Chronic prostatitis – inflammatory prostate disease of various etiologies (including non-infectious), manifested by pain or discomfort in the pelvic region and urinary disorders for 3 months or more.
I. Introductory part
Protocol name: Inflammatory prostate diseases
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
N41. 9 Inflammatory prostate disease, unspecified
N42 prostate stones. 0
prostate stone
N42. 1 Congestion and bleeding in the prostate
N42. 2 Prostate atrophy
N42. 8 Other specified prostate diseases
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
MSCT – multislice computed tomography
DRE – digital rectal exam
PSA – prostate specific antigen
DRE – digital rectal exam
PC - prostate cancer
CPPS – chronic pelvic pain syndrome
TURP – transurethral resection of the prostate
Ultrasound – ultrasound examination
ED – erectile dysfunction
ECG – electrocardiography
IPSS – International Prostate Symptom Score (international symptom index for prostate diseases)
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 obtained from at least one well-designed, controlled, non-randomized trial |
| 2b | Evidence obtained from at least one well-designed and 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
| ONE | 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 were 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, found in 5-10% of cases; Category III – chronic bacterial prostatitis/chronic pelvic pain syndrome, diagnosed in 90% of cases;
Subcategory IIIA – chronic inflammatory pelvic pain syndrome with increased leukocytes in prostate secretions (more than 60% of total cases); Subcategory IIIB – CPPS – chronic non-inflammatory pelvic pain syndrome (without an increase in leukocytes in prostate secretion (around 30%));
Category IV – asymptomatic inflammation of the prostate gland, detected during examination for other diseases, based on the results of the analysis of prostate secretions or its biopsy (histological prostatitis, 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 tests carried out on an outpatient basis:
- collection of complaints, medical history;
- digital rectal examination;
- completing the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostate secretion;
Additional diagnostic tests performed on an outpatient basis: prostate secretion;
The minimum list of tests that must be carried out upon referral to 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 tests carried out 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.
Complementary diagnostic tests carried out at hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures carried out in the emergency phase: not carried out.
Diagnostic criteria
Complaints and anamnesis:
Complaints:
- pain or discomfort in the pelvic region lasting 3 months or more;
- The frequent location of pain is the perineum;
- a feeling of discomfort may be in the suprapubic region;
- 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 more advanced stages of the disease, ejaculation is slow;
- "erasing" of the emotional coloring of 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:
- prostate swelling and tenderness;
- widening and smoothing of the median groove of the prostate.
Laboratory research
To increase the reliability of laboratory test results, they should be performed before the consultation or 2 weeks after the end of antibacterial use.
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 tenfold or greater increase in the titer of bacteria in the third portion of urine or 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 occurrence of chronic bacterial prostatitis of gram-negative microorganisms from the Enterobacteriaceae family (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 not be performed earlier than 10 days after digital rectal examination. 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: for differential diagnosis, to determine the form and stage of the disease with subsequent monitoring throughout treatment.
Ultrasound: assessment of the size and volume of the prostate, echostructure (cysts, stones, fibro-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 further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): performed according to strict indications for differential diagnosis purposes, covering broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of the urethral pressure profile, pressure/flow study,
Cystometry and myography of the pelvic floor muscles: if there is a suspicion of bladder outlet obstruction, which often accompanies chronic prostatitis, as well as neurogenic disorders of urination and the 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 formation of the prostate.
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 region lasting 3 months or more. The most common location of pain is the perineum, but the sensation of discomfort can 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 dysfunction often manifests as irritative symptoms, less frequently as symptoms of bladder outlet obstruction. |
DURING - you can detect swelling and tenderness of the prostate, 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 - determines 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 (bacterial or abacterial prostatitis) is determined. Criteria for bacterial prostatitis
Prostate ultrasound in chronic prostatitis has high sensitivity but low specificity. The study allows not only to make differential diagnoses, but also to determine the form and stage of the disease with subsequent monitoring throughout the treatment. Ultrasonography allows you to evaluate the size and volume of the prostate, echostructure |
| Benign prostatic hyperplasia (prostate adenoma) | It is seen most often in people over 50 years of age. A gradual increase in urination and a slow increase in urinary retention. Increased urinary frequency is typical at night (for chronic prostatitis, increased urinary frequency during the day or early in the morning). | PRI - the prostate 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 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 enlargement of the gland in the anteroposterior direction. With fibroadenoma, bright echoes from connective tissue are detected. |
| Prostate cancer | People over 45 are affected. When diagnosing chronic prostatitis and prostate cancer, an identical localization of pain occurs. Pain from prostate cancer in the lower back, sacrum, perineum and lower abdomen can be caused by both a process in the gland itself and metastases in the bones. Complete urinary retention often develops rapidly. Severe bone pain and weight loss may occur. | SE - these are determined individual cartilaginous density nodules or dense, protruding infiltration of the entire prostate, which is limited or spreads into the surrounding tissues. The prostate is still and painless. PSA - more than 4. 0 ng/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 bulging 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 objectives:
- elimination of inflammation in the prostate;
- relief of exacerbation symptoms (pain, discomfort, disturbances in urination and sexual function);
- prevention and treatment of complications.
Treatment tactics
Non-drug treatment:
Diet #15.
Mode: general.
Drug 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, normalization of blood circulation in the prostate, adequate drainage of prostatic acini, especially in the peripheral zones, normalization of the level of essential hormones and immunological reactions. Antibacterial medications, anticholinergics, immunomodulators, 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 a stationary level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other types of treatment provided in the emergency phase: not provided.
Surgical intervention
Surgical interventions performed on an outpatient basis: not performed.
Surgical intervention carried out in a hospital environment
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Indications:
carried out in a hospital environment if the patient has prostatic fibrosis with clinical signs of bladder outlet obstruction.
Types:
Transurethral resection
Indications:
use for calculous prostatitis (especially when stones that cannot be treated conservatively are located in the central, transitional 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:
- 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;
- Ultrasound of the prostate and residual urine in the bladder, digital rectal examination, 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 prostate swelling and sensitivity according to the results of the rectal exam;
- reduction of inflammatory indicators of prostate secretion;
- reduction of swelling and size of the prostate according to ultrasound.