed, which reduce a man’s ability to fertilize (fertility):

  • The pH of the sperm decreases towards the acidic side - because with inflammation of the prostate, acid products from pathological oxidation begin to accumulate secretly. The acidic environment severely damages spermatozoa, causing them to not move and even die;
  • Fusion of sperm - the adhesive of spermatozoa primarily by the head - is associated with changes in secretory physicochemical properties;
  • Asthenospermia - a decrease in sperm motility - is closely related to the shift of pH to the acid side and with a violation of the production of lecithin cells by the prostate, which ensures the vital activity of sperm.

Urethroprostatitis

In some cases, prostatitis is combined with chronic urethritis, which is indicated by mucopurulent discharge from the urethra (especially after prolonged urinary retention).

Prostatitis and Sexual Disorders

The question "Does prostatitis cause impotence? " Has been a source of professional controversy for decades.

Under the influence of sexual stimulation, with full saturation of the body with androgens in the formation of cortical-subcortical regions of the brain, appear nerve signals, which are sent to the erection center located in the spinal cord, from where it leads to the sinusoidal smooth muscle of the penis cave body formation, whicheither resting (arteries and sinusoids) or narrow (veins). There is no role for the prostate in this process.

Ejaculation and orgasm occur with sufficient irritation to special receptor cells, located in the seminal tubinal region where the excretory ducts of the prostate gland fall, these same receptors are responsible for sending nerve impulses to the cerebral cortex where orgasmic sensations are formed.

The inflammatory process of the prostate gland (prostatitis) can cause damage to the seminal tuberculosis and, as a consequence, both violate male potency, as well as premature ejaculation and elimination of orgasm. Impotence in chronic prostatitis is pathogenetically associated with the degree of damage to the neural apparatus of the prostate gland. This form of impotence (neuroreceptor impotence) is a special example of the effect phenomenon, when the presence of pathological impulses from the organs affected by the inflammatory process causes irradiation of the excitatory process to the centers that control sexual function, and the latter disruption. A particular role, although not leading, in the pathogenesis of neuroreceptor impotence is also played by the suppression of testicular androgenic activity and sensitivity to androgens in the central hypothalamus and pituitary gland.

At the same time, there is an opinion that in the Russian Federation there is an overdiagnosis of prostatitis and too high its role in the development of erectile dysfunction.

Diagnostics

The doctor's job is to detect inflammatory processes in the prostate, identify possible causes of the disease and assess the dysfunction of the prostate gland. In 1990, Stamey wrote that prostatitis was a "trash can of clinical ignorance" because of the variety of terms used, diagnostic methods and treatment. At the same time, several simple and clinical and laboratory tests make it possible to correctly diagnose, which allows the initiation of appropriate therapy.

Digital rectal examination of the prostate

Very informative way. The inflammatory process can be assessed by assessing the shape, contour, size of the gland, the presence of a focus 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, excitement, pain. The fact that 80% of pancreatic cancers are detected by rectal examination proves it. We can say that this research method will always be used.

Microscopic examination of pancreatic secretions

It should be noted that an increase in the number of leukocytes secretly does not always indicate prostatitis, because the method of obtaining secretions during massage does not guarantee that the contents of the urethra and seminal vesicles will not get into 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 excretory tract that is obliterated, or closed.

Study of prostate gland secretion

Studies on prostate gland secretion (Expressed prostate secretion-EPS) allow you to determine the presence of inflammatory processes in the prostate gland and, in part, its functional capacity. This is the primary method for diagnosing and monitoring the treatment of chronic prostatitis. Prostate secretions can be examined using light microscopy without staining or using special staining methods. Also, the secretions of the prostate gland can undergo bacteriological examination or research with the polymerase chain reaction method to detect infectious agents in it. Get the secret through prostate massage. Secretions removed from the urethra were collected in sterile test tubes or on clean glass slides for examination. Sometimes the secretions of the prostate gland do not flow out of the urethra. In such cases, the patient is advised to immediately stand up. However, if the secretion cannot be obtained, more often this means it does not enter the urethra, but into the bladder. In this case, centrifugation of lavage fluid removed from the bladder after prostate gland massage is examined.

  • Lipoid seeds (lecithin bodies) are special products of the normal physiological secretion of the epithelium of the prostate gland. Gives the secret of the appearance of milk. Usually, the secretion is rich in lecithin grains. A decrease in their number, together with an increase in the number of leukocytes, indicates an inflammatory process, a tumor;
  • An amyloid body is a layered (starchy) body that turns purple or blue with a Lugol's solution, like starch;
  • The amyloid body is a thickened glandular secretion, having an oval shape and a layered structure, resembling a tree trunk. Usually, it does not occur, their detection indicates a stagnation of secretions in the glands, which can occur with adenomas, chronic inflammatory processes;
  • Erythrocytes can be single. They enter the secretion as a result of a strong sequence of the prostate gland. An increase in their number is observed in inflammatory processes, neoplasms.
  • Desquamation of the epithelium in large numbers is observed at the beginning of the inflammatory process and in tumors, at the same time disquamation often occurs with degeneration of proteins and fat cells of the epithelium. Macrophages can be seen with stagnation of secretions, a long -term inflammatory process;
  • Bettcher crystals are long crystals that form when the secretions of a mixture of male gonads (prostate juice mixed with sperm) from sperm and phosphate salts are cooled and dried. With severe azoospermia and oligozoospermia, Bettcher crystals form rapidly and in large numbers;
  • Retention syndrome - stagnation syndrome is observed with glandular adenomas. There are many macrophages, there are multinuclear cells such as foreign matter and amyloid bodies;
  • Symptoms of ferns - symptoms of secretion crystallization - crystal form of sodium chloride deposition depends on the physicochemical properties of prostate gland secretions. Studies on such symptoms were performed by adding a drop of 0, 9% sodium chloride solution to prostate secretions obtained by looking further after drying under a light microscope. In healthy men of reproductive age, crystallization of prostate secretions is characterized by a typical fern leaf phenomenon (3+). Androgenic deficiency or the presence of prostatitis gives varying degrees of violation of the crystal structure until its absence.

Bacteriological study of the urine and secretions of the pancreas

Sweep the urethra, including diagnostic PCR

Serological diagnosis of the agent (ELISA) that causes a urinary tract infection

Direct and indirect immunofluorescence (RIF) reactions

Detection of antibodies to known antigens.

Determination of blood serum PSA (prostate specific antigen)

The American Foundation for Urological Diseases recommends an annual rectal examination of the prostate gland, accompanied by PSA, for all men over the age of 50, and in the event of prostate cancer in blood relatives on the male line. There is still discussion about getting a PSA immediately after a digital examination of the prostate gland per rectum. Recent studies have not been able to confirm the presence of a significant increase in PSA content immediately after digital screening. Therefore, PSA levels can be determined by obtaining reliable results and after examination of the pancreas.

Sample four glasses

To diagnose chronic prostatitis, a 4 -glass test is recommended, based on a comparative bacteriological assessment of the nearly identical portion of urine received before and after prostate gland massage, as well as its secretions.

The diagnosis of prostatitis is made by a tenfold increase in the concentration of microorganisms in prostate secretions compared to their content in urine (1, 2 and 3 parts) 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 by more than 300x106 / l when counting them in the counting space. The body of lecithin, which is a product of the normal secretion of the epithelium of the prostate gland, should cover the field of view of the microscope densely (5-10 million in 1 ml). Amyloid bodies in prostate secretions are found in much smaller amounts. In mature males, they can be found 1-2 in the field of view.

Biochemical blood tests

Immunological and hormonal profiles (according to instructions).

Ultrasound, TRUS

Ultrasound diagnosis of prostatitis with abdominal and transrectal transducers (TRUS).

Uroflowmetry

Treatment of prostatitis

Complex treatment of patients with chronic prostatitis should include:

  • adherence to general regimens, diet, sexual hygiene, as well as the involvement of sexual partners in treatment in the presence of infectious agents;
  • selection of effective medications to suppress infection;
  • increase the general reactivity of the patient's body and the immunobiological tolerance of microorganisms to drugs;
  • increased secretion outflow and activation of local reparative processes in inflammatory foci;
  • sanitation of infection focuses on present and distant organs;
  • increased microcirculation in the prostate gland and pelvic organs;
  • appointment of boosting agents, enzymes and vitamins;
  • correction of hormonal disorders;
  • antispasmodic appointments;
  • appointment of analgesic and anti-inflammatory drugs;
  • taking sedatives and tranquilizers;
  • regulation of neurotropic disorders with local analgesic drugs;

Prostate massage

Prostate massageis a medical procedure used to diagnose and sometimes treat chronic prostatitis. Prostate massage was first described by Posner in 1893, and since 1936 it has been widely introduced into O’Conory’s urological practice. However, in 1968, after Meares and Stamey described achievement tests for the diagnosis of prostatitis, views on the causes of the disease changed and massage as a therapeutic procedure was removed from the list of steps in many manuals for the treatment of prostatitis in developed countries.

But since the mid-90s of the 20th century, many doctors involved in the diagnosis and treatment of prostatitis began to realize the ineffectiveness in some cases of proposed antibiotic therapy and the use of alpha-blockers, which led them to use this forgotten method in training.

Basically, prostate massage is now used as a diagnostic procedure to obtain prostate secretions (expressed prostate secretion -EPS) -for microscopic examination (culture) and for pre and post -massage tests (pre and postmassage tests -PPMT). secretions do the sequence. Massage is a medical procedure and must be performed by a previously trained specialist. Massage is performed after urination, and in case of discharge from the urethra after initial rinsing with isotonic sodium chloride solution, which is indispensable in cases where bacteriological examination of secretions should be performed. Prostate massage is done through the anus, because the prostate gland is close to the rectal ampulla and is only there for examination. Massage the first, then another lobe of the prostate gland with the movement of the finger from the periphery to the central groove along the excretory tract, trying not to touch the seminal vesicles. Complete the sequence by pressing on the central sulcus from above. Secretions removed from the urethra were collected in sterile test tubes or on clean glass slides for examination. Sometimes the secretions of the prostate gland do not flow out of the urethra. In such cases, the patient is advised to immediately stand up. If, however, the secretion cannot be obtained, this means that it does not enter the urethra, but into the bladder. In this case, centrifugation of lavage fluid removed from the bladder after prostate gland massage is examined.

Prostate massage for therapeutic purposes (Recurrent 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 for the treatment of prostatitis in Southeast Asian countries, China, and some European countries. Some North American and Canadian urologists 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 evaluate the effectiveness or ineffectiveness of prostate massage. There are several conflicting studies, in one study conducted by Egyptian doctors, no differences were found in patient groups, some of whom received massage in combination with antibiotic therapy and antibiotic therapy, others performed by American and Philippine researchers, on the other hand, ona group of patients with prostatitis who received massage in combination with antibiotic therapy showed a significant improvement.

Proponents of the use of massage for therapeutic purposes believe that the main effect of its use is to drain the prostate duct - that is. freeing them from purulent and dead cells. Another effect is thought to increase blood flow in the prostate gland, which increases the penetration of antibiotics into it and activates local protective immunological processes.

There is little data in the world literature on 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 are studies that after massage the level of PSA (prostate -specific antigen) increases temporarily. Massage is contraindicated in acute inflammation of the prostate gland (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcification and prostate adenoma, it is usually recommended to massage the prostate 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 treatment of complex prostatitis aims to directly affect the prostate gland of physical agents to normalize functional and pathological changes, and the administration of electrophoretic drugs into prostate tissue.

The use of physiotherapeutic methods with a background of drug therapy gives much better results than with treatment alone. The following methods for influencing the prostate gland have become widespread and have proven their effectiveness:

  • shock wave therapy;
  • electrostimulation of the pancreas with current modulating electrodes of the skin or rectum;
  • thermotherapy in various versions (including high -frequency thermotherapy);
  • magnetotherapy;
  • microwave therapy;
  • laser therapy.
  • transrectal ultrasound therapy and phonophoresis;
  • microclysers.