Bacterial prostatitis is easy to diagnose because of its obvious and typical clinical presentation; the clinical features of chronic prostatitis are more variable and inexact. Many symptoms and signs are often indistinguishable in chronic bacterial prostatitis, chronic non-bacterial prostatitis, and prostate pain. Radiology and urethral cystoscopy, which may be of some help in diagnosis, do not confirm the diagnosis. Histological examination of the prostate is only needed in some rare types of prostatitis, such as granulomatous prostatitis.
1. Urine and prostate fluid examination
(1) urine routine and urine three cups test In acute prostatitis, urine is mostly alkaline, mostly accompanied by urinary tract infection, urine often has inflammatory manifestations, while bloodstream infection of acute prostatitis, urine may be normal.
Urine three cup test: the initial 10 a 15ml of urine for the first cup, the last 10m1 of urination for the third cup, and the middle part 10m1 for the second cup. The urine flow should be continuous during collection. The three-cup urine test can initially determine the source of hematuria and pus urine and the site of the lesion. If the first cup of urine is abnormal, it suggests that the lesion is in the urethra or bladder neck. An abnormal third cup of urine suggests that the lesion is in the posterior urethra, bladder neck, or triangle. If all three cups of urine are abnormal, it suggests that the lesion is in the bladder or above.
The three-cup urine test in the case of prostatitis may show the following.
① the first cup has debris and concentrated urine.
② the second cup is often clearer.
The third cup is cloudy, with debris and epithelial cells. The change in the third cup clearly indicates that the pus comes from the posterior urethra and bladder neck, and the increase in pus at the end of urination when the bladder neck is contracted can reflect inflammation of the prostate.
When urethritis or urethral discharge is high, a smear of the secretion should be made, stained to find bacteria, and a bacterial culture and drug sensitivity test.
(2) Prostate examination and prostate massage fluid examination
Prostate examination The examination of the prostate gland and seminal vesicles is generally done by anal fingering. Before the examination, the bladder should be emptied first, and the patient should be placed in knee-chest, right side, upright and supine position, and the examiner should wear gloves and apply petroleum jelly to the finger before performing the anal finger examination. When performing the examination, attention should be paid to the tension of the anal sphincter. The prostate gland should be palpated for size, shape, hardness, tenderness, central groove and mobility. The normal adult prostate is smooth and tough, generally the size of the same thumb, about 4 cm in diameter (more than that is an increase), with a longitudinal shallow groove in the middle, called the central groove. When prostate cancer, stones, tuberculosis, inflammatory granuloma, hardness increases, nodular, or even hard as a stone, the surface is not smooth, with a granular feel. When the gland is normal, there is no obvious tenderness, but when there is acute inflammation or abscess, the tenderness is extremely obvious, so do not squeeze hard at this time, and the examination should be gentle to avoid causing unnecessary pain to the patient. If the physiological mobility of the prostate gland disappears, especially if it is adherent to the seminal vesicles and hard and fixed, it is a sign of cancerous infiltration.
Prostate massage fluid examination When massaging the prostate, the technique should be gentle, starting from both sides of the lobe, 2 to 3 times on each side, then squeeze from both sides of the gland to the midline 2 to 3 times each, then press from the midline to the anal opening 2 to 3 times, then squeeze the perineal urethra to expel and take out the prostate fluid for examination. If no prostate fluid drips out after squeezing, you can squeeze the posterior urethra by hand and push down the urethra from the posterior urethra, you can also get a little prostate fluid for smear examination.
When massaging the prostate, the following points should be noted.
When the prostate has acute inflammation (such as an abscess), do not press to prevent the spread of inflammation. When prostate cancer or prostate tuberculosis is suspected, the gland should not be squeezed to prevent the metastasis of the cancer and the spread of nodules.
If the prostate has an obvious tendency to bleed, you should not squeeze it to prevent excessive bleeding.
If you want to make a culture of prostate fluid, you should flush the urethral orifice after the patient urinates before massage and use aseptic methods to prevent contamination.
The normal prostate fluid is light white and thin. The smear microscopic examination can be seen in the amount of phospholipid vesicles, white cells do not exceed 10 / high magnification field. A routine urine examination should be done before prostate massage. If prostate fluid is not obtained, 10 a 15m1 primary urine can be collected after massage and sent for examination to compare the number of leukocytes before and after massage, for indirect examination. Microscopic examination of prostate massage fluid is important for the diagnosis and classification of prostatitis. An increase in white blood cells is an infectious inflammation, and if the bacterial culture is positive, it is a bacterial inflammation, but it may also cause false impressions. For example, a large number of white blood cells in prostate massage fluid may come from urethral disease (urethritis, urethral strictures, warts and diverticula). The number of white blood cells in prostate fluid can also increase in healthy men several hours after intercourse and ejaculation.
2. Semen examination
The effect of prostatitis on semen is still controversial. Many studies have shown that normal ejaculated fresh semen containing too many microorganisms can reduce sperm viability, but this only happens when there is a large amount of bacteria (bacterial count >106/ml), and it is generally difficult for sperm in patients with chronic bacterial prostatitis to encounter such high concentrations of bacteria. Reduced fertility in patients with chronic bacterial prostatitis may not be a direct effect of pathogenic bacteria on sperm. The secretion dysfunction that accompanies chronic bacterial prostatitis plays a detrimental role on sperm and can cause reduced fertility. Semen examination is complicated by the difficulty of distinguishing immature sperm from leukocytes; routine examination shows a decrease in total sperm count, decreased motility, increased mortality, and the presence of a variable number of leukocytes.
3.Immune response measurement
In the past 20 years, studies have proven that in patients with chronic bacterial prostatitis, the entire level of immune proteins in the prostatic fluid is elevated, there are high levels of antigen-specific antibodies in the prostatic secretion, and the level of antigen-specific antibodies against prostate pathogenic bacteria in the serum is also increased. The most recent studies suggest that in bacterial prostatitis, the local immune response in the prostate exceeds the response in the serum, and further research and understanding of this response will be important for the diagnosis, clinical management and prevention of bacterial prostate.
Of greater clinical significance at present are the changes in IgG and IgA in the blood and prostatic fluid of patients with chronic prostatitis. If the treatment of prostatitis is effective, the IgG and IgA in the prostate fluid of the patient can gradually decrease, while when the treatment is ineffective, the IgG and IgA in the prostate fluid tend to remain high.
4. Bacteriological diagnosis
The easiest and most accurate way to identify and diagnose chronic prostatitis bacterial and non-bacterial prostatitis is to perform quantitative bacterial cultures of urethra, bladder urine and prostate massage fluid at the same time (Stamey four-cup method). Before collecting the urine, the patient was asked to drink more water, the foreskin was turned up to clean the head of the penis and the urethral orifice, the patient was asked to urinate 10 ml of urine (VB1), then about 200 m1 of urine was urinated to obtain the middle urine (VB2), the prostate was massaged to obtain the prostatic fluid (EPS), then about 10 ml of urine was urinated (VB3), and the above specimens were examined and cultured separately. The number of bacterial colonies in each specimen can be compared to distinguish the source of infection and help confirm the nature of prostatitis.
The bacteria cultured in the prostate fluid in bacterial prostatitis are often gram negative bacilli, similar to urinary tract infections. In contrast, there is no bacterial growth in non-bacterial prostatitis.
Sometimes Gram-positive bacteria can be cultured in the prostate fluid; there are two main views on this: one view is that Gram-positive bacteria come from the patient’s own contamination such as foreskin or contamination during the culture process; the other view is that Gram-positive bacteria are commonly found in the prostate fluid of normal people, and Gram-positive bacteria are not directly related to the occurrence of prostatitis.
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