Chronic prostatitis is a chronic inflammation of the prostate gland (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 reviewed and updated.
According to the classification (NIH), chronic prostatitis includes the second type, i.e. chronic bacterial prostatitis (CRF), the third type (chronic non-bacterial 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 – 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.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, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is initially carried out.
With the fourth type of prostatitis there are no complaints from patients.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 carried out not due to the patient's complaints of specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated PSA (prostate specific antigen) levels.With prolonged elevated PSA during antibacterial therapy, the patient is advised to undergo periodic biopsies of the pancreas.
Chronic bacterial prostatitis (CRF)
Chronic bacterial prostatitis is caused by a bacterial infection of the prostate gland (PG).Chronic renal failure causes a characteristic clinical picture, in which recurrent inflammation of the organs of the urinary system comes to the fore (most often, the exacerbation of inflammation is caused by the same microorganism).
Chronic kidney disease is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatodynia.
By definition, chronic kidney disease is associated with an overgrowth of pathogenic microorganisms in a culture of prostatic secretions, semen, or a portion of urine obtained after prostate massage.Typically, microscopy of pancreatic secretions reveals 10 or more leukocytes and macrophages in one field of view.
The symptom complex of prostatitis is very common.About half of men develop a clinical picture similar to that of prostatitis over the course of their lives.
This set of symptoms accounts for 8% of all visits to the urologist.Patients with symptoms of prostatitis are more likely to consult a specialist than patients with pancreatic hyperplasia or pancreatic cancer.
Often the symptoms of prostatitis are not associated with chronic bacterial infection of the gland.Despite this, traditionally patients with prostatitis symptoms are prescribed antibacterial therapy (50% of patients with prostatitis symptoms receive antibiotic therapy, only in 5-10% of men these symptoms are caused by a bacterial infection, and treatment is accompanied by patient care).
In most cases, antibacterial therapy leads to a 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 are "fussy" microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause chronic kidney disease, but do not grow well in nutrient media.
In this case the situation can be mistakenly interpreted 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.
There is currently ongoing research into the possible relationship 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 act as a source of recurrent infections.The peripheral part of the gland is made up of a system of communicating ducts with poor drainage capacity, which can lead to stagnation of glandular secretion.
With age, the pancreas increases, symptoms of obstruction of the urinary system and reflux of urine into the ducts of the gland develop.
Urinary reflux is also possible with the development of urethral stricture.Backflow of urine, even sterile (not containing bacteria), can cause chemical irritation and initiate tubular fibrosis and stone formation in the pancreatic ducts, which subsequently leads to intraductal obstruction and stagnation of pancreatic secretions.
When stagnation occurs, bacterial flora can join the secretion, leading to the formation of a chronic focus of 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.
The infection in the gland can persist 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 across the membrane.
The most common causative agents of chronic kidney disease:
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Protein species
- Staphylococcal 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 prostatic secretion (pH = 6.4), which is significantly lower than plasma acidity (plasma pH = 7.4) and reduces the diffusion of antibiotics with high acidity into prostatic secretion.
Escherichia coli (E. coli) infection in chronic kidney disease 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 chronic kidney disease is controversial.
These microorganisms usually live in the anterior urethra and can "contaminate" the material once obtained, leading to erroneous 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 pancreatic infection.Ascending urethral infection 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 the infection are:
- Infection ascending from 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.
About 5 in 10 patients will develop symptoms similar to those of pancreatic inflammation during their lifetime.Less than 5-10% of men with symptoms of pancreatic inflammation have bacterial prostatitis.
Symptoms of prostatitis most often develop between the ages of 36 and 50.Prostatitis is the most common urological problem in patients under the age of 50 and the third most common urological disease in patients over the age of 50.The frequency of prostatitis symptoms is 10% in the age group of men from 20 to 74 years.
Prognosis for chronic kidney disease
The cure rate when treated with a drug from the sulphonamide group is 30-40%, with fluoroquinolones 60-90%.
Morbidity
Inflammation of the pancreas significantly affects the patient's quality of life (the quality of life is reduced to the level of a patient with coronary heart 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 chronic kidney disease and the incidence of sexual dysfunction in men (erectile dysfunction, duration of sexual intercourse, premature ejaculation).The exact nature of the association of these diseases (psychogenic or somatic cause) is not yet clear.
In one study, scientists compared the course of chronic kidney disease 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 the patients was noted;Patients most often complained of premature ejaculation during sex.
In a study of 110 infertile men with chronic renal failure, 78 achieved good results when a drug from the fluoroquinolone group was prescribed: 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-alpha decreased.
In a control group of 37 healthy men, none of the listed indicators changed when a fluoroquinolone drug was prescribed.In the group of patients with a poor response to antibiotics, these indicators worsened.
Clinical picture
Patients suffering from chronic renal failure often come to the doctor with a list of subjective complaints.Only a small part of the disorders described during the interview with the patient are specific to inflammation of the pancreas and allow the doctor to narrow the search for the pathology.
Patients complain of pain, which 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 obstruction or irritation of the urinary tract: increased frequency of urination, urination in small portions, decreased flow pressure, nocturia (increased nighttime urination), urinary incontinence.
Patients with chronic renal failure often 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 chronic renal failure is suspected, the urologist makes a differential diagnosis with another common pathology from the following list:
- Acute prostatitis.Accompanied by a more pronounced clinical picture, severe intoxication and severe pancreatic symptoms.If not treated promptly or with an incorrect regimen of antibacterial therapy, it can develop into a chronic infection of the pancreas and be complicated by an abscess of the gland.
- Prostate stones.
- Obstruction of the urinary tract due to benign pancreatic hyperplasia, urethral stricture, bladder neck dysfunction.Accompanied by symptoms of slow flow.They are not accompanied by intoxication, increased bacteria in pancreatic secretions or in 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 the pancreatic tissue), using 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, curettage of the surface of the urethra is used, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
For an accurate diagnosis of chronic renal failure, it is necessary to conduct microscopy of pancreatic secretions, bacterial culture of a urine sample after massage of the gland and bacterial culture of sperm.
The spectrum of flora in chronic kidney disease is similar to the causative agents of acute inflammation of the pancreas.Most cases of chronic renal failure 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 content/concentration of bacteria 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).
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, chronic kidney disease is established on the basis of microscopy 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 the examination, the doctor should refrain from performing a transrectal examination and prostate massage.
In this situation, there is a possibility that the patient has acute prostatitis and the possibility of developing sepsis increases due to prostate massage.
CKD is characterized by increased leukocyte content in the biomaterial under the microscope and positive bacterial culture results of the biomaterial.
Bacterial culture of prostatic secretions
The implementation of this study facilitates the diagnosis of chronic renal failure.For the study, a portion of urine is used after transrectal massage of the pancreas.
The resulting material is used for bacterial culture to determine bacterial resistance to antibiotics.
The prostate massage is carried out until a white secretion is obtained from the urethra;the entire procedure may take about a minute.Before conducting the study, it is necessary to inform the patient about the research methodology and its objectives.
Sometimes, following massage of the pancreas, urine mixed with white excrement 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 changes from pH 6.5 to pH 8.0.
Prostate specific antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with proven chronic renal failure experience a marked increase in PSA.
An increase in PSA in prostatitis is not associated with an increased risk of pancreatic cancer.Based on the increase in PSA, it is impossible to distinguish between pancreatic cancer and inflammation in it;further examination is required (TRUS, pancreatic biopsy).
In patients with chronic renal failure and elevated PSA levels, it is necessary to repeat the test of this marker 6-8 weeks after the end of therapy for prostatitis.
The marker level should return to normal values once the prostatitis has healed.If elevated PSA results persist for a long time, a pancreatic biopsy is necessary to exclude other possible pathologies.
Example of three glasses
This method has historically been the standard for diagnosing chronic kidney disease.The technique was originally described in 1968. Nowadays, doctors are increasingly resorting to this study.
Instead of testing three glasses, doctors conduct a study on cultures of microorganisms in urine before and after transrectal massage of the pancreas.
This method is of great use 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 makes research possible.
Testing technique:
- The first portion of urine is 5-10 ml, collected in a separate glass and contains microorganisms of 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 portion in a separate glass).The second portion 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 portion is sent for bacterial culture.
Transrectal ultrasound
This study is informative only in the presence of a pancreatic abscess.Pancreatic abscess is a rare pathology accompanied by severe intoxication.
If TRUS is not possible and a pancreatic abscess is suspected, computed tomography may be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent exacerbations of chronic renal failure, 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 further examine the patient.
Pancreatic biopsy
The most informative study is a pancreatic biopsy.However, this procedure is rarely performed for chronic kidney disease, as microscopy and bacterial culture of the biomaterial are sufficient for an accurate diagnosis.
Microscopic examination of the biopsy sample obtained allows identification of focal infiltration of the pancreatic stroma with inflammatory cells.
The biopsy can be used for bacterial culture and for determining the sensitivity of the flora to certain antibacterial drugs.
Contraindications to performing a biopsy are severe intoxication of the patient, high fever, symptoms of acute inflammation in the pancreas (performing a biopsy in 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 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 chronic kidney disease and urethral stricture.To conduct this study, a radiopaque contrast medium is injected into the urethra and an x-ray is taken.If a urethral stricture is present, the image shows a narrowing of the contrast strip in a limited area.
Chronic non-bacterial 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 media.
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 course of treatment is 30-40 days.According to modern studies, among patients of group IIIA it is preferable to use short antibacterial therapy (2 weeks), while among patients of 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.
- CNP is equally common among different ethnic groups.
Risk factors for CNP:
- Damage (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation in 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 prostatitis symptoms.
The clinical picture of CNP is very varied and may not differ from the clinical picture of CKD.
Diagnostics
The diagnosis of CNP is established on the basis of symptoms, physical examination of the patient by a urologist, study of medical history and additional laboratory tests.
The following is used in the diagnosis of CNP:
- Digital rectal exam: The posterior surface of the pancreas is examined transrectally.On palpation, the pancreas may be markedly tender, firm, and slightly enlarged.
- A general urinalysis 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 your daily diet (they contain a large amount of antioxidants and help reduce inflammation in the internal organs).
- Reduce wheat products in your diet.
- Taking probiotics during antibacterial therapy.
- Increased 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 a pronounced anti-inflammatory activity.
- Drink water daily.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 contraceptive methods.
- Avoid injury to the perineal area.Cycling or cycling can damage the pancreas and contribute to the development of inflammation within it.
- Drink cranberry juice, juice, decoction of cranberries.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 to drink alcohol.
- Avoid the use of spices.Spices can aggravate the symptoms of prostatitis.
- Reduce caffeine consumption.Caffeine leads to irritation of the pancreas and worsening of prostatitis.