Chronic prostatitis is a chronic inflammation of the prostate (hereinafter, the abbreviation prostate may appear), and the etiology of the inflammatory process may differ in different patients.That is why the classification of prostatitis is constantly revised and updated.
According to the classification (NIH), chronic prostatitis includes the second type, that is, 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 – inflammatory syndrome of chronic pelvic pain (leukocytes in the 3rd portion of urine, seminal fluid)
- III B – non-inflammatory chronic pain syndrome in the pelvis (without leukocytes in urine, seminal fluid)
- Type IV – asymptomatic prostatitis (inflammatory process is determined histologically)
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.The diagnosis is based on the study of pancreatic secretions, the clinic and the results of bacterial culture.
As a rule, even in the absence of a bacterial component of prostatitis, empiric antibacterial therapy (fluoroquinolones or sulfonamides) is initially carried out.
In the fourth type of prostatitis, there are no patient complaints.This type of prostatitis is diagnosed accidentally, during a biopsy of the prostate to rule out another possible pathology (prostate cancer).
The fourth type of prostatitis is determined on the basis of a biopsy, examination of a surgical specimen or analysis of sperm that is taken not because of the patient's complaints about specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by an elevated level of PSA (prostate-specific antigen).In case of prolonged elevated PSA during antibacterial therapy, periodic pancreatic biopsy is recommended to the patient.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by a bacterial infection of the prostate (PG).Chronic obstructive pulmonary disease causes a characteristic clinical picture, in which repeated inflammation of the organs of the urinary system is expressed (the most common worsening of inflammation is caused by the same microorganism).
CKD is often confused with non-bacterial prostatitis, chronic pelvic pain syndrome (CPPS) and prostatodynia.
By definition, CKD is associated with the overgrowth of pathogenic microorganisms in culture of prostate secretions, semen, or part of the urine obtained after prostate massage.As a rule, microscopy of pancreatic secretions reveals 10 or more leukocytes and macrophages in one field of view.
The prostatitis symptom complex is very common.Approximately 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 the urologist.Patients with symptoms of prostatitis are more likely to seek specialist advice than patients with pancreatic hyperplasia or pancreatic cancer.
Often the symptoms of prostatitis are not related to a chronic bacterial infection of the gland.Despite this fact, traditionally patients with symptoms of prostatitis are prescribed antibacterial therapy (50% of patients with symptoms of prostatitis receive antibiotic therapy, only in 5-10% of men these symptoms are caused by a bacterial infection and the treatment is followed by a cure 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 antibiotics.
A complicating factor in the diagnosis of prostatitis are "picky" microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause CKD, but do not grow well in nutrient media.
In this case, the situation can be misinterpreted as non-bacterial prostatitis.Further examination of the patient using bacterial nucleic acid detection technology indicates a more frequent association of prostatitis symptoms with bacterial infection.
Research is currently being conducted into a possible link between prostatitis and pancreatic cancer.The theory is that anti-inflammatory drugs that reduce the activity of the cyclooxygenase enzyme may lead to a reduction in the incidence of pancreatic cancer.
Etiology
The pancreas, due to its anatomical configuration, can serve as a source of recurrent infections.The peripheral part of the gland consists of a system of communication channels with poor drainage capacity, which can lead to stagnation of glandular secretions.
With age, the pancreas increases, symptoms of urinary system obstruction and urine reflux into the ducts of the gland develop.
Urine reflux is also possible with the development of urethral stricture.Backflow of urine, even sterile (without 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.
When there is stagnation, the bacterial flora can join the secretion, which leads to the creation of a chronic focus of infection with periodic exacerbations.
Infection of the pancreas can develop as a result of an ascending infection on the background of urethritis or when infected urine enters the ducts of the gland.
Infection in the gland can last for a long time due to poor accumulation of antibacterial drugs in its tissues.There are no active mechanisms for the transfer of antibacterial drugs into pancreatic cells;the concentration of the drug in the cell depends on its passive diffusion through the membrane.
The most common causes of CKD:
- 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 prostate secretions (pH = 6.4), which is significantly lower than plasma acidity (plasma pH = 7.4) and reduces the diffusion of antibiotics with high acidity into prostate secretions.
Escherichia coli (E. coli) infection in CKD occurs in 8 out of 10 patients.Other pathogens are much rarer.The role of gram-positive flora (Staphylococcus epidermidis and S. saprophyticus) in the development of CKD is controversial.
These microorganisms usually inhabit the anterior urethra and can "contaminate" the material when it is obtained, leading to false conclusions.Therefore, patients are prescribed treatment based on a different bacterial culture of the material.
Transmission of infection
In most cases, it is not possible to determine the exact source of the infection of the pancreas.Ascending infection of the urethra is a known source due to the frequent association of prostatitis with gonococcal flora in the urethra (gonococcal urethritis).
Among the most common routes of transmission of infection are:
- Ascending infection from the urethra.
- Reflux of urine containing pathogenic microorganisms into the ducts of the pancreas.
- 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 prostatitis-related symptoms.
About 5 out of 10 patients will develop symptoms similar to those of pancreatitis during their lifetime.Less than 5-10% of men with symptoms of pancreatitis suffer from bacterial prostatitis.
Symptoms of prostatitis most often occur in the age group of 36-50 years.Prostatitis is the most common urological problem in patients under 50 years of age and the 3rd most common urological pathology in patients over 50 years of age.The frequency of symptoms of prostatitis is 10% in the age group of men from 20 to 74 years.
Prognosis for CKD
The cure rate when treated with drugs from the sulfonamide group is 30-40%, with fluoroquinolones - 60-90%.
Morbidity
Pancreatitis significantly affects the patient's quality of life (the quality of life is reduced to the level of patients with coronary disease or patients with Crohn's disease).
Research shows 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 frequency of dysfunction in the sexual sphere in men (erectile dysfunction, duration of sexual intercourse, premature ejaculation).The exact nature of the connection between these diseases (psychogenic or somatic cause) is still unclear.
In one study, scientists compared the course 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 observed;patients more often complained of early ejaculation during sex.
In a study of 110 infertile men with CKD, 78 had a good result when they were prescribed a drug from the fluoroquinolone group: significantly increased sperm motility, decreased number of leukocytes in the seminal fluid, decreased viscosity of the seminal fluid, decreased content of free radicals, IL-6, TNF-6 and T.
In a control group of 37 healthy men, none of the above indicators changed when fluoroquinolones were prescribed.In the group of patients with a weak response to antibiotics, these indicators worsened.
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 is specific for inflammation of the pancreas and allows the doctor to narrow the search for the pathology.
Patients complain of pain, which can be noticed 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, reduced jet pressure, nocturia (increased urination at night), urinary incontinence.
Often, patients with CKD complain of urethral discharge (can be colorless or milky), pain during ejaculation, blood in the ejaculate, and impaired erectile function of the penis.
If CKD is suspected, the urologist performs a differential diagnosis with another common pathology from the list below:
- Acute prostatitis.It is accompanied by a more pronounced clinical picture, severe intoxication and severe pancreatic symptoms.If it is not treated in time or with the wrong regimen of antibacterial therapy, it can develop into a chronic infection of the pancreas and be complicated by an abscess of the gland.
- Stones in the prostate.
- Urinary tract obstruction as a result of benign pancreatic hyperplasia, urethral stricture, bladder neck dysfunction.It is 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.Bladder inflammation 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.It follows severe intoxication and severe pain in the perineum.In some cases, pancreatic abscess can be palpated through the rectum (defined as the area of softening of pancreatic tissue), transrectal ultrasound, computed tomography 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, a scraping from the surface of the urethra is used, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
Accurate diagnosis of CKD requires microscopy of pancreatic secretions, bacterial culture of urine sample after gland massage, and bacterial culture of semen.
The spectrum of flora in CKD is similar to the causative agents of acute pancreatitis.Most cases of CKD are associated with a single pathogen, but the combination of several bacteria as the source of prostatitis is not uncommon.
When examining the urine, it is important to compare the content/concentration of bacteria in the 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 in the middle of urination).
The detection of more than 10 leukocytes in the field of view during material microscopy indicates the presence of a pronounced inflammatory syndrome.
Microscopic examination
Most often, CKD is determined on the basis of microscopy of pancreatic secretions and urine after transrectal pancreatic massage.If the patient has symptoms of acute urogenital infection or fever at the time of examination, the physician should refrain from transrectal examination and prostate massage.
In this situation, there is a possibility that the patient has acute prostatitis and the possibility of developing sepsis due to prostate massage increases.
CKD is characterized by an increased content of leukocytes in the biomaterial under the microscope, and positive results of the bacterial culture of the biomaterial.
Bacterial culture of prostate discharge
Conducting this study facilitates the diagnosis of CKD.Part of the urine after transrectal massage of the pancreas is used for the study.
The obtained material is used for bacterial culture to determine the resistance of bacteria to antibiotics.
Prostate massage is performed until white discharge is obtained from the urethra;the whole process can take about one minute.Before conducting the study, it is necessary to inform the patient about the research methodology and its goals.
Sometimes, as a result of pancreatic massage, urine mixed with white feces is released from the urethra;in this case, the resulting liquid is subjected to bacterial culture.In the presence of infection in the pancreas, the acidity of the secretion shifts from pH 6.5 to pH 8.0.
Prostate Specific Antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with proven CKD experience a significant rise in PSA.
Increased PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on PSA increase, it is impossible to differentiate between pancreatic cancer and inflammation in it;an additional examination is required (TRUS, pancreatic biopsy).
In patients with CKD and an elevated PSA level, this marker should be retested 6-8 weeks after the end of prostatitis therapy.
Marker levels should return to normal 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.
A sample of three cups
This method has historically been the standard for diagnosing CKD.The technique was originally described in 1968.Currently, doctors are increasingly resorting to this study.
Instead of testing three glasses, doctors conduct a study of cultures of microorganisms in the urine before and after transrectal massage of the pancreas.
This method is of greatest value 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 the urine in the bladder and enables research.
Testing technique:
- The first portion of urine is 5-10 ml, collected in a special glass and contains microorganisms from the urethra.
- After collecting the first portion, the patient urinates in the toilet;after 150-200 ml of urine has passed, another 10-15 ml of urine is collected (the second part in a separate cup).The second part contains the microorganisms of the urinary bladder.
- The third portion is a mixture of pancreatic secretions and urine, obtained after massaging the pancreas and is about 5-10 ml, collected in a special glass.The third portion is sent for bacterial culture.
Transrectal ultrasound
This study is informative only in the presence of pancreatic abscess.Pancreatic abscess is an uncommon pathology accompanied by severe intoxication.
If TRUS is not possible and pancreatic abscess is suspected, computed tomography can be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent exacerbations of CKD, pancreatic stones can be a significant trigger for recurrent attacks.
The use of TRUS does not enable the 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 physician to further examine the patient.
Biopsy of the pancreas
The most informative study is a biopsy of the pancreas.However, this procedure is rarely performed for CKD, as microscopy and bacterial culture of biomaterials are sufficient for an accurate diagnosis.
Examining the obtained biopsy sample under a microscope enables the identification of focal infiltration of the pancreatic stroma by inflammatory cells.
A biopsy can be used for bacterial culture and determining the sensitivity of the flora to certain antibacterial drugs.
Contraindications for performing a biopsy are strong intoxication of the patient, high temperature, symptoms of acute inflammation of the pancreas (performing 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 diagnosed only on the basis of a biopsy of the pancreas.This category of prostatitis is characterized by asymptomatic inflammation in 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 perform this study, a radiopaque contrast agent is injected into the urethra and an X-ray is taken.If there is a urethral stricture, the image shows 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 biomaterials on nutrient media.
CNP belongs to type III prostatitis according to the modern classification and is divided into IIIA (chronic pelvic pain inflammatory syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs have been used in the treatment of CNP;the course of treatment is 30-40 days.According to modern research, in patients of group IIIA, it is preferable to use a short (2 weeks) antibacterial therapy, while in group IIIB, urologists try to avoid the use of antibiotics.
Epidemiology
CNP can develop in men of any age group.
- Most often, CNP develops at the age of 35-45 years.
- CNP is equally common among different ethnic groups.
Risk factors for CNP:
- Damages (traumas, operations, intraurethral manipulations) can lead to the development of inflammation in the tissue of the gland.
- Previous episodes of pancreatitis.
- Stress.
- General hypothermia, hypothermia of the perineum during prolonged sitting on cold surfaces.
- Disturbances in the psycho-emotional state.
The exact cause of CNP has not yet been determined.Scientists suggest that the possible etiology of CNP lies in a combination of several factors: psychoemotional 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 cannot be distinguished from the clinical picture of CKD.
Diagnostics
The diagnosis of CNP is made on the basis of symptoms, physical examination of the patient by a urologist, study of the medical history and additional laboratory tests.
In the diagnosis of CNP, the following is used:
- Digital rectal examination: the posterior surface of the pancreas is examined transrectally.During palpation, the pancreas can be extremely painful, firm and somewhat enlarged.
- A general urine test reveals an increase in leukocytes.
- Bacterial culture of urine and pancreatic secretions does not lead to the growth of microorganisms.
- Bacterial seeding of sperm does not allow the growth of microorganisms.
Disease prevention
- Increasing the amount of fruits and vegetables in the daily diet (they contain a large amount of antioxidants and help reduce inflammation in the internal organs).
- Reduction of wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- Increased consumption of polyunsaturated fatty acids.
- Increasing vegetable protein in the diet and decreasing animal protein.
- Drinking green tea.Green tea contains catechins, which are good antioxidants.Catechins have a pronounced anti-inflammatory effect.
- Drink your daily intake of water.Sufficient hydration of the body helps prevent urinary tract infections and, as a result, prostatitis.
- Maintaining physical condition and normal body weight.
- Avoiding stressful situations.
- Maintain personal hygiene.
- Use of barrier methods of contraception.
- Avoiding injuries to the perineal area.Horse riding or cycling can damage the pancreas and contribute to the development of inflammation in it.
- Drink cranberry juice, juice, cranberry decoction.These juices and decoctions have a pronounced uroseptic effect and can prevent the development of inflammation in the organs of the genitourinary system.
- Limiting or refusing to consume alcohol.
- Avoiding the use of spices.Spices can worsen the symptoms of prostatitis.
- Reduce your caffeine consumption.Caffeine leads to irritation of the pancreas and exacerbation of prostatitis.