Chronic prostatitis

If the situation with infectious (or more precisely, bacterial) prostatitis is more or less clear, then abacterial chronic prostatitis is still a serious urological problem with many unanswered questions. Perhaps, under the mask of a disease called chronic prostatitis, there is a whole range of diseases and pathological conditions characterized by various organic changes in tissues and functional disorders of not only the prostate, organs of the male reproductive system and lower urinary tract, but also other organs and systems in general.

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

According to the definition of the National Institute of Health of the USA, the diagnosis of chronic prostatitis implies the presence of pain (discomfort) in the pelvic area, perineum and genitourinary organs for at least 3 months. In this case, dysuria, as well as bacterial flora in the prostate secretion, may be absent.

The main objective sign 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 a puncture biopsy or surgical intervention), and/or microbiological examination of prostate secretion; or characteristic changes in the prostate revealed by ultrasound, symptoms of urination disorders.

ICD-10 codes

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

[ 1 ], [ 2 ], [ 3 ]

Epidemiology of chronic prostatitis

Chronic prostatitis is the most common inflammatory disease of the male reproductive system and one of the most common male diseases in general. It is the most common urological disease in men under 50. The average age of patients suffering from chronic inflammation of the prostate is 43 years. By the age of 80, up to 30% of men suffer from chronic or acute prostatitis.

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

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

What causes chronic prostatitis?

Modern medical science considers chronic prostatitis as a polyetiological disease. The occurrence and recurrence of chronic prostatitis, in addition to the action of infectious factors, is caused by neurovegetative and hemodynamic disorders, which are accompanied by a weakening of local and general immunity, autoimmune (the effect of endogenous immunomodulators - cytokines and leukotrienes), hormonal, chemical (urine reflux into the prostatic ducts) and biochemical (possible role of citrates) processes, as well as aberrations of peptide growth factors. Risk factors for the development of chronic prostatitis include:

• lifestyle factors that cause infection of the genitourinary system (promiscuous sexual intercourse without protection and personal hygiene, the presence of an inflammatory process and/or infections of the urinary and genital organs in the sexual partner):
• performing transurethral manipulations (including TUR of the prostate) without prophylactic antibacterial therapy:
• the presence of a permanent urethral catheter:
• chronic hypothermia;
• sedentary lifestyle;
• irregular sexual life.

Among the etiopathogenetic risk factors of chronic prostatitis, immunological disorders are of great importance, in particular, the imbalance between various immunocompetent factors. First of all, this applies to cytokines - low-molecular 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 has allowed for a more detailed study of the nervous system and the diagnosis of neurogenic disorders of the pelvic organs and prostate. This primarily concerns the pelvic floor muscles and smooth muscle elements of the bladder wall, urethra and prostate. Neurogenic dysfunction of the pelvic floor muscles is considered one of the main causes of the non-inflammatory form of chronic abacterial prostatitis.

Chronic pelvic pain syndrome may also be associated with the formation of myofascial trigger points located at the sites of muscle attachment to the bones and fascia of the pelvis. Impact on these trigger points, located in close proximity to the genitourinary system, causes pain radiating to the suprapubic region, perineum and other projection zones of the genitals. As a rule, these points are formed during diseases, injuries and surgical interventions on the pelvic organs.

Symptoms of chronic prostatitis

Symptoms of chronic prostatitis include pain or discomfort, urinary disorders, and sexual dysfunction. The main symptom of chronic prostatitis is pain or discomfort in the pelvic area that lasts for 3 months or more. The most common location of pain is the perineum, but discomfort can also occur in the suprapubic, inguinal, anus, and other areas of the pelvis, on the inner thighs, as well as in the scrotum and lumbosacral region. One-sided testicular pain is usually not a sign of prostatitis. Pain during and after ejaculation is most specific for chronic prostatitis.

Sexual function is impaired, including suppression of libido and deterioration of the quality of spontaneous and/or adequate erections, although most patients do not develop severe impotence. Chronic prostatitis is one of the causes of premature ejaculation (PE), but in the later stages of the disease, ejaculation may be slow. A change ("erasure") of the emotional coloring of orgasm is possible.

Urination disorders are more often manifested by irritative symptoms, less often by symptoms of urinary incontinence.

In chronic prostatitis, quantitative and qualitative disturbances of the ejaculate can also be detected, which are rarely the cause of infertility.

Chronic prostatitis is a wave-like disease, periodically increasing and decreasing. 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 groin and suprapubic areas, frequent urination and discomfort at the end of urination, accelerated ejaculation, pain at the end or after ejaculation, increased and painful adequate erections.

In the alternative stage, the patient may be bothered by pain (unpleasant sensations) in the suprapubic region, less often in the scrotum, inguinal region and sacrum. Urination is usually not impaired (or is more frequent). 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 at this stage is not impaired or is somewhat slowed down, the intensity of adequate erections is normal or moderately reduced.

At the stage of cicatricial changes and sclerosis of the prostate, patients are bothered by heaviness in the suprapubic region, in the sacrum, frequent urination day and night (total pollakiuria), weak, intermittent urine stream and imperative urge to urinate. Ejaculation is slow (up to absence), adequate, and sometimes spontaneous erections are weakened. Often at this stage, attention is drawn to the "erased" orgasm.

Of course, the strict staging of the inflammatory process and the correspondence of clinical symptoms to it do not always manifest themselves and not in all patients, as well as the diversity of symptoms of chronic prostatitis. More often, one or two symptoms are observed, which are inherent in different groups, for example, pain in the perineum and frequent urination or imperative urges with accelerated ejaculation.

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

[ 12 ]

Classification of chronic prostatitis

There is still no unified classification of chronic prostatitis. The most convenient to use is the classification of prostatitis proposed in 1995 by the US National Institute of Health.

• 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;
• Type IIIB (non-inflammatory form) - without an increase in the number of leukocytes in the prostate secretion (about 30%);
• Type IV - asymptomatic inflammation of the prostate, detected accidentally during examination for other diseases based on the results of prostate secretion analysis 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 manifest chronic prostatitis is not difficult and is based on the classic triad of symptoms. Considering that the disease often proceeds asymptomatically, it is necessary to use a complex of physical, laboratory and instrumental methods, including determination of the immune and neurological status.

Questionnaires are of great importance when assessing subjective manifestations of the disease. Many questionnaires have been developed that are filled in by the patient and that help the doctor to form 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 psychoemotional state. The most popular questionnaire at present is the Chronic Prostatitis Symptom Scale (NIH-CPS). The questionnaire was developed by the US National Institute of Health and is an effective tool for identifying symptoms of chronic prostatitis and determining its impact on quality of life.

[ 18 ], [ 19 ]

Laboratory diagnostics of chronic prostatitis

It is laboratory diagnostics of chronic prostatitis that allows us to make a diagnosis of “chronic prostatitis” (since 1961, when Farman and McDonald established the “gold standard” in the diagnosis of prostate inflammation - 10-15 leukocytes in the field of vision) and conduct a differential diagnosis between its bacterial and non-bacterial forms.

Laboratory diagnostics also allow us to detect possible infection of the prostate with atypical, non-specific bacterial and fungal flora, as well as viruses. Chronic prostatitis is diagnosed if the prostate secretion or 4 urine samples (3-4-glass samples were proposed by Meares and Stamey in 1968) contain bacteria or more than 10 leukocytes 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 for chlamydia and other STIs.

During a microscopic examination of the discharge from the urethra, the number of leukocytes, mucus, epithelium, as well as trichomonads, gonococci and non-specific flora are determined.

When examining a scraping of the mucous membrane of the urethra using the PCR method, the presence of microorganisms that cause sexually transmitted diseases is determined.

Microscopic examination of prostate secretion determines the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallemand bodies and macrophages.

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

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

[ 20 ], [ 21 ]

Instrumental diagnostics of chronic prostatitis

TRUS of the prostate in chronic prostatitis has high sensitivity, but low specificity. The study allows not only to conduct differential diagnostics, but also to determine the form and stage of the disease with subsequent monitoring throughout the course of treatment. Ultrasound makes it possible to assess the size and volume of the prostate, echostructure (cysts, stones, fibrous-sclerotic changes in the organ, abscesses, hypoechoic areas in the peripheral zone of the prostate), size, degree of expansion, density and echo-homogeneity of the contents of the seminal vesicles.

UDI (UFM, determination of the urethral pressure profile, pressure/flow study, cystometry) and myography of the pelvic floor muscles provide additional information if there is a suspicion of neurogenic urination disorders and dysfunction of the pelvic floor muscles, as well as IVO, which often accompanies chronic prostatitis.

X-ray examination should be performed in patients diagnosed with 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 performed for differential diagnosis with prostate cancer, as well as in cases of suspected non-inflammatory form of abacterial prostatitis, when it is necessary to exclude pathological changes in the spine and pelvic organs.

[ 22 ], [ 23 ], [ 24 ]

Differential diagnosis of chronic prostatitis

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

Chronic abacterial prostatitis should also be differentiated:

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

[ 25 ], [ 26 ], [ 27 ], [ 28 ], [ 29 ]

Treatment of chronic prostatitis

Treatment of chronic prostatitis, like any chronic disease, should be carried out in compliance with the principles of consistency and an integrated approach. First of all, it is necessary to change the patient's lifestyle, his thinking and psychology. By eliminating the influence of many harmful factors, such as physical inactivity, alcohol, chronic hypothermia and others. In this way, we not only stop further progression of the disease, but also promote recovery. This, as well as normalization of sexual life, diet and much more, is the preparatory stage in treatment. Then comes the main, basic course, which involves the use of various drugs. Such a step-by-step approach to the treatment of the disease allows you to control its effectiveness at each stage, making the necessary changes, and also to fight the disease according to the same principle by which it developed. - from predisposing factors to producing ones.

Indications for hospitalization

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

[ 30 ], [ 31 ], [ 32 ], [ 33 ], [ 34 ]

Drug treatment of chronic prostatitis

It is necessary to use several drugs and methods simultaneously, acting on different links of pathogenesis, in order 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, normalize the level of the main hormones and immune reactions. Based on this, it is possible to recommend antibacterial and anticholinergic drugs, immunomodulators, NSAIDs, angioprotectors and vasodilators, as well as prostate massage for chronic prostatitis. In recent years, chronic prostatitis has been treated using drugs that were not previously used for this purpose: alpha1-adrenergic blockers (terazosin), 5-a-reductase inhibitors (finasteride), cytokine inhibitors, immunosuppressants (cyclosporine), drugs that affect urate metabolism (allopurinol) and citrates.

The basis of treatment of chronic prostatitis caused by infectious agents is antibacterial treatment of chronic prostatitis, carried out taking into account the sensitivity of a specific pathogen to a particular drug. The effectiveness of antibacterial therapy has not been 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, provided that the drugs are selected taking into account the sensitivity of microorganisms to them, as well as the properties of the drugs themselves. It is necessary to correctly select their daily dose, frequency of administration 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 using microscopic, bacteriological and immune diagnostic methods), a short course of empirical antibacterial treatment of chronic prostatitis can be administered and, if clinically effective, continued. The effectiveness of empirical antimicrobial therapy in patients with both bacterial and abacterial prostatitis is about 40%. This indicates the undetectable bacterial flora or the positive role of other microbial agents (chlamydia, mycoplasma, ureaplasma, fungal flora, trichomonas, viruses) in the development of the infectious inflammatory process, which has not been confirmed at present. Flora that is not determined by standard microscopic or bacteriological examination of prostate secretion can in some cases be detected by histological examination of prostate biopsy specimens or other subtle methods.

In non-inflammatory chronic pelvic pain syndrome and asymptomatic chronic prostatitis, the need for antibacterial therapy is controversial. The duration of antibacterial therapy should be no more than 2-4 weeks, after which, if the results are positive, it is continued for 4-6 weeks. If there is no effect, antibiotics can be discontinued and drugs from other groups can be prescribed (for example, alpha1-adrenergic blockers, herbal extracts of Serenoa repens).

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

For chronic prostatitis the most commonly used are:

• 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.

If fluoroquinolones are ineffective, combination antibacterial therapy should be prescribed: amoxicillin + clavulanic acid and clindamycin. Tetracyclines (doxycycline) have not lost their importance, especially if 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 also recommended for the prevention of relapses of bacterial prostatitis.

If relapses occur, the previous course of antibacterial drugs may be prescribed in lower single and daily doses. Ineffectiveness of antibacterial therapy is usually due to the incorrect choice of drug, its dosage and frequency, or the presence of bacteria persisting in ducts, acini or calcifications and covered with a protective extracellular membrane.

Given the important role of intraprostatic reflux in the pathogenesis of chronic abacterial prostatitis, if obstructive and irritative symptoms of the disease persist after antibacterial therapy (and sometimes together with it), alpha-blockers are indicated. Their use is due to the fact that up to 50% of intraurethral pressure in humans is maintained by stimulating alpha-1-adrenergic receptors. The contractile function of the prostate is also controlled by alpha-1-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, reducing detrusor tone. A positive effect occurs in 48-80% of cases, regardless of the use of a specific drug from the alpha-blocker group.

The following alpha-blockers are used:

• 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.

In the late 1990s, the first scientific publications on the use of finasteride for prostatodynia appeared. 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 prostate cells is 5 times or more higher than the activity of testosterone. Androgens play a major role in the age-related activation of the proliferation of stromal and epithelial components and other processes leading to an increase in the prostate. The use of finasteride leads to atrophy of stromal tissue (after 3 months) and glandular (after 6 months of taking the drug), with the volume of the latter in the prostate decreasing by about 50%. The epithelial-stromal ratio in the transition zone also decreases. Accordingly, the secretory function is also inhibited. The conducted studies confirmed a decrease in the severity 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 the volume of the prostate, 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 prescription of NSAIDs, which are used both in complex therapy and as an alpha-blocker on its own when antibacterial therapy is ineffective (diclofenac at a dose of 50-100 mg/day).

Some studies have shown the effectiveness of herbal medicine, but these findings have not been confirmed by multicenter, placebo-controlled studies.

In our country, the most widespread medicinal preparations are those based on Serenoa repens (Sabal palm). According to modern data, the effectiveness of these medicinal preparations is ensured by the presence of phytosterols in their composition, which have a complex anti-inflammatory effect on the inflammatory process in the prostate. This effect of Serenoa repens is due to the ability of the extract to suppress the synthesis of inflammation mediators (prostaglandins and leukotrienes) by inhibiting phospholipase A2, which is actively involved in the conversion of membrane phospholipids into arachidonic acid, as well as inhibiting cyclooxygenase (responsible for the formation of prostaglandins) and lipoxygenase (responsible for the formation of leukotrienes). In addition, Serenoa repens preparations have a pronounced anti-edematous effect. The recommended duration of therapy for chronic prostatitis with preparations based on Serenoa repens extract is at least 3 months.

If clinical symptoms of the disease (pain, dysuria) persist after the use of antibiotics, alpha-blockers and NSAIDs, subsequent treatment should be aimed either at relieving pain, or at solving problems with urination, or at correcting both of the above symptoms.

In case of pain, tricyclic antidepressants have an analgesic effect due to blocking H1-histamine receptors and anticholinesterase action. Amitriptyline and imipramine are prescribed most often. However, they should be taken with caution. Side effects include drowsiness and dry mouth. In extremely 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) and, if possible, video urodynamic study should be performed before starting drug therapy. Further treatment is prescribed depending on the results obtained. In case of increased sensitivity (hyperactivity) of the bladder neck, treatment is carried out as in interstitial cystitis, i.e. amitriptyline, antihistamines, and instillations of antiseptic solutions into the bladder are prescribed. In case of detrusor hyperreflexia, anticholinesterase drugs are prescribed. In case of hypertonicity of the external sphincter of the bladder, benzodiazepines (e.g., diazepam) are prescribed, and if drug therapy is ineffective, physiotherapy (spasm relief), neuromodulation (e.g., 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 cytokine involvement in the development of chronic inflammation, the possibility of using cytokine inhibitors in chronic prostatitis, such as monoclonal antibodies to tumor necrosis factor (infliximab), leukotriene inhibitors (zafirlukast, which belongs to a new class of NSAIDs) and tumor necrosis factor inhibitors, has been considered.

[ 35 ], [ 36 ], [ 37 ], [ 38 ], [ 39 ]

Non-drug 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 stimulation of microcirculation and, as a consequence, increased accumulation of drugs in the prostate.

The most effective physical methods of treating chronic prostatitis:

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

Depending on the nature of changes in the prostate tissue, the presence or absence of congestive and proliferative changes, as well as concomitant prostate adenoma, various temperature regimes of microwave hyperthermia are used. At a temperature of 39-40 °C, the main effects of microwave electromagnetic radiation, in addition to the above, are anticongestive and bacteriostatic action, as well as activation of the cellular link of immunity. At a temperature of 40-45 °C, sclerosing and neuroanalgesic effects prevail, with the analgesic effect due to the suppression of sensitive nerve endings.

Low-energy magneto-laser therapy has an effect on the prostate similar to microwave hyperthermia at 39-40 °C, i.e. it stimulates microcirculation, has an anticohesive effect, promotes accumulation of drugs in the prostate tissue and activation of the cellular link of 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 prevail and is therefore used to treat acute and chronic prostatovesiculitis and epididymoorchitis. In the absence of contraindications (prostate stones, adenoma), prostate massage has not lost its therapeutic value. Sanatorium-resort treatment and rational psychotherapy are successfully used in the treatment of chronic prostatitis.

[ 40 ], [ 41 ], [ 42 ], [ 43 ]

Surgical treatment of chronic prostatitis

Despite its prevalence and known difficulties in diagnosis and treatment, chronic prostatitis is not considered a life-threatening disease. This is proven by cases of long-term and often ineffective therapy, turning the treatment process into a purely commercial enterprise with minimal risk to the patient's life. Much more serious danger is posed by its complications, which not only disrupt the process of urination and negatively affect the reproductive function of a man, but also lead to serious anatomical and functional changes in the upper urinary tract - sclerosis of the prostate and the neck of the urinary bladder.

Unfortunately, these complications often occur in young and middle-aged patients. That is why the use of transurethral electrosurgery (as a minimally invasive operation) is becoming increasingly relevant. In case of severe organic IVO caused by sclerosis of the bladder neck and prostate sclerosis, transurethral incision is performed at 5, 7 and 12 o'clock on the conventional clock face, or economical electroresection of the prostate. In cases where the outcome of chronic prostatitis is prostate sclerosis with severe symptoms that do not respond to conservative therapy, the most radical transurethral electroresection of the prostate is performed. Transurethral electroresection of the prostate can also be used for banal calculous prostatitis. Calcifications localized in the central and transitory zones disrupt tissue trophism and increase congestion in isolated groups of acini, leading to the development of pain that is difficult to treat conservatively. In such cases, electroresection should be performed until the calcifications are removed as completely as possible. In some clinics, TRUS is used to control the resection of calcifications in such patients.

Another indication for endoscopic surgery is sclerosis of the seminal tubercle, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate. Such patients, as a rule, seek medical attention with complaints of a sexual nature: pale emotional coloring of orgasm, up to a complete absence of sensations, pain during ejaculation or absence of sperm (anejaculatory syndrome). Obstruction of the drainage ducts of the prostate makes it difficult to evacuate prostatic secretion, causing its stagnation in the acini and thereby worsening not only the secretory function of the gland (production of citric acid, zinc, lytic enzymes and other substances), but also the barrier function. As a result, the synthesis of humoral and cellular defense factors decreases, which affects the state of local immunity. In these cases, in order to restore the patency of the vas deferens and prostatic ducts, one of the options is resection of the seminal tubercle, incision of the ejaculatory ducts and seminal vesicles.

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. Of this entire group of patients, only 18-45% of patients are diagnosed with chronic prostatitis at the pre-hospital stage during outpatient examinations, and another 10-17% are diagnosed in the hospital as part of a routine preoperative examination. The remaining patients are operated on with previously undiagnosed chronic prostatitis, often in the acute stage, with pronounced inflammatory changes in the parenchyma and acini, which become surgical findings.

Often, during transurethral electroresection of the prostate, the contents of the prostatic ducts and sinuses opened during resection are released, which can have either a thick, viscous consistency (in case of a purulent process in the prostate) and be released like a "paste from a tube", or liquid-serous-purulent. And this is despite the fact that any transurethral endoscopic manipulations during exacerbation of chronic inflammatory processes of the organs of 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 stricture 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 complete sanitation of the prostate after the treatment. In other words, it is not enough to detect the presence of inflammation of the prostate in the preoperative period; it is also necessary to prove the effectiveness of the subsequent antibacterial and anti-inflammatory therapy, which can be somewhat more difficult to do.

If an exacerbation of the 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. The prostate is removed by electroresection with subsequent point coagulation of bleeding vessels with a ball electrode and installation of a trocar cystostomy to reduce intravesical pressure and prevent resorption of infected urine into the prostatic ducts.

[ 44 ], [ 45 ], [ 46 ], [ 47 ], [ 48 ], [ 49 ]

What is the prognosis for chronic prostatitis?

The cure of chronic prostatitis, like any chronic disease, means achieving an infinitely long remission. The criteria for the cure of patients diagnosed with chronic prostatitis, proposed by Dimming and Chittenham in 1938, are still relevant. They include a complete absence of symptoms, a normal level of leukocytes in the prostate secretion, the absence of a clinically significant concentration of pathogenic (and/or opportunistic) bacteria in a bacteriological study and in a native preparation of the prostate secretion, the elimination of all foci of infection, a normal or close to normal level of antibodies.

[ 50 ], [ 51 ], [ 52 ]