Prostatitisis an inflammatory disease of the prostate gland. Manifested by frequent urination, pain in the penis, scrotum, rectum, sexual disorders (erection dysfunction, premature ejaculation, etc. ), sometimes urinary retention, blood in the urine. The diagnosis of prostatitis is established by a urologist or andrologist according to a typical clinical picture, the results of a rectal examination. In addition, an ultrasound of the prostate, bakposev of the prostatic secretion and urine is performed. Treatment is conservative: antibiotic therapy, immunotherapy, prostate massage, lifestyle correction.
General Information
Prostatitis is inflammation of the seminal (prostate) gland, the prostate. It is the most common disease of the genitourinary system in men. Most often it affects patients between the ages of 25 and 50. According to various data, 30-85% of men over the age of 30 suffer from prostatitis. Possible formation of abscesses of the prostate gland, inflammation of the testicles and appendages, which threatens infertility. The rise of infection leads to inflammation of the upper genitourinary system (cystitis, pyelonephritis).
Pathology develops with the penetration of an infectious agent that enters the prostate tissue from the organs of the genitourinary system (urethra, bladder) or from a distant inflammatory focus (with pneumonia, flu, tonsillitis, furunculosis).
Prostate adenoma is a benign neoplasm of the paraurethral glands located around the urethra in its prostatic section. The main symptom of prostate adenoma is a violation of urination due to the gradual compression of the urethra by one or more growing nodules. The pathology is characterized by a benign course.
Only a small fraction of patients seek medical assistance, however a detailed examination reveals the symptoms of the disease in one in four men aged 40 to 50 and in half of men aged 50 to 60. The disease is detected in 65% of men between the ages of 60 and 70, in 80% of men between the ages of 70 and 80, and in more than 90% of men over the age of 80. The severity of symptoms can vary significantly. Studies in the field of clinical andrology suggest that problems with urination occur in about 40 percent of men with BPH, but only one in five patients in this group seek medical attention.
Causes of prostatitis
As an infectious agent in an acute process, Staphylococcus aureus (Staphylococcus aureus), Enterococcus (Enterococcus), Enterobacter (Enterobacter), Pseudomonas (Pseudomonas), Proteus (Proteus), Klebsiella (Klebsiella) and Escherichia coli (E. Coli) can act. . Most microorganisms belong to the conditionally pathogenic flora and cause prostatitis only in the presence of other predisposing factors. Chronic inflammation is usually due to polymicrobial associations.
The risk of developing the disease increases with hypothermia, a history of infections and specific conditions accompanied by congestion in the tissues of the prostate. There are the following predisposing factors:
- General hypothermia (one-time or permanent, associated with working conditions).
- A sedentary lifestyle, a specialty that forces a person to stay in a sitting position for a long time (IT operator, driver, etc. ).
- Constant constipation.
- Violations of the normal rhythm of sexual activity (excessive sexual activity, prolonged abstinence, incomplete ejaculation during "habitual" sexual intercourse devoid of emotional coloration).
- The presence of chronic diseases (cholecystitis, bronchitis) or chronic infectious foci in the body (chronic osteomyelitis, untreated caries, tonsillitis, etc. ).
- Past urological diseases (urethritis, cystitis, etc. ) and sexually transmitted diseases (chlamydia, trichomoniasis, gonorrhea).
- Conditions that cause suppression of the immune system (chronic stress, irregularity and malnutrition, regular lack of sleep, overtraining in athletes).
It is assumed that the risk of developing pathologies increases with chronic intoxication (alcohol, nicotine, morphine). Studies in the field of modern andrology show that chronic perineal trauma (vibration, concussion) in motorists, motorcyclists and cyclists is a provoking factor. However, the vast majority of experts believe that all these circumstances are not the real causes of the disease, but only contribute to the exacerbation of the latent inflammatory process in the tissues of the prostate.
A decisive role in the onset of prostatitis is played by congestion in the tissues of the prostate. Violation of capillary blood flow causes an increase in lipid peroxidation, edema, exudation of the tissues of the prostate and creates conditions for the development of an infectious process.
The mechanism of development of prostate adenoma has not yet been fully determined. Despite the widespread opinion that it links the pathology to chronic prostatitis, there are no data confirming the connection between these two diseases. Researchers found no relationship between prostate adenoma development and alcohol and tobacco use, sexual orientation, sexual activity, sexually transmitted diseases and inflammatory diseases.
There is a pronounced dependence of the incidence of prostate adenoma on the patient's age. Scientists believe that adenoma develops due to hormonal imbalances in men during andropause (male menopause). This theory is supported by the fact that men who are neutered before puberty never suffer from pathology and, extremely rarely, men who are neutered after it.
Prostatitis Symptoms
Acute prostatitis
There are three stages of acute prostatitis, which are characterized by the presence of a certain clinical picture and morphological changes:
- Acute catarrhal. Patients complain of frequent, often painful urination, pain in the sacrum and perineum.
- Acute follicular. The pain becomes more intense, sometimes radiating to the anus, aggravated by defecation. Urination is difficult, urine flows out in a thin stream. In some cases, there is urinary retention. Subfebrile condition or moderate hyperthermia is typical.
- Acute parenchymal. Severe general intoxication, hyperthermia up to 38-40 ° C, chills. Dysuric disorders, often - acute urinary retention. Sharp, stabbing pains in the perineum. Difficulty in defecation.
Chronic prostatitis
In rare cases, chronic prostatitis becomes the result of an acute process, however, as a rule, a primary chronic course is observed. The temperature occasionally rises to subfebrile values. The patient notes a slight pain in the perineum, discomfort during the act of urination and defecation. The most characteristic symptom is poor discharge from the urethra during defecation. The primary chronic form of the disease develops over a considerable period of time. It is preceded by prostatosis (stagnation of blood in the capillaries), which gradually turns into abacterial prostatitis.
Chronic prostatitis is often a complication of the inflammatory process caused by the causative agent of a specific infection (chlamydia, trichomonas, ureaplasma, gonococcus). Symptoms of a specific inflammatory process in many cases mask the manifestations of damage to the prostate. Perhaps a slight increase in pain when urinating, mild pain in the perineum, poor discharge from the urethra when defecating. A slight change in the clinical picture often goes unnoticed by the patient.
Chronic inflammation of the prostate gland can be manifested by a burning sensation in the urethra and perineum, dysuria, sexual disorders, increased general fatigue. The consequence of violations of potency (or fear of these violations) often becomes mental depression, anxiety and irritability. The clinical picture does not always include all the listed symptom groups, it differs in different patients and changes over time. There are three main syndromes characteristic of chronic prostatitis: pain, dysuric, sexual disorders.
There are no pain receptors in the prostate tissue. The cause of pain in chronic prostatitis becomes almost inevitable due to the abundant innervation of the pelvic organs, involvement in the inflammatory process of the nerve pathways. Patients complain of pain of varying intensity, from weak, painful to intense and disturbing sleep. There is a change in the nature of the pain (intensification or weakening) with ejaculation, excessive sexual activity, or sexual abstinence. The pain radiates to the scrotum, sacrum, perineum, sometimes to the lumbar region.
As a result of inflammation in chronic prostatitis, the volume of the prostate increases, compressing the urethra. The lumen of the ureter is reduced. The patient frequently needs to urinate, a feeling of incomplete emptying of the bladder. As a rule, dysuric phenomena are expressed in the early stages. Then compensatory hypertrophy of the muscle layer of the bladder and ureters develops. The symptoms of dysuria during this period weaken and then increase again with the decompensation of the adaptive mechanisms.
In the early stages, despotency can develop, which manifests itself differently in different patients. Patients may complain of frequent nocturnal erections, blurred orgasm or worsening of erections. Accelerated ejaculation is associated with a decrease in the threshold level of arousal of the orgasmic center. Painful sensations during ejaculation can cause rejection of sexual activity. In the future, sexual dysfunctions become more pronounced. In the advanced stage, impotence develops.
The degree of sexual disorder is determined by many factors, including the patient's sexual constitution and psychological mood. Violations of potency and dysuria can be due both to changes in the prostate gland and to the suggestibility of the patient, who, if he has chronic prostatitis, expects the inevitable development of sexual disorders and urination disorders. Psychogenic disorder and dysuria particularly often develop in suggestible and anxious patients.
Impotence, and sometimes the very threat of possible sexual disorders, is difficult for patients to tolerate. There is often a change of character, irritability, hatred, excessive concern for one's health and even "cure for the disease".
There are two groups of symptoms of the disease: irritative and obstructive. The first group of symptoms includes increased urination, persistent (imperative) urge to urinate, nocturia, urinary incontinence. The group of obstructive symptoms includes difficulty in urination, delayed onset and increased urination time, feeling of incomplete emptying, intermittent slow flow urination, need to exert themselves. There are three stages of prostate adenoma: compensated, subcompensated and decompensated.
Compensated phase
In the compensated phase, the dynamics of the act of urination changes. It becomes more frequent, less intense and less free. It is necessary to urinate 1-2 times at night. Normally, stage I nocturia of prostate adenoma is of no concern in a patient who associates constant nocturnal awakenings with the development of age-related insomnia. During the day it is possible to maintain the normal frequency of urination, however patients with stage I prostate adenoma notice a waiting period, which is particularly pronounced after a night's sleep.
Then the frequency of daytime urination increases and the volume of urine released during urination decreases. There are imperative impulses. The urine stream, which previously formed a parabolic curve, is discharged slowly and falls almost vertically. Hypertrophy of the bladder muscles develops, due to which the efficiency of its emptying is maintained. There is little or no urine left in the bladder at this stage (less than 50ml). The functional state of the kidneys and upper urinary tract is preserved.
Subcompensated phase
At stage II of prostate adenoma, the bladder increases in volume, dystrophic changes develop in its walls. The amount of residual urine exceeds 50ml and continues to increase. During the act of urination, the patient is forced to intensely strain the abdominal muscles and diaphragm, which leads to an even greater increase in intravesical pressure.
The act of urination becomes multiphase, intermittent, undulatory. The passage of urine along the upper urinary tract is gradually disturbed. Muscle structures lose their elasticity, the urinary tract dilates. Kidney function is impaired. Patients are concerned about thirst, polyuria and other symptoms of progressive chronic kidney failure. When the compensation mechanisms fail, the third stage begins.
Decompensated stage
The bladder in patients with stage III prostate adenoma is elongated, filled with urine, easily determined by palpation and visually. The upper edge of the bladder can reach navel level and beyond. Emptying is impossible even with intense abdominal muscle tension. The desire to empty the bladder becomes continuous. There may be severe pain in the lower abdomen. Urine is excreted frequently, in drops or in very small portions. In the future, pain and the urge to urinate gradually weaken.
A characteristic paradoxical urinary retention, or paradoxical ischuria develops (the bladder is full, urine is constantly excreted drop by drop). The upper urinary tract is enlarged, the functions of the renal parenchyma are impaired due to constant obstruction of the urinary tract, which leads to an increase in pressure in the pelvicalyceal system. The chronic renal failure clinic is growing. If medical assistance is not provided, patients die from progressive CRI.
Complications
In the absence of timely treatment of acute prostatitis, there is a significant risk of developing a prostate abscess. With the formation of a purulent focus, the patient's body temperature rises to 39-40 ° C and can become hectic in nature. Periods of heat alternate with severe chills. Sharp pains in the perineum make urination difficult and make defecation impossible.
Increased prostate edema leads to acute urinary retention. Rarely, an abscess spontaneously ruptures in the urethra or rectum. When opened, purulent, cloudy urine appears in the urethra with an unpleasant, pungent odor; when opened, the stool contains pus and mucus in the rectum.
Chronic prostatitis is characterized by an undulatory course with long-term periods of remission, during which inflammation of the prostate is latent or manifests itself with extremely poor symptoms. Patients who are not bothered by anything often stop treatment and only refer when complications develop.
The spread of the infection through the urinary tract causes the onset of pyelonephritis and cystitis. The most common complication of the chronic process is inflammation of the testicles and epididymis (epdidymo-orchitis) and inflammation of the seminal vesicles (vesiculitis). The outcome of these diseases is often infertility.
Diagnostics
In order to assess the severity of the symptoms of prostate adenoma, the patient is asked to fill in a urination diary. During the consultation, the urologist performs a digital examination of the prostate. To exclude infectious complications, a sampling and examination of the prostate secretion and smears from the urethra is performed. Further tests include:
- Ultrasound.In the process of ultrasound of the prostate, the volume of the prostate gland is determined, stones and areas with congestion are detected, the amount of residual urine, the condition of the kidneys and urinary tract are evaluated.
- Urodynamic study.Uroflowmetry allows you to reliably judge the degree of urinary retention (the time of urination and the speed of urine flow are determined by a special apparatus).
- Definition of tumor markers.To exclude prostate cancer, it is necessary to evaluate the level of PSA (prostate specific antigen), the value of which should normally not exceed 4 ng / ml. In controversial cases, a prostate biopsy is performed.
Cystography and excretory urography for prostate adenoma have been performed less frequently in recent years due to the emergence of new, less invasive and safer research methods (ultrasound). Sometimes cystoscopy is done to rule out diseases with similar symptoms or in preparation for surgical treatment.
Treatment of prostatitis
Treatment of acute prostatitis
Patients with a simple acute process are treated by a urologist on an outpatient basis. With severe intoxication, suspicion of a purulent process, hospitalization is indicated. Antibacterial therapy is performed. Preparations are selected taking into account the sensitivity of the infectious agent. Antibiotics are widely used which can penetrate the prostate tissue well.
With the development of acute urinary retention on the end of prostatitis, they resort to the installation of a cystostomy, and not a urethral catheter, since there is a danger of the formation of an abscess of the prostate. With the development of an abscess, a transrectal or transurethral endoscopic opening of the abscess is performed.
Treatment of chronic prostatitis
Treatment of chronic prostatitis should be complex, including etiotropic therapy, physiotherapy, correction of immunity:
- Antibiotic therapy. The patient is prescribed long courses of antibacterial drugs (within 4-8 weeks). The selection of the type and dosage of antibacterial drugs, as well as determining the duration of the course of treatment, is carried out individually. The drug is chosen based on the sensitivity of the microflora based on the results of urine culture and prostatic secretion.
- Prostatic massage.Massage of the gland has a complex effect on the affected organ. During the massage, the inflammatory secret accumulated in the prostate gland is squeezed into the ducts, then enters the urethra and is removed from the body. The procedure improves blood circulation in the prostate, minimizing congestion and ensuring better penetration of antibacterial drugs into the tissue of the affected organ.
- Physiotherapy.To improve blood circulation, laser exposure, ultrasonic waves and electromagnetic vibrations are used. If it is impossible to carry out physiotherapeutic procedures, the patient is prescribed warm medicinal microenemas.
In long-term chronic inflammation, consultation of an immunologist is indicated to select the tactics of immunocorrective therapy. The patient receives advice on lifestyle changes. Making certain changes in the lifestyle of a patient with chronic prostatitis is both a curative and a preventive measure. The patient is recommended to normalize sleep and wakefulness, establish a diet, conduct moderate physical activity.
Conservative therapy
Conservative therapy is carried out in the initial stages and in the presence of absolute contraindications to surgery. To reduce the severity of the symptoms of the disease, alpha-blockers, 5-alpha reductase inhibitors, herbal preparations (extract of African plum bark or sabal fruit) are used.
Antibiotics are prescribed to fight the infection that often accompanies prostate adenoma. At the end of the course of antibiotic therapy, probiotics are used to restore normal intestinal microflora. Perform immunity correction. Atherosclerotic vascular changes that develop in most elderly patients prevent the flow of drugs into the prostate gland, so special drugs are prescribed to normalize blood circulation.
Surgery
There are the following surgical methods for the treatment of prostate adenoma:
- TOUR(transurethral resection). Minimally invasive endoscopic technique. The operation is performed with an adenoma volume of less than 80 cm3. Not applicable for renal insufficiency.
- Adenomectomy.It is performed in the presence of complications, the mass of the adenoma is more than 80 cm3. Currently, laparoscopic adenomectomy is widely used.
- Laser vaporization of the prostate.It allows to perform surgery with a tumor mass of less than 30-40 cm3. It is the method of choice for young patients with prostate adenoma, because it allows to save sexual function.
- Laser enucleation(holmium - HoLEP, thulium - ThuLEP). The method is recognized as the "gold standard" of surgical treatment of prostate adenoma. Allows you to remove an adenoma with a volume greater than 80 cm3 without open intervention.
There are a number of absolute contraindications to surgical treatment of prostate adenoma (decompensated diseases of the respiratory and cardiovascular systems, etc. ). If surgical treatment is not possible, bladder catheterization or palliative surgery is performed: cystostomy, installation of a urethral stent.
Forecast and prevention
Acute prostatitis is a disease that has a marked tendency to become chronic. Even with proper and timely treatment, more than half of patients end up with chronic prostatitis. Healing is far from always achieved, however, with correct and consistent therapy and following the doctor's recommendations, it is possible to eliminate unpleasant symptoms and achieve long-term stable remission in a chronic process.
Prevention consists in eliminating risk factors. It is necessary to avoid hypothermia, to alternate between sedentary work and periods of physical activity, to eat regularly and completely. For constipation, laxatives should be used. One of the preventive measures is the normalization of sexual life, since both excessive sexual activity and sexual abstinence are risk factors in the development of prostatitis. If symptoms of a urological or sexually transmitted disease appear, it is necessary to consult a doctor in a timely manner.