Calculous chronic prostatitis

In clinical practice - when there are stones in the case of inflammation of the prostate gland (in Latin calculus - a pebble) - calculous prostatitis is diagnosed. Although this type of prostatitis in ICD-10 is not allocated, and prostate stones are assigned to a separate subcategory.

Epidemiology

Statistics on the prevalence of calculous prostatitis is unknown, and stones in the prostate gland are accidentally detected by ultrasound in 7.4–40% of cases and in almost 70% of elderly men with benign prostatic hyperplasia. [1]

In chronic pelvic pain, the detection of stones is, according to some reports, about 47%. [2]

Category IIIA prostatitis (chronic prostatitis / chronic pelvic pain syndrome with signs of inflammation) accounts for more than 90% of all cases of chronic inflammation of the prostate gland.

Causes of the calculous prostatitis

Prostatolitis, prostatic calculi, or  prostate stones  are divided into endogenous and exogenous - depending on their etiology. 

Prostate stones can be divided into primary or endogenous stones (found in the acini of the prostate gland) and secondary or external (caused by reflux of urine into the prostate). [3], [4] 

Endogenous calculi, often multiple and often asymptomatic, often occur with age (at the sixth decade) and are caused by obstruction of the ducts of the enlarged prostate or chronic inflammation. They are found during endoscopic examinations in the deeper structures of the prostate gland or its diverticula.

Exogenous stones are found mainly around the prostatic urethra (part of the urethra covered by the prostate gland) and are considered to be the result of urethroprostatic (intraprostatic) urine reflux and crystallization of its salts. Their appearance does not correlate with age and may be secondary to chronic urinary tract infection.

As a rule, the stones themselves do not cause symptoms, and the causes of calculous prostatitis are associated with the fact that most stones (78-83%) have cells and entire colonies of bacteria - a source of infection of the prostate gland that causes not just  chronic prostatitis , but chronic calculous prostatitis. [5]

According to clinical data, patients with prostate stones are more often diagnosed with category IIIA prostatitis (according to the NIH classification) - chronic pelvic pain syndrome with signs of inflammation, and category IIIB - chronic pelvic pain syndrome without signs of inflammation. More information in the material -  Prostatitis: types .

Risk factors

The list, which includes the most likely risk factors for the development of chronic calculous prostatitis, reflects various points of view in modern urology regarding the role of infection and its connection with prostatic stones as a result of the lithogenic process of calcification of the prostate gland.

So, the risk of calculous inflammation of the prostate is increased:

• in case of circulatory disturbance in the pelvic area (this is a problem for those who are sedentary and do not move much), which leads to ischemia and worsening of trophic tissue of the gland;
• with stagnation of the prostatic secretion in the parenchyma of the gland (due to the lack of regular sex);
• if there are chronic infections, primarily, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma, Ureaplasma urealyticum, gram-negative bacteria (Escherichia coli, Pseudomonas aeruginosa, Pseudomonas spp.) and gram-positive bacteria (Enterococcus faecalis, Staphylococcus aureus, Staphylococcus  haemolyticus, Staphylococcus epidermidis); [6], [7]
• in men of mature and old age due to degenerative changes in the tissues of the gland (due to a decrease in testosterone levels and an increase in the level of dihydrotestosterone);
• with an increase in the size of the prostate (its benign hyperplasia);
• in connection with the existing  prostate adenoma ; Stones are a pathophysiological phenomenon that occurs during aging, mainly after 50 years. Moore and Kirby et al.,  [8]As part of his hypothesis regarding external stones, came to the conclusion that prostatic hypertrophy causes chronic inflammation of the prostate, which affects stone formation.
• against the background of  diffuse changes in the prostate gland ;
• with narrowing of the prostatic urethra;
• with dysfunction of the detrusor of the bladder or spasmodic state of its neck, that is, when there are  impaired urination of a  neurogenic nature;
• with  urolithiasis ;
• due to  disturbances in mineral metabolism , in particular calcium and phosphorus;
• if disturbances in general metabolism lead to acidosis with an increase in urine pH.

Pathogenesis

Although the formation of prostatic stones, as the researchers suggest, may be a late stage of such a pathological process as calcification (calcification) of the prostate gland, the exact mechanism of development of calculous prostatitis - its pathogenesis - is still unclear. This is the result of not only different approaches to the causes of inflammation (in particular, as complications of chronic prostatitis), but also the obvious combined effect of many factors that specific patients have.

According to some foreign studies  [9],  [10]more than 83% of prostatic stones are composed of calcium phosphate to form hydroxyapatite; almost 9% - from calcium carbonate and only about 4.5% - from calcium oxalate. There are also calculi of mixed composition.

Also, the identification of the main protein components of prostatic stones contributed to the identification of the presence of calculi in the prostate with its inflammation. So, amyloid bodies (corpora amylacea) of prostate secretion were found in them; lactoferrin (a protein of cellular immunity that stimulates phagocytosis); leukocyte-produced calprotectin; myeloperoxidase (antimicrobial factor of neutrophils), α-defensin (immune peptide of neutrophils); calcium binding proteins (S100 A8 and A9), as well as keratin and the remains of exfoliated epithelial cells.

Thus, prostate stones play an important role in the pathogenesis of its inflammation, and their formation appears to be the result of calcification caused by inflammation.

In this case, chronic congestive calculous prostatitis, that is, congestive, is referred to as non-bacterial prostatitis. And stagnation of prostate secretion may be associated with its difficult excretion from the acini of the gland during the formation of endogenous stones overlying the excretory ducts.

Symptoms of the calculous prostatitis

The first clinical report of urinary symptoms associated with stones in the prostate was published at the end of the 19th century. [11]To date, it is generally accepted that stones in the prostate are found in proportion to age, without causing any specific symptoms. [12]

In some cases, calculous prostatitis does not manifest itself in any way, and the first signs of the disease, especially in the initial stage, can be felt as discomfort in the scrotum and perineum with periods of minor pain.

But in general, the symptoms of calculous prostatitis are similar to the clinical manifestations of ordinary chronic prostatitis,  [13]and this:

• burning during or after urination;
• difficulty at the very beginning of the mickey;
• dysuria (soreness and increased frequency of urination);
• incomplete emptying of the bladder after mictation, accompanied by leakage of urine;
• pain of a aching nature over the penis, in the scrotum or under it, was beaten in the pelvic area (including rectal) and lower back;
• pain during or after intercourse.

The intensity of the symptoms is individual. More information in the materials:

• Symptoms of Chronic Prostatitis
• Non-inflammatory chronic pelvic pain syndrome

Complications and consequences

Stones of the prostate and its inflammation can have consequences and complications such as;

• urethral obstruction;
• enuresis;
• decreased libido or impotence;
• sclerotic changes in the parenchyma of the prostate;
• the development of inflammation of the seminal vesicles (vesiculitis);
• recurrent bacteriuria.

Diagnostics of the calculous prostatitis

Prostate stones are detected by  transrectal ultrasound (TRUS) . Recently, when the introduction of TRUS has increased, more research has been done on prostate stones, and some reports have appeared about the shape and composition of the stones. However, the frequency of occurrence of stones, the mechanism of their formation, their relationship with benign or malignant formations in the prostate gland and the clinical significance of stones are not yet known.

Experts note such echographic signs of chronic calculous prostatitis as a discrete, multiple small echo, usually diffusely distributed throughout the gland, while the white spots of calculi are hyperechoic, and the area of inflammation manifests itself in a hypoechoic area.

Also, instrumental diagnostics can be performed using pulse-wave Doppler ultrasound, urethroscopy, urethrocystography, and  magnetic resonance imaging of the prostate .

Assignments are prescribed, including: a general blood test, urine tests (clinical, biochemical and bacterial seeding), an analysis of prostate secretion, a smear from the urethra.

Differential diagnosis

Differential diagnosis should exclude the presence of interstitial cystitis, neurogenic bladder dysfunction, tuberculosis or bladder carcinoma.

Treatment of the calculous prostatitis

Prostate stones, which usually do not have symptoms, usually do not require special treatment. However, the most problematic cases of stones in the prostate are associated with chronic inflammation of the prostate. In this case, treatment with antibiotics in combination with treatment of prostatitis can lead to the disappearance of symptoms. However, since prostate calculi infected with bacteria are a source of persistent inflammation, careful removal of prostate calculi is the preferred treatment for chronic bacterial inflammation of the prostate. Lee and Kim analyzed the effectiveness of oral antibiotics in 64 patients with chronic bacterial prostatitis and reported that the recovery rate with pharmacotherapy was 63.6% in patients without stones and 35.7% in patients with stones.

Medication includes prescribing a course of taking antibacterial drugs of the fluoroquinolone group (Ciprofloxacin, Cephalexin, Ofloxaci, Levofloxacin), tetracycline antibiotic Doxycycline, etc. According to some studies, the cure rate after using fluoroquinolones is from 63% to 86%. [14],  [15]. See -  Chronic prostatitis: treatment with antibiotics .

The anticholinergic drugs Tolterodin (Detrol, Detruzin, Urotol) help to reduce the urge to urinate - 1-2 mg twice a day. The drug can cause headache and dizziness, palpitations, dry mucous membranes, urinary retention, peripheral edema.

In case of chronic calculous prostatitis with benign prostatic hypertrophy, a drug of the group of 5-α-reductase inhibitors Finasteride (Prosteride, Proscar) is used - 5 mg per day (one tablet); Dusteride (Avodart) - per day 0.5 mg (one capsule); Duration of admission is six months. Side effects include erectile dysfunction and decreased fertility.

Pain relieves drugs such as No-shpa or Ibuprofen (and other NSAIDs). Locally use  candles from prostatitis . And to reduce the oxidative stress of prostate cells, vitamins A, C and E. Are prescribed.

Read more:

• Treatment of chronic prostatitis
• Prostatitis Pills

Physiotherapeutic treatment - in detail in the publications:

• Physiotherapy for prostatitis
• Treatment of chronic prostatitis used in a spa

Acupuncture significantly reduces general pain, urination symptoms and quality of life in men with chronic prostatitis and chronic pelvic pain syndrome. [16]

In this disease, homeopathy offers such remedies as Sabal serrulata, Pulsatilla, Kali bichromium, Baryta carbonica, Conium Maculatum, Chimaphilla umbellate, Causticum, Lycopodium clavatum.

In the absence of positive results of conservative therapy, when patients continue to have difficulty urinating or chronic pain, they undergo surgical treatment:

• removal of prostatoliths - transurethral ultrasound, electromagnetic or laser lithotripsy;
• removal of a part of the prostate (transurethral resection);
• transurethral electrovaporization (evaporation) of the prostate;
• laser enucleation prostatectomy;
• removal of the entire gland (open prostatectomy).

Prostate stones are asymptomatic in most cases, but in some cases, a large prostate stone protruding into the urethra causes serious symptoms in the lower urinary tract, such as obstruction of the urinary tract. In such cases, prostate stones can be removed using a transurethral endoscope.

An alternative treatment is to take moderately warm baths with decoctions of medicinal plants (chamomile flowers, sage, peppermint, sage, thyme and cinnamon) also have antimicrobial activity)  [17]and to take pumpkin oil inside   (pumpkin seed oil can inhibit prostate hyperplasia caused by testosterone and therefore may be useful in the treatment of benign prostatic hyperplasia). [18]The effectiveness of trans-perineal phonophoresis in the treatment of chronic non-bacterial prostatitis using pumpkin seed oil as a binding medium has been proven. [19]

Creeping sulfur (lat. Serenoa repens) is widely used in many Asian, African and European countries. In a compositional analysis, sterols and free fatty acids are found in S. Repens berries. Initial studies have shown that the efficacy of S. Repens may be similar to that of pharmaceutical inhibitors such as finasteride. These preliminary data prompted the study of the mechanism, usefulness and effectiveness of this plant in an in vitro assay and in clinical trials. Several studies have examined the use of S. Repens for the treatment of symptoms associated with BPH [20], [21]and chronic prostatitis. [22]

A pollen extract called Cernilton is believed to be beneficial for a variety of urological conditions. Unconfirmed data and links from the texts indicate the potential anti-inflammatory properties and potential of Zernilton in the treatment of symptomatic relief of pain and urinary dysfunction, which are often present both in chronic prostatitis and in BPH. [23]In vitro studies demonstrate various experiments with this particular extract, including a histopathological analysis of its effect on cell proliferation, apoptosis, serum cytokines and testosterone. [24],  [25]The literature also lists many clinical trials of pollen extract; however, five in Japanese and one in German. [26]While many of these studies report the efficacy of pollen extract and suggest its usefulness for chronic prostate and chronic pelvic pain syndrome, the data from these studies have not been compiled due to inaccessibility and translation of articles.

One study proved the effectiveness of quercetin in treating symptoms of chronic prostatitis (P = 0.003) compared with the placebo group. Although this is the only clinical study that studies the effect of quercetin quercetin on alleviating the symptoms of prostatitis, a positive result confirms the need for further research, including an analysis of the cost of quercetin therapy in this group of patients. [27]

One study found that the multi-herbal formula WSY-1075 (25% C. Fructus, 25% A. Gigantis radix, 25% L. Fructus, 10% C. Parvum cornu, 10% G. Radix rubra and 5% C. Cortke) has antimicrobial, anti-inflammatory and antioxidant effects in the treatment of chronic bacterial prostatitis. [28]

Prevention

Methods aimed at preventing chronic calculous prostatitis have not been developed to date. But it is recommended to lead a healthier lifestyle and not neglect physical exercises - in order to avoid stagnation in the prostate gland.

Forecast

Calculous prostatitis has a very favorable prognosis, although getting rid of chronic pelvic pain is a serious medical problem.