Chronic prostatitis – inflammatory disease of the prostate of various etiologies (including non-infectious), manifested by pain or discomfort in the pelvic region and urinary problems 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 prostate diseases
N41. 9 Inflammatory disease of the prostate, unspecified
N42. 0 Prostatic stones
Prostate stone
N42. 1 Prostate congestion and hemorrhage
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 imaging
MSCT – multi-slice computed tomography
DRE – digital rectal exam
PSA – prostate specific antigen
DRE – digital rectal exam
PC - prostate cancer
CPPS – chronic pelvic pain syndrome
TUR – transurethral resection of the prostate
Ultrasound – ultrasound examination
ED – erectile dysfunction
ECG – electrocardiography
IPSS – International Prostate Symptom Score
NYHA – New York Heart Association
Date of protocol development: 2014
Patient category: men of childbearing 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 of 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 | Results are based on consistent, 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 to 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 prostatic secretions (more than 60% of the total number of cases); Subcategory III B – CPPS – chronic non-inflammatory pelvic pain syndrome (without increase in leukocytes in prostatic secretion (around 30%));
Category IV – asymptomatic inflammation of the prostate, detected during examination for other diseases, based on 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 diagnostic examinations (mandatory) carried out on an outpatient basis:
- collection of complaints, medical history;
- digital rectal exam;
- complete the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostate secretion;
Additional diagnostic examinations carried out on an outpatient basis: prostate secretion;
The minimum list of examinations to be carried out during a planned hospitalization referral:
- general blood test;
- general urine analysis;
- 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;
- ECG;
- blood group.
Basic (mandatory) diagnostic examinations carried out at the hospital level:
- PSA (total, free);
- bacteriological culture of prostate secretions obtained after massage;
- transrectal ultrasound of the prostate;
- Bacteriological culture of prostate secretions obtained after massage.
Additional diagnostic examinations carried out at hospital level:
- urine flowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures carried out urgently: not carried out.
Diagnostic criteria
Complaints and history:
Complaints:
- pain or discomfort in the pelvic area lasting 3 months or more;
- The common location of pain is the perineum;
- a feeling of discomfort may be felt 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.
History:
- sexual dysfunction;
- suppression of libido;
- deterioration in the quality of spontaneous and/or adequate erections;
- premature ejaculation;
- in later stages of the disease, ejaculation is slow;
- "erasure" of 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 and diseaseof Crohn's. (level of evidence - II, strength of recommendation - B).
Physical examination:
- swelling and tenderness of the prostate;
- enlargement and smoothing of the median furrow of the prostate.
Laboratory research
To increase the reliability of laboratory test results, 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 quantity 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 prostatic secretions: determination of the nature of the disease (bacterial or abacterial prostatitis).
Criteria for bacterial prostatitis:
- the third portion of urine or prostatic secretion contains bacteria of the same strain at 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 part of the urine or in the prostate secretion compared to the second part;
- the third part of the urine or prostate secretion contains more than 103 CFU/ml of true uropathogenic bacteria, different from the other bacteria present in the second part of the urine.
The predominant importance in the occurrence 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 proven.
A blood sample to determine the serum PSA concentration should be taken no earlier than 10 days after the 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: 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, fibrous-sclerotic changes in the organ, prostate abscess). Hypoechoic areas in the peripheral zone of the prostate are suspicious for prostate cancer.
X-ray studies: with diagnosed bladder obstruction to clarify its cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): performed according to strict indications for the purpose of differential diagnosis, coated with broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of the urethral pressure profile, pressure/flow study,
Cystometry and myography of the pelvic floor muscles: in case of suspicion of obstruction of the bladder orifice, which often accompanies chronic prostatitis, as well as neurogenic disorders of urination and functioning of the pelvic floor muscles.
MSCT and MRI of the pelvic organs: for the differential diagnosis of prostate cancer.
Indications for consultation with specialists: consultation with an oncologist - if the PSA is above 4 ng/ml, to exclude malignant formation of the prostate.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purposes 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 location of pain is the perineum, but a feeling 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 often as symptoms of bladder outlet obstruction. |
DURING - you can detect swelling and tenderness of the prostate, and sometimes its enlargement and softness of the median furrow. For the purpose of differential diagnosis, the condition of the rectum and surrounding tissues should be assessed. Prostatic 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 in chronic prostatitis has high sensitivity but low specificity. The study allows not only to carry out a 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, the echostructure |
| Benign prostatic hyperplasia (prostate adenoma) | It is observed more often in people over 50 years old. A gradual increase in urination and a slow increase in urinary retention. An increased frequency of urination is typical at night (in chronic prostatitis, an increased frequency of urination during the day or early in the morning). | PRI - the prostate is painless, enlarged, densely elastic, the central furrow is smoothed, the surface is smooth. Prostatic 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 the anteroposterior direction. With fibroadenoma, bright echoes of connective tissue are detected. |
| Prostate cancer | People over 45 are affected. When chronic prostatitis and prostate cancer are diagnosed, the location of the pain is identical. Prostate cancer pain in the lumbar region, sacrum, perineum and lower abdomen can be caused both by a process in the gland itself and by metastases to the bones. Rapid development of complete urinary retention often occurs. Severe bone pain and weight loss may occur. | SI - individual cartilaginous lymph nodes of density or dense lumpy infiltration of the entire prostate are determined, which are limited or spread to the surrounding tissues. The prostate is immobile and painless. PSA - more than 4. 0 ng/ml Prostate biopsy - a collection of malignant cells in the form of duct casts 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, its significant deformation. |
Treatment
Treatment goals:
- elimination of prostate inflammation;
- relief of symptoms of exacerbation (pain, discomfort, disturbances in urination and sexual function);
- 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 drugs and methods that act on different parts of the pathogenesis and provide elimination of the infectious agent, normalization of blood circulation in the prostate, drainageadequate 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 treatment with alpha-blockers is also possible.
Other treatments
Other types of care 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 emergency care: not provided.
Surgery
Surgical interventions performed on an outpatient basis: not performed.
Surgical intervention performed in a hospital setting
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Directions:
carried out in a hospital setting if the patient has prostatic fibrosis with a clinical picture of obstruction of the bladder orifice.
Types:
Transurethral resection
Directions:
use for calculous prostatitis (especially when stones are localized and cannot be treated conservatively in central, transitional and periurethral areas).
Types:
Resection of the spermatic tubercle.
Directions:
with sclerosis of the seminal tubercle, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- give up bad habits;
- eliminate the influence of harmful influences (cold, sedentary lifestyle, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sexual life.
Subsequent 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 symptoms (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;
- reduction in swelling and size of the prostate according to ultrasound.