Prostatitis: types

Since ancient times, urologists have recognized clinical differences between acute and chronic inflammation of the prostate. They distinguished between active, latent and bacterial prostatitis. After the role of microorganisms in the etiology of this disease was discovered, prostatitis was classified as primary (caused by gonococcal infection) and secondary - as a consequence of other infections. In the 1930s, a third group of prostatitis was identified - the so-called persistent, that is, not resolved after a course of therapy. In the mid-20th century, "silent" prostatitis was described, which is asymptomatic, despite signs of inflammation in the urine and prostate secretion.

In 1978, Drach GW et al. proposed a classification based on the Meares and Stamey 4-glass test. This classification included the well-known forms of acute and chronic bacterial prostatitis, abacterial prostatitis, and prostatodynia.

• Bacterial prostatitis was associated with urinary tract infection, a significant number of inflammatory cells in prostatic secretions, and isolation of a bacterial pathogen during prostatic secretion culture.
• Acute bacterial prostatitis was characterized by a sudden onset, an increase in body temperature, and pronounced symptoms of damage to the genitourinary tract.
• Bacterial chronic prostatitis was manifested by recurrent symptoms caused by the persistence of the bacterial agent in the prostatic secretion, despite the antibacterial therapy.
• Abacterial prostatitis was characterized by a high number of inflammatory cells in the prostatic secretion, but there was no documented history of urogenital tract infection, and bacteria were not detected when the prostatic secretion was cultured.
• Prostatodynia was not characterized by changes in prostate secretion compared to the norm, there was no infection in the genitourinary tract, and bacteriological analysis was negative.

The urological community, which was in dire need of systematization of prostatitis and principles of its therapy, accepted this classification as a guide to action. However, after 20 years, the imperfection of this classification and the algorithm of diagnosis and treatment based on it became obvious, especially with regard to prostatodynia, the symptoms of which were often caused by diseases of other organs.

The diagnosis and classification of prostatitis at the beginning of the 20th century was based on microscopic and cultural findings in specimens of the sex glands (prostatic secretion, ejaculate), as well as in a portion of urine obtained after prostate massage, and/or in prostate biopsies.

The uncertainty in the classification of chronic prostatitis served as the basis for the creation of a new classification. It was proposed to the attention of the urological community at a consensus meeting on prostatitis of the US National Institute of Health and the National Institute of Diabetes and Digestive and Kidney Diseases (NIH and NIDDK) in Maryland in December 1995. At this meeting, a classification was developed for research purposes, and already in 1998, the International Prostatitis Collaborative Network (IPCN) assessed three years of experience in using this classification and confirmed its effectiveness in practice. Categories I and II correspond to acute and chronic bacterial prostatitis according to the traditional classification. An innovation is category III - chronic pelvic pain syndrome, inflammatory and without inflammation, as well as asymptomatic prostatitis (category IV).

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NIH Classification of Prostatitis

• I Acute bacterial prostatitis - Acute infectious inflammation of the prostate
• II Bacterial chronic prostatitis - Recurrent urinary tract infections, chronic prostate infection
• III - Chronic abacterial prostatitis (CAP), chronic pelvic pain syndrome - Discomfort or pain in the pelvic area, various symptoms of urinary disorders, sexual dysfunction, conditions with undetected infection
  • IIIA Chronic pelvic pain syndrome with signs of inflammation - Increased number of leukocytes in ejaculate, prostatic secretion, third portion of urine
  • IIIB Chronic pelvic pain syndrome without signs of inflammation - Low number of leukocytes in ejaculate, prostatic secretion, third portion of urine
• IV Asymptomatic prostatitis - Signs of inflammation in prostate biopsy, ejaculate, prostate secretion, third portion of urine - without clinical manifestations

It is obvious that the classification has a number of shortcomings. Thus, it is hardly advisable to combine acute and chronic prostatitis. Acute prostatitis is a rather diverse disease that deserves a separate classification, distinguishing serous, purulent, focal, diffuse and other types of inflammation with possible complications.

Category III causes the most controversy. First of all, in the original classification, category III is designated as chronic pelvic pain syndrome. The allocation of the syndrome to a separate line of the clinical classification is confusing due to its obvious illogicality, therefore in Russia chronic prostatitis of category III is usually called abacterial prostatitis. However, the definition of "abacterial prostatitis" is also not entirely accurate, since inflammation of the prostate can be caused not only by bacterial microflora, but also by mycobacterium tuberculosis, viruses, protozoa, etc. Probably, the most successful term is "non-infectious".

Another question arises - to what extent is CAP really abacterial, especially category III A. Category III A implies clinical and laboratory symptoms of chronic prostatitis, i.e. the prostate secretion contains an increased number of leukocytes, although there is no growth of microflora. The fact of aseptic inflammation in this case is very doubtful, most likely, there is insufficient qualification of bacteriologists or incomplete equipment of the bacteriological laboratory. In addition, patients with IIIA disease have received more than one course of antibacterial therapy in their lives, which could lead to the transformation of microorganisms into L-forms and their persistence in the parenchyma of the gland. L-forms do not grow on conventional standard media. Or, say, the inflammation is caused by aerobic microflora, which most bacteriological laboratories are unable to detect.

The prostate is made up of two lobes, each of which consists of 18-20 separate glands that open into a single duct through independent ducts. As a rule, the primary introduction of an infectious agent into one of the acini or a small group of glands occurs.

Chronic prostatitis develops with the release of a large number of leukocytes and microorganisms. Then, as a result of treatment or by mobilizing the body's own defenses, the focus of chronic inflammation is isolated: the excretory ducts become clogged with purulent-necrotic detritus and an imaginary improvement is observed in the tests. Such an improvement in laboratory parameters (up to normalization) can also be facilitated by pronounced inflammatory edema of the excretory ducts; such a condition should be classified as category IIIA or even IIIB, although in fact, in this case, chronic prostatitis was and remains infectious (bacterial). This fact is confirmed by an increased number of leukocytes in the prostate secretion after the following actions:

• prostate massage course;
• a short course of local transperineal low-intensity laser therapy (LT) (both of these manipulations help cleanse the gland's excretory ducts);
• prescription of alpha-blockers (it is optimal to use tamsulosin for diagnostic purposes, as it does not affect blood pressure - accordingly, it can be used in full dosage from the first day).

It is believed that in the structure of chronic prostatitis up to 80-90% falls on abacterial chronic prostatitis. There is an opinion that in order to recognize prostatitis as bacterial, it is necessary to detect in the specific material of the prostate gland (secretion, portion of urine after massage, ejaculate) during repeated exacerbations (relapses) mainly the same pathogenic bacterial pathogen - different from the microflora of the urethra, while only 5-10% of cases of chronic prostatitis correspond to the specified criterion. However, the same group of scientists recommends that all patients with chronic prostatitis prescribe antibacterial therapy for a long time and often receives a positive treatment result. How else, except for the presence of a latent undiagnosed infection, can such a phenomenon be explained?

Indirect confirmation of the high frequency of chronic prostatitis is provided by the results of a large-scale study SEZAN - Sexual Health Analysis.

According to the data obtained, 60% of men engage in casual sexual relations, but only 17% of them always use a condom. It is naive to believe that in our time of the absence of strict morality and censorship they will only come across healthy partners; certainly, a significant proportion of men will be infected (at best - with opportunistic microflora, which can be curbed by local immunity), which under unfavorable conditions will cause the development of urethrogenic prostatitis.

Certainly recognized causes of bacterial inflammation of the prostate are: E. coli, Proteus, Enterobacter, Klebsiella, Pseudomonas. Gram-positive

Enterococci, and especially intracellular infections (chlamydia, ureaplasma, mycoplasma and mycobacterium tuberculosis) seem to many researchers to be dubious causative factors that cause chronic prostatitis.

There is an opinion that in our country there is a sharply expressed hyperdiagnosis of urogenital chlamydia, mycoplasmosis, gardnerellosis. The following arguments confirm this:

• it is difficult to identify the indicated pathogens;
• there are no completely reliable tests;
• there are erroneous conclusions about the chlamydial nature of prostatitis based on the detection of corresponding microorganisms in the epithelium of the urethra

However, intracellular sexually transmitted infections should not be completely ignored. According to recent studies, it has been established that chlamydia interferes with natural cell apoptosis, which can lead to the development of tumors. It has been established that about 14% of men currently or in their anamnesis have an established diagnosis of chronic prostatitis, but only in 5% of cases is a bacterial pathogen detected (mainly E. coli and enterococci). Despite the overwhelming prevalence of the abacterial form of the disease, the author believes that a short initial course of antimicrobial therapy is justified.

Other researchers also express doubts about the truly non-infectious nature of chronic prostatitis category III A and its frequency. Thus, M.I. Kogan et al. (2004) rightly believe that the severity of the inflammatory process depends not only on the type and degree of microbial contamination, but also on the presence of their waste products.

The presence of lipids in tissues that are not typical for the human body leads to their incorporation into biological membranes, changes in the physical and chemical properties of cells, disruption of their permeability and, ultimately, destruction.

In one study, 776 people without complaints or urological history were examined during a routine medical examination. All of them had normal urine and blood test results, and no pathology was detected during a rectal examination. However, 44.1% of men had leukocytosis in their secretions. In 107 of them, nonspecific microorganisms were found to grow: hemolytic staphylococcus in 48 (44.8%), epidermal staphylococcus in 28 (26.2%), streptococcus in 11 (10.3%), and E. coli in 5 (14%); only 5 (4.7%) had no microflora growth.

Another study examined the secretion of 497 patients with chronic prostatitis. Microflora was detected in 60.2% of them, with 66.9% of them having one pathogen, and the rest having two to seven. Chlamydia (28.5%) and staphylococci (20.5%) predominated in the microbial landscape. Trichomonas were detected in 7.5% of cases, ureaplasma in 6.5%; hemolytic streptococcus, E. coli, gardnerella, herpes, Candida fungi, gonococcus, proteus, enterococcus, enterobacter, and pseudomonas aeruginosa were encountered with a frequency of 1.5-4.5%.

Low seeding of microflora may be due to errors in the standard research scheme. This is clearly demonstrated by the work of V.M. Kuksin (2003), who doubled the frequency of positive seeding after reducing the time between material collection and seeding to 5 minutes.

Thus, the analysis of domestic literature and data obtained in studies indicate that the frequency of chronic abacterial prostatitis is greatly overestimated; the failure to detect microflora in the experimental samples of the sex glands does not mean its absence.

The following classification of prostatitis is proposed:

• acute prostatitis:
  • serous or purulent;
  • focal or diffuse;
• complicated course or without complications - chronic infectious prostatitis:
  • bacterial chronic prostatitis;
  • viral chronic prostatitis;
  • specific chronic prostatitis with specification of the infectious agent (caused by Mycobacterium tuberculosis or sexually transmitted pathogens);
  • typical chronic prostatitis (caused by anaerobic infection);
  • mixed infectious (caused by several pathogens);
  • latent infectious, in which it was not possible to establish the presence of a microbial factor using several methods (bacteriological culture, microscopy of a Gram-stained smear, DNA diagnostics), but a positive effect was obtained against the background of antibacterial therapy;
• non-infectious chronic prostatitis:
• autoimmune chronic prostatitis;
• ischemic chronic prostatitis, due to microcirculation disorders caused by various reasons (hypothermia, compression by an adenomatous node or other surrounding tissues, varicose veins of the pelvis, etc.), consequences of past trauma to the perineum, including after horse riding, cycling, and certain sports;
• chemical chronic prostatitis, developed due to certain disturbances in homeostasis, accompanied by a sharp change in the chemical properties of urine and its reflux into the excretory ducts of the prostate gland;
• dystrophic-degenerative chronic prostatitis, prostatosis - mainly the outcome of CIP. In this form, there are no signs of inflammation and infection, and the leading clinical symptom is chronic pelvic pain due to circulatory failure, local neurological disorders, dystrophic changes in prostate tissue. In this form of prostatitis, fibrous-sclerotic changes predominate;
• Chronic prostatitis, like any other chronic disease, can be in the phase of exacerbation, attenuation, remission, and a continuously recurring course of chronic prostatitis is possible.
• primary chronic prostatitis is possible (which is more common) and chronicization of inadequately treated acute prostatitis (which is rare).

Chronic pelvic syndrome should be excluded from the classification of prostatitis, since this complex of symptoms reflects the pathological state of many organs and systems, only a small part of which is actually associated with inflammation of the prostate.

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