Pathogenetic treatment of chronic prostatitis

If the course of adequate antibacterial therapy has been unsuccessful, there is no need to prescribe other antibiotics. In this case, good results can be obtained if you begin pathogenetic treatment of chronic prostatitis. If patients have symptoms of obstruction (clinical or confirmed by uroflowmetry), it is indicated to prescribe alpha-blockers. Non-steroidal anti-inflammatory drugs are prescribed for severe inflammation, finasteride - for prostate enlargement, pentosan polysulfate (hemoclar) for predominant pain in the bladder and primary irritative urination disorders. Phytotherapy is also useful in some patients. In extreme cases, if complaints persist, transurethral microwave thermotherapy is permissible. Surgical interventions are indicated only in the development of complications, such as stenosis of the bladder neck, stricture of the urethra.

Treatments for chronic prostatitis and chronic pelvic pain syndrome that have some evidence base or theoretical support (developed by 1PCN in order of priority)

Patients with chronic prostatitis category III B (chronic pelvic pain syndrome), according to the NIH classification, or dystrophic-degenerative prostatitis (prostatosis), according to the classification given in this book, are extremely difficult to treat. The main goal of treatment is to relieve symptoms, for which analgesics, alpha-blockers, muscle relaxants, tricyclic antidepressants are used - simultaneously or sequentially. Sessions with a psychotherapist, massage of the pelvic organs and other types of supportive conservative therapy (diet, lifestyle changes) often alleviate the suffering of patients. Phytotherapy should be considered promising, for example, the use of prostanorm, tadenan. Experience in using these drugs has shown their high efficiency both in complex therapy of patients with chronic prostatitis of infectious origin, and as monotherapy for non-infectious prostatitis.

Each tablet of tadenan contains 50 mg of African plum bark extract, which supports the secretory activity of prostate cells, normalizes urination by regulating the sensitivity of the bladder muscles to various impulses, has anti-inflammatory, anti-sclerotic and anti-edematous effects. The effectiveness of the drug in chronic prostatitis was assessed based on observation of 26 patients with non-infectious chronic prostatitis.

The main clinical manifestations (pain in the perineum, above the pubis, in the groin, in the scrotum; stranguria, nocturia, pollakiuria, weakening of the urine stream, erectile dysfunction) were taken into account on a three-point scale (0 - no sign, 1 - moderately expressed, 2 - strongly expressed). Before treatment, pain syndrome, dysuria and sexual weakness on average manifested themselves with a strength of 1.2-2.4 points, after treatment the intensity of the first two indicators decreased to 0.4-0.5, however, the average erectile dysfunction remained relatively high - 1.1, although it decreased compared to the initial more than 1.5 times.

In laboratory studies of prostate secretion, the number of leukocytes is important as a sign of inflammation and lecithin grains - as a sign of the functional activity of the gland. Leukocytes were counted in a native preparation based on the maximum number of cells in the field of view. Lecithin grains were also taken into account on a three-point scale.

On admission to the hospital, patients had an average of 56.8 × 10 ³ μl of leukocytes in the prostate secretion; the number of lecithin grains corresponded to an average of 0.7 points. At the end of treatment, the number of leukocytes in the main group of patients decreased almost 3 times (an average of 12.4 cells), while the saturation of the smear with lecithin grains, on the contrary, increased more than 2 times (an average of 1.6).

The maximum and average urine flow rates also increased after a two-month course of tadenan. All patients without exception showed a decrease in IPSS scores - from an average of 16.4 to 6.8.

TRUS initially recorded a violation of the echo structure of the prostate gland in all patients; repeated images were identical. However, both ultrasound and LDF confirmed the beneficial effect of tadenan on microcirculation in the prostate, a decrease in areas of congestion was noted.

No negative effects of tadenan on the qualitative and quantitative characteristics of ejaculate have been noted, which allows us to confidently recommend it to patients of reproductive age.

A certain niche in the pathogenetic treatment of patients with chronic prostatitis belongs to tykveol. It contains pumpkin seed oil, is available in the form of capsules, oil for oral administration and rectal suppositories. The active substance is a complex of biologically active substances from pumpkin seeds (carotenoids, tocopherols, phospholipids, sterols, phosphatides, flavonoids, vitamins B1, B2, C, PP, saturated, unsaturated and polyunsaturated fatty acids). The drug has a pronounced antioxidant effect, inhibits lipid peroxidation in biological membranes. The direct effect on the structure of epithelial tissues ensures normalization of differentiation and functions of the epithelium, reduces swelling and improves microcirculation, stimulates metabolic processes in tissues, inhibits prostate cell proliferation in prostate adenoma, reduces the severity of inflammation, and has a bacteriostatic effect.

The drug has a hepatoprotective, reparative, anti-inflammatory, antiseptic, metabolic and anti-atherosclerotic effect. The hepatoprotective effect is due to membrane-stabilizing properties and is manifested in slowing down the damage of hepatocyte membranes and accelerating their recovery. Normalizes metabolism, reduces inflammation, slows down the development of connective tissue and accelerates the regeneration of the parenchyma of the damaged liver. Eliminates dysuric phenomena in prostate hypertrophy, reduces pain in patients with prostatitis, increases potency, activates the body's immune systems.

Method of administration and dosage for prostate adenoma and chronic prostatitis: 1-2 capsules 3 times a day or rectally 1 suppository 1-2 times a day. Duration of treatment from 10 days to 3 months or short courses of 10-15 days each month for 6 months.

Of particular practical interest is prostate extract (prostatilen) - a peptide preparation isolated by acid extraction from the prostate of animals. The drug belongs to a new class of biological regulators - cytomedines. Samprost - the active substance of vitaprost - a complex of water-soluble biologically active peptides isolated from the prostate glands of sexually mature bulls - belongs to this class of drugs. The use of vitaprost in rectal suppositories allows the active pathogenetic substance to be delivered directly to the diseased organ through the lymphatic pathways. It reduces swelling of the prostate gland and leukocyte infiltration of the interstitial tissue, in addition, it helps to reduce thrombus formation and has antiaggregatory activity.

V.N. Tkachuk et al. (2006) observed 98 patients with chronic prostatitis who received monotherapy with rectal suppositories Vitaprost. The authors concluded that the duration of treatment with Vitaprost for this disease should be at least 25-30 days, not 5-10 days, as previously recommended. Long-term treatment improves not only immediate but also remote results. The most pronounced effect of Vitaprost is improved microcirculation in the prostate, which reduces prostate edema, reduces the main clinical manifestations of the disease (pain, urination disorders) and improves prostate function. This is accompanied by improved biochemical properties of the ejaculate and increased sperm motility. Vitaprost corrects pathological shifts in the hemocoagulation and immunity systems.

Currently, there is a form of the drug Vitaprost-Plus, which contains 400 mg of lomefloxacin along with 100 mg of the main active ingredient. Vitaprost-Plus should be preferred in patients with infectious prostatitis; rectal administration of the antibiotic simultaneously with the Vitaprost suppository allows for a significant increase in its concentration in the lesion and thus ensures faster and more complete destruction of the pathogen.

In extremely rare cases, when the patient cannot use suppositories (irritable bowel syndrome, severe hemorrhoids, post-operative condition, etc.), Vitaprost is prescribed in tablet form.

Currently, the problem of hypovitaminosis has acquired a new meaning. At the stages of evolution passed, man consumed a variety of food and received a lot of physical exercise. Today, refined food in combination with physical inactivity sometimes leads to serious metabolic disorders. V.B. Spirichev (2000) believes that vitamin deficiency is a polyhypovitaminosis, accompanied by a lack of microelements and is observed not only in winter and spring, but also in the summer-autumn period, i.e. it serves as a constantly acting factor.

For the normal functioning of the male reproductive system, among other things, zinc is absolutely necessary, which should be contained in large quantities in sperm and prostate secretion, and selenium is an important component of the antioxidant system.

Zinc selectively accumulates in the prostate, it is a specific component of its secretion. It is believed that spermatozoa are the carriers of zinc reserves necessary for the normal course of all phases of fertilized egg division, up to its fixation in the uterine cavity. The so-called zinc-peptide complex serves as an antibacterial factor of the prostate. In chronic prostatitis and prostate cancer, the concentration of zinc in the secretion of the prostate gland is reduced. Accordingly, the use of zinc preparations leads to an increase in the concentration and mobility of spermatozoa, increases the effectiveness of treatment of patients with chronic prostatitis.

The role of selenium is more diverse. This microelement is a component of the catalytic center of the main enzyme of the antioxidant system (glutathione peroxidase), which ensures the inactivation of free forms of oxygen. Selenium has a pronounced protective effect on spermatozoa and ensures their mobility. The need of an adult for selenium is about 65 mcg per day. Selenium deficiency contributes to damage to cell membranes due to the activation of LPO.

E.A. Efremov et al. (2008) studied the effectiveness of the drug selzinc plus, containing selenium, zinc, vitamins E, C, beta-carotene, in the complex treatment of patients with chronic prostatitis. The authors found the best clinical results in the group of patients taking selzinc. In addition, according to ultrasound data, an improvement in the condition of the prostate and seminal vesicles, a decrease in their volume were noted both due to a decrease in

The severity of irritative symptoms and improvement of the drainage function of the prostate gland, as well as as a result of a decrease in swelling of the gland and restoration of the drainage function of the seminal vesicles.

Chronic prostatitis, especially of autoimmune origin, is accompanied by significant changes in the rheological properties of the blood, therefore, in the pathogenetic treatment of patients with chronic prostatitis, drugs that improve them are indicated.

A study was conducted on three groups of patients. Patients in the first group received classic basic treatment, including antibacterial drugs, vitamin therapy, tissue therapy, prostate massage, and physiotherapy. In the second group, drugs were additionally prescribed that improve the rheological properties of blood [dextran (rheopolyglucin), pentoxifylline (trental), and escin (escusan)]. Patients in the third group received therapy using non-traditional methods (fasting, homeopathy, acupuncture, and phytotherapy) in combination with the basic treatment.

Analysis of clinical symptoms and laboratory parameters in 43 patients of the first group revealed that dysuric phenomena occurred in 16 of them (37.2%) before treatment. Pain was localized mainly in the lower abdomen and groin areas in 14 patients (32.6%). Digital examination of the prostate revealed an increase in its size in 33 patients (76.8%), the gland was clearly contoured in most patients (26 patients; 60.5%). Its consistency was mainly dense-elastic (28 patients; 65.1%). Pain upon palpation was noted by 24 patients (55.8%). In the analysis of prostate secretion, the number of leukocytes was increased in 34 patients (79%), lecithin grains were found in small quantities in 32 patients (74.4%).

All patients underwent basic conservative treatment of chronic prostatitis: antibiotic therapy taking into account the results of bacteriological examination for 7-10 days; non-steroidal anti-inflammatory drugs, vitamin therapy, tissue therapy; physiotherapy with the Luch-4 device, prostate massage (as indicated) 5-6 times, every other day.

After 12-14 days from the start of treatment, the following changes in clinical symptoms and laboratory parameters were noted: dysuric phenomena decreased by 1.2 times, pain in the lumbosacral region and perineum also decreased by 1.2 times. The size of the gland normalized in 15 patients (34.9%). Pain on palpation decreased by 2.4 times. In the analysis of prostate secretion, the number of leukocytes decreased by 1.4 times, the number of macrophages, layered bodies and lecithin grains increased. The treatment was considered effective in 63% of patients. The study of hemorheology and hemostasis parameters showed no reliable improvement in blood rheology, and thrombinemia parameters even increased. Blood viscosity after treatment remained significantly higher than normal, plasma viscosity also did not change. However, the rigidity of erythrocytes, slightly decreasing, became unreliably higher than the control figures. During the treatment, stimulated aggregation of erythrocytes normalized, and their spontaneous aggregation did not change significantly. The hematocrit level remained high both before and after the treatment.

Changes in hemostasis consisted of a slight increase in hypocoagulation along the intrinsic coagulation pathway against the background of treatment of patients with chronic prostatitis. Prothrombin time and fibrinogen levels did not change and were within normal values. The amount of RFMC increased significantly by 1.5 times by the end of treatment, and the time of CP-dependent fibrinolysis remained increased by 2 times. Changes in the amount of antithrombin III and platelets were insignificant.

Thus, classical treatment, including antibacterial drugs, vitamin therapy, tissue therapy, physiotherapy and massage, does not lead to normalization of hemorheological parameters in patients with chronic prostatitis, and hemostasis parameters even worsen by the end of treatment.

In 23 of 68 patients (33.8%) of the second group, predominance of complaints was established about pain and burning sensation during urination before treatment. The pain was localized mainly in the lower abdomen and inguinal regions - 19 patients (27.9%). The size of the prostate, determined by palpation, was increased in 45 patients (66.2%), while the contours and groove were clearly defined in half of the patients (51.5%), the consistency was dense-elastic also in half of the patients (57.3%) and mostly homogeneous (89.7%). Pain during palpation was noted by 41 people (60.3%). In the analysis of the prostate secretion, an increase in the number of leukocytes was observed in 47 people (69.1%), a decrease in the number of lecithin grains - in almost the same number of patients (41, or 60.3%).

All patients underwent conservative treatment, which consisted of two stages. At the first stage, treatment was carried out with drugs that improve the rheological properties of blood [dextran (rheopolyglucin), pentoxifylline (trental A) and escin (escusan)]. During this period, a bacteriological study of the secret was carried out. From the 6th day, antibacterial therapy was started, which was carried out according to the identified sensitivity of the microflora. All patients were prescribed the non-steroidal anti-inflammatory drug indomethacin, vitamins B1 and B6, vitamin E, tissue therapy, physiotherapy with the Luch-4 device, and prostate massage.

26 patients (38.2%) reported an improvement in their well-being after the first course of treatment, i.e. after taking rheological preparations. Patients reported a decrease or disappearance of pain, a feeling of heaviness in the perineum, and improved urination. Changes in clinical symptoms, the objective state of the prostate, and laboratory parameters were detected 12-14 days after the onset of the disease. Urination returned to normal in all patients. Pain in the perineum disappeared, and in the lower abdomen it significantly decreased (from 27.9 to 5.9%). The size of the prostate gland normalized in 58 patients (85.3%) due to the relief of edema and congestion. Pain during palpation of the gland significantly decreased. The number of leukocytes in the prostate secretion decreased. Pathological changes persisted only in 8 patients (11.8%). The treatment was considered effective in 84% of patients.

In the second group of patients, drugs improving the rheological properties of blood were introduced into the generally accepted treatment regimen, and at the end of treatment, significant positive shifts in hemorheological and hemostatic indices were observed in v patients. All blood rheology indices decreased and became reliably indistinguishable from the control, except for stimulated erythrocyte aggregation, which decreased to 2.5±0.79 c.u. (control - 5.75±0.41 c.u.) (/K0.05). With nonparametric recalculation, positive shifts in blood viscosity and stimulated erythrocyte aggregation indices were insignificant; the remaining group shifts were reliable.

The hemostasis study also showed positive dynamics of the indices. APTT decreased to the norm. Prothrombin time also normalized. The amount of fibrinogen decreased, but its change did not go beyond the normal fluctuations. The indices of OFT and CP-dependent fibrinolysis significantly decreased by 1.5 times, but remained higher than the control ones. Changes in the level of antithrombin III and platelets were insignificant and did not go beyond the normal limits.

Thus, in the second group of patients with chronic prostatitis, to whom the generally accepted treatment regimen included drugs that improve the rheological properties of blood [dextran (rheopolyglucin), pentoxifylline (trental) and escin (escusan)], significant positive changes in hemorheological and hemostatic indices were obtained. First of all, blood viscosity was normalized due to a decrease in the rigidity of erythrocyte membranes, a decrease in the hematocrit level and erythrocyte aggregation. These changes probably led to a decrease in thrombinemia and an improvement in coagulation and fibrinolysis, without affecting the level of antithrombin III and the number of platelets.

Analysis of clinical symptoms and laboratory parameters in 19 patients of the third group before treatment revealed pain during urination and a burning sensation in the urethra in 6 patients (31.6%), pain in the lower abdomen and inguinal areas - also in 6 patients (31.6%). During digital examination of the prostate, an increase in its size was noted in 12 patients (63.1%), in 10 people (52.6%) the contours of the gland and the groove were clearly defined, and in 7 (36.8%) they were blurred. According to the consistency of the gland in half of the patients, it was dense-elastic. Pain during palpation was noted by 1 patient (5.2%), moderate pain - 7 people (36.8%). An increase in the number of leukocytes in the prostate secretion was observed in 68.4% of patients, the number of lecithin grains was reduced in 57.8% of patients.

The treatment of patients in the third group was based on the method of unloading and dietary therapy in combination with reflexology, homeopathy and phytotherapy and supplemented by traditional treatment. Acupuncture included corporal and auricular effects. Biologically active points of general action were used (located in the lower abdomen, lumbosacral region, on the shin and foot, as well as individual acupuncture points in the cervical spine). Tinctures of peony, calendula, aralia, zamaniha, sterculia and ginseng were used for phytotherapy. Homeopathic remedies were prescribed differentially.

The method of fasting-diet therapy was used - from 7 to 12 days of fasting. Extended blind probing of the gallbladder and liver was carried out beforehand. All patients noted deterioration of their condition on the 5-6th day of fasting, headache, weakness, fatigue, subfebrile body temperature. The number of leukocytes increased in the analysis of the prostate secretion. A particularly sharp increase in the number of leukocytes in the secretion was noted in 9 patients (47.3%). This exacerbation of the disease is probably associated with the activation of the focus of chronic inflammation due to an increase in local tissue immunity. During this period, antibacterial therapy was added to the treatment according to an individual bacteriogram. All patients were prescribed anti-inflammatory drugs and vitamins. From the 7th-9th days, courses of acupuncture, phytotherapy, homeopathy, tissue therapy, physiotherapy, prostate massage began.

In 12-14 days after the start of treatment, dysuria decreased in more than half of the patients, pain disappeared in 74% of patients, and the size of the gland returned to normal in 68.4%. A positive effect from the treatment was noted in 74% of patients. Hemorheology and hemostasis indices in patients of the third group before treatment were indistinguishable from the norm, except for a slight but reliable decrease in the number of platelets and prolongation of CP-dependent fibrinolysis. This was probably due to the fact that patients with a milder course of chronic prostatitis agreed to unconventional treatment methods. During treatment, hemorheological indices changed insignificantly: blood viscosity decreased slightly, plasma viscosity and stimulated erythrocyte aggregation increased slightly, erythrocyte rigidity decreased, spontaneous erythrocyte aggregation and hematocrit increased.

Changes in hemostasis parameters during treatment with traditional methods were characterized by a slight prolongation of blood clotting time. The amount of fibrinogen increased. OFT became higher than the control values. CP-dependent fibrinolysis decreased by 1.5 times. The level of antithrombin III did not change. Unlike the two previous groups, the number of platelets increased during treatment.

Thus, patients with chronic prostatitis, treated with traditional methods, experienced multidirectional changes in hemorheology and hemostasis, which were characterized by thrombogenic shifts by the end of treatment (increased hematocrit and platelet count, increased spontaneous erythrocyte aggregation, increased fibrinogen levels and OFT results). Treatment of chronic prostatitis was effective in 74% of patients.

Comparison of hemorheology indices in three groups of patients allowed to establish that the most pronounced therapeutic effect was achieved in patients of the second group against the background of using rheoprotectors. Their indices of blood viscosity, hematocrit, and erythrocyte rigidity coefficient were normalized. Less pronounced changes occurred in patients of the third group, and in the first group against the background of treatment, these indices remained almost unchanged. As a result, the best clinical effect was achieved in patients of the second and third groups.

Thus, classical treatment, including antibacterial drugs, vitamin therapy, tissue therapy, prostate massage and physiotherapy, does not lead to normalization of hemorheology parameters, and hemostasis parameters even worsen by the end of treatment; the overall effectiveness of therapy is 63%.

In patients of the second group, who additionally received drugs that improve the rheological properties of blood [dextran (rheopolyglucin), pentoxifylline (trental) and escin (escusan), significant positive changes in hemorheological and hemostatic parameters were obtained. As a result, the treatment was effective in 84% of patients.

Thus, for the treatment of patients with chronic prostatitis, treatment can be carried out with drugs that improve the rheological properties of the blood. The use of rheoprotectors is advisable to prescribe at the beginning of treatment, for 5-6 days intensively (intravenously), and continue in maintenance doses for up to 30-40 days. Basic drugs can be considered dextran (rheopolyglucin), pentoxifylline (trental) and escin (escusan). Dextran (rheopolyglucin) when administered intravenously circulates in the bloodstream for up to 48 hours. It thins the blood, causes disaggregation of formed elements, smoothly reduces hypercoagulation. The drug is administered at a rate of 20 mg / kg per day for 5-6 days. The effect of dextran (rheopolyglucin) appears 18-24 hours after administration, while coagulation activity and rheological properties of the blood are normalized by the 5th-6th day.

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