Nonbacterial chronic prostatitis

Non-bacterial chronic prostatitis is characterized by an increased amount of leukocytes in the exprimates of the gonads, but microflora growth on media is not obtained, DNA-diagnostic tests for BHV, infections are also negative. In addition to infection, inflammation of the prostate can provoke autoimmune processes, microcirculation disorders and chemical burn due to urine reflux.

According to the NIH classification, this form of prostatitis is defined as chronic prostatitis associated with chronic pelvic pain syndrome. In other words, the inflammatory lesion of the prostate is of an unknown etiology, in which there is no history of infection of the urinary tract in the anamnesis, and microscopy and seeding of the prostate secretion do not reveal bacteria, and inflammatory and non-inflammatory syndromes are possible.

With non-inflammatory syndrome of chronic pelvic pain, there are no signs of inflammation of the prostate, although the patient's complaints are typical of prostatitis. For a sufficiently long period of time, urologists distinguished non-bacterial prostatitis and prostatodynia - one of the variants of non-bacterial prostatitis, the most characteristic feature of which was chronic pelvic pain. At present, such a separation is considered inadvisable, since both typical video-dynamic findings and treatment of these two conditions are identical, and the term "chronic prostatitis associated with chronic pelvic pain syndrome" is adopted.

A typical patient with this form of prostatitis, described by Meares EM (1998) is a 20-45-year-old man with symptoms of irritative and / or obstructive urinary tract dysfunction who has no history of documented urogenital infections, with negative results of bacteriological analysis of the prostate secretion and with the presence in the secretion of the prostate a significant number of inflammatory cells. One of the main complaints of this patient is chronic pelvic pain. Pain can have different localization: in the perineum, scrotum, suprapubic region, lower back, urethra, especially in the distal region of the penis. In addition, typical complaints include frequent urination and imperative urges, nocturia. Often the patient notes a "sluggish" jet of urine, sometimes - its intermittence ("pulsating" character). Neurological and urological examinations, as a rule, do not reveal any specific abnormalities except for the painful tension of the prostate / paraprostatic tissues and the spasmodic condition of the anal sphincter that are found in some patients during palpation through the rectum.

The ultrasound picture of the prostate is nonspecific. Microscopic and bacteriological studies do not reveal reliable signs of bacterial prostatitis, but may indicate an inflammatory process. Additional signs of inflammation, in addition to increasing the number of leukocytes, include a shift in the pH of the secretion to the alkaline side, a decrease in the content of acid phosphatase.

Urodynamic examination reveals a decrease in the flow rate of urine, incomplete relaxation of the cervix and the proximal part of the urethra when urinating and an abnormally high maximum closure pressure of the urethra at rest. In this case, involuntary contractions of the bladder wall during urination are not characteristic, and the electromyography of the external (transverse striated sphincter) demonstrates its electrical "silence", that is, complete relaxation. All these signs indicate a spastic condition of the neck of the bladder and the prostatic part of the urethra, more precisely - the internal (smooth muscle) sphincter of the bladder. This condition was called a spasm of the neck of the bladder or urethra.

Endoscopic examination confirms or rejects concomitant urethritis and can detect inflammatory changes in the mucous membrane of the prostatic urethra, but it is not necessary to perform fibrourethrocopy as a standard procedure. If a stricture of the urethra or a sclerosis of the neck of the bladder is suspected, urethrocystography is performed. This examination is also shown for all patients with a continuously recurring course of chronic prostatitis and inadequate efficacy of standard therapy - for the exclusion of prostate tuberculosis.

It is not so rare that chronic prostatitis is combined with interstitial cystitis. There is an opinion that the diagnosis of "interstitial cystitis" can be assumed in patients with clinical symptoms of non-bacterial prostatitis in the case of resistance to adequate therapy. In such cases, an appropriate additional examination is carried out.

The etiology of chronic prostatitis associated with chronic pelvic pain syndrome is still not completely clear. Rather, we can say about those pathogens that, as a result of numerous studies, were excluded from the list of possible etiologic factors of this disease. Thus, it has been proved that fungi, viruses, obligate anaerobic bacteria and trichomonads are not the cause of this variant of chronic prostatitis. Most researchers also deny the etiological role of such pathogens as Mycoplasma and Ureaplasma urealiticum. More controversial views exist regarding Ch. Trachomatis. On the one hand, this organism is considered one of the most frequent pathogens of non-gonococcal urethritis and acute epididymitis in young men and, therefore, the most probable cause of ascending urethral infection; on the other hand, despite carrying out special immunological studies, reliable evidence for the etiological role of chlamydia has not been obtained. At present, the prevailing opinion is that, firstly, the diagnosis of urogenital chlamydia, mycoplasmosis, ureaplasmosis can be considered eligible only with the positive results of several complementary laboratory tests. Secondly, it should be borne in mind that in the presence of an active inflammatory process and the absence of clear laboratory data on the nature of the infectious agent, chlamydia are the most likely pathogens of urethritis and prostatitis. But in this case the prostatitis should be classified as infectious - latent, mixed or specific. Thus, the point of view of OBLoran and A.S. Segal confirms the thesis about the obviously low frequency of infectious prostatitis.

The question remains unclear whether the process can be initially abacterial, or, beginning as a result of the infiltration of infectious agents into the gland, later it proceeds without their participation.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]