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prostate inflammatory disease

chronic prostatitis– Inflammatory disease of the prostate of various etiologies (including non-infectious), manifested by pain or discomfort in the pelvic area and urinary tract disorders lasting 3 months or longer.male prostate disease1. Introduction partAgreement name:Prostate inflammatory diseaseProtocol code:ICD-10 code:N41. 0 Acute prostatitisN41. 1 Chronic prostatitisN41. 2 Prostatic abscessN41. 3 ProstatitisN41. 8 Other inflammatory diseases of the prostateN41. 9 Unspecified inflammatory disease of the prostateN42. 0 Prostate stonesprostate stonesN42. 1 Prostatic congestion and bleedingN42. 2 Prostate atrophyN42. 8 Other specific diseases of the prostateN42. 9 Prostate disease, unspecifiedAbbreviations used in the agreement:ALT - alanine aminotransferaseAST - aspartate aminotransferaseHIV - human immunodeficiency virusELISA—enzyme-linked immunoassayCT - computed tomographyMRI - magnetic resonance imagingMSCT - multi-slice computed tomographyDRE - digital rectal examinationPSA - prostate specific antigenDRE - digital rectal examinationPC - prostate cancerCPPS - chronic pelvic pain syndromeTUR - transurethral resection of the prostateUltrasound examination - Ultrasound examinationED - erectile dysfunctionECG-electrocardiogramIPSS – International Prostate Symptom Score (International Prostate Disease Symptom Index)NYHA - New York Heart AssociationDate of establishment of agreement:2014Patient categories:Men of childbearing age.Agreement users:Andrologists, urologists, surgeons, therapists, general practitioners.

Level of evidence
grade Evidence type
1a Evidence from meta-analyses of randomized trials
1b Evidence from at least one randomized trial
2a Evidence from at least one well-designed, controlled, non-randomized trial
2b Evidence from at least one well-designed, controlled, quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies (comparative studies, correlational studies, scientific report analyses)
4 Evidence based on expert opinion or experience
Recommendation
one Results are based on homogeneous, high-quality, question-specific clinical trials, including at least one randomized trial
exist Results obtained from well-designed, non-randomized clinical studies
and Clinical studies of sufficient quality have not yet been conducted

Classification

clinical classificationClassification of prostatitis (National Institutes of Health(NYHA), USA, 1995)A category– Acute bacterial prostatitis;Category 2– Chronic bacterial prostatitis, seen in 5-10% of cases; Category III – chronic non-bacterial prostatitis/chronic pelvic pain syndrome, diagnosed in 90% of cases;Subcategory III A– Chronic inflammatory pelvic pain syndrome with leukocytosis in prostate secretions (more than 60% of cases);Subcategory III B– CPPS – chronic non-inflammatory pelvic pain syndrome (no increase in white blood cells in prostate secretions (approximately 30%));Category 4– Asymptomatic inflammation of the prostate (histological prostatitis) discovered during examination for other diseases, based on the analysis of prostate secretions or its biopsy;

diagnosis

2. Diagnosis and treatment methods, approaches and proceduresList of basic and additional diagnostic measuresBasic (mandatory) diagnostic tests performed in the outpatient clinic:
  • Collect complaints and medical history;
  • digital rectal examination;
  • Complete the IPSS questionnaire;
  • Prostate ultrasound;
  • Prostatic secretion;
Additional diagnostic tests performed in the outpatient clinic:Prostatic secretion;Minimum checklist that must be performed when referral is planned for hospitalization:
  • General blood tests;
  • General urinalysis;
  • Biochemical blood tests (measurement of blood glucose, bilirubin and fraction, AST, ALT, thymol test, creatinine, urea, alkaline phosphatase, blood amylase);
  • microreaction;
  • coagulation chart;
  • HIV;
  • Viral hepatitis ELISA;
  • Fluorography;
  • electrocardiogram;
  • blood type.
Basic (mandatory) diagnostic tests performed at hospital level:
  • PSA(total, free);
  • Bacterial cultures of prostate secretions were obtained after massage;
  • transrectal prostate ultrasound;
  • Bacteriological cultures of prostate secretions were obtained after massage.
Additional diagnostic tests performed at the hospital level:
  • Uroflowmetry;
  • Bladder tone measurement;
  • MSCT or MRI;
  • Urethrocystoscopy.
(Level of Evidence - I, Strength of Recommendation - A)Diagnostic measures implemented during the emergency phase: Not implemented.diagnostic criteriaComplaints and Medical Records:complaint:
  • Pain or discomfort in the pelvic area that lasts 3 months or longer;
  • A common site of pain is the perineum;
  • There may be discomfort on the pubic bone;
  • Discomfort in the groin and pelvis;
  • A feeling of discomfort in the scrotum;
  • Sensation of rectal discomfort;
  • Discomfort in the lumbosacral region;
  • Pain during and after ejaculation.
Past history:
  • sexual dysfunction;
  • suppresses sexual desire;
  • Deterioration in the quality of spontaneous and/or full erections;
  • premature ejaculation;
  • In the later stages of the disease, ejaculation is slow;
  • "Erasing" the emotional color of orgasm.
The impact of chronic prostatitis on quality of life, according to the Unified Quality of Life Assessment Scale, is comparable to the impact of myocardial infarction, angina pectoris, and Crohn's disease.(Level of Evidence - II, Strength of Recommendation - B).Physical examination:
  • Prostate swelling and tenderness;
  • Enlargement and smoothing of the median prostatic sulcus.
laboratory researchIn order to increase the reliability of laboratory test results, it should be performed before the appointment or 2 weeks after the end of taking antimicrobial drugs.Microscopic examination of prostate secretions:
  • Determination of white blood cell count;
  • Determination of lecithin granule content;
  • Determination of the number of amyloid bodies;
  • Determine the number of Trousseau-Lallemand bodies;
  • Determination of macrophage numbers.
Bacteriological study of prostate secretions: determines the nature of the disease (bacterial or nonbacterial prostatitis).Diagnostic criteria for bacterial prostatitis:
  • The third portion of urine or prostate secretions contains bacteria of the same strain with a potency of 103 CFU/ml or higher, provided that the second portion of urine is sterile;
  • A tenfold or greater increase in bacterial titers in urine or prostate secretions in part III compared with part II;
  • Part III urine or prostate secretions contain more than 103 CFU/ml of true urinary tract pathogenic bacteria, unlike other bacteria in Part II urine.
Gram-negative microorganisms from the family Enterobacteriaceae (E. coli, Klebsiella spp. , Proteus spp. , Enterobacter spp. , etc. ) and Pseudomonas spp. , as well as Enterococcus faecalis, have been shown to play a role in the development of chronic bacterial prostatitis. play a leading role in.Blood collection should be performed within 10 days of DRE to determine serum PSA concentration. Prostatitis can cause elevated PSA concentrations. Nonetheless, when PSA concentrations are above 4 ng/ml, other diagnostic methods, including prostate biopsy, are needed to rule out prostate cancer.Instrumental Studies:Transrectal Ultrasound of the Prostate: Used for differential diagnosis, determining the form and stage of the disease, and for subsequent monitoring throughout treatment.Ultrasonography: assesses the size and volume of the prostate, echogenic structures (cysts, stones, fibrosclerotic changes in the organs, prostatic abscesses). Hypoechoic areas in the periprostatic region are suspicious for prostate cancer.X-ray: Diagnose bladder outlet obstruction to determine its cause and determine further treatment strategies.Endoscopic examination methods (urethroscopy, cystoscopy): performed strictly in accordance with the indications, with the purpose of differential diagnosis, and the use of broad-spectrum antibiotics.Urodynamic studies (uroflowmetry): determination of urethral pressure distribution, pressure/flow studies,Cystometry and pelvic floor muscle electromyography: If bladder outlet obstruction is suspected, which often accompanies chronic prostatitis, as well as neurogenic voiding disorders and pelvic floor muscle function.MSCT and MRI of the pelvic organs: for differential diagnosis of prostate cancer.Indications for consultation with an expert:Consult an oncologist - if PSA exceeds 4 ng/ml to rule out malignant prostatic formation.

Differential diagnosis

Differential diagnosis of chronic prostatitis
For differential diagnosis, the condition of the rectum and surrounding tissues should be assessed(Level of Evidence - I, Strength of Recommendation - A).
Nosology Characteristic syndromes/symptoms Differentiation test
chronic prostatitis The average age of patients was 43 years old.Pain or discomfort in the pelvic area that lasts 3 months or longer. The most common site of pain is the perineum, but discomfort may also occur in the suprapubic and pelvic inguinal areas, as well as in the scrotal, rectal, and lumbosacral areas. Pain during and after ejaculation.Voiding dysfunction usually presents with symptoms of irritation and, less frequently, symptoms of bladder outlet obstruction. During - you can detect swelling and tenderness of the prostate and sometimes enlargement and smoothness of the median sulcus. For differential diagnosis, the condition of the rectum and surrounding tissues should be evaluated.Prostatic secretion - Determine the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lalerman bodies, and macrophages.Bacteriological studies were performed on prostate secretions or urine obtained after massage. Based on the results of these studies, the nature of the disease (bacterial or nonbacterial prostatitis) is determined.Diagnostic criteria for bacterial prostatitis
  • The third portion of urine or prostate secretion contains bacteria of the same strain with a titer of 103 CFU/ml or higher, provided the second portion of urine is sterile.
  • Bacterial titers in urine or prostate secretions increased tenfold or more in part III compared with part II.
  • Part III urine or prostate secretions contain more than 103 CFU/ml of true urinary tract pathogenic bacteria, unlike other bacteria in Part II urine.
Prostate ultrasonography has high sensitivity but low specificity for chronic prostatitis. The study allows not only differential diagnosis but also identification of the form and stage of the disease and subsequent monitoring throughout treatment. Ultrasound can assess prostate size and volume, echogenicity
Benign prostatic hyperplasia (prostatic adenoma) This condition is more common in people over 50 years old. Urination gradually increases and urinary retention slowly increases. Increased frequency of urination at night is typical (in chronic prostatitis, increased frequency of urination during the day or early morning). PRI - The prostate is painless, enlarged, elastic, has a smooth central sulcus and a smooth surface.Prostatic secretion - the amount of secretion increases, but the number of leukocytes and lecithin granules remains within the normal physiological range. The secretion reaction is neutral or slightly alkaline.Ultrasound - Bladder neck deformation was observed. The adenoma appears as a bright red mass extending into the bladder cavity. There is significant proliferation of glandular cells in the cranial part of the prostate. The structure of adenomas is uniform, with regularly shaped darkened areas. The glands are enlarged in the anteroposterior direction. In fibroadenoma, bright echogenicity from connective tissue can be detected.
prostate cancer People over the age of 45 are affected. The location of pain is the same when diagnosing chronic prostatitis and prostate cancer. Prostate cancer pain in the waist, sacrum, perineum, and lower abdomen may be caused by lesions in the gland itself and metastases in the bones. Rapid development of complete urinary retention often occurs. Severe bone pain and weight loss may occur. IF - Identifies a single node of cartilage density or a patchy dense infiltrate throughout the prostate that is limited to or spreads to surrounding tissue. The prostate is immobile and painless.PSA - more than 4. 0 ng/mlProstate biopsy - identifies collections of malignant cells in the form of ductal casts. Atypical cells are characterized by hyperchromasia, polymorphism, variability in nuclear size and shape, and mitotic figures.Cystoscopy - A pale pink mass is found in a ring around the bladder neck (result of infiltration of the bladder wall). The mucosa is often swollen and congested, and epithelial cells proliferate malignantly.Ultrasound - asymmetry and enlargement of the prostate, its marked deformation.

treat

Treatment goals:
  • Eliminate prostate inflammation;
  • Relieve worsening symptoms (pain, discomfort, urinary and sexual dysfunction);
  • Prevention and treatment of complications.
treatment strategiesNon-drug treatments:Diet No. 15.Mode: Normal.drug treatmentWhen treating chronic prostatitis, it is necessary to use a variety of drugs and methods at the same time to act on different parts of the pathogenesis, eliminate the source of infection, normalize blood circulation in the prostate, and fully drain the prostate acini, especially in prostatitis. Normalization of surrounding areas, essential hormone levels and immune response. It is recommended to use antibacterial drugs, anticholinergic drugs, immunomodulators, nonsteroidal anti-inflammatory drugs, vasoprotective agents, vasodilators, prostate massage, and alpha blockers.Other treatmentsOther types of treatments provided on an outpatient basis:
  • transrectal microwave hyperthermia;
  • Physiotherapy (laser therapy, mud therapy, acoustophoresis).
Other types of services provided at a fixed level:
  • transrectal microwave hyperthermia;
  • Physiotherapy (laser therapy, mud therapy, acoustophoresis).
Other types of treatment provided during the emergency phase: Not provided.surgical interventionSurgical intervention provided on an outpatient basis: Not performed.Providing surgical intervention in an inpatient settingtype:Transurethral incisions were made at the 5, 7, and 12 o'clock positions.Indications:This is performed in a hospital setting if the patient has prostatic fibrosis and clinical manifestations of bladder outlet obstruction.type:transurethral resectionIndications:For the treatment of calculus prostatitis (especially when the stones are located in the central zone, transient prostatitis and periurethral zone and cannot be treated conservatively).type:Spermatic tuberectomy.Indications:It is accompanied by sclerosis of the spermatozoa and obstruction of the ejaculatory and excretory ducts of the prostate.Precautions:
  • Quit bad habits;
  • Eliminate harmful effects (cold, lack of exercise, long-term abstinence, etc. );
  • diet;
  • spa treatments;
  • Normalize sex life.
Further management:
  • Observed by a urologist 4 times per year;
  • Prostate and bladder residual urine ultrasound, DRE, IPSS, prostate secretions 4 times a year
Indicators of therapeutic effectiveness and safety of diagnostic and therapeutic methods described in the protocol:
  • Disappearance or reduction of characteristic complaints (pain or discomfort in the pelvis, perineum, suprapubic area, pelvic inguinal area, scrotum, rectum);
  • According to the results of the DRE, prostate swelling and tenderness reduce or disappear;
  • Reduces inflammatory markers secreted by the prostate;
  • According to the ultrasound, the prostate swells and decreases in size.