Chronic prostatitis – inflammatory prostate disease of various etiologies (including non-infectious), manifested by pain or discomfort in the pelvic area and urination 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 diseases of the prostate
N41. 9 Inflammatory prostate disease, unspecified
N42. 0 Prostate stones
Prostate stone
N42. 1 Congestion and hemorrhage in the prostate
N42. 2 Prostate atrophy
N42. 8 Other specified diseases of the prostate
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 (international index of symptoms of 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.
Test levels
Level |
Type of test |
| 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 study |
| 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 |
Recommendation grades
| A | The results are based on homogeneous, high-quality, problem-specific clinical studies, with at least one randomized study |
| IN | Results obtained from well-designed, non-randomized clinical trials |
| WITH | No clinical studies of adequate quality have been conducted |
Classification
Clinical classification
Classification of prostatitis (National Institute of Health (NYHA), United States, 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 increased leukocytes in prostatic secretions (over 60% of all cases); Subcategory III B – CPPS - chronic non-inflammatory pelvic pain syndrome (without increased leukocytes in prostatic secretion (about 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 histological frequency of this form is unknown);
Diagnostics
II. Methods, approaches and procedures for diagnosis and treatment
List of basic and additional diagnostic measures
Basic diagnostic tests (mandatory) performed on an outpatient basis:
- collection of complaints, medical history;
- digital rectal exam;
- completion of the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostate secretion;
Further diagnostic tests performed on an outpatient basis: prostate secretion;
The minimum list of tests to be carried out in the event of planned hospitalization:
- general blood test;
- general urinalysis;
- biochemical blood test (determination of blood sugar, 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 group.
Basic diagnostic tests (mandatory) carried out at hospital level:
- PSA (total, free);
- bacteriological culture of prostatic secretion obtained after massage;
- transrectal ultrasound examination of the prostate;
- bacteriological culture of prostatic secretion obtained after massage.
Further 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 medical history:
Complaints:
- pain or discomfort in the pelvic area lasting 3 months or more;
- The frequent localization of pain is the perineum;
- a feeling of discomfort may be in the suprapubic position;
- 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.
Medical history:
- 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" 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 exam:
- swelling and tenderness of the prostate gland;
- widening and smoothing of the median sulcus of the prostate gland.
Laboratory research
To increase the reliability of laboratory test results, they should be performed before the appointment or 2 weeks after the end of taking antibacterial agents.
Microscopic examination of prostatic secretion:
- determination of the number of leukocytes;
- determination of the amount of lecithin granules;
- determination of the number of amyloid bodies;
- determination of the number of Trousseau-Lallemand organs;
- 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 in a titer equal to or greater than 103 CFU/ml, provided that the second portion of urine is sterile;
- a tenfold or more increase in the bacterial titer in the third portion of urine or in prostatic secretion compared to the second portion;
- the third portion of urine or prostatic secretion contains more than 103 CFU/ml of true uropathogenic bacteria, different from the other bacteria present in the second portion of urine.
The predominant importance in the appearance 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 demonstrated.
Blood sampling to determine serum PSA concentration should be performed no earlier than 10 days after the DRE. Prostatitis can cause an increase in PSA concentration. Nonetheless, 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 during the course of treatment.
Ultrasound: evaluation of the size and volume of the prostate, echostructure (cysts, stones, fibro-sclerotic changes of the organ, prostatic abscesses). Hypoechoic areas in the peripheral area of the prostate are suspicious for prostate cancer.
Radiographic 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, covering with broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of the 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 the PSA is above 4 ng/ml, to exclude malignant formation of the prostate.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the purpose of differential diagnosis, it is necessary to evaluate 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 sensation of discomfort can occur 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 - swelling and tenderness of the prostate gland and sometimes its enlargement and smoothness of the median sulcus may be detected. For the purpose of differential diagnosis, it is necessary to evaluate the condition of the rectum and surrounding tissues. Prostate 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 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
Ultrasound of the prostate gland 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 during the course of treatment. Ultrasound allows you to evaluate the size and volume of the prostate, the echostructure |
| Benign prostatic hyperplasia (prostatic adenoma) | It is most often seen in people over the age of 50. A gradual increase in urination and a slow increase in urinary retention. Increased frequency of urination is typical at night (in chronic prostatitis, increased frequency of urination during the day or early in the morning). | PRI: the prostate gland is painless, enlarged, densely elastic, the central groove is smooth, the surface is smooth. Prostate secretion: the amount of secretion increases, but the number of leukocytes and lecithin granules 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 significant proliferation of glandular cells in the cranial part of the prostate gland. The structure of the adenomas is homogeneous with regularly shaped areas of darkening. There is an increase in the gland in the anteroposterior direction. With fibroadenoma, light echoes from the connective tissue are detected. |
| Prostate cancer | People over the age of 45 are affected. When diagnosing chronic prostatitis and prostate cancer, there is the same localization of pain. Pain in prostate cancer in the lumbar region, sacrum, perineum and lower abdomen can be caused either by a process in the gland itself or by metastases in the bones. Rapid development of complete urinary retention often occurs. Severe bone pain and weight loss may occur. | SE - single nodes of cartilaginous density or dense, lumpy infiltration of the entire prostate gland are determined, which is limited or spreads to the surrounding tissues. The prostate gland is immobile, 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 the nuclei and mitotic figures. Cystoscopy: Pale pink lumpy masses surround the neck of the bladder in a ring (the result of infiltration of the bladder wall). Often swelling, hyperemia of the mucosa, 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 gland;
- relief of symptoms of exacerbation (pain, discomfort, urination and impaired sexual function);
- prevention and treatment of complications.
Treatment tactics
Non-drug treatment:
Diet no. 15.
Mode: general.
Pharmacological treatment
In the treatment of chronic prostatitis it is necessary to simultaneously use multiple drugs and methods that act on different sites of the pathogenesis and allow the elimination of the infectious agent, the normalization of blood circulation in the prostate, adequate drainage of the prostatic acini, especially in the peripheral areas, normalization of the level of essential hormones and immune reactions. Antibacterial, anticholinergic, immunomodulatory drugs, NSAIDs, angioprotectors, vasodilators, prostate massage are recommended and therapy 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 stationary level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other types of care provided in the emergency phase: not provided.
Surgery
Surgical interventions performed on an outpatient basis: not performed.
Surgical intervention performed on an inpatient basis
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 bladder outlet obstruction.
Types:
Transurethral resection
Directions:
use in calculous prostatitis (especially when stones that cannot be treated conservatively are located in the 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:
- abandon bad habits;
- eliminate the influence of harmful influences (cold, physical inactivity, prolonged sexual abstinence, etc. );
- diet;
- spa treatments;
- 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, prostatic secretion 4 times a year
Indicators of the effectiveness of treatment and safety of the diagnostic and therapeutic methods described in the protocol:
- absence or reduction of characteristic disorders (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 the DRE;
- reduction of inflammatory indicators of prostatic secretion;
- reduction of swelling and size of the prostate according to ultrasound.