chronic prostatitis – inflammatory prostate disease of various etiologies (including non-infectious), manifested by pain or discomfort in the pelvic area and urinary disorders for 3 months or more.
I. Introductory part
Protocol name: Inflammatory diseases of the prostate gland.
Protocol code:
ICD-10 code(s):
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 prostate disease, unspecified
N42. 0 Prostate stones
prostate stone
N42. 1 Congestion and bleeding in the prostate gland.
N42. 2 Prostate atrophy
N42. 8 Other specified diseases of the prostate gland
N42. 9 Prostate gland 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 – rectal examination
PSA – prostate specific antigen
DRE – 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
Protocol development date: 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, nonrandomized trial |
| 2b | Evidence obtained 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 | The evidence is based on expert opinion or experience. |
Recommendation grades
| TO | The results are based on homogeneous, high-quality, problem-specific clinical trials, with at least one randomized trial. |
| IN | Results obtained from well-designed and non-randomized clinical studies |
| WITH | No clinical studies of adequate quality have been carried out. |
Classification
Clinical classification
Classification of prostatitis (National Institute of Health (NYHA), USA, 1995)
Category I – acute bacterial prostatitis;
Category II – chronic bacterial prostatitis, which is found in 5-10% of cases; Category III: chronic abacterial prostatitis/chronic pelvic pain syndrome, diagnosed in 90% of cases;
Subcategory III A – chronic inflammatory pelvic pain syndrome with increased leukocytes in prostate secretions (more than 60% of the total number of cases); Subcategory III B – CPPS: chronic non-inflammatory pelvic pain syndrome (without increased leukocytes in prostate secretion (about 30%));
Category IV – asymptomatic inflammation of the prostate, detected during examination for other diseases, according to the results of the analysis of prostate secretions or its biopsy (the frequency of this form is unknown);
Diagnosis
II. Methods, approaches and procedures for diagnosis and treatment.
List of basic and additional diagnostic measures.
Basic (mandatory) diagnostic examinations performed on an outpatient basis:
- collection of complaints, medical history;
- digital rectal exam;
- fill out the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostate discharge;
Additional diagnostic examinations performed on an outpatient basis: prostate discharge;
The minimum list of examinations that must be performed when referring for planned hospitalization:
- general blood test;
- general urinalysis;
- biochemical blood test (determination of blood glucose, bilirubin and fractions, AST, ALT, test for thymol, creatinine, urea, alkaline phosphatase, amylase in blood);
- microreaction;
- coagulogram;
- HIV;
- ELISA for viral hepatitis;
- fluorography;
- ECG;
- blood group.
Basic (mandatory) diagnostic examinations performed at the hospital level:
- PSA (total, 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 the hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures carried out in the emergency stage: not carried out.
Diagnostic criteria
Complaints and anamnesis:
Complaints:
- pain or discomfort in the pelvic area that lasts 3 months or more;
- The frequent location of pain is the perineum;
- there may be a feeling of discomfort in the suprapubic area;
- feeling of discomfort in the groin and pelvis;
- feeling of discomfort in the scrotum;
- feeling of discomfort in the rectum;
- feeling of discomfort in the lumbosacral region;
- Pain during and after ejaculation.
Anamnesis:
- sexual dysfunction;
- suppression of libido;
- deterioration in the quality of spontaneous and/or adequate erections;
- premature ejaculation;
- in the later stages of the disease, ejaculation is slow;
- "erasing" the emotional coloring of the orgasm.
The impact of chronic prostatitis on quality of life, according to the Unified Quality of Life Assessment Scale, is comparable to the impact of myocardial infarction, 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 sulcus of the prostate gland.
laboratory research
To increase the reliability of laboratory test results, they should be carried out before the appointment or 2 weeks after finishing taking antibacterial agents.
Microscopic examination of prostate secretion:
- determination of 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 secretions: determination of the nature of the disease (bacterial or abacterial prostatitis).
Criteria for bacterial prostatitis:
- the third portion of urine or prostate secretion contains bacteria of the same strain in a titer of 103 CFU/ml or more, provided that the second portion of urine is sterile;
- a ten-fold or more increase in the bacterial titer in the third portion of urine or in prostate secretion compared to the second portion;
- The third portion of urine or prostate secretion contains more than 103 CFU/ml of true uropathogenic bacteria, unlike other bacteria in the second portion of urine.
The predominant importance in the appearance of chronic bacterial prostatitis of gram-negative microorganisms of the Enterobacteriaceae family (E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, etc. ) and Pseudomonas spp, as well as Enerococcus faecalis, has been demonstrated.
Blood sampling to determine serum PSA concentration should be performed no earlier than 10 days after DRE. Prostatitis can cause an increase in PSA levels. Despite this, when the PSA concentration is greater than 4 ng/ml, the use of additional diagnostic methods, including prostate biopsy, is indicated to exclude prostate cancer.
Instrumental studies:
Transrectal ultrasound of the prostate: for differential diagnosis, to determine the form and stage of the disease with subsequent monitoring throughout the treatment.
Ultrasound: assessment of the size and volume of the prostate, echostructure (cysts, stones, fibrous-sclerotic changes in the organ, prostatic 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 its cause and determine additional treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): performed according to strict indications for differential diagnosis purposes, covered with broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of urethral pressure profile, pressure/flow study,
Cystometry and myography of the pelvic floor muscles: if bladder outlet obstruction is suspected, which usually accompanies chronic prostatitis, as well as neurogenic disorders of urination and function of the pelvic floor muscles.
MSCT and MRI of pelvic organs: for differential diagnosis with prostate cancer.
Indications for consultation with specialists: Consultation with an oncologist: if the PSA is greater than 4 ng/ml, to exclude the formation of a malignant prostate.
Differential diagnosis
Differential diagnosis of chronic prostatitis.
For the purposes 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. Pain or discomfort in the pelvic area that lasts 3 months or more. The most common location of pain is the perineum, but the feeling of discomfort can occur in the suprapubic, inguinal areas 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 and, less frequently, as symptoms of bladder outlet obstruction. |
DURING: swelling and tenderness of the prostate gland and sometimes its enlargement and softness of the median sulcus can be detected. To make a differential diagnosis, the condition of the rectum and surrounding tissues must be evaluated. Prostate secretion: determine the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallemand bodies and macrophages. A bacteriological study is carried out on the prostate secretions or urine obtained after a massage. Based on the results of these studies, the nature of the disease (bacterial or abacterial prostatitis) is determined. Criteria for bacterial prostatitis.
Ultrasound of the prostate in chronic prostatitis has high sensitivity but low specificity. The study allows not only to make a differential diagnosis, but also to determine the form and stage of the disease, followed by monitoring throughout the treatment. Ultrasound makes it possible to evaluate the size and volume of the prostate, the echostructure. |
| Benign prostatic hyperplasia (prostate adenoma) | It is seen more frequently in people over 50 years of age. A gradual increase in urination and a slow increase in urinary retention. Increased frequency of urination is typical at night (in the case of chronic prostatitis, an 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, and 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 secretion reaction is neutral or slightly alkaline. Ultrasound: deformation of the bladder neck is observed. The 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. The structure of adenomas is homogeneous with regularly shaped areas of darkening. There is an increase in the gland in an anteroposterior direction. In fibroadenoma, bright echoes of the connective tissue are detected. |
| prostate cancer | People over 45 years of age are affected. When diagnosing chronic prostatitis and prostate cancer, an identical localization of pain is observed. Pain in prostate cancer in the lumbar region, sacrum, perineum and lower abdomen can be caused by both a process in the gland itself and metastasis to the bones. There is often rapid development of complete urinary retention. Severe bone pain and weight loss may occur. | YES: Individual cartilaginous density nodes or dense, lumpy infiltration of the entire prostate gland are determined, which is limited or spread to the surrounding tissues. The prostate is motionless, painless. PSA: more than 4. 0ng/ml Prostate biopsy: a collection of malignant cells in the form of duct cylinders is determined. Atypical cells are characterized by hyperchromatism, polymorphism, variability in the size and shape of nuclei and mitotic figures. Cystoscopy: pale pink lumpy masses surrounding the neck of the bladder in a ring are determined (the result of infiltration of the bladder wall). Often swelling, hyperemia of the mucous membrane, malignant proliferation of epithelial cells. Ultrasound: asymmetry and enlargement of the prostate, its significant deformation. |
Treatment
Treatment goals:
- elimination of inflammation in the prostate;
- relief of exacerbation symptoms (pain, discomfort, urination and sexual function disorders);
- prevention and treatment of complications.
Treatment tactics
Non-pharmacological treatment:
Diet No. 15.
Mode: general.
Pharmacological treatment
In the treatment of chronic prostatitis, it is necessary to simultaneously use several drugs and methods that act on different parts of the pathogenesis and allow the elimination of the infectious agent, the normalization of blood circulation in the prostate, adequate drainage of the prostatic acini, especially in peripheral areas, normalization of the level of essential hormones and immune reactions. Antibacterial, anticholinergic, immunomodulatory drugs, NSAIDs, angioprotectors, vasodilators, prostate massage are recommended, and alpha-blocker therapy is also possible.
Other treatments
Other types of treatment provided on an outpatient basis:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other types of services provided at the stationary level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other types of treatment provided in the emergency stage: not provided.
surgical intervention
Surgical interventions performed on an outpatient basis: not performed.
Surgical intervention performed in a hospital environment.
Guys:
Transurethral incision at 5, 7 and 12 hours.
Indications:
It is performed in the hospital setting if the patient has prostatic fibrosis with a clinical picture of bladder outlet obstruction.
Guys:
transurethral resection
Indications:
use for calculous prostatitis (especially when stones that cannot be treated conservatively are located in the central, transient and periurethral zones).
Guys:
Resection of the spermatic tubercle.
Indications:
with sclerosis of the seminal tubercle, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- abandon bad habits;
- eliminate the influence of harmful influences (cold, physical inactivity, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sexual life.
Additional management:
- 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 swelling and tenderness of the prostate gland based on DRE results;
- reduction of inflammatory indicators of prostate secretion;
- Reduction in swelling and size of the prostate according to ultrasound.