Chronic prostatitis: causes

Chronic prostatitis was the most common reason for men under 50 to see a urologist; this category of patients accounted for 8% of all patients of urologists in the outpatient clinic in the United States. On average, a urologist sees 150-250 patients with prostatitis per year, about 50 of whom are newly diagnosed patients. The impact of prostatitis on quality of life is quite significant and is quite comparable to the impact of myocardial infarction, angina pectoris, and Crohn's disease.

Until recently, large-scale epidemiological studies on the incidence and morbidity of prostatitis were not conducted. One of the pioneers in the study of this disease, Stamey T. (1980), believed that half of men will definitely suffer from prostatitis at least once in their lives. Relatively recent (end of the last century) international studies confirmed the correctness of his assumption: 35% of the surveyed men had symptoms of prostatitis during the last year. The frequency of prostatitis was 5-8% of the male population.

In our country, the diagnosis of "prostatitis" has long been treated with skepticism, all the attention of urologists was directed at prostate cancer and its adenoma (benign prostatic hyperplasia). However, recently the problem of prostatitis has become much more urgent. In 2004, the company "Nizhpharm" conducted a survey of 201 doctors and an analysis of 4175 patients from different cities of Russia. Analysis of the obtained data showed that the main nosologies encountered by urologists in clinics are chronic prostatitis.

In 2004, the Russian Society of Urologists considered it necessary to include the issues of diagnostics and treatment of prostatitis in the program of its plenum. What can cause inflammation of the prostate, seemingly so securely hidden in the depths of the small pelvis? At the end of the 19th century, it was believed that chronic prostatitis develops as a result of repeated perineal trauma (for example, as a result of horseback riding) or abnormal sexual activity [including masturbation]. Understanding the inflammatory nature of prostatitis, its connection with the infectious agent, appeared in the first half of the 20th century. At first, gonococcal infection was considered the indisputable etiologic factor. Then, large-scale microbiological studies confirmed the hypothesis that nonspecific gram-positive and gram-negative microflora can also cause inflammation in the prostate. The presence of these microorganisms in the lower urinary tract and leukocytosis in the prostate secretion were considered the basis for recognizing them as the etiologic factor of prostatitis for half a century. In the 1950s, new data were obtained proving the possibility of non-infectious prostatitis, and the dogma "leukocytes and bacteria are the cause of prostatitis" was revised. Patients in whom the bacterial factor of prostatitis was not detected were considered to have become ill due to high pressure of urine flow, the occurrence of turbulence of its flow in the prostatic part of the urethra and reflux of urine into the excretory ducts of the prostate. This causes a chemical burn, an immunological reaction and abacterial inflammation.

At the same time, the concept of prostatodynia appeared - a condition in which there are all the symptoms of prostatitis, but there is no microflora and an increased number of leukocytes in the gonads. Reliable evidence of the mechanism of development of prostatodynia has not been proposed, but there is an opinion that the cause of the disease are neuromuscular disorders of the pelvic floor and perineal complex.

Thus, the following are now considered to be the causes of the development of chronic prostatitis:

• repeated perineal trauma (horse riding, cycling);
• abnormal or excessively active sexual life;
• abuse of fatty foods and alcohol;
• gonococcal infection (now rare);
• other infectious - gram-positive and gram-negative microflora (E. Coli, Klebsiella spp, Pseudomonas spp, Enterococcus spp, staphylococci, anaerobes, diphtheroids, corynebacteria, etc.)
• intracellular pathogens (chlamydia, mycoplasma, mycobacterium tuberculosis
• microbial biofilms, viruses;
• immunological disorders (including autoimmune)-
• chemical damage due to urinary reflux;
• neurogenic disorders.

Understanding the etiopathogenesis of the disease is necessary for adequate therapy. Several mechanisms of prostate inflammation are quite possible, simultaneously or sequentially, and all of them should be taken into account in the patient management tactics.

Professor T.E.V. Johansen, in his master class “What is chronic prostatitis?” emphasized that this disease includes:

• a syndrome that includes signs of inflammation of the prostate and symptoms of inflammation of the lower urinary tract;
• inflammation of the prostate, including asymptomatic;
• symptoms reflecting prostate damage, including those without signs of inflammation.

Below are brief excerpts from Professor T.V. Johansen's speech.

According to the classification of the National Institutes of Health (USA) (NIH)/NIDDK, all cases of prostatitis except acute are considered chronic. Such conditions are clinically expressed in the recurrence of symptoms of bacterial infection and an increased content of leukocytes in the prostate secretion.

To determine the category of prostatitis, you need to do the following:

• carefully examine the medical history and symptoms, using, among other things, specially designed questionnaires;
• conduct a urine analysis - microscopic examination of sediment, microflora culture, perhaps the Meares and Stamey test;
• perform a microscopic examination of prostate secretions;
• analyze the ejaculate to determine signs of inflammation, growth of microflora, and the spermogram as a whole;
• conduct a biochemical blood test to identify systemic signs of inflammation;
• microbiologically and pathomorphologically examine prostate tissue samples obtained by needle biopsy.

Histologically, almost all biopsies show signs of inflammation of varying degrees of severity, which indirectly indicates the widespread prevalence of prostatitis in the male population. However, there is no correlation between clinical symptoms and pathomorphological findings. In practice, one fundamental criterion is used in the classification - the presence or absence of microflora growth. Depending on this, prostatitis is classified as bacterial or abacterial.

Most of all, patients with chronic prostatitis are bothered by pain, which in 46% of patients is localized in the perineum, in 39% - in the scrotum/testicles, in 6% - radiates to the penis, in 6% - to the bladder area; in 2% - to the sacrococcygeal zone.

Symptoms of lower urinary tract inflammation include frequent urges, weakened urine stream, occurrence and increase of pain during urination. For objective assessment of symptoms, the NIH scale is used, which takes into account three main parameters: pain intensity, lower urinary tract inflammation symptoms and quality of life.

When diagnosing chronic prostatitis, it is first necessary to exclude organic pathology of the prostate, other types of urogenital infections and venereal diseases. Differential diagnosis is carried out in relation to diseases of the anorectal region, adenoma and prostate cancer (cancer in situ), interstitial cystitis, bladder and myofasciitis of the small pelvis.

European experts recommend performing a general urine analysis using the Meares and Stamey method, proposed back in 1968:

• the patient releases 10 ml of urine into the first container;
• into the second container - 200 ml of urine, after which the patient stops urinating (which is antiphysiological and not feasible in all cases);
• a prostate massage is performed, the resulting secretion is sent for examination - the so-called third portion;
• The fourth container collects the remaining urine released after the prostate massage.

During light microscopy of a native smear of prostate gland secretion, a sign of inflammation is the detection of more than 10 leukocytes in the field of view (or > 1000 in 1 μl).

Evidence of inflammation in the prostate is also an increase in the pH of the secretion, the appearance of immunoglobulins, the ratio of the LDH-5/LDH-1 level (>2), as well as a decrease in the specific gravity of urine, the level of zinc, acid phosphatase and prostatic antibacterial factor.

Many urologists, in order not to bother themselves with the "unaesthetic" procedure of prostate massage, limit themselves to examining the ejaculate. This should not be done, since there is a high risk of incorrectly determining the number of leukocytes, and the results of the culture may be different. In some cases, the prescription of antibiotics can be considered as a test therapy. Some patients may be shown a prostate biopsy to exclude intracellular infections, urodynamic studies, measurement of cytokines, etc. The level of prostate-specific antigen (PSA) does not correlate with the pathomorphological signs of prostatitis, but is related to the degree of inflammation. However, this test has no diagnostic value in chronic prostatitis.

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