Chronic prostatitis - inflammatory disease of the prostate of various etiologies (including non-infectious ones), which manifests itself in pain or discomfort in the pelvic area, as well as in urinary tract disorders lasting 3 months or more.
I. Introductory part
Protocol name: Inflammatory diseases of the prostate
Protocol code:
ICD-10 code(s):
N41. 0 Acute prostatitis
N41. 1 Chronic prostatitis
N41. 2 Prostatic abscess
N41. 3 Prostatocystitis
N41. 8 Other inflammatory diseases of the prostate
N41. 9 Prostate inflammatory, unspecified disease
N42. 0 Prostate stones
Prostate stone
N42. 1 Congestion and bleeding in the prostate gland
N42. 2 Prostate atrophy
N42. 8 Other specific diseases of the prostate
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 - multislice 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
NYHA - New York Heart Association
Date of development 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 | The evidence comes from a meta-analysis of randomized trials |
| 1b | Evidence from at least one randomized trial |
| 2a | Evidence from at least one well-designed, controlled, non-randomized trial |
| 2b | Evidence from at least one well-designed, controlled, quasi-experimental study |
| 3 | Evidence obtained from well-designed, non-experimental research (comparative research, correlational research, analysis of scientific reports) |
| 4 | Evidence is based on expert opinion or experience |
Degrees of recommendation
| THE | Results are based on homogeneous, high-quality, problem-specific clinical trials with at least one randomized trial |
| TENDON | The results are from well-designed, non-randomized clinical trials |
| WITH | Clinical trials of adequate quality have not been conducted |
Classification
Clinical classification
Classification of prostatitis (National Institute of Health (NYHA), USA, 1995)
Category I - acute bacterial prostatitis;
II. category - chronic bacterial prostatitis, in 5-10% of cases; III. category - chronic abacterial prostatitis/chronic pelvic pain syndrome, diagnosed in 90% of cases;
Subcategory IIIA - chronic inflammatory pelvic pain syndrome with an increase in leukocytes in the secretion of the prostate (more than 60% of cases); Subcategory III B - CPPS - chronic non-inflammatory pelvic pain syndrome (without an increase in the number of leukocytes in the secretion of the prostate (about 30%));
ARC. category - asymptomatic prostatitis detected during the examination of other diseases based on the analysis of prostate secretion or biopsy (the frequency of histological prostatitis is unknown);
Diagnostics
II. Methods, approaches and procedures of diagnosis and treatment
List of basic and additional diagnostic measures
Basic (mandatory) diagnostic tests performed on an outpatient basis:
- collection of complaints, medical history;
- digital rectal examination;
- completing the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostatic secretion;
Additional diagnostic tests performed on an outpatient basis: prostatic secretion;
The minimum list of examinations that must be carried out when referring to a planned hospital treatment:
- general blood test;
- general urinalysis;
- biochemical blood test (determination of blood sugar, bilirubin and fractions, AST, ALT, thymol test, creatinine, urea, alkaline phosphatase, blood amylase);
- microreaction;
- coagulogram;
- HIV;
- ELISA for viral hepatitis;
- fluorography;
- EKG;
- blood type.
Basic diagnostic tests performed at hospital level:
- PSA (full, 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 tests performed at hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures performed in the emergency phase: not performed.
Diagnostic criteria
Complaints and medical history:
Complaints:
- pain or discomfort in the pelvic area lasting 3 months or longer;
- A common localization of pain is the perineum;
- there may be discomfort above the pubis;
- 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 erection;
- premature ejaculation;
- in the later stages of the disease, ejaculation is slow;
- the "erasure" of the emotional coloring of the orgasm.
According to the unified quality of life assessment scale, the impact of chronic prostatitis on the quality of life is comparable to the impact of heart attack, angina pectoris and Crohn's disease. (level of evidence - II, strength of recommendation - B).
Physical examination:
- swelling and tenderness of the prostate;
- enlargement and smoothing of the median groove of the prostate gland.
Laboratory research
In order 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 particles;
- 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 discharge: determination of the nature of the disease (bacterial or abacterial prostatitis).
Criteria for bacterial prostatitis:
- the third part of the urine or prostatic secretion contains bacteria of the same strain in a titer of 103 CFU/ml or higher, provided that the second part of the urine is sterile;
- a tenfold or greater increase in bacterial titers in the third part of urine or prostatic secretions compared to the second part;
- the third part of the urine or prostatic secretion contains more than 103 CFU/ml of true uropathogenic bacteria, which is different from the other bacteria in the second part of the urine.
The predominant significance of Enterobacteriaceae (E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, etc. ) and Pseudomonas spp, as well as Gram-negative microorganisms belonging to the Enerococcus faecalis family in the occurrence of chronic bacterial prostatitis has been confirmed.
A blood sample should be taken no earlier than 10 days after the DRE to determine the serum PSA concentration. Prostatitis can cause an increase in PSA concentration. Nevertheless, if the PSA concentration is above 4 ng/ml, the use of additional diagnostic methods, including a prostate biopsy, is recommended to rule out prostate cancer.
Instrumental studies:
Transrectal ultrasound of the prostate: for differential diagnosis, to determine the form and stage of the disease, with subsequent monitoring during the entire period of treatment.
Ultrasound: assessment of the size, volume and echostructure of the prostate (cysts, stones, organ fibro-sclerotic lesions, prostatic abscesses). Hypoechoic areas in the peripheral zone of the prostate are suspicious for prostate cancer.
X-rays: in the case of diagnosed bladder outlet obstruction, in order to clarify its cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): according to strict indications, for the purpose of differential diagnosis, covered with broad-spectrum antibiotics.
Urodynamic tests (uroflowmetry): determining the pressure profile of the urethra, pressure/flow test,
Cystometry and myography of the pelvic floor muscles: if you suspect bladder obstruction that often accompanies chronic prostatitis, as well as neurogenic disorders of urination and pelvic floor muscle function.
MSCT and MRI examination of the pelvic organs: for the differential diagnosis of prostate cancer.
Indications for consultation with a specialist: oncologist consultation - if PSA is more than 4 ng/ml, to rule out malignant prostate formation.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues must be assessed (level of evidence - I, strength of recommendation - A).
Nosologies |
Characteristic syndromes/symptoms | Differentiation test |
| Chronic prostatitis | The average age of the patients is 43 years. Pain or discomfort in the pelvic area lasting 3 months or longer. The most common localization of pain is the perineum, but discomfort may occur in the suprapubic and inguinal areas of the pelvis, as well as in the scrotum, rectum, and lumbosacral region. Pain during and after ejaculation. Urinary tract dysfunction often manifests as irritative symptoms, less often as symptoms of bladder obstruction. |
UNDER - you may notice swelling and tenderness of the prostate gland, and sometimes enlargement and smoothness of the central sulcus. For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues must be assessed. Prostatic secretion - determines the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallemand bodies and macrophages. Bacteriological examination of the prostate discharge or urine obtained after the massage is carried out. Based on the results of these tests, the nature of the disease is determined (bacterial or abacterial prostatitis). Criteria for bacterial prostatitis
Ultrasound of the prostate has high sensitivity but low specificity in chronic prostatitis. The test allows not only differential diagnosis, but also determination of the form and stage of the disease, followed by follow-up during the entire duration of treatment. Ultrasound makes it possible to assess the size, volume, and echostructure of the prostate |
| Benign prostatic hyperplasia (prostatic adenoma) | It is more often observed in people over 50 years of age. A gradual increase in urination and a slow increase in urinary retention. Increased frequency of urination is characteristic at night (in case of chronic prostatitis, increased frequency of urination during the day or early morning). | PRI - the prostate is painless, enlarged, densely elastic, the central groove is smoothed, the surface is smooth. Prostatic secretion - the amount of secretion increases, but the number of leukocytes and lecithin granules remains within the physiological norm. The secretory reaction is neutral or slightly alkaline. Ultrasound - deformation of the bladder neck can be observed. The adenoma protrudes into the bladder cavity in the form of bright red nodular formations. The proliferation of glandular cells in the skull part of the prostate gland is significant. The structure of adenomas is homogeneous, with regularly shaped dark areas. Growth of the gland can be observed in the anteroposterior direction. In the case of fibroadenoma, a bright echo of the connective tissue can be detected. |
| Prostate cancer | People over the age of 45 are affected. When diagnosing chronic prostatitis and prostate cancer, pain has the same localization. Prostate cancer pain in the lumbar region, sacrum, perineum and lower abdomen can be caused both by the processes taking place in 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 are determined, which is limited or spreads to the surrounding tissues. The prostate is motionless and painless. PSA - more than 4. 0 ng / ml Prostate biopsy - they determine the collection of malignant cells in the form of channels. Atypical cells are characterized by hyperchromatism, polymorphism, variability in the size and shape of the nuclei, and mitotic figures. Cystoscopy - pale pink nodular masses are determined, which surround the neck of the bladder in a ring (result of infiltration of the bladder wall). Often swelling, mucosal hyperemia, malignant proliferation of epithelial cells. Ultrasound - asymmetry and enlargement of the prostate gland, significant deformation. |
Treatment
Treatment goals:
- elimination of prostate inflammation;
- alleviation of symptoms of exacerbation (pain, discomfort, urinary and sexual dysfunction);
- prevention and treatment of complications.
Management tactics
Non-drug treatment:
Diet number 15.
Mode: general.
Drug treatment
The treatment of chronic prostatitis requires the simultaneous use of several drugs and methods that act on different parts of the pathogenesis and enable the removal of the infectious agent, the normalization of blood circulation in the prostate, the proper drainage of prostate acini, especially in the peripheral zones, the normalization of the level of essential hormones andimmune reactions. Antibacterial agents, anticholinergic agents, immunomodulators, NSAIDs, angioprotectors, vasodilators, prostate massage are recommended, alpha-blocker therapy is also possible.
Other treatments
Other outpatient treatment methods:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other services provided at fixed level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other treatment methods provided in the emergency phase: not provided.
Surgical intervention
Outpatient surgical interventions: not performed.
Surgical intervention in inpatient conditions
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Indications:
should be performed in a hospital setting if the patient suffers from prostatic fibrosis and has a clinical picture of bladder obstruction.
Types:
Transurethral resection
Indications:
in case of calculous prostatitis (especially in the case of localized stones that cannot be treated conservatively in the central, transition and periurethral zones).
Types:
Resection of the sperm tubercle.
Indications:
with sclerosis of seminal tuberculosis, accompanied by obstruction of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- giving up bad habits;
- eliminating the effects of harmful effects (cold, physical inactivity, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sex life.
Additional administration:
- observation by a urologist 4 times a year;
- Prostate ultrasound and residual urine in the bladder, DRE, IPSS, prostate secretion 4 times a year
Indicators of treatment effectiveness and safety of the diagnostic and treatment methods described in the protocol:
- absence or reduction of characteristic complaints (pain or discomfort in the pelvis, perineum, suprapubic region, inguinal areas of the pelvis, scrotum, rectum);
- reduction or absence of prostate swelling and tenderness according to DRE results;
- reduction of inflammatory indicators of prostate secretion;
- reducing the swelling and size of the prostate with ultrasound.