Chronic prostatitis Inflammatory disease of the prostate gland of various etiologies (including non-infectious) manifested by pain or discomfort in the pelvic area and urinary incontinence for 3 months or more.
I. Introductory part
Protocol Name: Inflammatory diseases of the prostate gland
Protocol code:
ICD-10 codes:
N41. 0 Acute prostatitis
N41. 1 Chronic prostatitis
N41. 2 Prostate abscess
N41. 3 Prostatocystitis
N41. 8 Other inflammatory diseases of the prostate gland
N41. 9 Inflammatory disease of the prostate, unspecified
N42. 0 Prostate stones
Prostate stone
N42. 1 Obstruction and bleeding in the prostate gland
N42. 2 Prostate gland atrophy
N42. 8 Other prescribed diseases of the prostate gland
N42. 9 Prostate disease, unspecified
Abbreviations used in the protocol:
ALT - alanine aminotransferase
AST - aspartate aminotransferase
HIV - human immunodeficiency virus
ELISA - enzyme immunoassay
CT - computed tomography
MRI - magnetic resonance imaging
MSCT - multi-slice computed tomography
DRE - digital rectal examination
PSA - prostate specific antigen
DRE - digital rectal examination
PC - prostate cancer
CPPS - chronic pelvic pain syndrome
TUR – transurethral resection of the prostate gland
Ultrasound - ultrasound examination
ED - erectile dysfunction
ECG - electrocardiography
IPSS - International Prostate Symptom Score (international symptom index for prostate diseases)
NYHA - New York Heart Association
Date of preparation of the protocol: 2014
Patient category: men of reproductive age.
Protocol users: andrologists, urologists, surgeons, therapists, general practitioners.
Levels of Evidence
Level |
Type of evidence |
| 1a | Evidence comes from meta-analysis of randomized trials |
| 1b | Evidence from at least one randomized trial |
| 2a | Evidence from at least one well-designed, controlled, nonrandomized trial |
| 2b | Evidence from at least one well-designed, controlled, quasi-experimental study |
| 3 | Evidence from well-designed non-experimental studies (comparative research, correlational research, analysis of scientific reports) |
| 4 | Evidence is based on expert opinion or experience |
Recommendation rates
| A | Conclusions are based on homogeneous, high-quality, problem-specific clinical trials with at least one randomized trial. |
| IN | Results from well-designed, nonrandomized clinical studies |
| WITH | No clinical studies of adequate quality have been conducted |
Classification
Clinical classification
Classification of prostatitis (National Institutes of Health (NYHA), USA, 1995)
Category I - acute bacterial prostatitis;
Category II – chronic bacterial prostatitis, which occurs in 5-10% of cases; Category III – chronic abacterial prostatitis/chronic pelvic pain syndrome diagnosed in 90% of cases;
III subcategory A - chronic inflammatory pelvic pain syndrome with an increase in leukocytes in prostate secretion (more than 60% of the total number of cases); Subcategory III B – CPPS - chronic non-inflammatory pelvic pain syndrome (without an increase in leukocytes in prostate secretion (about 30%));
Category IV - asymptomatic inflammation of the prostate detected during the examination of other diseases based on the results of the analysis of prostate secretion or its biopsy (the frequency of this form is unknown);
Diagnostics
II. Diagnosis and treatment methods, approaches and procedures
List of basic and additional diagnostic measures
Basic (mandatory) diagnostic examinations performed in ambulatory conditions:
- collection of complaints, medical history;
- digital rectal examination;
- Filling out the IPSS questionnaire;
- ultrasound examination of the prostate gland;
- prostate secretion;
Additional diagnostic examinations carried out in ambulatory conditions: prostate secretion;
The minimum list of examinations that must be carried out when applying for planned hospitalization:
- general blood test;
- general urinalysis;
- biochemical blood test (determination of blood glucose, bilirubin and fractions, AST, ALT, thymol test, creatinine, urea, alkaline phosphatase, blood amylase);
- microreaction;
- coagulogram;
- HIV;
- ELISA for viral hepatitis;
- fluorography;
- ECG;
- blood group.
Basic (mandatory) diagnostic examinations performed at the hospital level:
- PSA (public, free);
- bacteriological culture of prostate secretion obtained after massage;
- transrectal ultrasound examination of the prostate;
- bacteriological culture of prostate secretion obtained after massage.
Additional diagnostic examinations are performed at the hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures performed at the emergency stage: not performed.
Diagnostic criteria
Complaints and anamnesis:
Complaints:
- pain or discomfort in the pelvic region lasting 3 months or more;
- A frequent localization of pain is the perineum;
- discomfort may be in the suprapubic area;
- discomfort in the groin and pelvis;
- discomfort in the scrotum;
- discomfort in the rectum;
- discomfort in the lumbosacral region;
- pain during and after ejaculation.
Anamnesis:
- sexual dysfunction;
- suppression of libido;
- deterioration of the quality of spontaneous and/or adequate erections;
- premature ejaculation;
- in the later stages of the disease, discharge is slow;
- "erasure" of the emotional color of orgasm.
The impact of chronic prostatitis on the quality of life is comparable to the impact of myocardial infarction, angina pectoris and Crohn's disease according to the single quality of life assessment scale. (level of evidence - II, strength of recommendation - B).
Physical examination:
- swelling and tenderness of the prostate gland;
- enlargement and smoothing of the median groove of the prostate gland.
Laboratory research
To increase the reliability of the results of laboratory tests, they should be performed before the appointment or 2 weeks after the end of taking antibacterial agents.
Microscopic examination of prostate secretion:
- determining the number of leukocytes;
- determination of the amount of lecithin grains;
- determination of the number of amyloid bodies;
- Determination of the number of Trousseau-Lallemand bodies;
- determination of the number of macrophages.
Bacteriological examination of prostate secretion: to determine the nature of the disease (bacterial or bacterial prostatitis).
Criteria for bacterial prostatitis:
- the third part of urine or the second part of urine in prostatic secretion, provided that the urine is sterile, contains bacteria of the same strain at a titer of 103 CFU/ml or more;
- a tenfold or more increase in the titer of bacteria in the third part of urine or prostate secretion compared to the second part;
- the third part of urine or prostatic secretion contains more than 103 CFU/ml of true uropathogenic bacteria, unlike other bacteria in the second part of urine.
Enterobacteriaceae (E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, etc. ) and Pseudomonas spp, as well as gram-negative microorganisms from the Enerococcus faecalis family have been proven to be predominant in the development of chronic bacterial prostatitis.
A blood sample to determine the serum PSA concentration should be taken no later than 10 days after the DRE. Prostatitis can cause an increase in PSA concentration. However, when the PSA concentration is above 4 ng/ml, additional diagnostic methods, including prostate biopsy, are used to rule out prostate cancer.
Instrumental studies:
Transrectal ultrasound of the prostate gland: for differential diagnosis, to determine the form and stage of the disease, subsequent monitoring during the entire course of treatment.
Ultrasound: evaluation of the size and volume of the prostate, its structure (cysts, stones, fibrous-sclerotic changes in the organ, prostate abscesses). Hypoechoic areas in the peripheral zone of the prostate are suspicious for prostate cancer.
X-ray studies: with diagnosed bladder outlet obstruction to clarify the cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): It is carried out according to strict instructions for the purpose of differential diagnosis, covered with broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of urethral pressure profile, pressure/flow study,
Cystometry and myography of pelvic floor muscles: if there is bladder outlet obstruction often accompanied by chronic prostatitis, as well as neurogenic disorders of urine and pelvic floor muscle function.
MSCT and MRI of pelvic organs: for differential diagnosis with prostate cancer.
Tips for consulting with experts: consultation with an oncologist - if PSA is greater than 4 ng/ml, to rule out prostate malignancy.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues should be evaluated (level of evidence - I, strength of recommendation - A).
Nosologies |
Characteristic syndromes/symptoms | Differentiation test |
| Chronic prostatitis | The average age of patients is 43 years. Pelvic pain or discomfort lasting 3 months or more. The most common localization of pain is the perineum, but discomfort can be felt in the suprapubic and inguinal regions of the pelvis, as well as in the scrotum, rectum, and lumbosacral region. Pain during and after ejaculation. Urinary dysfunction often manifests as irritative symptoms, less often as symptoms of bladder outlet obstruction. |
DURING - you can detect swelling and tenderness of the prostate gland, sometimes its expansion and smoothness of the median groove. For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues should be evaluated. Prostate secretion - determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallemand bodies and macrophages. Bacteriological examination of prostate secretion or urine obtained after massage is carried out. Based on the results of these studies, the nature of the disease is determined (bacterial or bacterial prostatitis). Criteria for bacterial prostatitis
Ultrasound of the prostate gland in chronic prostatitis has high sensitivity, but low specificity. The research allows not only to carry out differential diagnosis, but also to determine the form and stage of the disease with further monitoring during the entire course of treatment. Ultrasound allows to evaluate the size and volume, echostructure of the prostate |
| Benign prostatic hyperplasia (prostatic adenoma) | It is more common in people over 50 years old. Gradual increase in urine output and slow increase in urinary retention. Increased frequency of urination is characteristic at night (for chronic prostatitis, increased frequency of urination during the day or early in the morning). | PRI - the prostate gland is painless, enlarged, densely elastic, the central groove is smoothed, the surface is smooth. Prostate secretion - the amount of secretion increases, but the number of leukocytes and lecithin grains remains within the physiological norm. The secretory reaction is neutral or slightly alkaline. Ultrasound - deformation of the bladder neck is observed. Adenoma protrudes into the bladder cavity in the form of bright red lumpy formations. There is a significant proliferation of glandular cells in the cranial part of the prostate gland. The structure of adenomas is homogeneous with regular darkening areas. There is an increase in the gland in the anteroposterior direction. With fibroadenoma, bright echoes from the connective tissue are detected. |
| Prostate cancer | People over 45 are affected. When chronic prostatitis and prostate cancer are diagnosed, the pain has the same localization. Pain in the lower back, sacrum, perineum, and lower abdomen during prostate cancer can be caused both by the process of the gland itself and by metastases in the bones. Rapid development of complete urinary retention often occurs. Severe bone pain and weight loss may occur. | IF - individual cartilaginous dense nodules or nodular dense infiltration of the entire prostate gland is determined, which is limited or spreads to the surrounding tissues. The prostate gland is inactive and painless. PSA - more than 4. 0 ng/ml Prostate biopsy - the collection of malignant cells in the form of casts of the ducts is determined. Atypical cells are characterized by hyperchromatism, polymorphism, variations in size and shape of nuclei, and mitotic figures. Cystoscopy - pale pink lumpy masses surrounding the neck of the bladder in the form of a ring are identified (the result of infiltration of the bladder wall). Frequent swelling, hyperemia of the mucous membrane, malignant proliferation of epithelial cells. Ultrasound - asymmetry and enlargement of the prostate gland, its significant deformation. |
Treatment
Treatment goals:
- elimination of inflammation in the prostate gland;
- elimination of exacerbation symptoms (pain, discomfort, urinary and sexual dysfunction);
- prevention and treatment of complications.
Treatment tactics
Non-drug treatment:
Diet No. 15.
Mode: general.
Drug treatment
During the treatment of chronic prostatitis, it is necessary to simultaneously use several drugs and methods that affect different parts of the pathogenesis and allow to eliminate the infectious agent, normalize blood circulation in the prostate gland, and provide adequate drainage of the prostate gland, especially in the peripheral zones, normalization of the level of key hormones and immune reactions. Antibacterial drugs, anticholinergics, immunomodulators, NSAIDs, angioprotectors, vasodilators, prostate massage are recommended, and therapy with alpha-blockers is also possible.
Other treatments
Other types of treatment carried out in ambulatory conditions:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono-electrophoresis).
Other types of services provided at the stationary level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono-electrophoresis).
Other types of treatment indicated in the emergency phase: not provided.
Surgical intervention
Outpatient surgical interventions: not performed.
Surgical intervention is performed in an inpatient setting
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Indications:
If the patient has prostate fibrosis with a clinical picture of bladder outlet obstruction, it is performed in a hospital setting.
Types:
Transurethral resection
Indications:
use for calculous prostatitis (especially when stones that cannot be treated conservatively are localized in the central, transitory and periurethral zones).
Types:
Resection of spermatic tubercle.
Indications:
with sclerosis of the seminal tubercle, accompanied by discharge of the prostate gland and blockage of the excretory ducts.
Preventive measures:
- giving up bad habits;
- elimination of harmful effects (colds, physical inactivity, long-term sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sex life.
Additional management:
- observation of a urologist 4 times a year;
- 4 times a year prostate ultrasound and residual urine in the bladder, DRE, IPSS, prostate secretion
Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- absence or reduction of characteristic complaints (pain or discomfort in the pelvis, perineum, suprapubic region, inguinal regions of the pelvic cavity, scrotum, rectum);
- According to the DRE results, swelling and tenderness of the prostate gland is reduced or absent;
- reduction of inflammatory indicators of prostate secretion;
- prostate swelling and reduction in size according to ultrasound.