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 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 disease of the prostate, unspecified
N42. 0 Prostate stones
Prostatic stone
N42. 1 Congestion and hemorrhage in the prostate gland
N42. 2 Prostate atrophy
N42. 8 Other specified diseases of the prostate gland
N42. 9 Disease of the prostate gland, 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 (international index of symptoms for prostate diseases)
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 | Evidence comes from a meta-analysis of randomized trials |
| 1b | Evidence from at least one randomized trial |
| 2a | Evidence obtained from at least one well-designed, controlled, non-randomized 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 | Evidence is based on expert opinion or experience |
Degrees of recommendation
| A | The results are based on homogeneous, high-quality, problem-specific clinical trials, with at least one randomized trial |
| IN | Results obtained from well-designed, non-randomized clinical studies |
| WITH | No clinical studies of adequate quality have been conducted |
Classification
Clinical classification
Classification of prostatitis (National Institute of Health (NYHA), USA, 1995)
Category I – acute bacterial prostatitis;
Category II – chronic bacterial prostatitis, 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 an increase in leukocytes in prostate secretions (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 the prostate secretion (about 30%));
Category IV – asymptomatic inflammation of the prostate, detected during examination for other diseases, based on the results of analysis of prostate secretions or its biopsy (histological prostatitis); the frequency of this form is unknown.
Diagnostics
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 examination;
- filling out the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostate secretion;
Additional diagnostic examinations performed on an outpatient basis: prostate secretion;
The minimum list of examinations that must be carried out when referring 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 carried out 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 examinations carried out at the hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures carried out at the emergency stage: not carried out.
Diagnostic criteria
Complaints and anamnesis:
Complaints:
- pain or discomfort in the pelvic area lasting 3 months or more;
- Frequent localization of pain is the perineum;
- a feeling of discomfort may be in the suprapubic;
- 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" of the emotional coloring of orgasm.
The impact of chronic prostatitis on the 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 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 carried out before the appointment or 2 weeks after the end of 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 study of prostate secretions: determining 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 tenfold or more increase in the titer of bacteria 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, different from other bacteria in the second portion of urine.
The predominant importance in the occurrence of chronic bacterial prostatitis of gram-negative microorganisms from the family Enterobacteriaceae (E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, etc. ) and Pseudomonas spp, as well as Enerococcus faecalis has been proven.
Blood sampling to determine serum PSA concentration should be performed no earlier than 10 days after DRE. Prostatitis can cause an increase in PSA concentration. Despite this, when the PSA concentration is above 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 gland: for differential diagnosis, to determine the form and stage of the disease with subsequent monitoring throughout the course of treatment.
Ultrasound: assessment of the size and volume of the prostate, echostructure (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 its cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): carried out according to strict indications for the purpose of differential diagnosis, covering 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 often accompanies chronic prostatitis, as well as neurogenic disorders of urination and function of the pelvic floor muscles.
MSCT and MRI of the pelvic organs: for differential diagnosis with prostate cancer.
Indications for consultation with specialists: consultation with an oncologist - if PSA is more than 4 ng/ml, to exclude malignant prostate formation.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues should be assessed (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 lasting 3 months or more. The most common localization of pain is the perineum, but a feeling of discomfort can be 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 itself as irritative symptoms, less often as symptoms of bladder outlet obstruction. |
DURING - you can detect swelling and tenderness of the prostate gland, and sometimes its enlargement and smoothness of the median groove. For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues should be assessed. Prostate secretion - determine the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lallemand bodies and macrophages. A bacteriological study of prostate secretions or urine obtained after a massage is carried out. Based on the results of these studies, the nature of the disease is determined (bacterial or abacterial prostatitis). Criteria for bacterial prostatitis
Ultrasound of the prostate gland in chronic prostatitis has high sensitivity but low specificity. The study allows not only to carry out differential diagnosis, but also to determine the form and stage of the disease with subsequent monitoring throughout the course of treatment. Ultrasound makes it possible to assess the size and volume of the prostate, echostructure |
| Benign prostatic hyperplasia (prostate adenoma) | It is observed more often 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 (for chronic prostatitis, increased frequency of urination during the day or in the early 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 secretion reaction is neutral or slightly alkaline. Ultrasound - deformation of the bladder neck is observed. The adenoma protrudes into the cavity of the bladder 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 areas of darkening of regular shape. 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 years of age are affected. When diagnosing chronic prostatitis and prostate cancer, there is an identical localization of pain. Pain in prostate cancer in the lumbar region, sacrum, perineum, and lower abdomen can be caused both by a process 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 density nodes or lumpy dense infiltration of the entire prostate gland are determined, which is limited or spreads to surrounding tissues. The prostate gland is motionless, painless. PSA - more than 4. 0 ng/ml Prostate biopsy - a collection of malignant cells in the form of casts of ducts 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 are determined, surrounding the bladder neck in a ring (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 gland, its significant deformation. |
Treatment
Treatment goals:
- elimination of inflammation in the prostate gland;
- relief of symptoms of exacerbation (pain, discomfort, urination and sexual function disorders);
- prevention and treatment of complications.
Treatment tactics
Non-drug treatment:
Diet No. 15.
Mode: general.
Drug treatment
When treating chronic prostatitis, it is necessary to simultaneously use several medications and methods that act on different parts of the pathogenesis and allow for the elimination of the infectious agent, normalization of blood circulation in the prostate, adequate drainage of the prostatic acini, especially in the peripheral zones, normalization of the level of essential 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 provided on an outpatient basis:
- 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 provided at the emergency stage: not provided.
Surgical intervention
Surgical interventions provided on an outpatient basis: not performed.
Surgical intervention provided in an inpatient setting
Types:
Transurethral incision at 5, 7, and 12 o'clock.
Indications:
carried out in a hospital setting if the patient has prostate fibrosis with a clinical picture of bladder outlet obstruction.
Types:
Transurethral resection
Indications:
use for calculous prostatitis (especially when stones are localized that cannot be treated conservatively in the central, transient and periurethral zones).
Types:
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:
- giving up bad habits;
- eliminating the influence of harmful influences (cold, physical inactivity, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sexual life.
Further management:
- observation by a urologist 4 times a year;
- Ultrasound of the prostate and residual urine in the bladder, DRE, IPSS, prostate secretion 4 times a year
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 areas of the pelvis, scrotum, rectum);
- reduction or absence of swelling and tenderness of the prostate gland according to the results of DRE;
- reduction of inflammatory indicators of prostate secretion;
- reduction in swelling and size of the prostate according to ultrasound.