Chronic prostatitis is a chronic inflammation in 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 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) 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 pelvic pain syndrome (no 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 a study of discharge from the pancreas, 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 patient complaints.This type of prostatitis is diagnosed accidentally, during a biopsy of the prostate to exclude another possible pathology (prostate cancer).
The fourth type of prostatitis is established on the basis of a biopsy, examination of a surgical specimen, or semen analysis taken not because of the patient’s complaints about specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated levels of PSA (prostate-specific antigen).With prolonged elevated PSA during antibacterial therapy, 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 gland (PG).CKD causes a characteristic clinical picture, in which recurrent inflammation of the urinary system organs comes to the fore (most often, exacerbation 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 an overgrowth of pathogenic microorganisms in a culture of prostatic secretions, semen, or a portion of 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 symptom complex of prostatitis is very common.Approximately half of men develop a clinical picture during their lifetime that is similar to that of prostatitis.
This set of symptoms accounts for 8% of all visits to a 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 associated with 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 treatment is accompanied 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 the antibiotic.
A complicating factor in the diagnosis of prostatitis are “fastidious” microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause CKD, but do not grow well in nutrient media.
In this case, the situation may 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.
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 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 communicating ducts with poor drainage ability, which can lead to stagnation of gland secretion.
With age, the pancreas increases, symptoms of obstruction of the urinary system develop, and urine reflux into the ducts of the gland.
Urine 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 the formation of stones 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 an ascending infection against the background of urethritis or when infected urine enters the ducts of the gland.
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 in pancreatic cells; the concentration of the drug in the cell depends on its passive diffusion through the membrane.
The most common causative agents 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 the 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 the prostatic secretion.
Infection with Escherichia coli (E. coli) 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 usually inhabit the anterior urethra and can “contaminate” the material when it is obtained, 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 infection of the pancreas.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 infection are:
- Ascending infection from the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic ducts.
- Migration of bacteria from the rectum or its lymphogenous spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients suffer from symptoms associated with prostatitis.
Approximately 5 out of 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 suffer from bacterial prostatitis.
Symptoms of prostatitis develop most often 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 prostatitis symptoms is 10% in the age group of men from 20 to 74 years.
Prognosis for CKD
The cure rate when treated with a drug from the sulfonamide 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 CKD and the incidence of dysfunction in 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) 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 noted; patients more often complained of early ejaculation during sex.
In a study of 110 infertile men with CKD, 78 had a good result 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, 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 prescribed a fluoroquinolone drug.In the group of patients with a poor 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 patient interview are specific to inflammation of the pancreas and allow the doctor to narrow the search for 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 urinary tract obstruction or irritation: increased frequency of urination, urination in small portions, decreased stream pressure, nocturia (increased urination at night), urinary incontinence.
Often, patients with CKD complain of discharge from the urethra (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 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 a timely manner 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 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.
- Myalgia of pelvic floor tension.
- 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.
- Abscess of the pancreas.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), through 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, scraping from the surface of the urethra is used, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
Diagnostics
For an accurate diagnosis of CKD, 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 CKD is similar to 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 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 in the 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 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 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 an increased content of leukocytes in the biomaterial under microscopy, and positive results of bacterial culture of the biomaterial.
Bacterial culture of prostate discharge
Carrying out this study facilitates the diagnosis of CKD.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.
Prostate massage is carried out until a white discharge is obtained from the urethra; the entire procedure may 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 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 shifts from pH 6.5 to pH8.0.
Prostate-specific antigen (PSA)
Routine PSA testing for prostatitis is not recommended.Most patients with proven CKD experience a marked increase in PSA.
Increased 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 inflammation in it; additional examination is required (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 prostatitis therapy.
The marker level should return to normal values when prostatitis is cured.If elevated PSA test results persist for a long time, a pancreatic biopsy is necessary to exclude other possible pathologies.
Sample of three glasses
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 makes it possible for 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 into 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 about 5-10 ml, collected in a separate glass.The third portion is sent for bacterial culture.
Transrectal ultrasonography
This study is informative only in the presence of a pancreatic abscess.Pancreatic abscess is an uncommon pathology that is 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 CKD, pancreatic stones may be a significant trigger for recurrent attacks.
The use of TRUS does not make it possible to establish 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 for CKD, since microscopy and bacterial culture of the biomaterial are sufficient for accurate diagnosis.
Examination of the obtained biopsy specimen under a microscope makes it possible to identify focal infiltration of the pancreatic stroma with inflammatory cells.
The biopsy can be used for bacterial culture and determination of 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 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 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 conduct 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 a narrowing of the contrast strip in a limited area.
Chronic nonbacterial prostatitis (CNP)
CNP is a disease accompanied by chronic inflammation in 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 (inflammatory syndrome of chronic pelvic pain, 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, it is preferable to use short (2 weeks) antibacterial therapy among patients of group IIIA, while among 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:
- Damage (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation in the gland tissue.
- Previous episodes of inflammation of the pancreas.
- 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 established.Scientists suggest that the possible etiology of CNP lies in a combination of several factors: the psycho-emotional characteristics of the patient, immunity 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.
Diagnostics
The diagnosis of CNP is established based on symptoms, a physical examination of the patient by a urologist, a 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.On palpation, the pancreas may be markedly painful, firm, and somewhat enlarged in size.
- 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
- Increasing the volume of fruits and vegetables in the daily diet (contain a large amount of antioxidants and help reduce inflammation in internal organs).
- Reducing wheat products in the diet.
- Taking probiotics during antibacterial therapy.
- Increasing consumption of polyunsaturated fatty acids.
- Increase in plant protein in the diet and decrease in animal protein.
- Drinking green tea.Green tea contains catechins, which are good antioxidants.Catechins have pronounced anti-inflammatory activity.
- Drinking your daily water intake.Sufficient hydration of the body helps prevent urinary tract infections and, as a result, prostatitis.
- Maintaining physical fitness and normal body weight.
- Avoiding stressful situations.
- Maintain personal hygiene.
- Use of barrier methods of contraception.
- Avoiding injuries to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation in it.
- 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.
- Limiting or refusing to drink alcohol.
- Avoiding the use of spices.Spices can aggravate prostatitis symptoms.
- Reduce caffeine consumption.Caffeine leads to irritation of the pancreas and worsening of prostatitis.