Chronic prostatitis is chronic inflammation of the prostate gland (prostate may be abbreviated hereafter), and the etiology of the inflammatory process may be different in different patients.Therefore, 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 non-bacterial prostatitis, CNP), the fourth type, asymptomatic inflammatory prostatitis.
The NIH classification of prostatitis (1999) recommends 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 part 3 of urine, seminal fluid)
- III B – non-inflammatory chronic pelvic pain syndrome (no leukocytes in the urine, seminal fluid)
- Type IV - asymptomatic prostatitis (the inflammatory process is determined by histology)
A 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 examination of pancreatic secretions, the clinic and the results of bacterial culture.
Even in the absence of a bacterial component of prostatitis, empiric antibacterial therapy (fluoroquinolones or sulfonamides) is usually performed initially.
There are no patient complaints in the fourth type of prostatitis.This type of prostatitis is diagnosed incidentally during a biopsy of the prostate to rule out another possible pathology (prostate cancer).
The fourth type of prostatitis is diagnosed based on a biopsy, examination of a surgical specimen, or semen analysis, 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 PSA (prostate-specific antigen) level.In case of long-term elevated PSA during antibacterial therapy, the patient should undergo regular pancreatic biopsy.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by bacterial infection of the prostate gland (PG).CKD causes a characteristic clinical picture in which recurring inflammation of the urinary tract organs comes to the fore (most often the same microorganism causes the exacerbation of the inflammation).
CKD is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatodynia.
According to the definition, CKD is associated with the overgrowth of pathogenic microorganisms in a part of the prostate secretion, semen or urine obtained after prostate massage.Microscopic examination of pancreatic secretions usually reveals 10 or more leukocytes and macrophages per field of view.
The symptom complex of prostatitis is very common.About half of men develop a clinical picture similar to prostatitis during their lifetime.
This set of symptoms accounts for 8% of all urologist visits.Patients with symptoms of prostatitis are more likely to seek medical advice than patients with pancreatic enlargement or pancreatic cancer.
Symptoms of prostatitis are often unrelated to chronic bacterial infection of the gland.Nevertheless, traditionally, patients with symptoms of prostatitis are prescribed antibacterial therapy (50% of patients with symptoms of prostatitis receive antibiotics, only 5-10% of men have these symptoms due to bacterial infection, and the treatment is accompanied by recovery of 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.
The diagnosis of prostatitis is complicated by "sensitive" microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause CKD, but do not multiply well in culture medium.
In this case, the situation can be mistaken for non-bacterial prostatitis.Further examination of the patient using bacterial nucleic acid detection technology indicates a more frequent correlation of prostatitis symptoms with bacterial infection.
Research is currently underway to explore the possible link between prostatitis and pancreatic cancer.According to the theory, anti-inflammatory drugs that reduce the activity of the cyclooxygenase enzyme may reduce the incidence of pancreatic cancer.
Etiology
Due to the anatomical structure of the pancreas, it can be a source of recurrent infections.The peripheral part of the gland consists of a system of connecting channels with poor drainage, which can lead to stagnation of the gland's secretion.
With age, the pancreas grows, symptoms of urinary tract obstruction develop, and urine flows back into the ducts of the gland.
Urinary reflux is also possible with the development of urethral stricture.Backflow of still sterile (bacteria-free) urine can cause chemical irritation and cause tubular fibrosis and stone formation in the pancreatic ducts, which subsequently leads to intraductal obstruction and stagnation of pancreatic secretions.
When stagnation occurs, the bacterial flora can join the exudate, which can lead to the development of a chronic infection focus with periodic exacerbations.
An infection of the pancreas can develop as a result of an infection arising in 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 the tissues.There are no active mechanisms for the transfer of antibacterial drugs in the cells of the pancreas;the cellular concentration of the active substance depends on its passive diffusion through the membrane.
The most common causes of CKD are:
- 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 effectiveness of antibacterial drugs is the acidity of the prostatic secretion (pH = 6.4), which is significantly lower than the acidity of plasma (plasma pH = 7.4), and reduces the diffusion of highly acidic antibiotics into the prostatic secretion.
Escherichia coli (E. coli) infection in CKD occurs in 8 out of 10 patients.Other pathogens occur much less frequently.The role of gram-positive flora (Staphylococcus epidermidis and S. saprophyticus) in the development of CKD is controversial.
These microorganisms usually live in the anterior urethra and when obtained can "contaminate" the material, 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 precisely determine the source of the infection of the pancreas.It is a known source of ascending urethral infection due to the frequent association of prostatitis and gonococcus flora of the urethra (gonococcal urethritis).
The most common ways of transmission of the infection include:
- Infection ascending from the urethra.
- Backflow 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, 25% of urological patients suffer from prostatitis-related symptoms.
About 5 out of 10 patients develop symptoms similar to those of pancreatitis during their lifetime.Less than 5-10% of men with symptoms of pancreatitis have bacterial prostatitis.
The symptoms of prostatitis most often appear in the 36-50 age group.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 between 20 and 74 years.
Prognosis of CKD
The cure rate with sulfonamide drugs 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 heart disease or Crohn's disease).
Studies show that prostatitis leads to changes in mental status that are similar to those in patients with diabetes mellitus and chronic heart failure.
Retrospective studies show a correlation between the severity of CKD and the occurrence of male sexual dysfunctions (erectile dysfunction, duration of sexual intercourse, premature ejaculation).The exact nature (psychogenic or somatic cause) of these diseases is still unclear.
In one study, scientists compared the course of CKD during C. trachomatis infection and during infection with the most common uropathogenic flora.
A lower quality of life was observed in the group infected with C. trachomatis;patients more often complained of premature ejaculation during sex.
In a study involving 110 infertile men with CKD, 78 had good results when prescribed a drug from the fluoroquinolone group: sperm motility significantly increased, the number of leukocytes in the seminal fluid decreased, the viscosity of the seminal fluid decreased, and 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 they were prescribed a fluoroquinolone drug.In the group of patients who responded poorly to antibiotics, these indicators worsened.
Clinical picture
Patients with chronic kidney disease often come to the doctor with a list of subjective complaints.Only a small part of the complaints described during the patient interview are characteristic of pancreatitis and allow the doctor to narrow down the search for pathology.
Patients complain of pain in the perineum, head of the penis, testicles, rectum, lower abdomen, and back.
Periods of exacerbation of pancreatic infection alternate with periods of asymptomatic disease.
Patients may experience symptoms of urinary tract obstruction or irritation: more frequent urination, urination in small amounts, decreased flow pressure, nocturia (increased nighttime urination), urinary incontinence.
Patients with chronic kidney disease often complain of urethral discharge (can be colorless or milky), pain during ejaculation, blood in the ejaculate, and erectile dysfunction of the penis.
If CKD is suspected, the urologist makes a differential diagnosis with another common pathology from the list below:
- Acute prostatitis.It is accompanied by a more pronounced clinical picture, severe poisoning and severe pancreatic symptoms.If it is not treated in time or inappropriate antibacterial therapy is used, it can become a chronic pancreatic infection and can be complicated by an abscess of the gland.
- Prostate stones.
- Obstruction of the urinary tract due to benign pancreatic enlargement, urethral stricture, bladder neck dysfunction.It is accompanied by symptoms of slow flow.They are not accompanied by poisoning, bacterial growth in pancreatic secretions or the 3rd part of urine.
- Pelvic floor tension myalgia.
- Cystitis.Cystitis is accompanied by an increased urge to urinate, the patient urinates in small amounts, poisoning, pain in the lower abdomen.
- Abscess of the pancreas.Pancreatic abscess is a rare complication of acute prostatitis.It is accompanied by severe poisoning and severe pain in the perineum.In some cases, the pancreatic abscess can be palpated through the rectum (as an area of softening of the pancreatic tissue), with transrectal ultrasound, with 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, scraping from the surface of the urethra is used, followed by microscopic examination and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
Accurate diagnosis of CKD requires microscopic examination of pancreatic secretions, bacterial culture of the urine sample after massaging the gland, and bacterial culture of sperm.
The spectrum of the flora of CKD is similar to that of the pathogens of acute pancreatitis.Most chronic kidney diseases are associated with a single pathogen, but a combination of several bacteria is not uncommon as the source of prostatitis.
When examining the urine, it is important to compare the bacteria content/concentration of the three doses (it is characteristic of CKD that the microbial concentration in the 3rd dose, at the end of urination, is higher than at the beginning and in the middle of urination).
During microscopic examination of the material, the detection of more than 10 leukocytes indicates the presence of a pronounced inflammatory syndrome in the visual field.
Microscopic examination
Most often, CKD is diagnosed by microscopic examination of pancreatic secretions and urine after transrectal massage of the pancreas.If the patient has symptoms suggestive of an acute urogenital infection or fever at the time of the examination, the physician should refrain from transrectal examination and prostate massage.
In this situation, there is a possibility that the patient is suffering from acute prostatitis, and the possibility of developing sepsis increases due to prostate massage.
CKD is characterized under the microscope by an increased leukocyte content in the biomaterial and positive results of bacterial culture of the biomaterial.
Bacterial culture of prostate secretions
Performing this test will facilitate the diagnosis of CKD.For the test, part of the urine is used after transrectal massage of the pancreas.
The resulting material is used for bacterial culture to determine the resistance of bacteria to antibiotics.
The prostate is massaged until white discharge is produced from the urethra;the entire procedure should take about a minute.Before performing the examination, the patient must be informed about the research methodology and its goals.
Sometimes, as a result of massaging the pancreas, 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 an infection of 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 have a marked rise in PSA.
Elevated 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 investigation is required (TRUS, pancreatic biopsy).
In patients with CKD and elevated PSA levels, this marker should be reassessed 6-8 weeks after completion of prostatitis therapy.
When prostatitis heals, the marker level should return to normal.If the result of the elevated PSA test persists for a long time, a pancreatic biopsy is necessary to rule out other possible pathologies.
Three glass samples
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 test 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 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 dose, the patient urinates in the toilet;After passing 150-200 ml of urine, another 10-15 ml of urine is collected (the second dose in a separate glass).The second part contains bladder microorganisms.
- The third dose is a mixture of pancreatic secretions and urine obtained after pancreatic massage and collected in a separate glass of about 5-10 ml.The third part is sent for bacterial culture.
Transrectal ultrasound
This study is informative only in the presence of a pancreatic abscess.Pancreatic abscess is an uncommon pathology accompanied by severe poisoning.
If TRUS is not possible and a pancreatic abscess is suspected, computed tomography can be performed.TRUS can be used to detect pancreatic stones.
In some patients with frequent exacerbations of chronic kidney disease, pancreatic stones can be a significant trigger for recurrent attacks.
The use of TRUS does not make it possible to make a diagnosis of CKD, although 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 investigate the patient.
Pancreatic biopsy
The most informative study is a pancreatic biopsy.However, this procedure is rarely performed in CKD, as microscopic examination of biomaterial and bacterial culture are sufficient for accurate diagnosis.
Examination of the obtained biopsy sample under a microscope enables the identification of focal infiltration of the pancreatic stroma with inflammatory cells.
The biopsy can be used for bacterial culture and to determine 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 of the pancreas (biopsy under these conditions can lead to the spread of bacteria in the patient's body and the development of bacterial sepsis).
Type IV prostatitis is diagnosed 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.In the case of persistently elevated PSA levels, a pancreatic biopsy may be necessary to rule out pancreatic cancer.
Retrograde urethrography
Retrograde urethrography is used in the differential diagnosis of CKD and urethral stricture.To perform the test, a radiopaque contrast agent is injected into the urethra and an X-ray is taken.If there is a urethral stricture, the image shows the narrowing of the contrast strip in a limited area.
Chronic non-bacterial prostatitis (CNP)
CNP is a disease accompanied by symptoms of chronic pancreatitis, prostatitis and negative results of bacterial culture of biomaterial on culture medium.
According to the modern classification, CNP belongs to type III prostatitis and is divided into groups IIIA (chronic pelvic pain inflammatory syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antibacterial drugs are used to treat CNP;the duration of the treatment is 30-40 days.According to modern studies, it is preferable to use short (2-week) antibacterial therapy in patients belonging to group IIIA, while in group IIIB, urologists try to avoid the use of antibiotics.
Epidemiology
CNP can develop in any age group.
- Most often, CNP develops at the age of 35-45.
- CNP is equally common in different ethnic groups.
Risk factors for CNP:
- Damages (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation in the glandular tissue.
- Previous episodes of pancreatitis.
- Tension.
- General hypothermia, perineal hypothermia during prolonged sitting on cold surfaces.
- Disturbances in the psycho-emotional state.
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 variable and may not differ from the clinical picture of CKD.
Diagnostics
The diagnosis of CNP is made based on symptoms, a physical examination of the patient by a urologist, a study of the medical history, and additional laboratory tests.
The following are used to diagnose CNP:
- Digital rectal examination: the posterior surface of the pancreas is examined transrectally.On palpation, the pancreas may be very painful, firm and slightly enlarged.
- A general urinalysis shows an increase in leukocytes.
- Bacterial cultures of urine and pancreatic secretions do not result in the growth of microorganisms.
- Bacterial inoculation 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).
- Reducing wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- An increase in the consumption of polyunsaturated fatty acids.
- Increase plant protein in your diet and decrease animal protein.
- Drinking green tea.Green tea contains catechins, which are good antioxidants.Catechins have a pronounced anti-inflammatory effect.
- Consumption of daily water intake.Adequate hydration of the body helps prevent urinary tract infections and, as a result, prostatitis.
- Maintaining physical fitness and normal body weight.
- Avoiding stressful situations.
- Observe personal hygiene.
- Use of contraceptive methods.
- Avoiding injuries to the perineal area.Horse riding or cycling can damage the pancreas and contribute to inflammation.
- Drink cranberry juice, fruit juice, cranberry decoction.These fruit juices and decoctions have a pronounced uroseptic effect and can prevent the development of inflammation in the organs of the urogenital system.
- Limiting or refusing to drink alcohol.
- Avoiding the use of spices.Spices can aggravate the symptoms of prostatitis.
- Reduce your caffeine intake.Caffeine leads to irritation of the pancreas and exacerbation of prostatitis.