Chronic prostatitis: causes

Chronic prostatitis was the most common reason for seeking treatment for a urologist under the age of 50; This category of patients accounted for 8% of all patients receiving outpatient urology in the United States. On average, the urologist takes 150-250 patients with prostatitis a year, about 50 of which are newly diagnosed patients. The effect of prostatitis on the quality of life is very significant and quite comparable with the value of myocardial infarction, angina pectoris and Crohn's disease.

Until recently, a large-scale epidemiological study on morbidity and morbidity with prostatitis was not conducted. One of the pioneers in the study of this disease, StameyT. (1980), believed that half of men during life must at least once suffer from prostatitis. Relatively recent (late last century) international studies confirmed the correctness of his assumption: 35% of the men surveyed had symptoms of prostatitis within the last year. The frequency of prostatitis was 5-8% of the male population.

In our country for a long time to the diagnosis of "prostatitis" were skeptical, all the attention of urologists was directed to prostate cancer and its adenoma (benign prostatic hyperplasia). However, recently the problem of prostatitis: it has become much more relevant. In 2004, Nizhpharm conducted a survey of 201 physicians and an analysis of 4,175 patients from different Russian cities. The analysis of the obtained data showed that the main nosologies with which urologists are found in polyclinics are chronic prostatitis.

In 2004, the Russian Society of Urologists found it necessary to introduce into the program of its plenum the diagnosis and treatment of prostatitis. What can cause inflammation of the prostate, seemingly so safely hidden in the depth of the small pelvis? At the end of XIX century. It was thought that chronic prostatitis develops as a result of repeated perineal trauma (for example, as a result of riding) or abnormal sexual activity [including masturbation]. Understanding the inflammatory nature of prostatitis, its connection with an infectious agent, appeared in the first half of the XX century. Initially, an undeniable etiological factor was considered gonococcal infection. 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 parts of the urinary tract and leukocytosis in the secretion of the prostate for half a century were considered the basis for their recognition as the etiological factor of prostatitis. In the 1950s. New data were obtained proving the possibility of noninfectious prostatitis, and the dogma "leukocytes and bacteria - the cause of prostatitis" was revised. Patients in whom the bacterial factor of prostatitis was not detected, were considered as having fallen ill due to high urinary flow pressure, the occurrence of turbulence of its flow in the prostatic part of the urethra and urine reflux into the excretory ducts of the prostate. This causes a chemical burn, an immunological reaction and an abacterial inflammation.

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

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

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

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

Professor T.E.V. Johansen in the framework of his master class "What is chronic prostatitis?" Stressed that this disease can be attributed to:

• syndrome, including signs of inflammation of the prostate, and symptoms of inflammation of the lower urinary tract;
• inflammation of the prostate, including the course is asymptomatic;
• symptoms that reflect the defeat of the prostate, including without signs of inflammation.

Below are brief excerpts from the speech of Professor T.V. Johansen.

To chronic, according to the classification of the National Institutes of Health (USA) (NIH) / NIDDK, include all cases of prostatitis, except acute. Such conditions are clinically expressed in the re-emergence of symptoms of bacterial infection and elevated levels of leukocytes in the secretion of the prostate.

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

• carefully study the history and symptoms, using, among other things, specially designed questionnaires;
• conduct urine analysis - microscopy of sediment, seeding on the microflora, maybe a test of Meares and Stamey;
• perform a microscopic examination of the secretion of the prostate;
• analyze ejaculate for determining signs of inflammation, growth of microflora, spermogram as a whole;
• conduct a biochemical blood test to identify systemic signs of inflammation;
• microbiologically and pathomorphologically examine prostate tissue samples obtained with a needle biopsy.

Histologically, almost all biopsies show signs of inflammation of one degree or another, which indirectly indicates the widespread spread of prostatitis in the male population. However, there is no correlation between clinical symptoms and pathomorphological findings. Almost in the classification, one fundamental criterion is used: the presence or absence of microflora growth. Depending on this, prostatitis is classified as bacterial or abacterial.

The majority of patients with chronic prostatitis are concerned with pain, which in 46% of patients is located in the perineal region, 39% in the scrotum / testicles, 6% in the penis, 6% in the bladder; in 2% - in the sacrococcygeal zone.

Symptoms of inflammation of the lower urinary tract consist in frequent urge, weakening of the urine stream, the emergence and intensification of pain during urination. For an 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, first of all it is necessary to exclude organic pathology of the prostate, other types of urogenital infections and venereal diseases. Differential diagnosis is made for diseases of the anorectal region, adenoma and cancer of the prostate (cancer in situ), interstitial cystitis, bladder and pelvic myofascitis.

The general analysis of urine is recommended by European experts according to the method of Meares and Stamey, proposed back in 1968:

• the patient releases 10 ml of urine into the first container;
• in the second container - 200 ml of urine, after which the patient stops urinating (which is anti-physiological and not always feasible);
• a prostate massage is performed, a secret is sent to the study - the so-called third portion;
• in the fourth container, the remaining urine released after the prostate massage is collected.

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

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

Many urologists, in order not to bother with the "little esthetic" massage procedure of the prostate, are limited to researching the ejaculate. This can not be done, since the risk of incorrect determination of the number of leukocytes is high, and the results of sowing may be different. The appointment of antibiotics in some cases 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 correlates with the degree of inflammation. However, this test has no diagnostic significance for chronic prostatitis.

[1], [2], [3], [4], [5], [6], [7], [8]