Chronic prostatitis - inflammatory diseases of the prostate of various etiologies (including non-infectious ones), which are manifested by pain or discomfort in the pelvic area and urination disorders lasting 3 months or more.
I. Introductory part
Protocol name: Inflammatory diseases of the prostate
Protocol Code:
ICD-10 code(s):
N41. 0 Acute prostatitis
N41. 1 Chronic prostatitis
N41. 2 Prostatic abscess
N41. 3 Prostatocystitis
N41. 8 Other inflammatory diseases of the prostate
N41. 9 Inflammatory prostate disease, unspecified
N42. 0 Stones in the prostate
Prostate stone
N42. 1 Congestion and bleeding in the prostate
N42. 2 Atrophy of the prostate
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 – computerized tomography
MRI - magnetic resonance
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
Ultrasound - ultrasound examination
ED – erectile dysfunction
ECG - electrocardiography
IPSS – International Prostate Symptom Score
NYHA – New York Heart Association
Protocol creation date: in 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 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 professional opinion or experience |
Degrees of recommendation
| A | 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, 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 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 increase of leukocytes in prostate secretion (about 30%));
Category IV - asymptomatic inflammation of the prostate, detected during an examination for other diseases, based on the results of the analysis of prostate secretions or its biopsy (histological prostatitis 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 in 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 when referring to a 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, amylase in blood);
- microreaction;
- coagulogram;
- HIV;
- ELISA for viral hepatitis;
- fluorography;
- EKG;
- 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 implemented in the emergency phase: not implemented.
Diagnostic criteria
Complaints and medical history:
Complaints:
- pain or discomfort in the pelvic area lasting 3 months or more;
- Frequent localization of pain is the perineum;
- the feeling of discomfort may be 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;
- libido suppression;
- worsening of the quality of spontaneous and/or adequate erection;
- premature ejaculation;
- in the later stages of the disease, ejaculation is slow;
- "erasing" the emotional color of orgasm.
The impact of chronic prostatitis on the quality of life, according to the unique scale for assessing the quality of life, 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 middle groove of the prostate.
Laboratory research
In order 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 secretions:
- 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-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 part of urine or prostate secretion contains bacteria of the same strain in a titer of 103 CFU/ml or more, provided that the second part of urine is sterile;
- a tenfold or more increase in the titer of bacteria in the third portion of urine or in prostate secretions compared to the second portion;
- the third part of urine or prostate secretion contains more than 103 CFU/ml of true uropathogenic bacteria, unlike other bacteria in the second part of urine.
Gram-negative microorganisms from the Enterobacteriaceae family (E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, etc. ) and Pseudomonas spp, as well as Enerococcus faecalis, have been proven to play a dominant role in the development of chronic bacterial prostatitis.
Blood sampling to determine serum PSA concentration should be done no later than 10 days after DRE. Prostatitis can cause an increase in PSA concentration. Nevertheless, 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: for differential diagnosis, to determine the form and stage of the disease with follow-up during the entire treatment.
Ultrasound: assessment of the size and volume of the prostate, echostructure (cysts, stones, fibro-sclerotic changes on the organ, prostate abscesses). Hypoechoic areas in the peripheral zone of the prostate are suspicious for prostate cancer.
X-ray studies: with diagnosed obstruction of the outlet bladder in order to clarify its cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): are 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 pelvic floor muscle myography: if obstruction of the outlet bladder is suspected, which often accompanies chronic prostatitis, as well as neurogenic disorders of urination and pelvic floor muscle function.
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 higher than 4 ng/ml, to rule out a malignant formation of the prostate.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purpose of differential diagnosis, it is necessary to assess the condition of the rectum and surrounding tissues (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 the feeling of discomfort can be in the suprapubic, inguinal part 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 - swelling and tenderness of the prostate can be observed, and sometimes its enlargement and smoothing of the median groove. For the purpose of differential diagnosis, it is necessary to assess the condition of the rectum and surrounding tissues. Prostatic secretion - determine the number of leukocytes, lecithin granules, amyloid bodies, Trousseau-Lallemand bodies and macrophages. A bacteriological study of prostate secretions or urine obtained after 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
Ultrasound of the prostate in chronic prostatitis has high sensitivity, but low specificity. The study enables not only differential diagnosis, but also determination of the form and stage of the disease with subsequent monitoring during treatment. Ultrasound enables assessment of the size and volume of the prostate, echostructure |
| Benign prostatic hyperplasia (prostatic adenoma) | It is more often observed in people older than 50 years. Gradual increase in urination and 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 hours). | 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. Adenoma protrudes into the bladder cavity in the form of bright red, bumpy formations. There is significant proliferation of glandular cells in the cranial part of the prostate. The structure of the adenoma is homogeneous with areas of darkening of a regular shape. There is an increase in the gland in the anteroposterior direction. Bright echoes from connective tissue are detected in fibroadenomas. |
| Prostate cancer | People older than 45 years are infected. 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 by the process in the gland itself and metastases in the bones. Often there is a rapid development of complete retention of urine. Severe bone pain and weight loss may occur. | IF - individual nodules of cartilaginous density or nodular dense infiltration of the entire prostate, which is limited or spreads to the surrounding tissues, are determined. The prostate is motionless, painless. PSA - more than 4. 0 ng/ml Prostate biopsy - a collection of malignant cells is determined in the form of duct casts. Atypical cells are characterized by hyperchromatism, polymorphism, variability in size and shape of nuclei and mitotic figure. Cystoscopy - pale pink nodular masses are determined that surround the neck of the bladder in a ring (result of infiltration of the bladder wall). Frequent swelling, mucosal hyperemia, malignant proliferation of epithelial cells. Ultrasound - asymmetry and enlargement of the prostate, its significant deformation. |
Treatment
Treatment goals:
- elimination of inflammation in the prostate;
- alleviation of symptoms of exacerbation (pain, discomfort, urinary and sexual function disorders);
- prevention and treatment of complications.
Treatment tactics
Treatment without drugs:
Diet no. 15.
Mode of operation: 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 enable the elimination of the infectious agent, normalization of blood circulation in the prostate, adequate drainage of the prostate 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 alpha-blocker therapy is also possible.
Other treatments
Other types of treatment performed 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 phase: not provided.
Surgical intervention
Outpatient surgical interventions: not performed.
Surgical intervention is performed in an inpatient setting
Types:
Transurethral incision at 5, 7 and 12 o'clock.
Indications:
it is performed in hospital conditions if the patient has prostate fibrosis with a clinical picture of bladder outlet obstruction.
Types:
Transurethral resection
Indications:
use for calculous prostatitis (especially when the stones are localized and cannot be conservatively treated in the central, transitional and periurethral zones).
Types:
Resection of the spermatic tubercle.
Indications:
with sclerosis of the seminal tubercle, followed by occlusion of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- giving up bad habits;
- elimination of harmful influences (cold, physical inactivity, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalization of sexual life.
Further management:
- observation of 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 efficiency and safety of diagnostic and therapeutic 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 tenderness according to DRE results;
- reduction of inflammatory indicators of prostate secretion;
- reduction of swelling and prostate size according to ultrasound.