Prostatitis - Symptoms and Treatment

What is prostatitis? In the article of a doctor and urologist with 28 years of experience, we analyze the causes of the occurrence, the diagnosis and the methods of treatment.

Definition of the disease. Causes of the disease

Inflammation of the prostateAn inflammatory process in the tissue of the prostate, accompanied by pain in the lower back, perineum, or pelvic region, as well as a disorder of the work of the lower urinary tract.

The prostate (prostate) refers to the male reproductive system. It sits in front of the rectum, under the bladder, and surrounds the urethra (urethra). This is why when the prostate gland becomes inflamed, it compresses the urethra, leading to various additional urination problems. The main function of the prostate is the formation of secretions (fluid) that are part of the sperm and liquefy to ensure the normal motility of the sperm.

Abnormal conditions of the prostate gland, such as cancer or benign hyperplasia, are more common in elderly patients. Prostatitis differs in that it affects men of all ages, but the disease is most common in men of reproductive age (8-35% of cases).

Prostatitis most commonly occurs in the practice of a urologist. It can occur suddenly (acutely) or gradually, with constant and long-term (chronic) manifestations. The chronic form is much more common than the acute one. Chronic prostatitis ranks fifth among the twenty major urological diagnoses.

Prostatitis can be either an independent disease or can be combined with benign prostatic hyperplasia and prostate cancer. The incidence of prostatitis in the male population has decreased in recent years: if in 2012 the incidence fell to 275/100 thousand inhabitants, then in 2017 the primary incidence rate was 203/100 thousand inhabitants.

Causes of prostatitisbacterial (infectious) and non-bacterial (non-infectious).Infectious prostatitismost commonly in men under 35 years of age. Most often, this form of the disease is caused by gram-negative microorganisms, especially enterobacter, E. coli, dentition, pseudomonas and proteus, as well as sexually transmitted infections such as gonococcus, chlamydia, and so on. Very rarely, prostatitis for mycobacterium tuberculosis may occur. In chronic bacterial prostatitis, the spectrum of pathogens is wider and may include atypical pathogens. It should be recalled that chronic bacterial prostatitis is a polyethiological disease, i. e. it can have several causes.

Factors contributing to the development of inflammationin the prostate:

• sexually transmitted infections;
• immunodeficiency conditions;
• biopsy of the prostate;
• invasive manipulations and operations;
• Lifestyle;
• diarrhea, constipation;
• homosexual relationships;
• frequent exchange of sexual partners;
• sedentary lifestyle, etc.

Chronic, non-bacterial prostatitisthey are diagnosed in patients who complain of chronic pain in the prostate area until an infectious (bacterial) pathogen of the disease has been found in them. Despite several studies, the cause of this type of chronic prostatitis is not fully understood, but there are factors that can cause it to develop:

• increased prostate pressure;
• muscle pain in the pelvic region;
• emotional disorders;
• Autoimmune disorders (antibodies that are said to fight infection, sometimes attacking prostate cells for some reason);
• physical activity;
• irregular sex life;
• weight lifting, etc.

In some cases, prostatitis may occur after transurethral procedures such as urethral catheterization or cystoscopy, and after transrectal biopsy of the prostate.

Although the true incidence of different types of prostatitis has not been definitively determined, the following data are reported:

• acute bacterial prostatitis accounts for 5-10% of all prostatitis;
• chronic bacterial prostatitis - 6-10%;
• chronic, non-bacterial prostatitis - 80-90%;
• prostatitis, including prostatodynia (neurovegetative disorders of the prostate gland) - 20-30%.

If you experience similar symptoms, contact your doctor. Do not self-medicate - dangerous to your health!

Symptoms of prostatitis

All forms of inflammationthe prostate gland, in addition to asymptomatic, is united by the presence of the following symptoms:

• pain in the lumbar region;
• discomfort with intestinal peristalsis;
• pain in the perineum or pelvic region;
• disturbance of the work of the lower urinary tract.

The main symptoms of the lower urinary tract in the presence of prostatitis:

• frequent urination;
• difficulty urinating, i. e. , the need for poor flow and "exertion";
• burning pain or its intensity when urinating.

In diagnosed menacute bacterial prostatitisPelvic pain and urinary symptoms such as increased urination and urinary retention occur. This can lead to systemic manifestations such as fever, chills, nausea, vomiting and malaise. Acute bacterial prostatitis is characterized by a sharp onset of the disease with a vivid clinical picture. This is a serious illness.

Men were diagnosedchronic bacterial prostatitisrecord periodic symptoms that increase and decrease. In case of aggravation, pain and discomfort are observed. Feelings of pain are mainly localized at the base of the penis, around or above the anus. The pain can also occur directly above the pubic bone or in the lower back, spreading to the penis and testicles. Defecation also becomes painful. Sometimes signs of infection develop in the lower parts of the urinary system: burning pain and frequent urination, frequent urge. These symptoms may be confused with the manifestation of acute bacterial prostatitis, but usually occur suddenly, chills, fever, weakness, pain throughout the body, lower back and genitals, frequent and painful urination, pain with ejaculation. If you experience such symptoms, you should see a doctor immediately.

If standard modern examination has not found that chronic pain is caused by a pathological process in the prostate gland, then we are dealing with chronic, non-bacterial prostatitis, which is calledchronic pelvic pain syndrome(the term has been used since 2003). In the presence of chronic pelvic pain syndrome, a man’s quality of life deteriorates significantly, as this syndrome sometimes leads to a variety of psychological and sexual disorders:

• increased fatigue;
• feeling helpless;
• erectile dysfunction;
• painful ejaculation;
• pain after intercourse, etc.

In chronic nonbacterial prostatitis / chronic pelvic pain syndrome, persistent discomfort or pain occurs in the lower back, more often at the base of the penis and around the anus, for at least 3 months. Painful feelings are localized in one "target organ" or several pelvic organs. Most often, with this form of prostatitis, the pain is localized in the prostate gland (46%).

In chronic prostatitis, sexual disorders have many characteristics. First, all components of a man’s copulative (sexual) function are disturbed to varying degrees: libido, erection, ejaculation. Second, sexual dysfunction occurs mainly in individuals with a long medical history (more than 5 years). Third, sexual dysfunction is often the main reason for seeing a doctor.

Erectile dysfunction is observed in 30% of patients with chronic prostatitis, mainly due to the psychogenic factor - catastrophic detection of the disease.

Symptoms of prostatitis occur in 50% of men at least once in their lives.

Pathogenesis of prostatitis

The mechanism of prostatitis is multifaceted and very complex. Many factors are involved in its development. Most cases of acute bacterial prostatitis are caused by a cascade of processes caused by increasing urethral infection or intraprostatic reflux (reflux of urine).

Penetration of microorganisms into the prostate gland is possible by ascending pathway (through the urethra) or transrectally by the lymph. Diarrhea and constipation, which are associated with impaired rectal barrier function, are considered to be a provocative factor in chronic prostatitis. However, the mechanism by which microorganisms enter the prostate is still not clearly established.

Urinary incontinence with prostatitis can be caused by:

• increasing the tone of prostate urethral smooth muscle by increasing the activity of adrenergic receptors;
• enlargement of the prostate or narrowing of the urethra, resulting in turbulent urine flow, bladder outlet obstruction, and intraprostatic reflux.

In the future, the drainage of prostate ducts, stagnation of prostate secretions, edema, activation of the arachidonic acid cascade, inflammation and ischemia will be violated. A vicious circle of pathological changes is formed.

Classification and developmental stages of prostatitis

There are 4 main categories (types) of prostatitis.

1. Acute bacterial prostatitis(Category I).
2. Chronic bacterial prostatitis(Category II).
3. Chronic, non-bacterial prostatitis / syndromechronic pelvic pain (category III). It can be inflammatory (category III A) or non-inflammatory (category III B).
4. Asymptomatic inflammatory prostatitis.Histological prostatitis identified by prostate biopsy (Category IV).

Chronic bacterial prostatitisUnlikespicy,manifests as recurrent episodes of exacerbation with or without complete remission. Symptoms are usually less severe than acute prostatitis.

Classification of National American Institutes of Health. . .

• Type I(acute bacterial prostatitis) - an acute infection of the prostate gland: the symptoms of the disease appear suddenly. Chills, fever, pain throughout the body, weakness, pain in the lower back and genital area, frequent, painful urination, pain during ejaculation. Possible symptoms of acute bacterial prostatitis include blood in the urine and / or sperm. This is rare. It is effectively treated with antibiotics.
• Type II(chronic bacterial prostatitis) - a chronic or recurrent infection of the prostate gland: the symptoms are the same as in acute prostatitis, but they appear gradually and are less pronounced. Multiple antibiotic therapies may be required.
• Type III(chronic, non-bacterial prostatitis and chronic pelvic pain syndrome): no evidence of infection.
• III Type A: presence of leukocytes in the ejaculate / prostate secretions / in the third part of the urine received after the prostate massage.
• Type III B.: lack of leukocytes in ejaculate / prostate secretion / third of urine received after prostate massage. Pain in the lower back and genital area, frequent urination, difficulty urinating (often at night), burning or painful urination and ejaculation. It accounts for about 90% of all cases of prostatitis. There are no known causes or clinically proven treatments.
• Type IV(asymptomatic inflammatory prostatitis): Sometimes an increased white blood cell count. No treatment is required. It was detected on a prostate biopsy.

The boundaries between different forms of prostatitis are blurred.

Complications of prostatitis

In addition to inflammatory lesions of the prostate gland, nearby organs are involved in the pathological process: the gonad, the Cooper glands, the bladders, and the posterior urethra. The infection can enter the prostate and surrounding organs at the same time.

Vesiculitis- inflammation of the bladders. The pains are localized in the groin area and deep in the pelvis, radiating to the sacrum. The pain is usually unilateral, as both seminal vesicles are affected to varying degrees. Vesiculitis may be asymptomatic. The only complaint of patients may be the presence of blood in the sperm. Intermittent pyuria (pus in the urine) and pyospermia (pus in the ejaculate) are also observed.

Posterior urethritis, colliculitis (inflammation of the tuberculosis). . . In prostatitis, the infection penetrates the gonads, due to the fact that the prostate gland is close to the excretory ducts.

Abscess of the prostate gland.Pathogens that cause prostatitis can also cause abscesses in the prostate gland. It is a severe septic (bacterial) disease accompanied by weakness, fever, chills and sweating. In some cases, confusion and delirium may be observed. The patient needs hospital treatment.

Prostate sclerosis (fibrosis).This is a late complication of prostatitis based on the replacement of prostate tissue with scars (connective tissue degeneration, i. e. sclerosis), which leads to the fact that the gland shrinks, decreases in size and completely loses its function. As a general rule, sclerotic symptoms develop long after the onset of the inflammatory process in the prostate gland.

Prostate cysts.These formations can contribute to the formation of stones in the prostate. The presence of infection in the cyst can lead to prostate abscess. Diagnosis of a prostate cyst by ultrasound is not difficult. They can also be detected by digital rectal examination.

Prostate stones.They are quite common. The causes of the disease are not fully understood, but most experts agree that they occur as a result of a prolonged inflammatory process in the prostate gland. The stones are single and multiple, 1–4 mm in diameter. Large stones are rare. The stones clog the gland, causing the secret to stagnate in it, the gland to overstretch, to form discrete cysts into which the infection enters. Patients with stones in the prostate gland have to deal with the constant dull pain in the blunt perineum. Painful feelings spread to the vaginal penis and trigger frequent urination stimuli, which becomes difficult and painful.

Infertility.Chronic, long-term prostatitis primarily reduces the motor function of sperm, making them completely immobile. One consequence is a violation of their production, the formation of immature sperm that have abnormally changed shape (and are in smaller numbers than before).

Ejaculation disorder.All forms of prostatitis cause sexual dysfunction. At first, patients face premature ejaculation, a normal erection that then weakens and the rate of orgasm decreases. The prolonged presence of chronic prostatitis contributes to a decrease in the production of male sex hormones and a weakening of libido.

Erectile dysfunction.The association between chronic prostatitis / chronic pelvic pain syndrome and erectile dysfunction has been described. This disorder is especially painful for men.

Diagnosis of prostatitis

The appearance of the first signs of inflammation of the prostate gland requires immediate medical attention. The urologist rules out many diseases that have similar manifestations and determines which category (type) the disease belongs to. Before choosing a treatment, a specialist will perform the necessary tests and offer to take part in an evaluation test.

What questions can your doctor ask

At the discussion, the physician will determine: the duration of the clinical manifestations of the disease, the location and nature of the pain, such as in the perineum, scrotum, penis, and inner thigh; changes in the nature of sperm (presence of pus and blood).

At the reception, the urologist offers to fill in special questionnaires, one of which is an index of the symptoms of chronic prostatitis.

The patient should ask the doctor questionsabout what tests and examinations should be done, how to prepare for them, what treatment you plan to prescribe, and where I can get more information about the disease.

Chronic bacterial prostatitis is diagnosed if the symptoms last for at least three months.

The survey includes:

• Digital rectal examination of the gland to determine the extent and consistency of prostate enlargement.

• Examination of prostate, urine and / or ejaculatory secretions.
• Identification of urogenital infection.
• Ultrasound examination of the urinary system (kidney, prostate, bladder with determination of residual urine).

• Urodynamic examination.

In acute bacterial prostatitis, a swollen and painful prostate is found by rectal digital examination. Prostate massage is contraindicated as it can lead to bacteremia and sepsis.

The most important study in the study of patients with acute bacterial prostatitis is the culture of prostate secretion. Quantitative culture and microscopy of urine samples and prostate secretions obtained after prostate massage are still important methods for categorizing chronic prostatitis.

Androflor - a comprehensive study of microbiocenosis of the urogenital tract in men by PCR. It makes it possible to determine the qualitative and quantitative composition of the microflora. It is used to diagnose and treat inflammatory infectious diseases of the urogenital system.

Once the cause of the disease has been identified, the doctor will recommend a method of treatment. It should be recalled that standard methods are only able to detect an infection in 5-10% of cases, which eventually leads to prostatitis.

What is the relationship between prostatitis, prostate specific antigen (PSA) and prostate cancer

Measurement of total PSA and free PSA levels in prostatitis does not provide additional diagnostic information. Prostate-specific antigen (PSA) levels are known to increase in 60% and 20% of patients with acute and chronic bacterial prostatitis, respectively. After cessation of treatment, PSA levels decrease in 40% of patients. PSA is not considered a specific marker of prostate cancer because benign prostatic hyperplasia and prostatitis may increase PSA levels.

Treatment of prostatitis

Drug therapy plays a leading role in the treatment of pathology.

Treatment with alpha1-blockers

Alpha1-blockers are prescribed to patients who have difficulty urinating. These drugs make it easier to urinate and relax the muscles of the prostate and bladder. Some patients are prescribed medications to lower hormone levels that can help the gland shrink and reduce discomfort. Muscle relaxants can help relieve pain caused by the edematous prostate, which puts pressure on nearby muscles. Non-steroidal anti-inflammatory drugs (NSAIDs) can help if pain occurs.

Standard antibiotic therapy in most cases does not result in a reduction in the number of relapses of the disease, so an integrated approach is often used, which is also prescribedcomplementary medicines: biostimulants, extracts and biological components of various plants and insects, which may be in the formrectal suppositories. . . Despite the large arsenal of drugs, their effectiveness is still insufficient.

Physiotherapy in the treatment of prostatitis

In the case of chronic prostatitis of categories II, III A and III B, physiotherapy methods may also be used:

• prostate (prostate) massage;
• laser therapy;
• microwave hyperthermia and heat therapy;
• electrical stimulation with modulated current of skin or rectal electrodes;
• acupuncture (acupuncture).

The efficacy and safety of these treatments are still being investigated. It is also used to treat prostatitisfolk methods, for examplehirudotherapy.The efficacy and safety of this method in the treatment of prostatitis have not been established.

Stem cell injection

Cell therapy (stem cell injections) is currently a promising technique in the treatment of prostatitis in the early stages of development. Currently, we can only hypothesize the mechanisms of stem cell injection into the prostate, as well as the empirical data obtained by each research group.

Surgical treatment of prostatitis

Surgical methods are only used to treat the complications of prostatitis - swelling of the abscess and bladder.

Treatment of chronic pelvic pain syndrome requires special attention. Asymptomatic inflammatory prostatitis (Category IV) should only be treated if the patient is planning prostate surgery. In this case, the patient receives prophylactic antibiotic therapy.

Diet and lifestyle against prostatitis

A special diet against prostatitis is not necessary, but consuming lots of vegetables, lean meats and dairy products improves bowel function. It is important to eat enough fiber, foods rich in vitamin E (wheat germ, corn oil, etc. ), sugar should be replaced with natural honey. Proper nutrition for prostatitis can improve bowel function and reduce the likelihood of relapse or rapid recovery. We recommend following a healthy lifestyle, consuming more fluids, and limiting caffeine and alcohol.

Forecast. Prophylaxis

Acute prostatitis often becomes timely, even with timely and appropriate treatment.

Complete recovery is not always possible, however, with proper consistent therapy and adherence to the doctor’s recommendations, it is possible to eliminate discomfort and pain. Independenttreatment of prostatitis at homecan be dangerous and can lead to complications.

Not all cases of prostatitis can be identified as a cause, but there are several steps you can take to prevent prostatitis. The same steps can help you control your existing symptoms:

1. Drink plenty of fluids. High fluid intake leads to frequent urination, making it easier to flush infectious agents from the prostate urethra.
2. Empty your bladder regularly.
3. Avoid urinary tract irritation. Limit your intake of caffeine, spicy foods and alcohol.
4. Reduce prostate pressure. Men who often ride bicycles should use a split seat to relieve pressure on the prostate area.
5. Stay sexually active.