Chronic prostatitis is a chronic inflammation of the prostate (hereinafter the abbreviation prostate may appear) and the etiology of the inflammatory process may differ between 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 nonbacterial 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 – chronic pelvic pain inflammatory syndrome (leukocytes in the 3rd part of urine, seminal fluid)
- III B – chronic non-inflammatory pelvic pain syndrome (absence of leukocytes in urine, seminal fluid)
- Type IV – asymptomatic prostatitis (the inflammatory process is 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 pancreatic discharge, clinic and bacterial culture results.
As a rule, even in the absence of a bacterial component of prostatitis, empirical antibacterial treatment (fluoroquinolones or sulfonamides) is initially carried out.
With the fourth type of prostatitis, patients do not complain.This type of prostatitis is diagnosed accidentally, during a prostate biopsy to exclude another possible pathology (prostate cancer).
The fourth type of prostatitis is established on the basis of a biopsy, examination of a surgical sample or semen analysis, not due to the patient's complaints about specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by high levels of PSA (prostate specific antigen).In case of a prolonged increase in PSA during antibacterial treatment, the patient is advised to undergo periodic biopsies of the pancreas.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by a bacterial infection of the prostate (PG).CKD causes a characteristic clinical picture, in which recurrent inflammation of the urinary system organs appears (most often, the exacerbation of inflammation is caused by the same microorganism).
CKD is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatodynia.
By definition, CKD is associated with a proliferation of pathogenic microorganisms in a culture of prostate secretions, semen or a portion of urine obtained after a prostate massage.Typically, microscopy of pancreatic secretions reveals 10 or more leukocytes and macrophages in one field of view.
All of the symptoms of prostatitis are very common.About half of men develop a clinical picture similar to that of prostatitis during their lifetime.
This set of symptoms accounts for 8% of all visits to a urologist.Patients with symptoms of prostatitis are more likely to see a specialist than patients with pancreatic hyperplasia or pancreatic cancer.
Often, symptoms of prostatitis are not associated with a chronic bacterial infection of the gland.Despite this fact, traditionally, patients with symptoms of prostatitis are prescribed antibacterial treatment (50% of patients with symptoms of prostatitis receive antibiotic treatment, only in 5-10% of men, these symptoms are caused by a bacterial infection and treatment is accompanied by recovery 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 the antibiotic.
A complicating factor in the diagnosis of prostatitis is “fastidious” microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause chronic kidney disease, but do not develop well in nutrient media.
In this case, the situation may be misinterpreted as non-bacterial prostatitis.Further examination of the patient using bacterial nucleic acid detection technologies indicates a more frequent association of prostatitis symptoms with bacterial infection.
Research is currently being conducted into the possible relationship between prostatitis and pancreatic cancer.The theory is that anti-inflammatory drugs that reduce the activity of the cyclooxygenase enzyme could lead to a reduction in the incidence of pancreatic cancer.
Etiology
The pancreas, due to its anatomical configuration, can be a source of recurrent infections.The peripheral part of the gland consists of a system of communicating ducts with low drainage capacity, which can lead to stagnation of the gland's secretion.
With age, the pancreas enlarges, symptoms of obstruction of the urinary system develop and backflow of urine into the ducts of the gland.
Urinary reflux is also possible with the development of urethral stenosis.Backflow of urine, even sterile (containing no bacteria), can cause chemical irritation and initiate tubular fibrosis and stone formation in the pancreatic ducts, which then leads to intraductal obstruction and stagnation of pancreatic secretions.
In case of stagnation, bacterial flora can join the secretion, leading to the formation of a focus of chronic infection with periodic exacerbations.
Infection of the pancreas can develop as a result of ascending infection against the background of urethritis or when infected urine enters the ducts of the gland.
Infection of the gland can persist for a long time due to poor accumulation of antibacterial drugs in its tissues.There is no active mechanism for the transfer of antibacterial drugs into pancreatic cells;the concentration of the drug in the cell depends on its passive diffusion across the membrane.
The most common causative agents of chronic kidney disease:
- 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 the prostatic secretion (pH = 6.4), which is significantly lower than the plasma acidity (plasma pH = 7.4) and reduces the diffusion of antibiotics with high acidity into the prostatic secretion.
Escherichia coli (E. coli) infection in CKD occurs in 8 out of 10 patients. Other pathogens are much less common.The role of Gram-positive flora (Staphylococcus epidermidis and S. saprophyticus) in the development of CKD is controversial.
These microorganisms generally inhabit the anterior urethra and can “contaminate” the material when obtaining it, leading to false conclusions.Therefore, treatment is prescribed to patients based on the second bacterial culture of the material.
Transmission of infection
In most cases, it is not possible to determine the exact source of the pancreas infection.Ascending urethral infection is a known source because of the frequent association of prostatitis with gonococcal flora of the urethra (gonococcal urethritis).
Among the most common routes of transmission of infection are:
- Ascending infection of the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic ducts.
- Migration of bacteria from the rectum or its lymphogenic spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients suffer from symptoms associated with prostatitis.
Around 5 out of 10 patients will develop symptoms similar to those of pancreatic inflammation during their lifetime.Fewer than 5 to 10% of men with symptoms of pancreatic inflammation have bacterial prostatitis.
Symptoms of prostatitis most often develop in the age group of 36 to 50 years.Prostatitis is the most common urological problem in patients under 50 years old and the 3rd most common urological pathology in patients over 50 years old.The frequency of prostatitis symptoms is 10% in men aged 20 to 74.
CKD Prognosis
The cure rate when treated with a drug from the sulfa group is 30-40%, with fluoroquinolones 60-90%.
Morbidity
Inflammation of the pancreas significantly affects the patient's quality of life (quality of life is reduced to the level of a patient with coronary artery disease or a patient with Crohn's disease).
Studies show that prostatitis leads to changes in mental status comparable to the level of mental changes in patients with diabetes mellitus and chronic heart failure.
Retrospective studies indicate a relationship between the severity of CKD and the incidence of dysfunctions of the sexual sphere in men (erectile dysfunction, duration of sexual intercourse, premature ejaculation).The exact nature of the association of these diseases (psychogenic or somatic cause) still remains unclear.
In one study, scientists compared the development of CKD during infection with C. trachomatis 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 complained of premature ejaculation during sexual intercourse.
In a study of 110 infertile men with CKD, 78 achieved a good result when they were prescribed a drug 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-alfa decreased.
In a control group of 37 healthy men, none of the listed indicators changed when prescribing a fluoroquinolone drug.In the group of patients with a poor response to antibiotics, these indicators deteriorated.
Clinical picture
Patients with CKD often come to the doctor with a list of subjective complaints.Only a small part of the complaints described during the interview with the patient are specific to inflammation of the pancreas and allow the doctor to refine the search for a pathology.
Patients complain of pain that 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 develop symptoms of urinary tract obstruction or irritation: increased frequency of urination, urination in small portions, decreased jet pressure, nocturia (increased urination at night), urinary incontinence.
Often, patients with CKD complain of discharge from the urethra (which may be colorless or milky), pain during ejaculation, blood in the ejaculate, and impaired erectile function of the penis.
If CKD is suspected, the urologist carries out a differential diagnosis with another common pathology 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 incorrect antibacterial treatment, it can develop into a chronic infection of the pancreas and be complicated by an abscess of the gland.
- Prostatic stones.
- Urinary tract obstruction as a result of benign pancreatic hyperplasia, urethral stricture, bladder neck dysfunction.Accompanied by symptoms of slow flow.They are not accompanied by intoxication, an increase in bacteria in pancreatic secretions, or the 3rd portion of urine.
- Pelvic floor tension myalgia.
- Cystitis.Inflammation of the bladder is accompanied by an increased urge to urinate, the patient urinates in small portions, intoxication and pain in the lower abdomen.
- Pancreatic abscess.Pancreatic abscess is a rare complication of acute prostatitis.Accompanied by severe intoxication and severe pain in the perineum.In some cases, a pancreatic abscess can be palpated through the rectum (defined as an area of softening of pancreatic tissue), by transrectal ultrasound, CT scan of the pelvic organs.
- Urethritis.Urethritis is accompanied by mild intoxication, pain at the beginning of urination and discharge from the urethra.In the diagnosis of urethritis, scraping of the surface of the urethra is used, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnosis
For an accurate diagnosis of CKD, it is necessary to perform microscopy of pancreatic secretions, bacterial culture of a urine sample after massage of the gland and bacterial culture of semen.
The spectrum of flora in CKD is similar to that of the causative agents of acute inflammation of the pancreas.Most cases of CKD are associated with a single pathogen, but a combination of several bacteria as a source of prostatitis is not uncommon.
When examining urine, it is important to compare the bacteria content/concentration in three portions (CKD is characterized by a higher concentration of microbes in the 3rd portion, 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 microscopy of the material indicates the presence of a pronounced inflammatory syndrome.
Microscopic examination
Most often, CKD is established on the basis of microscopic examination of pancreatic secretions and urine after transrectal massage of the pancreas.If the patient has symptoms of acute urogenital infection or fever at the time of examination, the doctor should refrain from transrectal examination and prostate massage.
In this situation, there is a possibility that the patient may suffer from acute prostatitis and the possibility of developing sepsis increases due to prostate massage.
CKD is characterized by an increased content of leukocytes in the biomaterial under microscopy and positive results of bacterial culture of the biomaterial.
Bacterial culture of prostate discharge
Performing this study facilitates the diagnosis of CKD.For the study, part of the urine is used after transrectal massage of the pancreas.
The material obtained 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 whole procedure can take about a minute.Before carrying out the study, it is necessary to inform the patient about the research methodology and its objectives.
Sometimes, as a result of pancreas massage, urine mixed with white feces is released from the urethra;in this case, the liquid obtained is subjected to bacterial culture.In the presence of an infection of the pancreas, the acidity of the secretion increases from pH 6.5 to pH8.0.
Prostate specific antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with proven CKD have a marked increase in PSA levels.
An increase in PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on an increase in PSA, it is impossible to distinguish between pancreatic cancer and its inflammation;an additional examination is necessary (TRUS, pancreatic biopsy).
In patients with CKD and elevated PSA levels, it is necessary to retest this marker 6-8 weeks after the end of treatment for prostatitis.
The level of the marker should return to normal values when the prostatitis is cured.If elevated PSA test results persist for a long time, a pancreatic biopsy is necessary to rule out other possible pathologies.
Sample of three glasses
This method has always been the standard for diagnosing CKD.The technique was first described in 1968. Currently, doctors are increasingly using this study.
Instead of testing three glasses, doctors conduct a study of cultures of microorganisms in urine before and after transrectal massage of the pancreas.
This method is particularly useful 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 sterility of urine in the bladder and allows 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 in the toilet;after the flow of 150-200 ml of urine, another 10-15 ml of urine is collected (the second part in a separate glass).The second part contains bladder microorganisms.
- The third portion is a mixture of pancreatic secretion and urine, obtained after pancreatic massage and is approximately 5-10 ml, collected in a separate glass.The third part is sent for bacterial culture.
Transrectal ultrasound
This study is only informative in the presence of a pancreatic abscess.Pancreatic abscess is a rare pathology that is accompanied by serious poisoning.
If TRUS is not possible and a pancreatic abscess is suspected, a CT scan may be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent exacerbations of chronic kidney disease, pancreatic stones may be a significant trigger for recurrent attacks.
The use of TRUS does not allow establishing 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 additionally examine the patient.
Pancreatic biopsy
The most informative study is a pancreatic biopsy.However, this procedure is rarely performed in cases of CKD, because microscopy and bacterial culture of the biomaterial are sufficient for an accurate diagnosis.
Microscopic examination of the obtained biopsy specimen identifies focal infiltration of the pancreatic stroma with inflammatory cells.
Biopsy can be used for bacterial culture and determination of the sensitivity of flora to certain antibacterial drugs.
Contraindications to performing a biopsy are severe intoxication of the patient, high fever, symptoms of acute inflammation of the pancreas (conducting 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 a pancreatic biopsy.This category of prostatitis is characterized by asymptomatic inflammation of the stroma of the gland and an increase in PSA.A persistently elevated PSA level 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 product is injected into the urethra and an x-ray is taken.In case of urethral stenosis, the image shows a 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 bacterial culture of biomaterial on nutrient medium.
CNP belongs to type III prostatitis according to the modern classification and is divided into IIIA (chronic inflammatory pelvic pain syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs are used in the treatment of CNP;the duration of treatment is 30 to 40 days.According to modern studies, it is better to use a short (2 weeks) antibacterial course in patients of group IIIA, while among urologists of group IIIB they try to avoid the use of antibiotics.
Epidemiology
CNP can develop in men of any age group.
- Most often, CNP develops between the ages of 35 and 45.
- CNP is also common among different ethnic groups.
CNP Risk Factors:
- Damage (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation of the glandular tissue.
- Previous episodes of inflammation of the pancreas.
- Stress.
- General hypothermia, hypothermia of the perineum during prolonged sitting on cold surfaces.
- Psycho-emotional state disorders.
The exact cause of CNP has not yet been established.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 neurological disorders.The combination of these factors leads to the development of symptoms of prostatitis.
The clinical picture of CNP is very diverse and may not differ from the clinical picture of CKD.
Diagnosis
The diagnosis of CNP is made on the basis of symptoms, a physical examination of the patient by a urologist, a review of the 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 markedly tender, firm, and somewhat enlarged.
- A general urine test reveals an increase in leukocytes.
- Bacterial culture of urine and pancreatic secretions does not result in the growth of microorganisms.
- Bacterial seeding of sperm does not allow the growth of microorganisms.
Disease prevention
- Increase the volume of fruits and vegetables in the daily diet (contain a large amount of antioxidants and help reduce inflammation of internal organs).
- Reduce wheat products in the diet.
- Take probiotics during antibacterial treatment.
- Increasing consumption of polyunsaturated fatty acids.
- Increase in plant proteins in the diet and decrease in animal proteins.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechins have pronounced anti-inflammatory activity.
- Drink your daily intake of water.Sufficient hydration of the body helps prevent urinary tract infections and, consequently, prostatitis.
- Maintain physical fitness and normal body weight.
- Avoid stressful situations.
- Maintain personal hygiene.
- Use of barrier methods of contraception.
- Avoid injuries to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation.
- Drink cranberry juice, juice, lingonberry decoction.These juices and decoctions have a pronounced uroseptic effect and can prevent the development of inflammation in the organs of the genitourinary system.
- Limit or refuse drinking alcohol.
- Avoid the use of spices.Spices can make prostatitis symptoms worse.
- Reduce caffeine consumption.Caffeine causes irritation of the pancreas and worsening of prostatitis.