Chronic prostatitis - inflammatory diseases of the prostate gland of various etiologies (including non-infectious ones), manifested by pain or discomfort in the pelvic area and urination 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 Abscess of the prostate
N41. 3 Prostatocystitis
N41. 8 Other inflammatory diseases of the prostate gland
N41. 9 Inflammatory disease of the prostate, unspecified
N42. 0 Prostate stones
Prostate stone
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 - nuclear 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 gland
Echography - ultrasound examination
ED – erectile dysfunction
ECG - electrocardiography
IPSS – International Prostate Symptom Score
NYHA - New York Heart Association
Date of protocol development: 2014
Category of patients: men of reproductive age.
Users of the protocol: 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 studies (comparative studies, correlational studies, analysis of scientific reports) |
| 4 | Evidence is based on expert opinion or experience |
Degrees of recommendation
| A | Results were based on homogenous, high-quality, problem-specific clinical trials with at least one randomized trial |
| 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 Institutes of Health (NYHA), USA, 1995. )
Category I – acute bacterial prostatitis;
II category – 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 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 an increase in leukocytes in the prostate secretion (about 30%));
IV category – asymptomatic inflammation of the prostate detected during examination for other diseases, based on the results of the analysis of prostate secretion 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 examinations performed on an outpatient basis:
- collection of complaints, medical history;
- digital rectal examination;
- completing the IPSS questionnaire;
- ultrasound examination of the prostate;
- prostatic secretion;
Additional diagnostic tests performed on an outpatient basis: prostatic secretion;
The minimum list of examinations that must be carried out on referral for planned hospitalization:
- general blood test;
- general analysis of urine;
- 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;
- EKG;
- blood group.
Basic (mandatory) diagnostic examinations performed at the hospital level:
- PSA (general, 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 tests performed at the hospital level:
- uroflowmetry;
- cystotonometry;
- MSCT or MRI;
- urethrocystoscopy.
(level of evidence - I, strength of recommendation - A)
Diagnostic measures carried out at the emergency stage: not carried out.
Diagnostic criteria
Complaints and 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 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;
- suppression of libido;
- deterioration of the quality of spontaneous and/or adequate erections;
- premature ejaculation;
- in the 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 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 furrow of the prostate gland.
Laboratory studies
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-Lallemand bodies;
- determination of the number of macrophages.
Bacteriological examination of prostate secretion: 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 of 103 CFU/ml or more, provided that the second portion of urine is sterile;
- a tenfold or greater increase in bacterial titers in the third portion of urine or in prostatic secretions compared to the second portion;
- the third portion of urine or prostatic secretion contained more than 103 CFU/ml of true uropathogenic bacteria different from the other bacteria in the second portion of urine.
The predominant importance for 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 for determination of serum PSA concentration should be performed no earlier than 10 days after DRE. Prostatitis can lead to an increase in the concentration of PSA. However, 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, echo structure (cysts, stones, fibro-sclerotic changes in the organ, abscesses of the prostate). Hypoechoic areas in the peripheral zone of the prostate are suspicious for prostate cancer.
X-ray studies: with diagnosed bladder outlet obstruction to clarify the cause and determine further treatment tactics.
Endoscopic methods (urethroscopy, cystoscopy): performed according to strict indications for the purpose of differential diagnosis, including broad-spectrum antibiotics.
Urodynamic studies (uroflowmetry): determination of urethral pressure profile, pressure/flow study,
Cystometry and myography of the pelvic floor muscles: in case of suspected bladder outlet obstruction, 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 - for PSA above 4 ng/ml, to rule out prostate malignancy.
Differential diagnosis
Differential diagnosis of chronic prostatitis
For the 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 was 43 years. Pelvic pain or discomfort 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 region 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 commonly as symptoms of bladder outlet obstruction. |
IN TIME - you can find swelling and tenderness of the prostate gland, and sometimes its enlargement and smoothness of the median furrow. For the purposes of differential diagnosis, the condition of the rectum and surrounding tissues should be evaluated. Prostatic secretion - determines the number of leukocytes, lecithin beads, amyloid bodies, Trousseau-Lallemand bodies and macrophages. Bacteriological examination of prostate secretion or urine obtained after massage is 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 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, echostructure |
| Benign prostatic hyperplasia (prostatic adenoma) | It is seen more often in people over 50 years of age. Gradual increase in urination and slow increase in urinary retention. Increased frequency of urination is characteristic at night (in chronic prostatitis, increased frequency of urination during the day or early morning). | PRI - the prostate gland is painless, enlarged, densely elastic, the central groove 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 reaction of the secretion is neutral or slightly alkaline. Ultrasound - deformation of the bladder neck is observed. Adenoma stands out in the cavity of the bladder in the form of bright red lumps. There is significant proliferation of glandular cells in the cranial part of the prostate gland. The structure of the adenomas is homogeneous with areas of darkening of a regular shape. There is enlargement of the gland in the anterior-posterior direction. In fibroadenoma, bright echoes from the connective tissue are detected. |
| Prostate cancer | People over 45 are sick. When diagnosing chronic prostatitis and prostate cancer, there is an identical localization of pain. 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 bone metastases. Rapid development of complete urinary retention is often observed. Severe bone pain and weight loss may occur. | IF - separate nodules of cartilaginous density or a lump of dense infiltration of the entire prostate gland, which is limited or spreads to the surrounding tissues, are determined. The prostate gland 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 figures. Cystoscopy - pale pink lumps encircling the neck of the bladder in a ring shape (result of infiltration of the bladder wall) are determined. Frequent 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 exacerbation symptoms (pain, discomfort, urination and sexual function disorders);
- prevention and treatment of complications.
Tactics of treatment
Non-drug treatment:
Diet #15.
Mode: common.
Drug treatment
In the treatment of chronic prostatitis, the simultaneous use of several medications and methods is necessary, which 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 areas, normalization of the level ofbasic hormones and immune responses. Antibacterial drugs, anticholinergics, immunomodulators, NSAIDs, angioprotectors, vasodilators, prostate massage are recommended, 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 the inpatient level:
- transrectal microwave hyperthermia;
- physiotherapy (laser therapy, mud therapy, phonoelectrophoresis).
Other types of treatment provided in the emergency stage: not provided.
Surgical intervention
Surgical interventions performed on an outpatient basis: not performed.
The surgical intervention is performed in hospital conditions
Types:
Transurethral incision at 5, 7 and 12 hours.
Indications:
it is carried out in hospital conditions if the patient has prostatic fibrosis with a clinical picture of bladder outlet obstruction.
Types:
Transurethral resection
Indications:
use in calculous prostatitis (especially when stones are localized that cannot be treated conservatively in the central, transition and periurethral zones).
Types:
Resection of seminal tuberculosis.
Indications:
with sclerosis of seminal tuberculosis, accompanied by occlusion of the ejaculatory and excretory ducts of the prostate.
Preventive measures:
- giving up bad habits;
- elimination of the influence of harmful effects (cold, lack of physical activity, prolonged sexual abstinence, etc. );
- diet;
- spa treatment;
- normalizing sex life.
Additional management:
- monitoring by a urologist 4 times a year;
- Ultrasonography 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 area, 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;
- decrease in swelling and prostate size according to ultrasound.