Acute bacterial prostatitis

Acute prostatitis is an acute inflammation of the prostate, which is characterized by a certain symptom complex (pain, hyperthermia, dysuria, septic condition). The spectrum of pathogens of acute prostatitis is represented by the same pathogens as in other acute infections of the urinary tract.

The vast majority are anaerobic non-negative bacteria: Escherichia coli is 80% Serratia Pseudomonas, Klebsiella Pseudomonas, Proteus Pseudomonas - 10-15%; non-positive: Enterococcus - 5-10%, Staphilococcus aureus causes the development of acute prostatitis with prolonged drainage of the bladder by the urethral catheter. Other Gram-positive bacteria cause the development of the disease against a background of lower immunity indices (prolonged septic state, acquired immunodeficiency syndrome, tuberculosis and other conditions).

ICD-10 codes

• N41.0. Acute prostatitis.
• N41.8. Other inflammatory diseases of the prostate.
• N41.9. Inflammatory disease of the prostate, unspecified.

Epidemiology of acute prostatitis

Bacterial acute prostatitis in the structure of inflammatory diseases of the prostate is 5-10%. The disease occurs mainly in the reproductive age (35-50 years).

[1], [2], [3], [4]

What causes acute prostatitis?

To predisposing factors of development of acute prostatitis include situations that contribute to the penetration of bacterial infection and colonization of prostate tissues:

• indiscriminate sexual relations, the presence of chronic inflammatory diseases in the partner (bacterial vaginosis, chronic salpingoophoritis, etc.);
• intraprostatic reflux of urine (with functional disorders of the sphincter of the bladder);
• prostate stones (due to prolonged congestion or as a complication of chronic prostatitis);
• phimosis;
• urethral catheters;
• instrumental interventions on the urethra.

The development of an acute inflammatory process is facilitated by:

• venous congestion (stasis) of the pelvic organs due to hemorrhoids, paraproctitis, obesity and hypodynamia;
• concomitant diseases (diabetes mellitus, acquired immunodeficiency syndrome, alcoholism).

A special place is occupied by bacterial acute prostatitis, which developed against the background of urosepsis, a characteristic clinical picture of which is lightning with the development of characteristic complications (abscess of the prostate, phlegmon of the small pelvis).

The pathways of infection into the prostate are different.

The most common ways of penetrating the infection into the prostate are:

• canalicular pathway - from the back of the urethra through the excretory ducts of the prostate;
• lymphogenous pathway - with acute urethritis, "catheter urethral fever";
• hematogenous pathway - with bacteremia.

Pathogenesis of acute prostatitis

Morphological changes in the prostate can be traced in the course of a typical acute inflammatory process. In catarrhal acute prostatitis, the prostate size increases due to the expansion of the acini and jet edema of the interstitial tissue. Further inflammatory changes rapidly develop in the excretory ducts and prostate lobules. Their lumen is significantly narrowed or obturated due to edema of the whole organ.

In the inflammatory process, only the excretory ducts of the prostatic glands are directly involved, which open into the posterior part of the urethra. Inflammatory process does not extend deeper than the mucous and submucosal layers. Violation of the contractility of the excretory ducts and their relative constriction or complete blockage lead to a violation of secretion of the gland secretion in the posterior part of the urethra. They note the stasis of the secretion of the prostate, the lumen of the ducts and glands is filled with deflated epithelium, leukocytes, mucous-degenerated bodies. In the mucosa and submucosa - leukocyte infiltration. A hemodynamic disorder increases the edema of the organ. Catarrhal acute prostatitis often develops as a result of infection from the back of the urethra. The secretion of an inflammatory-altered secret to the back of the urethra supports the posterior urethritis.

Follicular prostatitis is the next stage in the development of acute prostatitis. The inflammatory process, spreading, affects the prostatic glands of individual lobules or the entire prostate. The stagnant secretion of glands in the form of pus is secreted into the urethra or forms isolated pustules. The glandular tissue is infiltrated, its cellular elements undergo various degrees of destructive changes. The hemo- and lymphodynamic disturbances increase. With the occlusion of the excretory ducts, individual minuses sharply expand. The prostate is enlarged.

The transition of the inflammatory process to the interstitial tissue of the prostate indicates a parenchymal acute prostatitis. It should be noted that with the contact (post-puncture or post-operative) and hematogenous pathways of infection, the parenchymal stage develops independently. Infection, hitting interstitium, easily overcomes weak interlobular septa, and the process takes a diffuse-purulent character. Leukocyte infiltration captures the stromal structures of the organ, leads to compaction and swelling of the organ.

The process can capture the proportion of the gland or the entire gland. The parenchymal stage develops first as a diffuse-focal stage, at which individual foci of purulent inflammation form. Then, leukocyte infiltration and foci of purulent fusion merge with the formation of prostate abscess. Against this background, the gland tissue can melt with the formation of a prostate abscess. If the inflammation seizes the fibrotic capsule of the prostate or surrounding the cellulose, talk about the pair of prostatitis. Phlebitis of paraprostatic venous plexus is a serious complication of acute parenchymatous prostatitis and can cause sepsis. The abscess of the gland is sometimes spontaneously opened into the bladder, the posterior part of the urethra is the rectum, rarely into the abdominal cavity. His opening into the surrounding pelvic fat is accompanied by her suppuration. With follicular and parenchymal acute prostatitis, as a rule, reactive inflammation of the back of the urethra and the neck of the bladder, which gives the clinical picture of the disease additional features.

Symptoms of acute prostatitis

Symptoms of acute prostatitis start acutely, accompanied by frequent, difficult and painful urination in small portions, pain in the perineum, in the anus and the suprapubic region, a feeling of pressure in the rectum, discomfort in the genital area. Symptoms of general intoxication join: hyperthermia reaches 39 ° C or more, there are tachycardia, tachypnea, nausea, chills, until the development of the septic state. Joining chills is an obvious sign of a serious illness. Within 20-30 minutes the chill passes, but general weakness, sweating, fatigue appears.

The intensity of complaints and the degree of clinical manifestations in different patients is heterogeneous and depends on the shape or stage of acute prostatitis, and also on the anatomical and topographic location of the inflammatory focus in the prostate in relation to the urethra, the neck of the bladder and the rectum. Diabetes mellitus, chronic alcoholism, drug addiction can hide the true severity of the disease, which leads to an underestimation of the patient's condition. Complaints of pain in acute prostatitis may be absent or limited to painful defecation, a feeling of pressure in the rectum, in the perineum when sitting.

In digital rectal examination, the prostate is significantly enlarged, edematous, sharply painful, the interfacing is not differentiated, the foci of fluctuations indicate the development of prostatic abscess. With pronounced pyuria, the urine is turbid, has a fetid odor.

Pronounced edema of the inflamed prostate and paraprostatic fiber leads to compression of the back of the urethra, increased difficulty of urination, up to the development of acute retention of urination. In a number of cases, this serves as the basis for the patient's treatment for urgent medical care.

Symptoms of acute prostatitis can be very scarce, so the disease is not diagnosed on time. Acute prostatitis can occur under the "mask" of common infectious diseases.

Therefore, it should be remembered that any sudden rise in temperature. In men with the scarcity of other clinical manifestations requires a digital rectal examination of the prostate.

In catarrhal acute prostatitis the prostate is either unchanged or slightly enlarged, with palpation noted for its moderate soreness, and with the follicular prostatitis, against a background of its moderate increase, it is possible to probe some sharply painful foci of tightly elastic density over the inflamed lobules. In patients with parenchymal acute prostatitis, the prostate is sharply tense and painful at the slightest touch to it. Its density is tight and uniform, with the abscessing of the foci noted softening.

When the inflammatory process spreads in the prostate to the surrounding tissues, the symptoms of acute prostatitis change. When the process captures the near-bubble cellulose and the wall of the bladder, clinical manifestations resemble acute cystitis with a sharp increase in urination and painful urge to urinate (tenesmus). With the transition of the inflammatory process to the rectum wall or pararectal tissue, the manifestations of the disease resemble proctitis and paraproctitis with painful defecation, secretion of mucus from the rectum, sharp pain in the perineum, painful spasm of the anal sphincter, preventing the execution of digital rectal examination.

This research should be carried out with extreme caution, first, because of pain and, secondly, because of the danger of provoking a sharp increase in the resorption of inflammatory exudates and even a direct "breakthrough" in the blood of microbial flora and bacterial toxins. The latter can not only enhance general intoxication, but also cause bacterial shock. For the same reasons, categorically forbidden prostate massage during the period of its acute inflammation, including with a diagnostic purpose. At the same time, any finger examination of the gland should be used as much as possible for diagnostic purposes, and therefore, when preparing it, it is necessary to prepare the necessary test tubes in advance to perform a three-glass sample, three-port urinalysis and its bacteriological study.

Classification of acute prostatitis

Acute prostatitis is divided into:

• catarrhal;
• follicular;
• parenchymal.

Complications of acute prostatitis:

• abscess of the prostate;
• paraprostatitis,
• phlebitis of the paraprostatic venous plexus.

According to the prevalence of the process, diffuse and focal acute prostatitis is distinguished. Classification of acute prostatitis is relative, as often all forms are presented simultaneously in the inflammatory process or they are consecutive stages of development of acute inflammation.

Acute prostatitis consistently passes from the catarrhal into the follicular and then into the parenchymal form. The time of development of each stage does not have a strict time limit and depends on the pathogenicity of the microorganism, the state of the organism, the accompanying pathological processes.

[5], [6], [7], [8]

Complications of acute prostatitis

Frequent complication of acute prostatitis - acute retention of urination or difficulty urinating with the appearance of residual urine of 100 ml or more, which requires immediate urine derivation. Preference is given to trocar cystostomy. Establish drainage with a diameter of 12-18 SN, the duration of drainage is 7-14 days.

Progression of the inflammation can lead to suppuration of the prostate tissue with the formation of an abscess.

Abscess of the prostate - purulent fusion of the prostate parenchyma with the formation around the focus of the pyogenic capsule, is usually a consequence or outcome of acute prostatitis. Significantly less often diagnosed idiopathic, primary prostate abscess, resulting from metastasis of purulent infection during septicopyemia associated with other pyoinflammatory diseases. In this case, there is a history of purulent focus (pyoderma, furunculosis, tonsillitis, maxillary sinusitis). On examination, you can find these purulent foci.

Abscess of the prostate can be suspected when the clinical picture and the severity of the patient's condition with acute prostatitis or with rapid development of the disease with deterioration of blood tests, increasing signs of intoxication. Abscess of the prostate, in turn, can be complicated by the development of endotoxic shock (a drop in blood pressure, hypothermia to 35.5 ° C, a decrease in the level of blood leukocytes below 4.5x10 ⁹ / l), as well as paraprostatic phlegmon.

However, one should also take into account the fact that restriction of purulent focus (the formation of an abscess in the prostate) can occur against a background of subjective improvement in the patient's condition.

The diagnosis is established by palpation in the rectum, when asymmetry of the enlarged and painful gland is revealed, balloting or fluctuation when pressing on it in a suspicious area. It is seldom possible to probe the pulsation of pelvic vessels, which is transmitted through the cavity located in the depth of the prostate (a symptom called the Pooul's rectal pulse). To detect a purulent cavity in the gland allows the ultrasound of the organ with the use of a rectal sensor.

Without surgical treatment, the abscess can spontaneously open into the back of the urethra or into the bladder, which is clinically accompanied by visible self-healing. Opening of the abscess in the rectum, the perineum, in the paraprostatic and peribuzyrnuyu fiber is accompanied by the formation of purulent fistula, phlegmon, also requiring surgical treatment.

The revealed abscess of the prostate is urgently opened, the abscess cavity is drained. Drainage of prostatic abscess is currently produced under ultrasonic guidance by transrectal or transperinial access. The choice of method depends on the equipment of the clinic and the preferences of the urologist, however, the best approach to abscess of the prostate is transperineal access. Under local anesthesia, a puncture of the abscess occurs. A drainage with a diameter of 6-8 SN is installed in the cavity. Duration of drainage is 5-7 days.

In the absence of ultrasound guidance, the opening of the prostate abscess is carried out under the control of the index finger of the left hand inserted into the rectum, which is felt for the place of the greatest fluctuation. The patient is then laid on his back with legs bent in the hip and knee joints. The operation is performed under general or epidural analgesia. 2-3 centimeters anterior to the anal opening to the right or left of the median seam of the perineum, according to the location of the abscess in one or both lobes, the abscess is punctured with a long needle with a syringe. After puncture and getting in the syringe, pus is made layerwise cut along the needle, open the abscess, empty it, perform a revision of the cavity, expand the course with the root canal and drain the drainage tube, as well as with ultrasound guidance.

If the abscess is located directly at the rectum wall, it can be opened transrectally. The position of the patient and anesthesia are the same. Under the control of the index finger of the left hand through the rectum puncture the cavity of the abscess. Completely emptying the abscess does not follow, as this can make it difficult to open it. Without removing the needle from the puncture site, the rectal mirror is injected into the rectum and under the vision control the abscess wall is opened for 1-2 cm. The pus is removed by sucking. The finger is used to inspect the abscess cavity and drain it with a drainage tube.

In the postoperative period, narcotic analgesics can be prescribed to delay the emptying of the intestine for 4-7 days.

Opening of the abscess can be accompanied by increased intoxication and, in rare cases, even the development of bacterial shock, which requires in the postoperative period a massive antibacterial therapy and constant monitoring of medical personnel.

In cases where purulent inflammation goes beyond the capsule of the prostate, there is a paraprostatic phlegmon, it. As a rule, develops in the behind-bubble space formed in front of the wall of the bladder, behind the apoplexy of Denonville and from the top of the peritoneum, on each side the posterolateral space is limited by seminal vesicles and prostate. Paraprostatic phlegmon is a relatively rare complication of prostate abscess. In the clinical picture, the symptoms of general intoxication and bacteremia prevail.

Depending on the state of the immune system of the patient and accompanying diseases, in particular diabetes, paraprostatic phlegmon can turn into panflegmon of the pelvis or into limited purulent foci. Purulent fusion from the posteropubic space easily spreads to the parietal tissue of the small pelvis, causing irritation of the abdominal wall with the development of peritonitis symptoms. The pus may spread around the prostate gland. Spreading along the visceral spaces of the pelvis, the abscess captures the rectal intestinal tissue and is opened on the perineum. So there is paraproctitis with pararectal festering fistulas. Only timely operative and antibacterial treatment gives hope for success. In this case, the ways of spreading paraprotic phlegmon determine the methods of draining the small pelvis.

[9], [10], [11]

Diagnosis of acute prostatitis

Diagnosis of acute prostatitis can often be established based on the history and physical examination. Laboratory studies and ultrasonography data, as a rule, confirm the diagnosis of acute prostatitis. When differential diagnosis should pay attention to possible chronic inflammation of the pelvic organs (chronic prostatitis, paraproctitis, fistulas of the urethra and bladder).

When diagnosing acute prostatitis, it is necessary to indicate its complications, which can be divided into local and general. To local complications include the development of acute retention of urination, prostate abscess, small pelvis phlegmon. To general - bacteremia, urosepsis, up to bacteriotoxic shock. Local complications require urgent surgery. Acute prostatitis can also lead to the development of acute epididymitis, orchoepidymitis.

[12], [13], [14], [15], [16]

Laboratory diagnostics of acute prostatitis

Laboratory diagnosis of acute prostatitis is an important component in determining the tactics of treatment. A general blood test reveals leukocytosis, a stab shift, increased ESR, which gives reason to judge the degree of inflammation and purulent inflammatory intoxication. A single urinalysis may not reveal changes, but repeated studies often detect pyuria and bacteriuria. It is especially important for this purpose to investigate the first portion of urine, which flushes the pus from the back of the urethra or the altered secret from the opening ducts of the prostatic glands. Since the study of secretion of the prostate obtained after rectal massage is impossible, we have to confine ourselves to a four-glass breakdown, in which leukocyturia and bacteriuria are detected in the last portions of urine.

A bacteriological study of urine reveals a typical uropathogenic flora. The results of bacteriological tests of urine (antibioticogram) allow to correct antibacterial therapy. It should also be borne in mind that the drainage of the inflamed parts of the prostate can be disturbed and only periodically restored, and then the secret of the prostate with an admixture of pus enters the back of the urethra. Repeated bacteriological tests of urine increase the probability of obtaining accurate information.

With increasing general intoxication, hectic temperature with chills, one should remember about the possibility of developing a septic state and repeatedly perform a culture examination (sowing) of blood, which allows to identify the causative agent of sepsis in a patient.

Given the large role of neutrophils in the body's response to inflammation. In recent years, ever increasing clinical application, immunological responses have been obtained in the study of their population. These tests, together with other immunological criteria, allow clinicians to judge the nature and dynamics of the inflammatory process, and most importantly - the danger of the transition of the inflammatory process to suppuration and the development of sepsis.

Instrumental diagnostics of acute prostatitis

Currently, in urological practice, an increasing place is occupied by puncture biopsy of the prostate in the diagnosis of various diseases. Complications in the form of acute prostatitis account for 1-2% of cases. Also, such complications are rarely diagnosed after TUR of the prostate, which, as a rule, occur against the background of an outbreak of nosocomial infection in a medical institution.

Endouretral endoscopic examination methods (urethroscopy, cystoscopy) in acute prostatitis are contraindicated

A little information can be obtained with excretory urography with a descending cystogram before and after urination. Cystograms sometimes reveal a filling defect in the lower contour of the bladder due to an enlarged prostate and enlarged seminal vesicles, on the descending urethrogram - changes in the posterior part of the urethra and the seminal tubercle (lengthening of the prostatic section of the urethra, an increase in the filling defect caused by the seminal tubercle). On the cystogram after urination, the presence and amount of residual urine can be determined indirectly.

Due to its prevalence, the most significant and accessible method for diagnosing acute prostatitis is ultrasound, the TRUSI prostate is more informative, but has the same contraindications as prostate massage,

When describing the data, ultrasound of the prostate draws attention to the size of the organ in three planes, its volume, echostructure (density), expansion of venous spitting, the state of intraprostatic divisions of seminal vesicles, and the presence of residual urine in the bladder. Hypoechoic areas in the prostate parenchyma are a sign of an emerging abscess.

When identifying residual urine against the background of acute prostatitis, it is necessary to decide the issue in favor of emergency urinary diversion - cystostomy.

Treatment of acute prostatitis

Patients diagnosed with acute prostatitis should be hospitalized preferably in a specialized urological department.

In uncomplicated acute prostatitis, antibacterial treatment of acute prostatitis, as a rule, is effective and is performed stepwise. With severe intoxication drugs are administered intravenously, with the normalization of temperature and relief of symptoms of acute prostatitis, it is possible to switch to oral administration of medications. The total duration of pharmacotherapy is at least 4 weeks.

With an increase in body temperature to 37.5 ° C, low leukocytosis, the absence of adverse factors (repeated acute inflammation, diabetes mellitus, elderly age) treatment is carried out for 10 days, fluoroquinolones can be prescribed on an outpatient basis.

With acute prostatitis, the drugs of choice are:

• fluoroquinolones (levofloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin);
• protected semi-synthetic penicillins (ampicillin + sulbactam, amoxicillin + clavulanic acid);
• cephalosporins of the second and third generations (cefuraxime, cefotaxime, cefaclor, cefixime, ceftibutene), sometimes in combination with aminiklikozidami.

Alternative drugs:

• macrolides (azithromycin, clarithromycin, roxithromycin, erythromycin);
• doxycycline.

The most commonly prescribed drugs are:

• Levofloxacin intravenously on 500 mg once a day for 3-4 days then inside 500 mg once a day up to 4 weeks;
• ofloxacin intravenously on 400 mg 2 times a day 3-4 days then inside 400 mg twice a day for 4 weeks;
• pefloxacin intravenously 400 mg 2 times a day 3-4 days then inside 400 mg 2 times a day 4 weeks;
• ciprofloxacin intravenously on 500 mg 2 times a day for 3-4 days then inside 500 mg twice a day up to 4 weeks.

Alternative drugs with acute prostatitis are prescribed less often:

• azithromycin inwards 0.25-0.5 g once daily 4-6 weeks;
• doxycycline orally in 100 mg twice a day for 4-6 weeks;
• erythromycin intravenously on 0.5-1.0 g 4 times a day, then inward by 0.5 g 4 times a day, only 4-6 weeks.

At use of high doses of preparations it is necessary to appoint simultaneously vitamin therapy (ascorbic acid, vitamins of group B), to watch a sufficient reception and allocation of a liquid.

As anti-inflammatory and pain-reducing agents, acetylsalicylic acid and other NSAIDs are useful (piroxicam, diclofenac, the latter can be administered intramuscularly, orally, and in the form of rectal suppositories and other forms). With unbearable painful pains, it is permissible to use narcotic drugs with belladonna, including rectal suppositories.

In patients with catarrhal and follicular acute prostatitis in the absence of a tendency to progress in the inflammatory process to accelerate the resorption of inflammatory infiltrates in the gland, stimulation of resolution of inflammation is recommended by physiotherapy, warm sessile baths, hot microclysters from chamomile broth.

Experience shows that an undiagnosed or late diagnosed acute prostatitis, usually a catarrhal (less often follicular) form, successfully succumbs to any antibacterial, anti-inflammatory treatment prescribed for another reason (with hyperdiagnosis of influenza, acute respiratory disease, etc.).

Further management

The further task of the doctor is to achieve a long-term remission and to prevent complications and possible relapses of the inflammatory process in the prostate.

How to prevent acute prostatitis?

Prevention of acute prostatitis includes:

• observance of personal hygiene;
• observance of sexual hygiene;
• timely sanation of foci of chronic purulent infection, especially in risk groups.

Since the frequency of catheterization of the bladder in surgical and therapeutic hospitals is 10-30%, and in the urological much more often, preventive measures that prevent acute prostatitis are particularly relevant.

Prognosis of acute prostatitis

The prognosis of acute prostatitis with timely and adequate treatment is generally favorable, but it is not always possible to achieve absolute cure, which is associated with the formation of foci of "dormant" infection in the prostate, which predisposes the complexity of its glandular structure. Catarrhal acute prostatitis with targeted therapy can be completely cured. After the treatment of follicular prostatitis, as a rule, the obliterated ducts of individual glands or their groups remain.

They may contain an infectious agent and, due to poor emptying of the secret, prostate stones form. These foci of impaired morphology and microcirculation are always considered the site of a possible onset of a relapse of the inflammatory process and the basis of chronic prostatitis. Parenchymal prostatitis often turns into a chronic form of the disease. The duration of temporary incapacity for work is 20-40 days. The danger of the transition of acute prostatitis to the chronic form of the disease requires dispensary observation of these patients.