Chronic prostatitis

If the situation with an infectious (or rather, bacterial) prostatitis is more or less clear, then abacterial chronic prostatitis is still a serious urological problem with many unexplained issues. Perhaps under the mask of the disease, called chronic prostatitis, hides a number of diseases and pathological conditions characterized by a variety of organic tissue changes and functional disorders of not only the prostate, male reproductive system and lower urinary tract, but also other organs and systems in general. 

The lack of a single definition of chronic prostatitis adversely affects the efficiency of diagnosis and treatment of this disease.

By definition, the National Institutes of Health of the United States, the diagnosis of chronic prostatitis suggests the presence of pain (discomfort) in the pelvic area, perineum, and organs of the urogenital system for at least 3 months. In this case, dysuria, as well as the bacterial flora in the prostate secret, may be absent.

The main objective symptom of chronic prostatitis is the presence of an inflammatory process in the prostate, confirmed by histological examination of prostate tissue (obtained as a result of puncture biopsy or surgery), and / or microbiological examination of prostate secretion; or characteristic changes in the prostate detected by ultrasound, symptoms of urination.

ICD-10 codes

• N41.1 Chronic prostatitis.
• N41.8 Other inflammatory diseases of the prostate gland.
• N41.9 Inflammatory disease of the prostate gland, unspecified.

[1], [2], [3]

Epidemiology of chronic prostatitis

Chronic prostatitis ranks first in the prevalence among inflammatory diseases of the organs of the male reproductive system and one of the first places among men's diseases in general. This is the most common urological disease in men younger than 50 years. The average age of patients suffering from chronic inflammation in the prostate is 43 g. By the age of 80, up to 30% of men suffer chronic or acute prostatitis.

The prevalence of chronic prostatitis in the general population is 9%. In Russia, chronic prostatitis by the most approximate estimates in 35% of cases is the reason for turning to a urologist for men of working age. In 7-36% of patients it is complicated by vesiculitis, epididymitis, disorders of urination, reproductive and sexual functions.

[4], [5], [6], [7], [8], [9], [10], [11],

What causes chronic prostatitis?

Modern medical science chronic prostatitis is considered as a polietiologic disease. The occurrence and recurrence of chronic prostatitis, in addition to the action of infectious factors, is due to neuro-vegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmune (the effects of endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (urine prostatic fluids, iridic biometrics (imitation of urine into prostatic ducts), biological idiopaths, leukotrienes), biologic factors (urinary reflux into prostatic ducts, idiopathic biometrics), biologic and leukotrienes; the role of citrates) processes, as well as aberrations of peptide growth factors. The risk factors for chronic prostatitis include:

• lifestyle features that cause infection of the urogenital system (promiscuous sexual intercourse without preservation and personal hygiene, the presence of an inflammatory process and / or infections of the urinary and genital organs of the sexual partner):
• carrying out transurethral manipulations (including prostate TUR) without prophylactic antibiotic therapy:
• the presence of a permanent urethral catheter:
• chronic hypothermia;
• sedentary lifestyle;
• irregular sex life.

Among the etiopathogenetic risk factors for chronic prostatitis, immunological disorders are important, in particular, an imbalance between various immunocompetent factors. First of all, this refers to cytokines - low molecular weight compounds of a polypeptide nature, which are synthesized by lymphoid and non-lymphoid cells and have a direct effect on the functional activity of immunocompetent cells.

Great importance is attached to intraprostatic reflux of urine as one of the main factors in the development of so-called chemical non-bacterial prostatitis.

The development of functional diagnostics allowed a deeper study of the nervous system and the diagnosis of neurogenic disorders of the pelvic organs and the prostate. First of all, it refers to the pelvic floor muscles and smooth muscle elements of the bladder wall, urethra and prostate. Neurogenic dysfunction of the pelvic muscles is considered as one of the main causes of the non-inflammatory form of chronic abacterial prostatitis.

Chronic pelvic pain syndrome can also be associated with the formation of myofascial trigger points, located in the places of attachment of muscles to the bones and fascia of the pelvis. Impact on these trigger points, which are in close proximity to the organs of the urogenital system, causes pain, radiating to the suprapubic area, perineum, and other areas of the projection of the genitals. As a rule, these points are formed in diseases, injuries and surgical interventions on the pelvic organs.

Symptoms of chronic prostatitis

Symptoms of chronic prostatitis are as follows: pain or discomfort, urinary and sexual dysfunction. The main symptom of chronic prostatitis is pain or discomfort in the pelvic area, which lasts 3 months. And more. The most frequent localization of pain is the perineum, but discomfort may occur in the suprapubic, inguinal, anus and other areas of the pelvis, on the inner surface of the thighs, as well as in the scrotum and lumbosacral region. Unilateral pain in the testicle, as a rule, is not a sign of prostatitis. Pain during and after ejaculation is most specific for chronic prostatitis.

Sexual function is impaired, including libido and impaired quality of spontaneous and / or adequate erections, although the majority of patients do not develop pronounced impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE), however, in the late stages of the disease, ejaculation can be delayed. It is possible to change (“erased”) the emotional color of the orgasm.

Violations of urination are more often manifested by irritative symptoms, less often - by symptoms of IVO.

In chronic prostatitis, they can also reveal quantitative and qualitative violations of the ejaculate, which are rarely the cause of infertility.

The disease of chronic prostatitis is wave-like, periodically increasing and weakening. In general, the symptoms of chronic prostatitis correspond to the stages of the inflammatory process.

The exudative stage is characterized by pain in the scrotum, in the inguinal and suprapubic areas, frequent urination and discomfort at the end of the act of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and soreness of adequate erections.

In the alternative stage, the patient may be disturbed by pain (discomfort) in the suprapubic region, less often in the scrotum, groin and sacrum. The urination, as a rule, is not broken (or speeded up). Against the background of accelerated, painless ejaculation, a normal erection is observed.

The proliferative stage of the inflammatory process may be manifested by a weakening of the intensity of the urine stream and frequent urination (during exacerbations of the inflammatory process). Ejaculation in this stage is not disturbed or somewhat slowed down, the intensity of adequate erections is normal or moderately reduced.

At the stage of cicatricial changes and sclerosis, prostate patients are worried about heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total pollakiuria), sluggish, interrupted urine flow and urgency to urinate. Ejaculation is slowed down (down to lack), adequate and sometimes spontaneous erections are weakened. Often, in this stage, the attention of the "erased" orgasm attracts attention.

Of course, strict staging of the inflammatory process and compliance with clinical symptoms does not always appear in all patients, as well as the diversity of symptoms of chronic prostatitis. More often, the presence of any one, rarely two symptoms inherent in different groups, such as pain in the perineum and frequent urination or urge to accelerate ejaculation, is observed.

The effect of chronic prostatitis on the quality of life, according to a unified scale for assessing the quality of life, is comparable to the effect of myocardial infarction. Angina pectoris or Crohn's disease.

[12],

Classification of chronic prostatitis

A single classification of chronic prostatitis does not exist until now. The classification of prostatitis, proposed in 1995 by the US National Institutes of Health, is considered the most convenient for use.

• Type I - acute bacterial prostatitis.
• Type II - chronic bacterial prostatitis, found in 5-1 cases.
• Type III - chronic abacterial prostatitis (chronic pelvic pain syndrome), diagnosed in 90% of cases;
• Type IIIA (inflammatory form) - with an increase in the number of leukocytes in the prostate secretion (more than 60% of the total number of chronic prostatitis;
• IIIB type (non-inflammatory form) - without increasing the number of leukocytes in the prostate secretion (about 30%);
• Type IV - asymptomatic inflammation of the prostate, detected by chance during examination for other diseases according to the results of analysis of prostate secretion or its biopsy (histological prostatitis). The frequency of this form of the disease is unknown.

[13], [14], [15], [16], [17]

Diagnosis of chronic prostatitis

Diagnosis of manifesting chronic prostatitis is not difficult and is based on the classic triad of symptoms. Given that the disease is often asymptomatic, it is necessary to use a complex of physical, laboratory and instrumental methods, including the determination of the state of immune and neurological status.

When assessing the subjective manifestations of the disease, a questionnaire is of great importance. Many questionnaires have been developed that are filled in by the patient and want the doctor to get an idea of the frequency and intensity of pain, urination disorders and sexual disorders, the patient's attitude to these clinical manifestations of chronic prostatitis, and also to assess the patient’s psycho-emotional state. The most popular currently questionnaire scale symptoms of chronic prostatitis (NIH-CPS). The questionnaire was developed by the US National Institutes of Health, and is an effective tool for identifying the symptoms of chronic prostatitis and determining its effect on the quality of life.

[18], [19], [20]

Laboratory diagnosis of chronic prostatitis

It is the laboratory diagnosis of chronic prostatitis that allows you to make a diagnosis of chronic prostatitis (since Farman and McDonald in 1961 set the gold standard in diagnosing prostate inflammation - 10-15 leukocytes per field of view) and to make a differential diagnosis between his bacterial and non-bacterial forms.

Laboratory diagnostics also allows to detect possible infection of the prostate with atypical, non-specific bacterial and fungal flora, as well as viruses. Chronic prostatitis is diagnosed if a prostate secretion or 4 urine samples (3-4 glasses samples suggested by Meares and Stamey in 1968) contain bacteria or more than 10 white blood cells in the field of view. If there is no bacterial growth in the prostate secretion with an increased number of leukocytes, it is necessary to conduct a study on chlamydia and other STIs.

Microscopic examination of the discharge of the urethra determines the number of leukocytes, mucus, epithelium, as well as Trichomonas, gonococci and nonspecific flora.

In the study of scraping the mucous membrane of the urethra by PCR, the presence of microorganisms that cause sexually transmitted diseases is determined.

Microscopic examination of prostate secretions determines the number of leukocytes, lecithin grains, amyloid bodies, Trusso-Lalleman's bodies and macrophages.

Carry out bacteriological research of a secret of a prostate or the urine received after its massage. The results of these studies determine the nature of the disease (bacterial or abacterial prostatitis). Prostatitis may cause an increase in PSA concentration. Blood sampling to determine serum PSA concentration should be carried out no earlier than 10 days after a digital rectal examination. Despite this fact, the use of additional diagnostic methods, including prostate biopsy, to exclude prostate cancer, is indicated at a PSA concentration above 4.0 ng / ml.

Of great importance in the laboratory diagnosis of chronic prostatitis is the study of the immune status (state of humoral and cellular immunity) and the level of non-specific antibodies (IgA, IgG and IgM) in the prostate secretion. Immunological research helps determine the stage of the process and monitor the effectiveness of treatment.

[21], [22],

Instrumental diagnosis of chronic prostatitis

TRUS prostate with chronic prostatitis has a high sensitivity, but low specificity. The study allows not only to carry out differential diagnostics, but also to determine the form and stage of the disease with subsequent monitoring during the entire course of treatment. Ultrasound provides an opportunity to assess the size and volume of the prostate, echostructure (cysts, stones, fibro-sclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), size, degree of expansion, density and echo uniformity of the contents of the seminal vesicles.

UDI (UFM, urethral pressure profile determination, pressure / flow study, cystometry) and pelvic muscle myography provide additional information for suspected neurogenic voiding disorders and pelvic floor muscle function disorders. And IVO, which often accompanies chronic prostatitis.

X-ray examination should be carried out in patients with a diagnosed IVO in order to clarify the cause of its occurrence and determine the tactics of further treatment.

CT and MRI of the pelvic organs are carried out for differential diagnosis with prostate cancer, as well as for suspected non-inflammatory forms of abacterial prostatitis, when it is necessary to exclude pathological changes of the spine and pelvic organs.

[23], [24], [25]

Differential diagnosis of chronic prostatitis

Establishing the nature of the dominant pathological process in the prostate is especially important, as under the “mask” of chronic prostatitis manifest various violations of trophism, innervation, contractile, secretory and other functions of this organ. Some of them can be attributed to manifestations of abacterial prostatitis, for example, its atonic form.

Chronic abacterial prostatitis should also be differentiated:

• with neuropsychiatric disorders - depression, neurogenic bladder dysfunction (including with detrusor-sphincter dyssynergy), pseudodissinergy, reflex sympathetic dystrophy;
• with inflammatory diseases of other organs - interstitial cystitis, osteitis of the pubic symphysis;
• with sexual dysfunction;
• with other causes of dysuria - bladder neck hypertrophy, symptomatic prostate adenoma, urethral stricture and ICD;
• with rectal diseases.

[26], [27], [28], [29], [30]

Treatment of chronic prostatitis

Treatment of chronic prostatitis, as well as any chronic disease, should be subject to the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's way of life, his thinking and psychology. Eliminating the influence of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others. Thus, we not only stop the further progression of the disease, but also contribute to recovery. This, as well as the normalization of sexual life, dieting and much more is a preparatory stage in treatment. This is followed by a basic, basic course involving the use of various drugs. Such a stepwise approach to the treatment of a disease allows you to control its effectiveness at each stage, making the necessary changes, as well as fight the disease according to the same principle on which it developed. - from predisposing factors to producing.

Indications for hospitalization

Chronic prostatitis, as a rule, does not require hospitalization. In severe cases of persistent chronic prostatitis, complex therapy, administered in a hospital, is more effective than outpatient treatment.

[31], [32], [33], [34], [35],

Drug treatment of chronic prostatitis

It is necessary to simultaneously use several medicinal preparations and methods acting on different pathogenesis to eliminate the infectious factor, normalize blood circulation in the pelvic organs (including improving microcirculation in the prostate), adequate drainage of prostatic acini, especially in peripheral zones, normalizing the level of hormones and immune responses. Based on this, antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators, and prostate massage can be recommended for use in chronic prostatitis. In recent years, chronic prostatitis has been treated with drugs not previously used for this purpose: alpha1-blockers (terazosin), 5-a-reductase inhibitors (finasteride), cytokine inhibitors, immunosuppressants (cyclosporine), drugs affecting urate metabolism ( allopurinol) and citrates.

The basis of the treatment of chronic prostatitis caused by infectious agents. - antibacterial treatment of chronic prostatitis, taking into account the sensitivity of a particular pathogen to a particular drug. The effectiveness of antibiotic therapy is not proven for all types of prostatitis. In chronic bacterial prostatitis, antibacterial treatment of chronic prostatitis is effective and leads to the elimination of the pathogen in 90% of cases, subject to the choice of drugs, taking into account the sensitivity of microorganisms to them, as well as the properties of the drugs themselves. It is necessary to choose their daily dose, frequency of treatment and duration of treatment.

In chronic abacterial prostatitis and inflammatory syndrome of chronic pelvic pain (in the case when the pathogen is not detected as a result of microscopic, bacteriological and immune methods of diagnosis), an empirical antibacterial treatment of chronic prostatitis can be carried out with a short course and its clinical efficacy is continued. The effectiveness of empirical antimicrobial therapy in both patients with bacterial prostatitis and abacterial is about 40%. This indicates that the bacterial flora is undetectable or that other microbial agents (chlamydia, mycoplasma, ureaplasma, fungal flora, trichomonads, viruses) play a positive role in the development of an infectious inflammatory process, which is currently not confirmed. Flora, which is not determined by standard microscopic or bacteriological examination of prostate secretion, in some cases can be detected by histological examination of prostate biopsies or other subtle methods.

In non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibiotic therapy is debatable. The duration of antibiotic therapy should be no more than 2-4 weeks, after which, with positive results, it lasts up to 4-6 weeks. In the absence of effect, antibiotics may be canceled and other groups may be prescribed (for example, alpha1-blockers. Plant extracts of Serenoa repens).

The drugs of choice for empiric treatment of chronic prostatitis are fluoroquinolones, since they have high bioavailability and penetrate well into the gland tissue (the concentration of some of them in secret is greater than that in serum). Another advantage of this group of drugs is activity against most gram-negative microorganisms, as well as chlamydia and ureaplasmas. The results of treatment of chronic prostatitis do not depend on the use of any specific drug from the group of fluoroquinolones.

In chronic prostatitis most often used:

• Norfloxacin at a dose of 400 mg 2 times a day for 10-14 days;
• pefloxacin at a dose of 400 mg 2 times a day for 10-14 days;
• Ciprofloxacin at a dose of 250-500 mg 2 times a day for 14-28 days.

With the ineffectiveness of fluoroquinolones, a combination antibacterial therapy should be prescribed: amoxicillin + clavulanic acid and clindamycin. Tetracyclines (doxycycline) have not lost their value, especially if a chlamydial infection is suspected.

Recent studies have shown that clarithromycin penetrates well into prostate tissue and is effective against intracellular pathogens of chronic prostatitis, including ureaplasma and chlamydia.

Antibacterial drugs are recommended to prescribe and in order to prevent the recurrence of bacterial prostatitis.

In the event of a relapse, a previous course of antibacterial drugs in lower single and daily doses may be prescribed. The ineffectiveness of antibiotic therapy, as a rule, is due to the wrong choice of the drug, its dosage and frequency rate, or the presence of bacteria persisting in ducts, acini or calcifications and covered with a protective extracellular membrane.

Considering the important role in the pathogenesis of chronic abacterial prostatitis intraprostatic reflux, while maintaining obstructive and irritative symptoms of the disease after antibacterial therapy (and sometimes together with it), a-adrenergic blockers are shown. Their use is due to the fact that in humans up to 50% of intraurethral pressure is maintained by stimulating a1-adrenoreceptors. The contractile function of the prostate is also under the control of a1-adrenergic receptors, which are localized mainly in the stromal elements of the gland. Alpha-blockers reduce increased intraurethral pressure and relax the neck of the bladder and smooth muscles of the prostate, reduce the tone of the detrusor. A positive effect occurs in 48-80% of cases, regardless of the use of a specific drug from the group of a-adrenoblockers.

Apply the following a-blockers:

• tamsulosin - 0.2 mg / day,
• terazosin - 1 mg / day with an increase in dose to 20 mg / day;
• Alfuzosin - 2.5 mg 1-2 times a day.

At the end of the 90s, the first scientific publications appeared on the use of finasteride in prostatodynia. The action of this drug is based on the suppression of the activity of the enzyme 5-a-reductase, which converts testosterone into its prostatic form, 5-a-dihydrotestosterone. The activity of which in the cells of the prostate 5 times or more exceeds the activity of testosterone. Androgens play a major role in the age-related activation of proliferation of stromal and epithelial components and other processes leading to an enlarged prostate. The use of finasteride leads to atrophy of stromal tissue (after 3 months) and glandular (after 6 months of taking the drug), and the volume of the latter in the prostate decreases by about 50%. The epithelial-stromal ratio in the transient zone is also reduced. Accordingly, the secretory function is inhibited. Studies have confirmed the reduction of pain and irritative symptoms in chronic abacterial prostatitis and chronic pelvic pain syndrome. The positive effect of finasteride may be due to a decrease in prostate volume. Accompanied by a decrease in the severity of interstitial tissue edema, a decrease in the tension of the gland and, accordingly, a decrease in pressure on its capsule.

Pain and irritative symptoms are an indication for the appointment of NPS, which are used both in complex therapy, as well as alpha-blocker alone with the ineffectiveness of antibiotic therapy (diclofenac 50-100 mg / day).

Some studies demonstrate the effectiveness of herbal medicine, but this information has not been confirmed by multicenter placebo-controlled studies.

In our country, the most widely used drugs based on Serenoa repens (Sabal palm). According to modern data, the effectiveness of these medicines ensures the presence of phytosterols in their composition, which have a complex anti-inflammatory effect on the inflammatory process in the prostate. This action of Serenoa repens is due to the ability of the extract to inhibit the synthesis of inflammatory mediators (prostaglandins and leukotrienes) by inhibiting phospholipase A2, which is actively involved in converting membrane phospholipids to arachidonic acid, as well as inhibiting cyclooxygenase (responsible for the formation of prostaglandins) and lipoxygenase (responsible for the formation of leukotrienes). In addition, the drugs Serenoa repens have a pronounced anti-edema effect. The recommended duration of treatment of chronic prostatitis with drugs based on Serenoa repens extract is at least 3 months.

While maintaining the clinical symptoms of the disease (pain, dysuria) after the use of antibiotics, α-adrenergic blockers and NSAIDs, subsequent treatment should be directed either to relieve pain, or to resolve urinary problems, or to correct both of the above symptoms.

For pain, tricyclic antidepressants have an analgesic effect due to blocking histamine H1 receptors and anticholinesterase action. Amitriptyline and Imipramine are prescribed most often. However, they must be taken with caution. Side effects - drowsiness, dry mouth. In extreme rare cases, narcotic analgesics (tramadol and other drugs) can be used to relieve pain.

If dysuria predominates in the clinical picture of the disease, UDI (UFM) should be carried out before the start of drug therapy, if possible a video urodynamic study. Further treatment is prescribed depending on the results obtained. In case of hypersensitivity (hyperactivity) of the bladder neck, treatment is carried out as in interstitial cystitis, they prescribe amitriptyline, antihistamine medicines, instillations of antiseptic solutions into the bladder. With detrusor hyperreflexia, anticholinesterase drugs are prescribed. In case of hypertonus of the external sphincter of the bladder, benzodiazepines (for example, diazepam) are prescribed, and if drug therapy is ineffective, physical therapy (spasm removal) and neuromodulation (for example, sacral stimulation) are prescribed.

Based on the neuromuscular theory of the etiopathogenesis of chronic abacterial prostatitis, antispasmodics and muscle relaxants can be prescribed.

In recent years, based on the theory of the involvement of cytokines in the development of a chronic inflammatory process, the possibility of using inhibitors of cytokines, such as monoclonal antibodies to tumor necrosis factor (infliximab), leukotriene inhibitors (zafirlukast, belonging to a new class of NSAIDs) and inhibitors in chronic prostatitis, is being considered. Tumor necrosis factor.

[36], [37], [38], [39], [40]

Non-pharmacological treatment of chronic prostatitis

Currently, great importance is attached to the local application of physical methods, which allow not to exceed the average therapeutic doses of antibacterial drugs due to the stimulation of microcirculation and, as a result, an increase in the cumulation of drugs in the prostate.

The most effective physical treatments for chronic prostatitis:

• transrectal microwave hyperthermia;
• physiotherapy (laser therapy, mud therapy, phono- and electrophoresis).

Depending on the nature of changes in prostate tissue, the presence or absence of congestive and proliferative changes, as well as concomitant prostate adenoma, different temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 "With the main effects of electromagnetic radiation of the microwave range, in addition to the above, are anti-congestive and bacteriostatic action, as well as activation of the cellular component of the immune system. Sclerosing and neuroanalgesing effects prevail at 40-45 ° C, and the analgesic effect is caused by suppression of sensitive nerves endings.

Low-energy magnetic laser therapy has an effect on the prostate that is close to microwave hyperthermia at 39–40 ° C, i.e. Stimulates microcirculation, has anti-drugs effect, contributes to the cumulation of drugs in the prostate tissue and the activation of cellular immunity. In addition, laser therapy has a biostimulating effect. This method is most effective when congestive-infiltrative changes in the organs of the reproductive system are predominant and are therefore used to treat acute and chronic prostatichesiitis and epididymoorchitis. In the absence of evidence against the evidence (prostate stones, adenoma), prostate massage has not lost its therapeutic value. They are successfully used in the treatment of chronic prostatitis spa treatment and rational psychotherapy.

[41], [42], [43], [44],

Surgical treatment of chronic prostatitis

Despite the prevalence and known difficulties of diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. This is proved by the cases of long-term and often ineffective therapy, which rotates the treatment process into a purely commercial enterprise with minimal risk to the life of the patient. Complications that do not only disturb the urination process and adversely affect the reproductive function of men, but also lead to serious anatomical and functional changes in the VMP - sclerosis of the prostate and bladder neck, are much more dangerous.

Unfortunately, these complications are often in patients of young and middle age. That is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly important. With a pronounced organic IVO, caused by bladder neck sclerosis and prostate sclerosis, transurethral incision is performed for 5, 7 and 12 hours of a conditional dial, or an economical prostate resection. In those cases when the outcome of chronic prostatitis is prostate sclerosis with severe symptoms, which can not be conservative treatment. Perform the most radical transurethral prostate resection. Transurethral prostate resection can also be used for banal calculous prostatitis. Calcinates. Localized in the central and transient zones violate tissue trophism and enhance congestion in isolated groups of acini, leading to the development of pain that is difficult to conservative treatment. Electrical resection in such cases should be carried out until the most complete removal of calcifications. In some clinics, TRUS is used to control the resection of calcifications in these patients.

Another indication for endoscopic surgery is sclerosis of the seminal tubercle, accompanied by occlusion of the vugi and the excretory ducts of the prostate. Such patients, as a rule, go to the doctor with complaints of a sexual nature: pallor of the emotional color of the orgasm, up to a total lack of sensations, pain during ejaculation, or the absence of sperm (anejaculatory syndrome). Violation of the patency of the prostate drainage paths makes it difficult to evacuate the prostatic secretion, causing it to stagnate in the acini and thus worsening not only the secretory function of the gland (production of citric acid, zinc, lytic enzymes and other substances), but also a barrier function. As a result, the synthesis of factors of humoral and cellular protection is reduced, which affects the state of local immunity. In these cases, for the purpose of restoring the patency of the vas deferens and the prostatic ducts, as one of the options, resection of the seminal tubercle, incision of the ejaculatory ducts and seminal vesicles are performed.

Another problem is the diagnosis and treatment of chronic prostatitis in patients with prostate adenoma, undergoing surgery. The course of prostate adenoma is complicated by chronic prostatitis of varying severity in 55.5-73% of patients. Out of this whole group of patients, only 18-45% of patients are diagnosed with chronic prostatitis at the prehospital stage with outpatient examinations, another 10-17% - in the hospital as part of a routine preoperative examination. The remaining patients are operated on, having previously diagnosed chronic prostatitis, often in the acute stage, with marked inflammatory changes in the parenchyma and acini, which become operational findings.

Often, when transurethral electroresection of the prostate, there is a release of the contents of the prostatic ducts and sinuses opened during resection, which can have both a thick, viscous consistency (with a purulent process in the prostate) and can be distinguished by the type of “paste from the tube” or liquid-serous purulent. And this is despite the fact that any transurethral endoscopic manipulations with exacerbation of chronic inflammatory processes in the male reproductive system are contraindicated due to the risk of developing secondary sclerosis of the prostate and bladder neck in the postoperative period, as well as striation of the posterior part of the urethra. The solution to this problem is complicated by the difficulty of obtaining objective laboratory and instrumental data confirming a complete reorganization of the prostate after the treatment. In other words, it is not enough to reveal the presence of inflammation of the prostate in the preoperative period, it is necessary to prove the effectiveness of the following antibacterial and anti-inflammatory therapy, which can be somewhat more difficult.

If an exacerbation of a chronic inflammatory process (purulent or serous-purulent discharge from the prostatic sinuses) is diagnosed during transurethral intervention, the operation must be completed by removing the entire remaining gland. At the same time, the prostate is removed by electroresection followed by dotted coagulation of the bleeding vessels with a spherical electrode and installation of trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.

[45], [46], [47], [48], [49], [50]

What is the prognosis of chronic prostatitis?

The cure of chronic prostatitis, like any chronic disease, means the achievement of an infinitely long remission. Criteria for the cure of patients diagnosed with chronic prostatitis, proposed by dimming and Chittenham in 1938, still remain relevant. These include the complete absence of symptoms, normal leukocyte levels in prostate secretions, the absence of clinically significant concentrations of pathogenic (and / or conditionally pathogenic) bacteria during bacteriological examination and in the native prostate secretion preparation, elimination of all foci of infection, normal or close to normal antibodies.

[51], [52], [53]