Pathogenetic treatment of chronic prostatitis

If the course of adequate antibiotic therapy was unsuccessful, no other antibiotics should be prescribed. In this case, good results can be obtained if we start to carry out pathogenetic treatment of chronic prostatitis. If patients have obstructive symptoms (clinical or confirmed by uroflowmetry), the appointment of a-adrenoblockers is indicated. Non-steroidal anti-inflammatory drugs are prescribed with a pronounced inflammation, finasteride - with an increase in the prostate, pentosan polysulfate (hemoclar) with predominance of pain in the bladder and primary irrational impairment of urination. Phytotherapy is also useful in a number of patients. In an extreme case, with persistent preservation of complaints, transurethral microwave thermotherapy is permissible. Surgical aids are shown only in the development of complications, such as stenosis of the neck of the bladder, stricture of the urethra.

Types of therapy for chronic prostatitis and chronic pelvic pain syndrome, with at least some evidence base or theoretical background (1PCN was developed in order of priority)

Patients on chronic prostatitis of 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 the treatment is the relief of symptoms, for which analgesics, a-adrenergic blockers, muscle relaxants, tricyclic antidepressants are used simultaneously or sequentially. Classes with a psychotherapist, pelvic massage and other types of maintenance conservative therapy (diet, lifestyle changes) often alleviate the suffering of patients. It should be considered promising herbal medicine, for example, the use of prostanorm, tadenana. The experience of using these drugs has shown their high effectiveness both in the complex therapy of patients for chronic prostatitis of infectious nature, and in the form of monotherapy with non-infectious prostatitis.

Each tadenan tablet contains 50 mg of African plum bark extract, which maintains the secretory activity of prostate cells, normalizes urination, regulates the sensitivity of the muscles of the bladder to different impulses, has anti-inflammatory, anti-sclerotic and decongesting action. The efficacy of the drug in chronic prostatitis was evaluated based on observation of 26 patients with non-infectious chronic prostatitis.

The main clinical manifestations (pain in the perineum, above the womb, in the groin, in the scrotum, strangury, 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 pronounced) . Prior to treatment, pain syndrome, dysuria and sexual weakness showed, on average, with a strength of 1.2-2.4 points, after treatment, the intensity of the first two indicators decreased to 0.4-0.5, but the average erectile function disorder remained relatively high - 1, 1, although it decreased in comparison with the original one by more than 1.5 times.

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

When admitted to the hospital, the patients on average found 56.8 × 10 ³ μL of leukocytes in the secretion of the prostate; the amount of lecithin grains corresponded to an average of 0.7 points. At the end of treatment in the main group of patients, the number of leukocytes decreased almost 3-fold (average 12.4 cells), the saturation of the smear with lecithin grains, on the contrary, increased more than 2 times (1.6 on average).

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

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

There was no negative effect of tadenan on the qualitative and quantitative characteristics of the ejaculate, 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 the pumpkin. It contains the pumpkin seed oil, is available in the form of capsules, oils for oral administration and in the form of 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 LPO in biological membranes. The direct effect on the structure of epithelial tissues ensures the normalization of differentiation and functions of the epithelium, reduces edema and improves microcirculation, stimulates metabolic processes in tissues, inhibits the proliferation of prostate cells in adenoma of the prostate gland, reduces the severity of inflammation, and has a bacteriostatic effect.

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

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

Of particular practical interest is the prostate extract (prostatilen) - a peptide preparation isolated by acid extraction from the prostate of animals. The drug refers to a new class of biological regulators - cytomedines. To the same class of drugs is samprost - the active substance vitaprost - a complex of water-soluble biologically active peptides isolated from the prostate gland in sexually mature bull-calves. Vitaprost application in rectal suppositories allows to deliver the active pathogenetic substance directly to the diseased organ along the lymphatic pathways. It reduces puffiness 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 on chronic prostatitis who received monotherapy with vitamin suppositories vitaprost. The authors concluded that the duration of treatment with vitaprost in this disease should be at least 25-30 days, and not 5-10 days, as was recommended earlier. With long-term treatment, not only immediate, but also long-term results are improved. The most pronounced effect of vitaprost is improvement of microcirculation in the prostate, which allows to reduce edema of the prostate, reduce the main clinical manifestations of the disease (pain, urination disorders) and improve the function of the prostate gland. This is accompanied by an improvement in the biochemical properties of the ejaculate and increased motility of the spermatozoa. Vitaprost corrects pathological changes in the system of hemocoagulation and immunity.

At present, there is a form of vitamin-plus-plus preparation containing 400 mg of lomefloxacin along with 100 mg of the main active ingredient. Vitaprost-plus should be preferred in patients with an infectious prostatitis; rectal administration of the antibiotic simultaneously with suppositories vitaprost allows to significantly increase its concentration in the lesion and thereby ensure a faster and complete death of the pathogen.

In extremely rare cases, when the patient can not use suppositories (irritable bowel syndrome, expressed hemorrhoids, postoperative conditions, etc.), vitaprost is administered in tableted form.

At present, the problem of hypovitaminosis has acquired a new meaning. On the passed stages of evolution, people consumed a variety of food and received a lot of physical activity. Today, refined food in combination with hypodynamia leads at times to serious metabolic disorders. V.B. Spirichev (2000) believes that the vitamin deficiency has the character of polyhypovitaminosis, is accompanied by a lack of trace elements and is observed not only in winter and spring, but also in the summer-autumn period, i.e. Is a constant factor.

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

Zinc selectively accumulates in the prostate, this is a specific component of its secretion. It is believed that it is the spermatozoa - the storage of zinc, necessary for the normal flow of all phases of the fragmentation of a fertilized egg, until it is fixed in the uterine cavity. The so-called zinc-peptide complex serves as an antibacterial factor in the prostate. With 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 action against spermatozoa and ensures their mobility. The need for an adult in selenium is about 65 μg per day. Deficiency of selenium helps to damage cell membranes due to activation of LPO.

E.A. Efremov et al. (2008) studied the effectiveness of 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, there was an improvement in the state of the prostate and seminal vesicles, a decrease in their volume as a result of a decrease

The severity of irritative symptoms and the improvement of the drainage function of the prostate gland, as well as a reduction in the 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, so in the pathogenetic treatment of patients with chronic prostatitis, drugs that improve them are shown.

A study was conducted in three groups of patients. Patients of the first group received classical basic treatment, including antibacterial drugs, vitamin therapy, tissue therapy, prostate massage, physiotherapy. In the second group, drugs were additionally prescribed that improved the rheological properties of blood [dextran (reopoliglyukin), pentoxifylline (trental), and escin (escuzan)]. Patients of the third group were treated with unconventional methods (starvation, homeopathy, acupuncture, phytotherapy) in combination with the baseline.

In the analysis of clinical symptoms and laboratory indicators, 43 patients of the first group found that before treatment dysuric phenomena occurred in 16 of them (37.2%). The pains were localized mainly in the lower abdomen and inguinal regions in 14 people (32.6%). In digital examination of the prostate, an increase in the size of the prostate was diagnosed in 33 patients (76.8%), iron was clearly contoured in the majority of patients (26 persons, 60.5%). Its consistency was basically dense-elastic (28 patients, 65.1%). Painfulness during palpation was noted by 24 people (55.8%). In the analysis of the secretion of the prostate, the number of leukocytes was increased in 34 patients (79%), lecithin grains in a small number were found in 32 patients (74.4%).

All patients underwent basic conservative treatment of chronic prostatitis: antibiotic therapy taking into account the results of bacteriological examination within 7-10 days; non-steroidal anti-inflammatory drugs, vitamin therapy, tissue therapy; physiotherapy with Luch-4, prostate massage (according to indications) 5-6 times, after 24 hours.

After 12-14 days after the beginning of treatment, the following changes in clinical symptoms and laboratory indicators were noted: dysuric phenomena decreased by 1.2 times, pains in the sacro-lumbar region and perineum also decreased by 1.2 times. The size of the gland normalized in 15 patients (34.9%). Pain during palpation decreased by 2-4 times. In the analysis of the secretion of the prostate, the number of leukocytes decreased by 1.4 times, the number of macrophages, layered corpuscles and lecithin grains increased. Treatment was found to be effective in 63% of patients. The study of hemorheology and hemostasis showed no significant improvement in blood rheology, and thrombinemia rates even increased. The viscosity of blood after treatment remained significantly above normal, the viscosity of the plasma also did not change. However, the rigidity of red blood cells, slightly decreasing, became unreliable above the control figures. Against the background of treatment the stimulated aggregation of red blood cells was normalized, and their spontaneous aggregation did not change reliably. The level of hematocrit remained high before and after treatment.

The change in hemostasis consisted of a slight increase in hypocoagulation along the internal way of coagulation against the background of treatment of patients for chronic prostatitis. Prothrombin time and the amount of fibrinogen did not change and were within the normal range. The amount of RFMK significantly increased by 1.5 times at the end of treatment, and the time of CP-dependent fibrinolysis remained 2-fold increased. 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 parameters of hemorheology in patients with chronic prostatitis, and the parameters of hemostasis to the end of treatment even worsen.

In 23 of 68 patients (33.8%) of the second group, before treatment, the prevalence of complaints of rubbing and burning sensation during urination was established. The pain was localized mainly in the lower abdomen and in the inguinal regions - 19 patients (27.9%). The dimensions of the prostate, determined palpation, were increased in 45 patients (66.2%), while the contours and groove were clearly defined in half of the patients (51.5%), the consistency was also tight in half of the patients (57.3%) and mostly homogeneous (89.7%). Painfulness 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 preparations that improved the rheological properties of blood [dextran (reopolyglucin), pentoxifylline (trental A) and escin (escusa)]. 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 revealed sensitivity of the microflora. All patients were prescribed non-steroidal anti-inflammatory drug indomethacin vitamins B1 and B6, vitamin E, tissue therapy, physiotherapy with Luch-4 apparatus, prostate massage.

In 26 patients (38.2%) there was an improvement in the state of health after the first course of treatment, that is, after taking rheological preparations. Patients noted a decrease or disappearance of pain, a feeling of heaviness in the perineum, an improvement in urination. After 12-14 days from the onset of the disease, changes in clinical symptoms, objective status of the prostate and laboratory parameters were revealed. Urination was normal in all patients. Pain in the perineum disappeared, and in the lower abdomen significantly decreased (from 27.9 to 5.9%). Dimensions of the prostate gland were normalized in 58 patients (85.3%) due to the reduction of edema and stagnant phenomena. Significantly decreased soreness in palpation of the gland. The number of leukocytes in the secretion of the prostate has decreased. Pathological changes persisted in only 8 people (11.8%). Treatment was found to be effective in 84% of patients.

In the second group of patients, drugs improving the rheological properties of blood were introduced into the generally accepted regimen of treatment, and at the end of treatment v patients showed significant positive changes in haemorheological and haemostatic parameters. All indices of blood rheology decreased and became significantly indistinguishable from control, except for stimulated aggregation of erythrocytes, which decreased to 2.5 ± 0.79 USD. (control - 5.75 ± 0.41 USD) (/ K0.05). In the case of nonparametric recalculation, the positive shifts in blood viscosity and stimulated aggregation of red blood cells were found to be unreliable; the remaining group shifts were reliable.

The study of hemostasis also showed a positive dynamics of indicators. AHTTV was reduced to the norm. Prothrombin time also normalized. The amount of fibrinogen decreased, but its change did not go beyond the limits of normal vibrations. The indices of the OFT and HP-dependent fibrinolysis significantly decreased by a factor of 1.5, but remained above the control ones. Changes in the level of antithrombin III and platelets were insignificant and did not go beyond the norm.

Thus, in the second group of patients with chronic prostatitis, drugs improving the rheological properties of blood [dextran (reopolyglucin), pentoxifylline (trental), and escin (escusa)] were introduced into the conventional treatment regimen, significant positive changes were made in hemorheological and haemostatic indicators. First of all, the viscosity of the blood was normalized by decreasing the rigidity of erythrocyte membranes, reducing the level of hematocrit and aggregation of red blood cells. These changes probably led to a decrease in thrombinemia and improved coagulation and fibrinolysis, without affecting the level of antithrombin III and the platelet count.

In the analysis of clinical symptoms and laboratory parameters, in 19 patients of the third group, before the treatment, the urine was set by urination and burning sensation in the urethra in 6 people (31.6%), lower abdominal pain and in the inguinal regions, also in 6 patients (31, 6%). In the finger examination of the prostate, an increase in its size was noted in 12 patients (63.1%), in 10 patients (52.6%), the contours of the gland and groove were clearly defined, and 7 (36.8%) were lubricated. According to the consistence of iron, half of the patients were tight-elastic. Pain in palpation was noted by 1 patient (5.2%), moderate morbidity - 7 people (36.8%). An increase in the number of leukocytes in the secretion of the prostate was observed in 68.4% of patients, the amount 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 with traditional treatment. Acupuncture included a corporal and auricular effect. Biologically active points of general action (located in the lower abdomen, lumbosacral region, on the lower leg and foot, as well as individual points of acupuncture in the cervical spine) were used. For herbal medicine used tinctures of peony, marigold, aralia, zamanichi, spikulii and ginseng. Homeopathic remedies were prescribed differentially.

The method of unloading and dietary therapy - from 7 to 12 days of hunger was applied. Preliminary extensive blind probing of the gallbladder and liver was performed. All patients reported worsening on the 5th-6th day of hunger, headache, weakness, weakness, subfebrile body temperature. In the analysis of the secretion of the prostate, the number of leukocytes increased. Especially a sharp increase in the number of leukocytes in a secret was observed in 9 patients (47.3%). This exacerbation of the disease is probably connected with activation of the focus of chronic inflammation due to an increase in local tissue immunity. During this period, antibiotic therapy was added to the treatment according to the individual bacteriogram. All patients were prescribed anti-inflammatory drugs and vitamins. From the 7th to the 9th day the courses of acupuncture, phytotherapy, homeopathy, tissue therapy, physiotherapy, prostate massage began.

12-14 days after the start of treatment dysuria decreased in more than half of patients, pain disappeared in 74% of patients, the size of the gland normalized in 68.4%. A positive effect of the treatment was observed in 74% of patients. The parameters of haemorheology and hemostasis in patients of the third group before treatment were indistinguishable from the norm, except for an insignificant but significant decrease in the number of platelets and lengthening of CP-dependent fibrinolysis. This probably was due to the fact that patients with non-traditional methods of treatment agreed with an easier course of chronic prostatitis. Against the background of treatment, the hemorheological indices changed insignificantly: the viscosity of the blood decreased somewhat, the viscosity of the plasma and the stimulated aggregation of erythrocytes increased insignificantly, the erythrocyte stiffness decreased, spontaneous aggregation of erythrocytes and hematocrit increased.

Changes in hemostatic parameters in the treatment with traditional methods were characterized by a slight lengthening of the clotting time. The amount of fibrinogen increased. The OFT rose above the benchmark. CP-dependent fibrinolysis was reduced by a factor of 1.5. The level of antithrombin III did not change. In contrast to the two previous groups, the number of platelets increased with the treatment.

Thus, in patients with chronic prostatitis, which was treated with traditional methods, there were multidirectional changes in hemorheology and hemostasis, which were characterized by thrombotic changes to the end of treatment (increase in hematocrit and platelet count, increased spontaneous aggregation of erythrocytes, increase in the amount of fibrinogen and the results of the OFT). Treatment of chronic prostatitis was effective in 74% of patients.

Comparison of hemorheology in three groups of patients made it possible to establish that the most pronounced therapeutic effect was achieved in patients of the second group against the background of the use of rheoprotectors. Their blood viscosity, hematocrit, erythrocyte stiffness ratio 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 patients of the second and third groups received the best clinical effect.

Thus, classical treatment, which includes antibacterial drugs, vitamin therapy, tissue therapy, prostate massage and physiotherapy, does not lead to normalization of parameters of hemorheology, and the parameters of hemostasis even worsen to 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 (reopolyglucin), pentoxifylline (trental), and escin (escuzane), significant positive changes in hemorheological and haemostatic parameters were obtained, which was effective in 84% of patients.

Thus, for the treatment of patients with chronic prostatitis, treatment can be carried out with preparations that improve the rheological properties of the blood. The use of reoprotectors should be prescribed at the beginning of treatment, for 5-6 days intensively (intravenously), and continue in maintenance doses up to 30-40 days. The basis drugs can be considered dextran (reopoliglyukin), pentoksifillin (trental) and escin (eskuzan). Dextran (reopolyglucin) with intravenous administration circulates in the bloodstream to 48 hours. It dilutes blood, causes disaggregation of uniform elements, smoothly reduces hypercoagulability. The drug is administered at a rate of 20 mg / kg per day for 5-6 days. The action of dextran (reopoliglyukin) is manifested 18-24 hours after administration, while coagulation activity and rheological properties of the blood are normalized to the 5th-6th day.

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