Non-bacterial chronic prostatitis

Non-bacterial chronic prostatitis is characterized by an increased number of leukocytes in the gonads' expirates, but no growth of microflora is obtained on the media, DNA diagnostics tests for BHV, infections are also negative. In addition to infection, inflammation of the prostate can be provoked by autoimmune processes, microcirculation disorders and chemical burns 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, an inflammatory lesion of the prostate of unclear etiology, in which there is no history of urinary tract infections, and microscopy and culture of prostate secretion do not reveal bacteria, and inflammatory and non-inflammatory syndromes are possible.

In non-inflammatory chronic pelvic pain syndrome there are no signs of inflammation of the prostate, although the patient's complaints are typical of prostatitis. For a long time, urologists distinguished between non-bacterial prostatitis and prostatodynia - one of the variants of non-bacterial prostatitis, the most characteristic symptom of which was chronic pelvic pain. At present, such a division is considered inappropriate, since both the typical video-urodynamic findings and the treatment of these two conditions are identical, and the term "chronic prostatitis associated with chronic pelvic pain syndrome" has been adopted.

A typical patient with this form of prostatitis, as described by Meares EM (1998), is a man aged 20-45 years, with symptoms of irritative and/or obstructive dysfunction of the urinary tract, no history of documented urogenital infections, negative results of bacteriological analysis of prostatic secretion and the presence of a significant number of inflammatory cells in the prostatic secretion. One of the main complaints of such a patient is chronic pelvic pain. The pain can have different localizations: in the perineum, scrotum, suprapubic region, lower back, urethra, especially in the distal area of the penis. In addition, typical complaints include frequent urination and imperative urges, nocturia. Often the patient notes a "sluggish" stream of urine, sometimes - its intermittent ("pulsating" nature). Neurological and urological examinations, as a rule, do not reveal any specific deviations from the norm, except for painful tension of the prostate/paraprostatic tissues and a spasmodic state of the anal sphincter, which are detected in some patients during palpation through the rectum.

The ultrasound picture of the prostate is non-specific. 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 an increase in 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 urine flow rate, incomplete relaxation of the bladder neck and proximal urethra during urination, and abnormally high maximum urethral closure pressure at rest. Involuntary contractions of the bladder wall during urination are not typical, and electromyography of the external (striated) sphincter demonstrates its electrical "silence", i.e. complete relaxation. All these signs indicate a spastic condition of the bladder neck and prostatic urethra, or more precisely, the internal (smooth muscle) sphincter of the bladder. This condition has been called bladder neck or urethral spasm syndrome.

Endoscopic examination confirms or refutes concomitant urethritis and can reveal inflammatory changes in the mucous membrane of the prostatic urethra, but fibrourethroscopy should not be performed as a standard procedure. If urethral stricture or bladder neck sclerosis is suspected, urethrocystography is performed. This examination is also indicated for all patients with continuously recurring chronic prostatitis and insufficient effectiveness of standard therapy - to exclude prostate tuberculosis.

Chronic prostatitis is often 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 case of resistance to adequate therapy. In such cases, appropriate additional examination is carried out.

The etiology of chronic prostatitis associated with chronic pelvic pain syndrome is still not entirely clear. Rather, one 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 proven that fungi, viruses, obligate anaerobic bacteria and trichomonads are not the cause of this variant of chronic prostatitis. Most researchers also deny the etiologic role of such pathogens as Mycoplasma and Ureaplasma urealiticum. More contradictory views exist regarding Ch. trachomatis. On the one hand, this organism is considered one of the most common pathogens of non-gonococcal urethritis and acute epididymitis in young men and, therefore, the most likely cause of ascending urethral infection; on the other hand, despite special immunological studies, no reliable evidence in favor of the etiologic role of chlamydia has been obtained. Currently, the prevailing opinion is that, firstly, the diagnosis of urogenital chlamydia, mycoplasmosis, ureaplasmosis can be considered valid only with positive results of several complementary laboratory tests. Secondly, it should be taken into account that in the presence of an active inflammatory process and the absence of clear laboratory data on the nature of the infectious agent, the most likely causative agents of urethritis and prostatitis are chlamydia. But in this case, prostatitis should be classified as infectious - latent, mixed or specific. Thus, the point of view of O.B. Loran and A.S. Segal confirms the thesis about the clearly underestimated frequency of infectious prostatitis.

The question remains unclear as to whether the process can be initially abacterial, or, having begun as a result of the penetration of infectious agents into the gland, it subsequently proceeds without their participation.

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