Chronic prostatitis is a chronic inflammation of the prostate gland (hereinafter referred to as prostatitis) and the cause of the inflammatory process may be different in different patients.That is why the classification of prostatitis is constantly being revised and updated.
According to the (NIH) classification, chronic prostatitis includes the second type, or 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 – chronic pelvic pain inflammatory syndrome (leukocytes in the third part of urine, semen)
- III B – chronic non-inflammatory pelvic pain syndrome (no white blood cells in urine, semen)
- Type IV – asymptomatic prostatitis (inflammatory process 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.Diagnosis is based on the study of secretions from the pancreas, clinic and bacterial culture results.
As a rule, even in the absence of a bacterial component causing prostatitis, empirical antibacterial therapy (fluoroquinolones or sulfonamides) is carried out initially.
With the fourth type of prostatitis, patients have no complaints.This type of prostatitis is diagnosed incidentally during a prostate biopsy to rule out another possible condition (prostate cancer).
The fourth type of prostatitis is determined on the basis of a biopsy, surgical specimen examination, or semen analysis performed other than because the patient complained of specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated PSA (prostate-specific antigen) levels.With persistently elevated PSA during antibiotic treatment, patients should undergo periodic pancreatic biopsies.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by infection of the prostate gland (PG).Chronic kidney disease causes a characteristic clinical picture in which recurrent inflammation of the organs of the urinary system appears (usually, the exacerbation of inflammation is caused by the same microorganisms).
CKD is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatitis.
By definition, CKD is associated with the overgrowth of pathogenic microorganisms in cultures of prostatic secretions, semen, or aliquots of urine obtained after prostate massage.As a rule, microscopy of pancreatic secretions shows 10 or more leukocytes and macrophages in a field of view.
Complicated symptoms of prostatitis are very common.About half of men have clinical manifestations similar to 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.
Usually the symptoms of prostatitis are not related to chronic bacterial infection in the gland.Despite this, traditionally, patients with symptoms of prostatitis are prescribed antibacterial therapy (50% of patients with symptoms of prostatitis are treated with antibiotics, in only 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 disease dynamics due to the placebo effect or anti-inflammatory effect of antibiotics.
A complicating factor in the diagnosis of prostatitis is “fastidious” microorganisms (chlamydia, mycoplasma, ureaplasma), which can cause chronic kidney disease but do not grow well in nutritional environments.
In this case, the condition may be misunderstood as nonbacterial prostatitis.Further examination of patients using bacterial nucleic acid detection technology revealed 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 cyclooxygenase enzyme activity may lead to a reduced incidence of pancreatic cancer.
reason
The pancreas, due to its anatomical structure, can serve as a source of recurrent infection.The periphery of the gland includes a system of ducts with poor drainage, which can lead to stagnation of the gland.
With age, the pancreas enlarges, symptoms of urinary tract obstruction develop, and urine refluxes into the ducts of the gland.
Urinary reflux can also occur when there is development of urethral stricture.Backflow of urine, even sterile (bacteria-free), can cause chemical irritation and initiate pancreatic duct fibrosis and intraductal stone formation, which then leads to intraductal obstruction and stagnation of pancreatic secretions.
When stagnation occurs, the bacterial flora can participate in excretion, leading to the formation of a chronic infection with periodic exacerbations.
Infection of the pancreas can develop as a result of ascending infection against a 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 is no known mechanism of action for the delivery of antibacterial drugs into pancreatic cells;Intracellular drug concentration depends on passive diffusion of the drug across the membrane.
The most common pathogens 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 effectiveness of antibacterial drugs is the acidity of prostatic secretions (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 prostatic secretions.
Escherichia coli (E. coli) infection 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 often reside in the anterior urethra and can “contaminate” the material once retrieved, leading to erroneous conclusions.Therefore, the treatment prescribed to the patient is based on a second bacterial culture of the material.
Infectious
In most cases, it is not possible to accurately determine the source of infection of the pancreas.Ascending urethral infection is a known cause due to the frequent association of prostatitis with gonococcal bacteria in the urethra (gonococcal urethritis).
Among the most common routes of disease transmission are:
- Infection ascends from the urethra.
- Reflux of urine containing pathogenic microorganisms into the pancreatic duct.
- Movement of bacteria from the rectum or spread through the lymphatic system.
- Bacterial penetration through the bloodstream.
Epidemiology
According to statistics, up to 25% of urological patients suffer from symptoms related to prostatitis.
About 5 out of 10 patients will develop symptoms similar to pancreatitis during their lifetime.Fewer than 5-10% of men with symptoms of pancreatitis have bacterial prostatitis.
Symptoms of prostatitis develop most often between the ages of 36-50.Prostatitis is the most common urinary disease in patients under 50 years old and the third most common urinary disease in patients over 50 years old.The frequency of prostatitis symptoms is 10% in the age group of men from 20 to 74 years old.
Prognosis of chronic kidney disease
The cure rate when treated with sulfonamide drugs is 30-40%, with fluoroquinolones - 60-90%.
Illness
Pancreatitis significantly affects the patient's quality of life (quality of life decreases to the level of patients with coronary heart disease or patients with Crohn's disease).
Studies show that prostatitis leads to changes in mental status comparable to those seen in patients with diabetes and chronic heart failure.
Retrospective studies indicate a relationship between the severity of CKD and the incidence of sexual dysfunction in men (erectile dysfunction, sexual intercourse time, premature ejaculation).The exact nature of the association between these diseases (psychological or physical causes) remains unclear.
In one study, scientists compared the progression of chronic kidney disease during C. trachomatis infection and during infection with the most common urinary tract-causing bacteria.
In the group infected with C. trachomatis, lower patient quality of life was observed;Patients often complain of premature ejaculation during sexual intercourse.
In a study of 110 infertile men with CKD, 78 had good results when prescribed fluoroquinolone drugs: sperm motility increased significantly, the number of white blood cells in seminal fluid decreased, semen viscosity decreased, and the content of free radicals, IL-6 and TNF-alfa decreased.
In a control group of 37 healthy men, none of the listed parameters changed when fluoroquinolone was prescribed.In the group of patients who respond poorly to antibiotics, these indicators become even more severe.
Clinical images
CKD patients often come to the doctor with a list of subjective complaints.Only a small portion of the complaints described in the patient interview are specific to pancreatitis and allow the physician 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 severe infection in the pancreas alternate with periods of asymptomatic disease.
Patients may develop symptoms of urinary tract obstruction or irritation: frequent urination, frequent urination, decreased urine flow pressure, nocturia (urinating frequently at night), urinary incontinence.
Typically, patients with CKD complain of discharge from the urethra (which may be colorless or milky), pain during ejaculation, blood during ejaculation, and impaired erectile function of the penis.
If CKD is suspected, the urologist will perform a differential diagnosis with another common condition from the list below:
- Acute prostatitis.Accompanied by a more obvious clinical picture, severe intoxication and severe symptoms in the pancreas.If not treated promptly or using the wrong antibacterial regimen, the disease can develop into a chronic infection in the pancreas and complications into a glandular abscess.
- Prostate stones.
- Urinary tract obstruction 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 the pancreatic juice or third part of the urine.
- Muscle pain due to pelvic floor tension.
- Cystitis.Cystitis is accompanied by the feeling of wanting to urinate more, the patient urinates in small portions, poisoning, and lower abdominal pain.
- 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 transrectally (defined as an area of soft pancreatic tissue), via transrectal ultrasound, or 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 urethral surface is used, followed by microscopy and nucleic acid analysis.
- Tuberculosis prostatitis.
Diagnose
To accurately diagnose chronic kidney disease, it is necessary to conduct microscopic examination of pancreatic secretions, culture of bacterial urine samples after gland massage, and culture of sperm bacteria.
The bacterial spectrum in chronic kidney disease is similar to the causative agents of acute pancreatitis.Most cases of CKD involve a single pathogen, but a combination of several bacteria as the source of prostatitis is not uncommon.
When testing urine, it is important to compare the bacterial content/concentration in the three fractions (CKD is characterized by higher bacterial concentrations in the third fraction, at the end of micturition, compared to the urine at the beginning and mid-void).
The detection of more than 10 leukocytes in the field of view when examining the material with a microscope indicates the presence of a pronounced inflammatory syndrome.
Check with a microscope
Typically, CKD is determined 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 physician should not perform rectal examination and prostate massage.
In this situation, it is likely that the patient has acute prostatitis and the likelihood of sepsis is increased by prostate massage.
CKD is characterized by an increase in leukocyte content in the biological material under the microscope and a positive result when culturing the bacteria in the biological material.
Culture of prostatic secretion bacteria
Conducting this study facilitates the diagnosis of chronic kidney disease.For the study, a portion of urine was used after massaging the pancreas through the rectum.
The resulting material is used to culture bacteria to determine their resistance to antibiotics.
Prostate massage is performed until white discharge from the urethra;The entire procedure may take about a minute.Before conducting research, patients should be informed about the research method and its goals.
Sometimes, due to massage of the pancreas, urine mixed with white feces will escape from the urethra;In this case, the resulting liquid is cultured with bacteria.When there is an infection in the pancreas, the acidity of the secretions will change 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 increase in PSA.
Increased 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;Additional testing (TRUS, pancreatic biopsy) is required.
In patients with chronic kidney disease and elevated PSA levels, this sign should be rechecked 6-8 weeks after completion of prostatitis treatment.
Marker levels will return to normal values when prostatitis is cured.If elevated PSA test results persist over a long period of time, a pancreatic biopsy is needed to rule out other possible pathologies.
Three-cup model
This method was previously the standard for diagnosing chronic kidney disease.This technique was originally described in 1968. Today, doctors increasingly use this research.
Instead of the three-cup test, doctors conduct microbial culture studies in 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 will be prescribed antibacterial drugs of the nitrofuran group, which leads to sterility of urine in the bladder and facilitates research.
Testing technique:
- The first portion of urine is 5-10 ml, is collected in a separate cup and contains microorganisms from the urethra.
- After taking the first portion, the patient urinates into the toilet;After 150-200 ml of urine has passed, take another 10-15 ml of urine (the second part is put in a separate cup).The second part contains bladder microorganisms.
- The third part is a mixture of pancreatic juice and urine, obtained after massaging the pancreas and about 5-10 ml, collected in a separate glass.The third portion was sent for bacterial culture.
Transrectal ultrasound
This study only provides information when a pancreatic abscess is present.Pancreatic abscess is a rare condition associated with severe toxicity.
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 severe chronic kidney disease, pancreatic stones may be a significant contributor to recurrent episodes.
The use of TRUS does not help establish the diagnosis of CKD, although the presence of inclusions and hypoechoic calcifications in the glandular stroma may indicate the presence of infection and chronic inflammation and prompt the physician to further examine the patient.
Pancreatic biopsy
The most informative study is the pancreatic biopsy.However, this procedure is rarely performed for CKD, as microscopy and bacterial culture of biological material are sufficient for accurate diagnosis.
Examination of the obtained biopsy specimen under a microscope helps to identify focal infiltration of pancreatic tissue with inflammatory cells.
A biopsy can be used to culture bacteria and determine bacterial sensitivity 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 determined only on the basis of a pancreatic biopsy.This type of prostatitis is characterized by asymptomatic inflammation in the glandular stroma and an increase in PSA.Persistently elevated PSA levels 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 radioactive contrast agent is injected into the urethra and X-rays are taken.If urethral stricture is present, imaging shows that the radiopaque band is narrowed 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 biomaterial bacterial cultures 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, short-term antibacterial therapy (2 weeks) should be used in group IIIA patients, while group IIIB urologists try to avoid the use of antibiotics.
Epidemiology
CNP can develop in men of any age.
- Typically, CNP develops between the ages of 35-45.
- CNP is equally common among different ethnic groups.
Risk factors for CNP:
- Damage (trauma, surgery, manipulation in the urethra) can lead to the development of inflammation in the glandular tissue.
- Previous episodes of pancreatitis.
- Emphasize.
- Hypothermia of the whole body, hypothermia of the perineum when sitting for a long time on a cold surface.
- Disturbances in psycho-emotional state.
The exact cause of CNP is unknown.Scientists believe that the possible cause of CNP lies in a combination of several factors: the patient's psychological-emotional characteristics, immune disorders, hormonal and neurological disorders.The combination of these factors leads to the development of prostatitis symptoms.
The clinical picture of CNP is diverse and may not be different from the clinical picture of CKD.
Diagnose
The diagnosis of CNP is established based on symptoms, physical examination of the patient by a urologist, study of medical history, and additional laboratory tests.
In diagnosing CNP, the following are used:
- Digital rectal examination: the posterior surface of the pancreas is examined rectally.When palpated, the pancreas may be noticeably painful, hard, and slightly enlarged in size.
- General urinalysis shows leukocytosis.
- Bacterial cultures of urine and pancreatic juice did not result in microbial growth.
- Seeding bacteria into sperm does not allow microorganisms to grow.
Disease prevention
- Increase the amount of fruits and vegetables in your daily diet (contains a large amount of antioxidants and helps reduce inflammation in internal organs).
- Reduce wheat products in the diet.
- Use probiotics during antibacterial treatment.
- Increase consumption of polyunsaturated fatty acids.
- Increase vegetable protein in the diet and reduce animal protein.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechin has obvious anti-inflammatory activity.
- Drink your daily amount of water.Staying hydrated will help prevent urinary tract infections and, therefore, prostatitis.
- Maintain physical fitness and normal body weight.
- Avoid stressful situations.
- Maintain personal hygiene.
- Use barrier contraceptives.
- Avoid trauma to the perineum.Cycling or cycling can damage the pancreas and contribute to the development of inflammation in the pancreas.
- Drink cranberry juice, juice, cranberry decoction.These juices and decoctions have a pronounced urological effect and can prevent the development of inflammation in the organs of the genitourinary system.
- Limit or refuse to drink alcohol.
- Avoid using spices.Spices can worsen prostatitis symptoms.
- Reduce caffeine consumption.Caffeine leads to stimulation of the pancreas and worsens prostatitis.