Chronic prostatitis is a chronic inflammation of the prostate (the abbreviation prostate may appear below), and the etiology of the inflammatory process may vary from patient to patient.This is why the classification of prostatitis is constantly revised and updated.
According to the NIH classification, chronic prostatitis includes type II, chronic bacterial prostatitis (CKD), type III (chronic nonbacterial prostatitis, CNP), and type IV, asymptomatic inflammatory prostatitis.
The NIH Classification of Prostatitis (1999) recommends the following groups and types of prostatitis:
- 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 (Part 3 Leukocytes in Urine, Semen)
- III B – Non-inflammatory chronic pelvic pain syndrome (no white blood cells in urine or semen)
- Type IV - Asymptomatic prostatitis (inflammatory process determined by histology)
The third type of prostatitis is related to chronic pelvic pain syndrome (CPPS) and is divided into inflammatory CPPS and non-inflammatory CPPS.
This type of prostatitis is not associated with bacterial infection of the pancreas.Diagnosis is based on pancreatic secretion studies, clinical and bacterial culture results.
Often, even if a bacterial component of prostatitis is absent, empiric antimicrobial therapy (fluoroquinolones or sulfonamides) is given first.
No patients complained about the fourth type of prostatitis.This type of prostatitis is diagnosed accidentally during a prostate biopsy with the aim of excluding another possible pathology (prostate cancer).
The fourth type of prostatitis is determined based on a biopsy, examination of a surgical specimen, or semen analysis, rather than because the patient complains of specific symptoms of prostatitis.Asymptomatic prostatitis does not require treatment.
Prostatitis is often accompanied by elevated PSA (prostate-specific antigen) levels.Because of chronic elevations in PSA during antimicrobial therapy, patients are advised to undergo periodic pancreatic biopsies.
Chronic bacterial prostatitis (CKD)
Chronic bacterial prostatitis is caused by a bacterial infection of the prostate (PG).CKD leads to a typical clinical picture in which recurrent inflammation of the urinary tract organs stands out (most often, exacerbations of inflammation are caused by the same microorganisms).
CKD is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatic pain.
By definition, CKD is associated with the overgrowth of pathogenic microorganisms in prostatic secretions, semen, or partial urine cultures obtained after prostate massage.Typically, microscopy of pancreatic secretions will reveal 10 or more leukocytes and macrophages in a single field.
Symptoms of prostatitis are common.Approximately half of men will develop clinical manifestations similar to those of prostatitis during their lifetime.
Such symptoms accounted for 8% of all urologist visits.Patients with symptoms of prostatitis are more likely to seek specialist advice than patients with pancreatic hyperplasia or pancreatic cancer.
The symptoms of prostatitis are usually not related to a chronic bacterial infection of the gland.Nonetheless, patients with symptoms of prostatitis have traditionally been treated with antimicrobials (50% of patients with symptoms of prostatitis receive antibiotics, only 5-10% of men have symptoms caused by a bacterial infection, and treatment accompanies the patient's recovery).
In most cases, antimicrobial treatment leads to a positive dynamic of the disease due to the placebo effect or the anti-inflammatory effect of the antibiotic.
A complicating factor in the diagnosis of prostatitis is “fastidious” microorganisms (Chlamydia, Mycoplasma, Ureaplasma) that can cause CKD but grow poorly in nutrient media.
In this case, the condition may be mistaken for nonbacterial prostatitis.Further examination of the patients using bacterial nucleic acid detection technology revealed a more frequent association between prostatitis symptoms and bacterial infection.
A possible relationship between prostatitis and pancreatic cancer is currently being studied.The theory is that anti-inflammatory drugs that reduce cyclooxygenase activity may reduce the incidence of pancreatic cancer.
etiology
Because of its anatomy, the pancreas can be a source of recurring infections.The peripheral part of the gland is composed of a system of communicating ducts with poor drainage capacity, which can lead to stagnation of glandular secretion.
As age increases, the pancreas enlarges, urinary system obstruction symptoms occur, and urine refluxes into the glandular ducts.
As urethral stricture develops, urinary reflux may also occur.Reflux of urine, even if sterile (free of bacteria), can cause chemical irritation, triggering renal tubular fibrosis and pancreatic duct stone formation, with subsequent intraductal obstruction and stagnation of pancreatic secretions.
When stasis occurs, bacterial flora can join the secretions, leading to the formation of chronic foci of infection that periodically worsen.
Pancreatic infection may result from ascending infection in the context of urethritis or when infected urine enters the glandular ducts.
Glandular infections may persist for a long time due to poor accumulation of antimicrobial drugs in glandular tissue.There is no active mechanism for the transfer of antimicrobial drugs in pancreatic cells; the concentration of the drug in the cells depends on its passive diffusion across the membrane.
The most common causes of CKD:
- E. coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Proteus
- Staphylococcus
- Enterococcus
- Trichomonas
- Candida
- Chlamydia trachomatis
- Ureaplasma urealyticum
- Mycoplasma hominis
Another factor that reduces the effect of antimicrobial agents is the acidity of prostatic secretions (pH=6.4), which is significantly lower than the acidity of plasma (plasma pH=7.4), reducing the diffusion of highly acidic antibiotics into prostatic secretions.
Eight out of 10 patients with chronic kidney disease (CKD) are infected with Escherichia coli (E. coli).Other pathogens are less common.The role of Gram-positive flora (Staphylococcus epidermidis and Staphylococcus saprophyticus) in the development of CKD is controversial.
These microorganisms often inhabit the anterior urethra and may "contaminate" the material when it is obtained, leading to erroneous conclusions.Therefore, the patient was treated based on a second bacterial culture of the material.
spread of infection
In most cases, the exact source of infection in the pancreas cannot be determined.Because prostatitis is often associated with gonococcal flora in the urethra (gonococcal urethritis), ascending urinary tract infection is a known source.
The most common ways the infection is spread include:
- Infection ascending from the urethra.
- Urine containing pathogenic microorganisms refluxes into the pancreatic duct.
- Bacteria migrate from the rectum or their lymphatic dissemination.
- Hematogenous introduction of bacteria.
Epidemiology
According to statistics, up to 25% of urology patients suffer from prostatitis-related symptoms.
About 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 have bacterial prostatitis.
Symptoms of prostatitis most commonly appear in the 36-50 age group.Prostatitis is the most common urinary tract problem in patients under 50 years of age and the third most common urinary tract pathology in patients over 50 years of age.In the male age group 20 to 74 years, the incidence of prostatitis symptoms is 10%.
Prognosis of CKD
Cure rates are 30-40% when treated with sulfonamides and 60-90% when treated with fluoroquinolones.
Incidence
Pancreatic inflammation significantly affects the patient's quality of life (quality of life is reduced to the level of patients with coronary heart disease or Crohn's disease).
Studies have shown that prostatitis causes mental status changes at levels comparable to those seen in patients with diabetes and chronic heart failure.
Retrospective studies have shown a relationship between the severity of CKD and the incidence of male sexual dysfunction (erectile dysfunction, duration of intercourse, premature ejaculation).The exact nature of the association between these disorders (psychological or somatic) remains unclear.
In one study, scientists compared the course of CKD during infection with Chlamydia trachomatis and infection with the most common urinary tract pathogenic bacteria.
Among people infected with Chlamydia trachomatis, patients have a lower quality of life; patients more often complain of premature ejaculation during intercourse.
In a study of 110 infertile men with CKD, 78 patients took fluoroquinolones with favorable results: a significant increase in sperm motility, a decrease in the number of white blood cells in the semen, a decrease in semen viscosity, and a decrease in free radicals, IL-6, and TNF-α levels.
In a control group of 37 healthy men, none of the listed parameters changed after taking fluoroquinolones.These indicators worsened in the group of patients who responded poorly to antibiotics.
clinical picture
People with chronic kidney disease often go to the doctor with a range of subjective complaints.Only a small proportion of the chief complaints described during patient interviews were for pancreatic inflammation, allowing doctors to narrow their search for pathology.
Patients complain of pain, which can be observed in the perineum, glans penis, testicles, rectum, lower abdomen, and back.
Periods of worsening pancreatic infection alternate with periods of asymptomatic disease.
Patients may experience symptoms of urinary tract obstruction or irritation: increased frequency of urination, decreased frequency of urination, decreased pressure of the urine stream, nocturia (increased urination at night), and urinary incontinence.
Patients with chronic kidney disease often complain of urethral discharge (which can be colorless or milky), pain during ejaculation, blood in the ejaculate, and impaired erectile function.
If CKD is suspected, the urologist will perform a differential diagnosis with another common pathology in the table below:
- Acute prostatitis.This is accompanied by more pronounced clinical manifestations, severe intoxication, and severe pancreatic symptoms.If treatment is not timely or the antimicrobial regimen is incorrect, chronic pancreatic infection may develop and be complicated by gland abscess.
- Prostate stones.
- Urinary tract obstruction caused by benign pancreatic hyperplasia, urethral stricture, and bladder neck dysfunction.Symptoms of slow blood flow.They are not accompanied by intoxication, increased bacteria in pancreatic secretions, or third portions of urine.
- Pelvic floor tension myalgia.
- Cystitis.Bladder inflammation is accompanied by urinary urgency, small urine output, intoxication 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, pancreatic abscesses can be palpated through the rectum (defined as an area of softened pancreatic tissue), 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, scrapings from the urethral surface are used, followed by microscopic examination and nucleic acid analysis.
- Tuberculous prostatitis.
diagnosis
To accurately diagnose CKD, microscopic examination of pancreatic secretions, bacterial culture of urine samples after gland massage, and bacterial culture of sperm are required.
The microbiota profile in CKD is similar to the causative agents of acute pancreatic inflammation.Most cases of CKD are associated with a single pathogen, but it is not uncommon for multiple bacterial combinations to be the source of prostatitis.
When examining urine, it is important to compare the bacterial content/concentration of the three sections (CKD is characterized by higher microbial concentrations in the third section at the end of urination than in the urine at the beginning and middle of urination).
On microscopic examination of the material, more than 10 leukocytes were detected in the field, indicating the presence of a significant inflammatory syndrome.
microscopy
Most commonly, CKD is determined by microscopic examination of pancreatic secretions and urine after transrectal massage of the pancreas.Physicians should avoid transrectal examination and prostate massage if the patient has symptoms of acute urogenital infection or fever at the time of examination.
In this case, the patient is likely to have acute prostatitis and the possibility of sepsis due to prostate massage is increased.
CKD is characterized by increased levels of white blood cells in biological material under a microscope and positive bacterial culture results from the biological material.
Bacterial culture of prostate secretions
This study was conducted to aid in the diagnosis of CKD.In this study, a portion of the urine was used after transrectal massage of the pancreas.
The resulting material is used for bacterial culture to determine bacterial resistance to antibiotics.
Massage the prostate until white discharge appears in the urethra; this may take about a minute.Before a study is conducted, it is necessary to inform patients about the study methods and its objectives.
Sometimes, as a result of massaging the pancreas, urine mixed with white excrement is discharged from the urethra; in this case, the resulting fluid is cultured for bacteria.When the pancreas becomes infected, the acidity of the secretions changes from pH 6.5 to pH 8.0.
Prostate-specific antigen (PSA)
Routine PSA testing is not recommended for prostatitis.Most patients with established CKD have significantly elevated PSA.
Elevated PSA in prostatitis is not associated with increased risk of pancreatic cancer.Based on the rise in PSA, pancreatic cancer and inflammation in it cannot be distinguished; additional tests (TRUS, pancreatic biopsy) are needed.
In patients with CKD and elevated PSA levels, retesting for this marker 6–8 weeks after completion of prostatitis treatment is necessary.
When prostatitis is cured, marker levels should return to normal values.If PSA test results remain elevated, a pancreatic biopsy may be necessary to rule out other possible pathologies.
Three cups of sample
This approach has historically been the standard for diagnosing CKD.The technique was first described in 1968.Currently, doctors are increasingly adopting this research.
Instead of testing three cups, doctors studied microbial cultures in urine before and after transrectal pancreatic massage.
This method is most valuable when the urine in the bladder is sterile.If microorganisms are present in the bladder, the patient is given a nitrofuran antibacterial agent, which causes the urine in the bladder to become sterile and opens the possibility for research.
Testing technology:
- The first portion of urine is 5-10 ml, collected in a separate glass, and contains microorganisms from the urethra.
- After collecting the first part, the patient voids urine into the toilet; after 150-200 ml of urine has been passed, an additional 10-15 ml of urine is collected (the second part is in a separate glass).The second part contains bladder microorganisms.
- The third part is a mixture of pancreatic secretions and urine, obtained after massaging the pancreas, approximately 5-10 ml, collected in a separate glass.The third part was sent for bacterial culture.
transrectal ultrasound
This study provides information only in the presence of pancreatic abscess.Pancreatic abscess is a rare pathology associated with severe intoxication.
If TRUS is not possible and 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 an important trigger of recurrent exacerbations.
The use of TRUS does not confirm the diagnosis of CKD, although the presence of hypoechoic inclusions and calcifications in the glandular stroma may indicate infection and chronic inflammation and prompt the physician to order additional testing of the patient.
pancreatic biopsy
The most informative study is pancreatic biopsy.However, this method is rarely used in CKD because microscopic examination of biological material and bacterial culture are sufficient for accurate diagnosis.
Microscopic examination of biopsy specimens obtained can identify focal infiltration of the pancreatic interstitium by inflammatory cells.
Biopsies can be used to culture bacteria and determine the susceptibility of the flora to certain antimicrobial drugs.
Contraindications to performing a biopsy are severe intoxication in the patient, high fever, symptoms of acute inflammation of the pancreas (biopsy under these conditions may lead to the spread of bacteria in the patient's body and the development of bacterial sepsis).
Type IV prostatitis is determined solely on pancreatic biopsy.This type of prostatitis is characterized by asymptomatic inflammation of the glandular stroma and elevated 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 CKD and urethral stricture.For this study, a radiopaque contrast agent is injected into the urethra and X-rays are taken.If urethral stricture is present, the image will show 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 bacterial culture results of biological material on nutrient media.
According to modern classification, CNP belongs to type III prostatitis, which is divided into IIIA (chronic pelvic pain inflammatory syndrome, CPPS) and IIIB (non-inflammatory CPPS).
Traditionally, antimicrobial drugs have been used to treat CNP; the course of treatment is 30-40 days.According to modern research, patients in group IIIA are best treated with short-term (2 weeks) antimicrobial therapy, while urologists in group IIIB try to avoid antibiotics.
Epidemiology
CNP can occur in men of any age.
- Most commonly, CNP occurs between the ages of 35-45 years.
- CNP is equally common across racial groups.
Risk factors for CNP:
- Injury (trauma, surgery, intraurethral manipulation) can lead to the development of inflammation of the glandular tissue.
- Have had pancreatic inflammation before.
- pressure.
- Hypothermia throughout the body, hypothermia in the perineum from sitting on a cold surface for a long time.
- Disturbed psycho-emotional state.
The exact cause of CNP has not been determined.Scientists believe that the possible cause of CNP is a combination of factors: the patient's psychoemotional characteristics, immune disorders, hormonal and neurological disorders.The combination of these factors leads to the onset of prostatitis symptoms.
The clinical manifestations of CNP are very diverse and may not be dissimilar to those of CKD.
diagnosis
The diagnosis of CNP is determined based on symptoms, a physical examination of the patient by a urologist, study of the medical history, and other laboratory tests.
In the diagnosis of CNP, the following is used:
- Digital rectal examination: A transrectal examination of the posterior surface of the pancreas.On palpation, the pancreas may be noticeably painful, firm, and enlarged in size.
- A general urine test shows an increase in white blood cells.
- Bacterial culture of urine and pancreatic secretions does not result in microbial growth.
- Bacterial seeding of sperm does not allow microorganisms to grow.
disease prevention
- Increase the amount of fruits and vegetables in your daily diet (they contain high amounts of antioxidants, which help reduce inflammation in your internal organs).
- Reduce wheat products in your diet.
- Take probiotics during antibacterial treatment.
- Increase consumption of polyunsaturated fatty acids.
- Increase plant protein and reduce animal protein in your diet.
- Drink green tea.Green tea contains catechins, which are good antioxidants.Catechins have significant anti-inflammatory activity.
- Drink your daily intake of water.Staying hydrated helps prevent urinary tract infections and, therefore, prostatitis.
- Maintain good health and a normal weight.
- Avoid stressful situations.
- Maintain personal hygiene.
- Use a barrier method of birth control.
- Avoid injury to the perineal area.Cycling or cycling can damage the pancreas and lead to the development of pancreatic inflammation.
- Drink cranberry juice, juice, lingonberry soup.These juices and decoctions have a pronounced urinary septic effect and prevent the development of inflammation of the urogenital organs.
- Limit or refuse alcohol use.
- Avoid using spices.Spices can worsen prostatitis symptoms.
- Reduce your caffeine intake.Caffeine can irritate the pancreas and worsen prostatitis.