Prostatitis (Prostatitis) is an inflammation of the prostate gland (an organ of the male reproductive and reproductive system) and a change in its physiological functions as a result of this process.
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 it, occupies a leading place among urological pathology.
There are many classifications of prostatitis, ie a very special terminology. The most common is the classification of prostatitis, proposed by the National Institutes of Health of SH. B. A. (NIH) in 1995:
|Category I||Acute bacterial prostatitis|
|Category II||Chronic bacterial prostatitis|
|Category III||Chronic abacterial prostatitis|
|Category IIIA||Chronic Infectious 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 secretion, ejaculation and urine.
Acute bacterial prostatitisIt is expressed by an acute infectious inflammation of the prostate gland with all the accompanying symptoms:
- an increased number of leukocytes in the urine;
- the presence of bacteria in the urine;
- general signs of infection (fever, intoxication symptoms).
Chronic bacterial prostatitis- accompanied by corresponding symptoms and an increase in the number of leukocytes and bacteria in the secretions of the prostate, ejaculation and urine taken after prostate massage.
Chronic Pelvic Pain Syndrome (CPPS)- The main clinical symptom is pain syndrome for more than 3 months in the absence of pathogenic microorganisms in the secretion of prostate, ejaculate and urine taken after prostate massage. The criterion for division into III A and III B is the presence of an increase in the number of leukocytes.
Category III A
Inflammatory syndrome of chronic pelvic pain- is characterized by the presence of pain syndrome and symptoms of prostatitis, while there is an increased number of leukocytes in the secretion of prostate gland, ejaculate and part of the urine, 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 there is no increase in the number of leukocytes and pathogenic microorganisms in the secretion of the prostate, ejaculation and urine obtained after prostate massage are not detected by standard methods.
Asymptomatic inflammatory prostatitis- the absence of characteristic symptoms of prostatitis, the disease is discovered accidentally during a histological examination of prostate tissue samples taken in connection with the diagnosis for other reasons (for example, a prostate biopsy due to increased specific level of prostate antigen -PSA).
Diagnosis of prostatitis
The symptoms of prostatitis are extremely varied, but they can be grouped into several groups.
As a result of insufficient blood supply, caused by inflammation or spasm of the vessels that nourish the prostate, oxygen starvation of glandular tissues is observed, as a result of which pathological oxidation byproducts are formed that affect the nerve endings of the prostate. associated with innervation of the pelvic floor, penis, scrotum, testicles, rectum, the localization of pain is variable. The following pain symptoms are the most common:
- Discomfort or pain in the perineum - mainly occurs after physical exertion, sexual intercourse, alcohol intake 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 provocative factors;
- Discomfort, cramps and pain in the urethra are mainly associated with a shift in pH of prostate secretion to the acidic side. Acid prostate secretion irritates the mucous urethra, so painful sensations, most often in the form of "burning" occur after the act of urination or sexual intercourse, when part of the secretion is squeezed into the lumen of the urethra during contraction of the muscles of the gland and pelvis.
Urinary Disorder Syndrome
It is associated with tight innervation of the prostate and bladder, as well as the involvement of prostate muscles in the act of urination. The phenomenon may be accompanied by the following manifestations:
- Frequent urination - frequent urination (up to 3 times per hour) with a sharp and sudden desire (impossible to tolerate) and quite small portions;
- Feeling of incomplete emptying of the bladder - after the act of urination, there is a feeling that urine remains in the bladder;
- Weak or interrupted urine flow - this may also include the "end point" symptom - despite all the patient's efforts, after the act of urination, a drop of urine is still released from the duct.
Ejaculation and disturbance of orgasm
It is associated with damage to the seminal tubercle (colic) during prostatitis, on the surface of which are nerve receptors that send a signal to the brain structures, where the feeling of orgasm is formed. Prostatitis does not directly cause erectile dysfunction (sexual arousal of the penis).
- Premature ejaculation, or vice versa, excessively prolonged intercourse - caused by inflammation of the seminal tubercle or its scarring due to the inflammatory process;
- Deleted orgasm - is also associated with inflammation of the seminal tubercle;
- Pain during ejaculation - is accompanied by an inflammatory process in the excretory ducts of the prostate through which the sperm is released.
When the secretory properties of the prostate change due to inflammation, the following changes are observed in the sperm, which reduce the man's ability to fertilize (fertility):
- A decrease in the pH of the sperm towards the acidic side - since with inflammation of the prostate, the acidic products of pathological oxidation begin to accumulate in secret. An acidic environment is extremely destructive to sperm, causing them to immobilize and even die;
- Sperm agglutination - the attachment of sperm mainly from the head - is accompanied by 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 to a violation of the production of lecithin cells by the prostate, which provide vital sperm activity.
In some cases, prostatitis is combined with chronic urethritis, which is manifested by low mucopurulent discharge from the urethra (mainly after prolonged retention of urine).
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 a complete saturation of the body with androgens in the formations of the cortical-subcortical region of the brain, a nerve signal arises, which is transmitted to the erection center located in the spinal cord, from where it goes to the smooth musclesof the sinusoids of the formations of the cavernous bodies of the penis, which either relax (arteries and sinusoids) or narrow (veins). There is no role for the prostate in this process.
Ejaculation and orgasm occur with sufficient irritation of specific receptor cells, which are located in the region of the seminal tubercle in which the excretory ducts of the prostate gland fall, the same receptors are responsible for sending a nerve impulse to the cerebral cortex orgasm is formed.
An inflammatory process in the prostate gland (prostatitis) can lead to damage to the seminal tubercle and, as a result, both to a violation of a man's potency and to premature ejaculation and cancellation of 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 a repercussion phenomenon, when the presence of pathological impulses from organs affected by the inflammatory process leads to radiation of the excitation process in the centers that control sexual function and the disorder of the latter. A certain, though not major, role in the pathogenesis of neuroreceptor impotence is also played by some suppression of testicular androgenic activity and androgen sensitivity in the centers of the hypothalamus and pituitary gland.
At the same time, there is an opinion that in the Russian Federation it exists as an over-diagnosis of prostatitis and an overestimation of its role in the development of erectile dysfunction.
The doctor's task is to detect the inflammatory process in the prostate, identify a possible causative agent of the disease and assess the dysfunction of the prostate gland. In 1990, Stamey wrote that prostatitis is a "trash of clinical ignorance" because of the variety of terms used, diagnostic methods, and treatments. At the same time, some simple and clinical and laboratory tests make accurate diagnosis possible, which allows the start of proper therapy.
Digital rectal examination of the prostate
A very informative way. The inflammatory process can be judged by assessing the shape, contours, size of the gland, the presence of foci of compression and (or) mitigation, pain. The main signs of prostatitis: increase or decrease in size, heterogeneity of consistency, the presence of foci of compression and softening, pastiness, bitterness. The fact that 80% of pancreatic cancers are detected by colon examination speaks for itself. We can say with certainty that this method of research will always be used.
Microscopic examination of pancreatic secretion
It should be remembered that an increase in the number of leukocytes in a secretion does not always indicate the prostate, because the methods of obtaining a secretion 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 a part of the secretory ducts destroyed, or closed.
Study of prostate gland secretion
The study of prostate gland secretion (Expressed Prostate Secrets-EPS) allows you to determine the presence of an inflammatory process in the prostate gland and, in part, its functional ability. It is the main method for diagnosing and monitoring the treatment of chronic prostatitis. Prostate secretion can be examined using light microscopy without staining or using special staining methods. Also, the secretion of the prostate gland may be subjected to bacteriological examination or research by the polymerase chain reaction method for the detection of infectious agents in it. Get the secret through prostate massage. The secretion released by the urethra is collected in a sterile test tube or in a clean glass slide for examination. Sometimes the secretion of the prostate gland does not come out of the urethra. In such cases, the patient is advised to stand up immediately. If, however, the secretion can not be obtained, more often it means that it does not enter the urethra, but the bladder. In this case, examine the centrifuge of car wash fluid released from the bladder after massaging the prostate gland.
- Lipoid granules (lecithin bodies) are a specific product of the normal physiological secretion of the glandular epithelium of the prostate gland. Gives the secret a milky look. Normally, 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;
- Amyloid bodies are layered bodies (starch) that turn purple or blue with Lugol's solution, like starch;
- The amyloid body is a thick secretion of the gland, it has an oval shape and a layered structure, resembling a tree trunk. Normally, they do not occur, their detection indicates stagnation of secretions in the gland, which may be with adenomas, chronic inflammatory processes;
- Erythrocytes can be single. They enter the secretion as a result of the powerful massage of the prostate gland. 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 with protein and fatty degeneration of epithelial cells. Macrophages can be seen with stagnation of secretions, a current long-term inflammatory process;
- Betcher crystals are long crystals formed when the mixed secretion of the male gonads (prostatic fluid mixed with sperm) from the sperm and phosphate salt cools and dries. With severe azoospermia and oligozoospermia, Bettcher crystals form rapidly and in large quantities;
- Retention syndrome - stagnation syndrome is observed with glandular adenoma. There is an abundance of macrophages, there are multinucleated cells like foreign bodies and amyloid bodies;
- Fiery symptom - a symptom of secretion crystallization - the form of precipitating sodium chloride crystals depends on the physicochemical properties of prostate gland secretion. The symptom study is performed by adding a drop of 0. 9% sodium chloride solution to the obtained prostate secretion with further observation after drying under a light microscope. In healthy men of reproductive age, the crystallization of prostate secretion is characterized by a typical fern leaf phenomenon (3+). Androgenic insufficiency or the presence of prostatitis give varying degrees of violation of the structure of the crystals to their absence.
Bacteriological studies of parts of urine and pancreatic secretions
Urethral swab, including PCR diagnosis
Serological diagnosis of agents (ELISA) that cause urinary tract infections
Direct and indirect immunofluorescence reaction (RIF)
Detection of antibodies to known antigens.
Determination of serum PSA (prostate specific antigen)
The American Foundation for Urological Diseases recommends an annual prostate colon examination, accompanied by PSA, for all men over the age of 50, and in the presence of prostate cancer in blood relatives in the male line. There is still a discussion about getting PSA right after a digital examination of the prostate gland for the rectum. Recent studies have not been able to confirm the presence of a significant increase in PSA content immediately after digital examination. Thus, the level of PSA can be determined by obtaining reliable results and after examination of the pancreas.
Sample with four cups
To diagnose chronic prostatitis, a 4-cup test was proposed, based on a comparative bacteriological evaluation of approximately equal portions of urine taken before and after massage of the prostate gland, as well as its secretion.
The diagnosis of prostatitis is made with a tenfold increase in the concentration of microorganisms in the secretion of the prostate compared to their content in the 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 more than 300x106 / l when counting them in the counting room. Lecithin bodies, which are the product of the normal secretion of the glandular epithelium of the prostate gland, should densely cover the field of view of the microscope (5-10 million in 1 ml). Amyloid bodies in prostate secretion are found in significantly smaller amounts. In mature men, they can be found 1-2 in the field of view.
Biochemical blood test
Immunological and hormonal profile (according to indications).
Ultrasound diagnosis of prostatitis with an abdominal and transrectal carrier (TRUS).
Treatment of prostatitis
The complex 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 in the presence of an infectious agent;
- choosing effective medications to suppress the infection;
- increased overall reactivity of the patient's body and immunobiological tolerance of microorganisms to drugs;
- increased secretion flow and activation of local repair processes in the focus of inflammation;
- channeling foci of infection in presenting and distant organs;
- improving microcirculation in the prostate gland and pelvic organs;
- appointment of tonic agents, enzymes and vitamins;
- correction of hormonal disorders;
- appointment of antispasmodics;
- appointment of analgesics and anti-inflammatory drugs;
- taking sedatives and tranquilizers;
- regulation of neurotrophic disorders with local analgesic drugs;
Prostate massageis a medical procedure used to diagnose and sometimes treat chronic prostatitis. The first prostate massage was described by Posner in 1893, and since 1936 it has been widely introduced into O'Conory urological practice. However, in 1968, after Meares and Stamey described the important test for the diagnosis of prostatitis, views on the causes of this disease changed and massage as a therapeutic procedure was removed from the list of measures in many manuals for the treatment of prostatitis in the developed world.
But by the mid-1990s, many physicians involved in diagnosing and treating prostatitis began to notice ineffectiveness in some cases of proposed antibiotic therapy and the use of alpha-blockers, which led them to use this method. forgotten. in practice.
Basically, prostate massage is currently used as a diagnostic procedure for obtaining prostate secretions (expressed prostate secretions-EPS) - for its microscopic (cultural) examination and for the test before and after the massage. (test before and after massage -PPMT). secretion perform her massage. Massage is a medical procedure and should be performed by a previously trained specialist. Massage is performed after urination, and in case of discharge from the urethra after its pre-washing with isotonic sodium chloride solution, which is especially necessary in cases where bacteriological examination of the secretion is assumed. Prostate massage is performed through the anus, as the prostate gland is adjacent to the rectal ampulla and is only available there for examination. Massage first one, then another lobe of the prostate gland by moving your fingers from the periphery to the central groove along the ejaculatory ducts, trying not to touch the seminal vesicles. Finish the massage by pressing the central sulcus area from above. The secretion released by the urethra is collected in a sterile test tube or in a clean glass slide for examination. Sometimes the secretion of the prostate gland does not come out of the urethra. In such cases, the patient is advised to immediately stand up. If, however, the secretion cannot be obtained, it means that it has not entered the urethra but the bladder. In this case, examine the centrifuge of car wash fluid released from the bladder after massaging the prostate gland.
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 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 conducted by Egyptian doctors, no change was found in the groups of patients, some of whom received massage in combination with antibiotic therapy and simply antibiotic therapy, in another conducted by American and Filipino researchers, on the contrary, in a group of prostate patients who received massage in combination with antibiotic therapy showed a marked improvement.
Proponents of the use of massage for therapeutic purposes believe that the main effect of its use is to drain the prostate ducts - d. m. th. freeing them from purulent and dead cells. Another effect is considered to increase blood flow to the prostate gland, 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 prescribed genital gangrene (Fournier) and in 2003 German doctors prescribed perioprostatic hemorrhage after prostate massage with the development of an embolic stroke (hemorrhage) of the lungs. There is a study that after massage the level of PSA (prostate specific antigen) temporarily increases. Massage is contraindicated in acute inflammation of the prostate gland (acute prostatitis), in acute urethritis, orchitis, prostate cancer. Massage is not recommended for prostate calcifications and prostate adenoma It is usually recommended to massage the prostate 2 or 3 times a week.
Any physiotherapy procedure (prostate massage, heat, etc. ) are contraindicated for acute prostatitis.
The use of physiotherapeutic procedures in the complex treatment of prostatitis aims as a direct effect on the prostate gland of physical agents to normalize functional and pathological changes, as well as electrophoretic administration of drugs into the prostate tissue.
The use of physiotherapeutic methods in the background of drug therapy gives a much better result than with treatment alone. The following methods of affecting the prostate gland have been widely used and proven to be effective:
- shock wave therapy;
- electrostimulation of the pancreas with modulated currents of cutaneous or rectal electrodes;
- thermotherapy in various versions (including high frequency thermotherapy);
- microwave microwave therapy;
- laser therapy.
- transrectal ultrasound therapy and phonophoresis;