Chronic prostatitis - inflammatory disease of the prostate gland of various etiologies (including non-infectious ones), 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 stones
N42. 1 Congestion and hemorrhage in the prostate gland
N42. 2 Atrophy of the prostate
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
Echography - ultrasound examination
ED – erectile dysfunction
ECG - electrocardiography
IPSS – International Prostate Symptom Score (International Prostate Symptom Index)
NYHA - New York Heart Association
Protocol development date: 2014
Category of patients: 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, 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
| or | Results are based on homogeneous, high-quality, problem-specific clinical evidence 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 |
Distribution
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 pelvic inflammatory 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 (no increase in leukocytes in prostate secretion (about 30%);
Category IV – asymptomatic inflammation of the prostate, detected during the examination for other diseases, based on the results of the analysis of the secretions of the prostate or its biopsy (the frequency of this form is unknown);
Diagnosing
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;
- completing 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 performed during the referral for planned hospitalization:
- general blood test;
- general analysis of urine;
- biochemical blood analysis (determination of blood glucose, bilirubin and fractions, AST, ALT, thymol test, creatinine, urea, alkaline phosphatase, amylase in the blood);
- microreaction;
- coagulogram;
- HIV;
- ELISA for viral hepatitis;
- fluorography;
- ECG;
- blood type.
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 examinations performed at the 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 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 area;
- feeling of discomfort in the groin and pelvis;
- discomfort in the scrotum;
- discomfort in the rectum;
- feeling of discomfort in the lumbosacral region;
- pain during and after ejaculation.
Anamnesis:
- sexual dysfunction;
- suppression of libido;
- worsening of 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 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 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-Lalemand bodies;
- determination of the number of macrophages.
Bacteriological study of prostate secretions: determination of the nature of the disease (bacterial or bacterial prostatitis).
Criteria for bacterial prostatitis:
- the third portion of urine or prostate secretion contains bacteria of the same type in a titer of 103 CFU/ml or more, provided that the second portion of urine is sterile;
- a tenfold increase or more in the bacterial titer in the third part of urine or in prostate secretion compared to the second part;
- 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 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 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 rule out 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: evaluation of the size and volume of the prostate, echostructure (cysts, stones, fibro-sclerotic changes in the organ, prostate abscesses). Hypoechoic areas in the peripheral area 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): are performed according to strict indications for the purposes of differential diagnosis, being covered with broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of the urethral pressure profile, pressure/flow study,
Cystometry and pelvic floor muscle myography: if bladder outlet obstruction is suspected, which often accompanies chronic prostatitis, as well as neurogenic disorders of urination and pelvic floor muscle function.
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 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 the 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 as irritating symptoms, less often as symptoms of bladder outlet obstruction. |
LONG - you can detect swelling and tenderness of the prostate gland, and sometimes its enlargement and softening of the median groove. For purposes of differential diagnosis, the condition of the rectum and surrounding tissues should be evaluated. Prostatic secretion - determine the number of leukocytes, lecithin grains, amyloid bodies, Trousseau-Lalemand bodies and macrophages. A bacteriological study of prostate secretions or urine obtained after a massage was performed. 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 gland in chronic prostatitis has high sensitivity, but low specificity. The study allows not only to perform 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 (prostatic adenoma) | It is seen more often in people over 50 years old. 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 early morning). | PRI - the prostate gland is painless, enlarged, dense elastic, the central groove is smooth, 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. 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 darkening areas 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 old are affected. When chronic prostatitis and prostate cancer are diagnosed, there is an identical localization of pain. Pain in prostate cancer in the lumbar region, sacrum, perineum and at the bottom of the abdomen can be caused both by a process in the gland itself and by bone metastases. Rapid development of complete urinary retention often occurs. There may be severe bone pain and weight loss. | IF - individual nodules of cartilaginous density or dense nodular infiltration of the entire prostate gland are determined, which is limited or spreads to the 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 duct tubes is determined. Atypical cells are characterized by hyperchromatism, polymorphism, variability in size and shape of nuclei and mitotic figure. Cystoscopy - pale pink lumpy masses are determined, surrounding the neck of the bladder in a ring (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 worsening symptoms (pain, discomfort, urination and sexual dysfunction);
- prevention and treatment of complications.
Treatment tactics
Treatment without drugs:
Diet no. 15.
Mode: general.
Drug treatment
During the treatment of chronic prostatitis, it is necessary to simultaneously use several medications 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, the adequate drainage of prostate acini, especially in peripheral areas, normalization of the level of essential hormones and immune reactions. Antibacterial drugs, anticholinergics, immunomodulators, NSAIDs, angioprotectors, vasodilators, prostate massage, and alpha-blocker therapy are recommended.
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 offered at the stationary level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phono-electrophoresis).
Other types of treatment provided in the emergency phase: not provided.
Surgical intervention
Surgical interventions provided on an outpatient basis: not performed.
Surgical intervention provided in a hospital setting
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Indications:
performed 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, transitional and periurethral areas).
Types:
Resection of spermatic tubercle.
Indications:
with sclerosis of seminal tuberculosis, accompanied by closure of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- giving up bad habits;
- elimination of 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 DRE results;
- reduction of inflammatory indicators of prostate secretion;
- reduction of swelling and size of the prostate according to ultrasound.