Chronic prostatitis is a chronic inflammation of the prostate gland (hereinafter the abbreviation “prostate” may be used), and the etiology of the inflammatory process may be different in different patients.For this reason, 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) and 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 third part of the urine, seminal fluid)
- III B – non-inflammatory chronic pelvic pain syndrome (no leukocytes in urine, semen)
- 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 associated with a bacterial infection of the pancreas.The diagnosis is based on an examination of discharge from the pancreas, clinical and the results of a bacterial culture.
As a rule, even if there is no bacterial component of prostatitis, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is carried out first.
With the fourth type of prostatitis, there are no patient complaints.This type of prostatitis is diagnosed accidentally during a prostate biopsy to exclude another possible pathology (prostate cancer).
The fourth type of prostatitis is determined on the basis of a biopsy, examination of a surgical sample or semen analysis, which is not carried out based on the patient's complaints about specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by an increased PSA level (prostate-specific antigen).With a prolonged increase in PSA during antibiotic therapy, the patient is recommended to undergo regular pancreatic biopsies.
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 the focus is on recurrent inflammation of the organs of the urinary system (most often the exacerbation of the 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 excessive growth of pathogenic microorganisms in a culture of prostatic secretion, 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 condition similar to prostatitis during their lifetime.
These symptoms account 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 associated with a chronic bacterial infection of the gland.Despite this fact, patients with symptoms of prostatitis are traditionally 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 accompanied by the patient's cure).
In most cases, antibiotic therapy leads to positive disease dynamics 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) that can cause CKD, but do not reproduce well in nutrient media.
In this case, the situation may be incorrectly interpreted as nonbacterial prostatitis.Further examination of the patient using bacterial nucleic acid detection technologies indicates a more common association between prostatitis symptoms and bacterial infections.
The possible connection between prostatitis and pancreatic cancer is currently being researched.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
Due to its anatomical nature, the pancreas 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 increasing age, the pancreas enlarges, symptoms of blockage of the urinary system and urine backflow into the glandular ducts occur.
With the development of a urethral stricture, urinary reflux is also possible.Reflux of urine, even sterile (without bacteria), can cause chemical irritation and trigger tubular fibrosis and the formation of stones in the pancreatic ducts, subsequently leading to intraductal obstruction and stagnation of pancreatic secretions.
If there is stagnation, the 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 gland ducts.
Infection of the gland can last for a long time due to the low accumulation of antibacterial drugs in its tissues.There are no active mechanisms for delivery 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 pathogens causing 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 the plasma acid content (plasma pH = 7.4) and reduces the diffusion of high acidity antibiotics into the prostatic secretion.
Escherichia coli (E. coli) infection in chronic kidney disease 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 normally colonize the anterior urethra and can “contaminate” the obtained material, leading to incorrect conclusions.Therefore, patients are prescribed treatment based on the second bacterial culture of the material.
Transmission of an infection
In most cases, it is not possible to determine the exact source of pancreatic infection.Ascending urethral infection is a known cause, as prostatitis is often associated with gonococcal flora in the urethra (gonococcal urethritis).
The most common routes of transmission of infections include:
- Ascending infection from the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic ducts.
- Migration of bacteria from the rectum or their lymphogenic spread.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urological patients suffer from symptoms associated with prostatitis.
Approximately 5 in 10 patients will develop symptoms similar to pancreatitis during their lifetime.Less than 5-10% of men with symptoms of pancreatitis have bacterial prostatitis.
Symptoms of prostatitis most often occur in the age group of 36 to 50 years.Prostatitis is the most common urological problem in patients under 50 years of age and the third most common urological pathology in patients over 50 years of age.The frequency of prostatitis symptoms is 10% in the men's age group from 20 to 74 years.
Prognosis for CKD
The cure rate when treated with a drug from the sulfonamide group is 30-40%, and 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 artery disease or a patient with Crohn's disease).
Studies show that prostatitis causes changes in mental status comparable to the extent of mental changes in patients with diabetes mellitus and chronic heart failure.
Retrospective studies indicate an association between the severity of CKD and the occurrence of sexual dysfunction 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 C. trachomatis-infected group, patients were found to have a lower quality of life;Patients complained more often about early ejaculation during sex.
In a study of 110 infertile men with chronic kidney disease, 78 achieved a good result when they were prescribed a drug from the group of fluoroquinolones: 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 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 proportion of the complaints described in the patient consultation are specific to inflammation of the pancreas and enable the doctor to narrow down the pathology search.
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 pancreatic infection alternate with periods of asymptomatic disease.
Patients may experience symptoms of urinary tract obstruction or irritation: increased urination, urination in small portions, decreased jet pressure, nocturia (increased urination at night), urinary incontinence.
Patients with chronic kidney disease often complain of urethral discharge (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 following list:
- Acute prostatitis.Accompanied by a more pronounced clinical picture, severe intoxication and severe pancreatic problems.If not treated in a timely manner or with incorrect antibacterial therapy, a chronic infection of the pancreas can occur 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 associated with poisoning, an increase in bacteria in the pancreatic secretion or the third portion of urine.
- Myalgia of pelvic floor tension.
- Cystitis.Cystitis 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.A 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), by transrectal ultrasound and computed tomography of the pelvic organs.
- Urethritis.Urethritis is accompanied by mild intoxication, pain at the beginning of urination and discharge from the urethra.When diagnosing urethritis, the surface of the urethra is scraped, followed by microscopy and nucleic acid analysis.
- Tuberculous prostatitis.
diagnosis
For an accurate diagnosis of chronic kidney disease, it is necessary to conduct a microscopy of pancreatic secretions, a bacterial culture of a urine sample after gland massage, and a bacterial culture of sperm.
The spectrum of flora in CKD is similar to the pathogens of acute inflammation of the pancreas.Most CKD cases are associated with a single pathogen, but a combination of several bacteria that triggers 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 third part, 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 when microscopy of the material indicates the presence of a pronounced inflammatory syndrome.
Microscopic examination
Most often, chronic kidney disease is diagnosed by microscopy of pancreatic secretions and urine after transrectal massage of the pancreas.If the patient has symptoms of acute genitourinary infection or fever at the time of the examination, the doctor should refrain from conducting transrectal examination and prostate massage.
In this situation, there is a possibility that the patient may suffer from acute prostatitis and the likelihood of sepsis due to prostate massage increases.
CKD is characterized by an increased leukocyte content in the biomaterial under the microscope and positive results of bacterial culture of the biomaterial.
Bacterial culture of prostate discharge
Conducting this study will make the diagnosis of CKD easier.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 the antibiotic resistance of the bacteria.
Prostate massage is performed until white discharge appears from the urethra;The entire process can take about a minute.Before conducting the study, it is necessary to inform the patient about the research methodology and its goals.
Sometimes massaging the pancreas releases urine mixed with white feces from the urethra;In this case, the resulting liquid is subjected to bacterial culture.When the pancreas becomes infected, 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 chronic kidney disease experience a significant increase in PSA.
Elevated PSA levels in prostatitis are not associated with an increased risk of pancreatic cancer.Due to an increase in PSA, it is impossible to distinguish between pancreatic cancer and inflammation within it;Additional examination is required (TRUS, pancreas biopsy).
In patients with chronic kidney disease and elevated PSA levels, it is necessary to retest this marker 6-8 weeks after the end of prostatitis therapy.
When the prostatitis is cured, the marker value should return to normal values.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 historically been the standard for diagnosing CKD.The technique was originally described in 1968.Doctors are currently increasingly relying on 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 of greatest benefit 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 containing microorganisms from the urethra.
- After collecting the first portion, the patient urinates into the toilet;After 150-200 ml of urine is excreted, another 10-15 ml of urine is collected (the second portion 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 and collected in a separate glass.The third part is sent for bacterial culture.
Transrectal ultrasound examination
This study is only meaningful in the presence of a pancreatic abscess.Pancreatic abscess is a rare pathology associated with 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 CKD exacerbations, pancreatic stones may be a major trigger for recurrent attacks.
The use of TRUS does not allow 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 conduct additional examination of the patient.
Pancreas biopsy
The most informative study is a pancreas biopsy.However, this procedure is rarely performed in CKD, since microscopy and bacterial culture of the biomaterial are sufficient for an accurate diagnosis.
Examination of the obtained biopsy sample under the microscope allows 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 and 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 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 for 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 a narrowing of the contrast strip in a limited area.
Chronic nonbacterial prostatitis (CNP)
CNP is a disease associated with chronic inflammation of the pancreas, symptoms of prostatitis and negative results of bacterial culture of biomaterial on nutrient media.
According to the modern classification, CNP belongs to type III prostatitis 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 duration of treatment is 30-40 days.According to modern studies, in patients of group IIIA it is preferable to carry out 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.
- CNP most commonly develops between the ages of 35 and 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 pancreatic inflammation.
- Stress.
- General hypothermia, hypothermia of the perineum during prolonged sitting on cold surfaces.
- Disturbances in the psycho-emotional state.
The exact cause of CNP is not yet clear.Scientists suggest that the possible etiology of CNP lies in a combination of several factors: the patient's psycho-emotional characteristics, immune system 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 be different from the clinical picture of CKD.
diagnosis
The diagnosis of CNP is made based on symptoms, a physical examination of the patient by a urologist, a review of medical history, and additional laboratory tests.
When diagnosing CNP, the following are used:
- Digital rectal examination: The posterior surface of the pancreas is examined transrectally.On palpation, the pancreas may be noticeably painful, firm, and somewhat enlarged.
- A general urine test shows an increase in leukocytes.
- Bacterial culture of urine and pancreatic secretions does not lead to the growth of microorganisms.
- Bacterial seeding of sperm prevents the growth of microorganisms.
Disease prevention
- Increasing the amount of fruits and vegetables in the daily diet (contain a large amount of antioxidants and help reduce inflammation in internal organs).
- Reduce wheat products in your diet.
- Taking probiotics during antibiotic therapy.
- Increasing consumption of polyunsaturated fatty acids.
- Increasing plant protein in the diet and decreasing animal protein.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechins have a pronounced anti-inflammatory effect.
- Drink your daily water intake.Keeping the body hydrated helps prevent urinary tract infections and thus prostatitis.
- Maintaining physical fitness and normal body weight.
- Avoid stressful situations.
- Pay attention to personal hygiene.
- Use of barrier methods for contraception.
- Avoiding injuries to the perineal area.Riding or cycling can damage the pancreas and contribute to the development of inflammation in the pancreas.
- Drink cranberry juice, juice and lingonberry decoction.These juices and decoctions have a pronounced uroseptic effect and are able to prevent the development of inflammation in the organs of the urogenital system.
- Restriction or refusal to consume alcohol.
- Avoid using spices.Spices can worsen the symptoms of prostatitis.
- Reduce caffeine consumption.Caffeine causes irritation of the pancreas and aggravation of prostatitis.