Prostatitis: Species

Since long ago, urologists have recognized the clinical differences between acute and chronic inflammation of the prostate. At the same time, active, latent and bacterial prostatitis was distinguished. After the discovery of the role of microorganisms in the etiology of this disease, prostatitis was classified as primary (caused by gonococcal infection) and secondary - as a consequence of other infections. In the 1930s. Was allocated a third group of prostatitis - the so-called persistent, that is, not approved after a course of therapy. In the middle of XX century. Was described "silent" prostatitis, which proceeds asymptomatically, despite the signs of inflammation in the urine and the secretion of the prostate.

In 1978, Drach GW et al. The classification based on the 4-cup test Meares and Stamey was proposed. This classification included 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 the secretion of the prostate, the release of a bacterial pathogen when sowing the secretion of the prostate.
• Acute bacterial prostatitis was characterized by a sudden onset, an increase in body temperature, a marked symptom of the urogenital tract injury.
• Bacterial chronic prostatitis manifested itself as a recurring symptom caused by the persistence of a bacterial agent in the secretion of the prostate, despite the ongoing antibiotic therapy.
• The abacterial prostatitis was characterized by a high number of inflammatory cells in the secretion of the prostate, but there was no documented infection of the urogenital tract in the anamnesis, bacteria were not detected during the secretion of the prostate secretion.
• Prostadeniya was not characterized by changes in the secretion of the prostate in comparison with the norm, infection in the urinary tract was absent, bacteriological analysis was negative.

The urological community, badly in need of systematization of prostatitis and the principles of their therapy, adopted such a classification as a guide to action. However, after 20 years, the imperfection of this classification and the diagnostic and treatment algorithm based on it became evident, especially with regard to prostatodynia, the symptoms of which were often caused by diseases of other organs.

Diagnosis and classification of prostatitis in the early XX century. Was based on microscopic and cultural findings in the exprimates of the gonads (secretion of the prostate, ejaculate), as well as in the portion of urine obtained after prostate massage, and / or in prostate biopsy.

Uncertainty in the systematization of chronic prostatitis served as the basis for the creation of a new classification. It was offered to the attention of the urological community at a conciliatory meeting on prostatitis of the National Institutes of Health of the United States and the National Institute of Diabetes, Digestive and Renal Diseases (NIH and NIDDK) in Maryland in December 1995. This meeting developed a classification for research purposes, 1998. The International Prostatitis Collaborative Network (IPCN) evaluated the three-year experience of applying 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 - a syndrome of chronic pelvic pain, inflammatory and without inflammation, as well as asymptomatic prostatitis (category IV).

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

Classification of prostatitis NIH

• I Acute bacterial prostatitis - Acute infectious inflammation of the prostate
• II Bacterial chronic prostatitis - Repeated urinary tract infections, chronic prostate infection
• III - Chronic abacterial prostatitis (HAP), chronic pelvic pain syndrome - Discomfort or pain in the pelvic region, various symptoms of urination disorders, sexual disorders, conditions with undiagnosed infection
  • IIIA Syndrome of chronic pelvic pain with signs of inflammation - Increased number of leukocytes in ejaculate, prostate secretion, third portion of urine
  • IIIB Syndrome of chronic pelvic pain without signs of inflammation - A small number of leukocytes in the ejaculate, a secretion of the prostate, a third portion of urine
• IV Asymptomatic prostatitis - Signs of inflammation in the prostate biopsy of the prostate ejaculate, secretion of the prostate, third dose of urine - without clinical manifestations

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

The greatest controversy is caused by category III. First of all, in the original classification, category III is designated as a syndrome of chronic pelvic pain. Isolation of the syndrome in a separate line of the clinical classification is confused by obvious illogicality, therefore in Russia chronic prostatitis of category III is usually called an 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 mycobacteria of tuberculosis, viruses, protozoa, and the like. Probably the most successful term is "non-infectious".

There is another question - how much HAP is really abacterial, especially category III A. Category III A implies clinical and laboratory symptoms of chronic prostatitis, that is, in the secretion of the prostate there is an increased number of leukocytes, although there is no growth of microflora. The very fact of aseptic inflammation in this case is very doubtful, most likely, there is insufficient qualification of bacteriologists or incomplete equipping of a bacteriological laboratory. In addition, patients with IIIA disease in their lives received not one course of antibiotic therapy, which could lead to the transformation of microorganisms into L-forms and their persistence in the parenchyma of the gland. L-forms do not allow growth on conventional standard media. Or, say, the inflammation is caused by an aerobic microflora, which most bacteriological laboratories can not detect.

Prostate is two lobes, in turn, each of them consists of 18-20 individual glands, opening themselves as independent ducts into a single duct. As a rule, there is a primary introduction of an infectious agent into one of the acini or a small group of glands.

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

• course of massage of the prostate;
• a short course of local transperineal low-intensity laser therapy (LT) (both of these manipulations help purify the excretory ducts of the gland);
• the appointment of a-adrenoblockers (optimally with a diagnostic purpose to use tamsulosin, as it does not affect blood pressure - accordingly, it can be used in full dosage from 1 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 for the recognition of prostatitis bacterial it is necessary to detect in a specific material of the prostate (secret, portion of urine after massage, ejaculate) with repeated exacerbations (relapses) of the same pathogenic bacterial pathogen - different from the microflora of the urethra, 5-10% of cases of chronic prostatitis correspond to the specified criterion. However, the same group of scientists recommends that all patients for chronic prostatitis prescribe antibacterial therapy for a long time and often receives a positive result of treatment. What other than the presence of latent undiagnosed infection, you can explain a similar phenomenon?

Indirect confirmation of the high incidence of chronic prostatitis is the results of a large-scale study SEZAN - Seksualnogo Health Analisis.

According to the data received, 60% of men enter into casual sex, but only 17% of them always use a condom. It is naive to believe that in our time of absence of strict morals and censorship they will receive exceptionally healthy partners; of course, a significant part of men will be infected (at best - a conditionally pathogenic microflora, which local immunity can curb), which under unfavorable conditions will cause the development of urethrogenic prostatitis.

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

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

There is an opinion that in our country there is a pronounced hyperdiagnosis of urogenital chlamydia, mycoplasmosis, gardnerelleza. This is confirmed by the following arguments:

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

Nevertheless, it is not worth completely neglecting intracellular sexual infections. According to recent studies, it is established that chlamydia interfere with the natural apoptosis of cells, which can lead to the development of tumors. It is established that about 14% of men have, at present or in anamnesis, an established diagnosis - chronic prostatitis, but only 5% of cases reveal a bacterial pathogen (mainly E. Coli and enterococci). Despite the overwhelming predominance of the abacterial form of the disease, the author believes that a short initial course of antimicrobial therapy is justified.

Doubts in the truly non-infectious nature of chronic prostatitis of category III A and its frequency are expressed by other researchers. So, 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 availability of products of their vital activity.

The presence in the tissues of lipids uncharacteristic to the human body leads to their incorporation into biological membranes, changes in the physicochemical properties of cells, the violation of their permeability, and ultimately to destruction.

In one study, during outpatient examination, 776 people were examined without complaints and a urological anamnesis. In all, the results of urine and blood tests were normal, and rectal examination also showed no pathology. However, 44.1% of men had a secret leukocytosis. In 107 of them, growth of nonspecific microorganisms was obtained: hemolytic staphylococcus in 48 (44.8%), epidermal staphylococcus in 28 (26.2%), streptococcus in 11 (10.3%), E. Coli in 5 14%); only 5 (4.7%) growth of microflora was absent.

In another study, the secret was studied in 497 patients with chronic prostatitis. Microflora was detected in 60.2%, 66.9% of them having one causative agent, and the rest - from two to seven. In the microbial landscape chlamydia prevailed (28.5%) and staphylococci (20.5%). Trichomonas were detected in 7.5% of cases, ureaplasma - in 6.5%; with a frequency of 1.5-4.5% met hemolytic streptococcus, Escherichia coli, Gardnerella, Herpes, Candida fungi, Gonococcus, Proteus, Enterococcus, Enterobacter, Pseudomonas aeruginosa.

Low sowability of microflora can be caused by errors in the standard study design. This is clearly demonstrated by the work of V.M. Kuksin (2003), which doubled the frequency of positive crops, after reducing the time between taking the material and sowing up to 5 minutes.

Thus, the analysis of domestic literature and the data obtained in the studies indicate that the frequency of chronic abacterial prostatitis is very high; the lack of detection of microflora in the exprimates of the sex glands does not mean that it is absent.

The following variant of prostatitis classification is proposed:

• acute prostatitis:
  • serous or purulent;
  • focal or diffuse;
• complicated or without complications - chronic infectious prostatitis:
  • bacterial chronic prostatitis;
  • viral chronic prostatitis;
  • specific chronic prostatitis with the specification of an infectious agent (caused by mycobacteria tuberculosis or sexually transmitted pathogens);
  •   a typical chronic prostatitis (caused by anaerobic infection);
  • mixed-infectious (caused by several pathogens);
  • latent infection, which failed to establish the presence of a microbial factor by several methods (bacteriological culture, microscopy of Gram stain smear, DNA diagnostics), but a positive effect was obtained on the background of antibacterial therapy;
• non-infectious chronic prostatitis:
• autoimmune chronic prostatitis;
• ischemic chronic prostatitis due to microcirculation disorders caused by various causes (hypothermia, adenomatous nodal or other surrounding tissues, varicose veins of the pelvis, etc.), the consequences of the transferred crotch injury, including after riding, riding a bicycle, with some kinds of sports;
• chemical chronic prostatitis, developed with certain violations of homeostasis, accompanied by a sharp change in the chemical properties of urine, and reflux it into the excretory ducts of the prostate gland;
• dystrophic degenerative chronic prostatitis, prostatosis - mainly the outcome of HIP. With this form, there are no signs of inflammation and infection, and the leading clinical symptom is chronic pelvic pain due to circulatory insufficiency, local neurologic disorders, dystrophic changes in prostate tissue. With this form of prostatitis, fibro-sclerotic changes predominate;
• chronic prostatitis, like any other chronic disease, can be in the phase of exacerbation, remission, remission, possibly a continuously-recurring course of chronic prostatitis.
• Primary-chronic prostatitis (which occurs in the bowl) and chronization of inadequately treated acute prostatitis (which is rare) is possible.

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

[9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]