Overview
Chronic prostatitis (CP) is a common disease of the male genitourinary system, mostly in young and middle-aged men, and is a hidden worry for young and middle-aged men. It is a very high incidence, and at some point in a man’s life, about half of the men, suffer from varying degrees of chronic prostatitis or have some symptoms of chronic prostatitis. The cause of this disease is more complex, the course of the disease is prolonged, often causing great mental pain to patients, so that many patients are in a state of long-term pessimism and disappointment.
The symptoms of CP are described in Chinese medicine as “gonorrhea”, “white turbidity”, “hanging pain”, “retention of urine”, and “depression”. “retention of urine”, “depression” and other conditions. The theoretical elaboration and clinical practice of these diseases originated from the “Internal Path” and was based on Zhongjing, and has evolved through the ages, and has seen more development in recent times.
Scholars at home and abroad have made a lot of researches on this disease, but no fundamental breakthrough has been made so far. The Chinese medicine has a strong advantage in the treatment of chronic prostatitis, which has a good effect in relieving symptoms and improving the quality of life of patients.
Etiology and pathogenesis
I. Etiology
The prostate gland is made up of glandular tissue and smooth muscle, with 30 to 50 tubular glands, forming 15 to 30 excretory ducts opening in the middle of the prostate on both sides of the crypt, from which the prostatic fluid secreted by the prostate gland is discharged. The reason for this is not well understood by modern medicine, but there are several theories. The following are theories
The first of these is that the prostate gland is a very large area of the prostate gland. The urodynamic data and the clinical efficacy of a-blockers corroborate this hypothesis.
2, sympathetic excitation theory: increased excitability of a-receptors at the bladder neck and posterior urethral sites is the pathological basis for inducing urinary reflux.
3, immune response: the immune function status of the host and the ability to adhere to certain infection factors is one of the mechanisms that induce CP. The abnormal expression of some cytokines in the prostate tissue and the application of non-steroidal anti-inflammatory drugs blocking COX-1 and COX-2 in clinical treatment corroborate this hypothesis.
4, bacterial infection: studies of patients with CP: some patients have a history of recurrent urinary tract infections before the disease, the presence of bacteria in the EPS of patients with CP expression products, antibiotics can produce short-term efficacy in patients with CP.
II. Classification
There are several ways to classify CP, but currently most follow the 1995 National Institutes of Health (NIH) classification of prostatitis.
Type I prostatitis (ABP): acute bacterial prostatitis, characterized by acute lower urinary tract infection symptoms and systemic symptoms, bacteriuria.
Type II prostatitis (CBP): chronic bacterial prostatitis, characterized by recurrent episodes of lower urinary tract infection with bacteria localized in the prostate.
Type III prostatitis (CPPS): chronic prostatitis/chronic pelvic pain syndrome, characterized by pain and discomfort in the pelvic region, various urinary symptoms and abnormal sexual function, without obvious signs of infection. Type IIIA is inflammatory CPPS with numerous white blood cells (WBC) seen in prostatic fluid (EPS)/post-prostate massage urine (VB3)/seminal fluid. Type IIIB is non-inflammatory CPPS with normal WBC in EPS/VB3/seminal fluid.
Type IV prostatitis (AIP): asymptomatic inflammatory prostatitis, characterized by inflammatory manifestations in biopsy/EPS/VB3/semen, but no clinical symptoms.
Three, Chinese medicine etiology pathogenesis
According to Chinese medicine, the etiology and pathogenesis of this disease can be summarized as follows.
1. Dampness and heat with stasis: excessive alcohol consumption, spicy and thick food, damage to the spleen and stomach, internal dampness and heat, or external dampness and heat, down to the bladder, contained in the seminal chamber. The damp-heat evil contains the lower jiao, blood flow is not smooth, or there is stagnation, damp-heat and blood stasis together with the disease, and see unfavorable urination, white cloudy dripping, perineal pain.
2.Dampness and stagnation: after living in a cold and wet place for a long time, after wading in water, feeling the evil of cold and dampness outside, or deficiency of cold in the spleen and kidneys, internal dampness and stagnation of dampness, and unfavorable gasification in the lower jiao, resulting in cold pain in the waist and knees, wet and cold scrotum, and dripping urine.
3.Qi stagnation and blood stasis: poor emotion, depression and liver injury, liver loss of drainage, unable to regulate the qi, or damp heat, dampness and turbidity of the evil to block the qi, the qi is not smooth, unable to move blood, resulting in qi stagnation and blood stasis, or by the stagnation of blood obstruction of qi and blood, resulting in the condition of stagnation, manifested as perineal tingling, urinary stagnation, etc.
4. Kidney deficiency and blood stasis: deficiency of kidney yin and incandescence of phase fire burn the essence and blood, resulting in stagnation of essence and blood, or deficiency of kidney yang and lack of warmth, resulting in cold stagnation of qi and blood and stasis in the lower jiao, resulting in soreness and weakness of the waist and knees and astringent pain in the perineum.
The disease is characterized clinically by a combination of kidney deficiency, dampness, heat and blood stasis.
Diagnosis and differentiation in Western medicine
I. Diagnosis in Western medicine
(A) Symptoms
The main clinical manifestations of chronic prostatitis include pain below the waist and above the knee, abnormal urination and psychosomatic symptoms. Type IV prostatitis is asymptomatic.
Most CP patients complain of pain or discomfort in the lower back, lower abdomen, perineum, and inner femur. This pain or discomfort is often mild and not intense, but the symptoms come on intermittently, often due to sedentary, spicy or alcoholic food, or after sexual intercourse.
Most patients with CP complain of frequent urination, mainly with increased urination during the day, and a few patients have frequent nighttime urination. Some patients may have urinary urgency, painful urination, incomplete urination, urine dripping, difficulty in urination, etc. White urine dripping is also a more common symptom, and a few patients may have painful ejaculation and hematogenous semen.
Sexual dysfunction is also a common manifestation of CP, often with low libido, impotence, premature ejaculation, etc. These manifestations are related to the pathology of CP itself and have been associated with psychiatric factors.
The vast majority of CP patients, there are generally mental symptoms, due to the direct suffering caused by the disease itself, and excessive attention to the discomfort caused by the disease, resulting in patients with a lot of concerns, depressed mood, or even the complication of neurosis, manifested as insomnia, dizziness, blurred vision, weakness, depression, individual patients may even nuisance, suicide and other extreme behavior.
The chronic prostatitis symptom score (NIH-CPSI) is divided into pain or discomfort symptom score, urinary symptom score and quality of life score, the higher the total score the more severe the disease. By filling out the questionnaire by CP patients, the patient’s degree of mildness can be objectively evaluated.
(II) Physical signs
Although patients can have pain in multiple areas with urinary symptoms and white drip, most of the painful areas and vulva are obvious abnormal signs. On anal examination of the prostate, most of the prostate glands have no obvious changes in size, both lobes may be asymmetrical and the surface may be irregular, with a hard or uneven texture, and there may be nodules of different sizes. Elasticity or mobility may be normal, with a few patients having decreased mobility due to fixation of adhesions around the gland. Most patients have mild pressure pain, and a few patients may have more intense pressure pain.
(C) Laboratory tests
1. Urine and prostate fluid laboratory tests: In most patients with CP, routine urine tests are normal, with white blood cells within the normal range and negative for red blood cells and urine protein. Routine prostate fluid tests, leukocytes > 10/HP and reduced lecithin vesicles, all suggest possible CP.
2, Bacterial culture is significant for the staging diagnosis of CP. Meares – Stamey four-cup method of culture is the classical method of bacterial culture. 10ml of primary urine (VB1), 10ml of middle urine, 10ml of prostate massage fluid (EPS), and 10ml of post-massage primary urine (VB3) are routinely disinfected at the urethral orifice before collection of specimens, and all collected All the specimens collected were subjected to bacterial culture and colony count, and drug sensitivity test. 4 cups of specimens with no bacterial growth can be diagnosed as non-bacterial prostatitis; VB1, VB2 negative, or 3000 strains/ml, while EPS or VB35000 strains/ml can be diagnosed as bacterial prostatitis; VB21000 strains/ml can be diagnosed as cystitis; if EPS failed to taken out, VB3 can be used to represent a dilution of 100 times the EPS calculation. The four-cup method of culture is cumbersome, so not many people actually apply it clinically, and the simplified two-cup method (i.e. PPMT method) is mostly used instead of the four-cup method. The two-cup method is simple and easy to perform bacterial culture on the urine before and after prostate massage, and is more often used clinically.
The pH value of EPS may be elevated in patients with CP (normal pH value of EPS is 6.3-6.6).
If the condition requires, imaging tests such as ultrasound, X-ray plain film and urine flow rate measurement can also be performed. Immunology, histology, cystoscopy, EPS lactate dehydrogenase and zinc content measurement can be performed if necessary.
II. Differential diagnosis
Since many diseases may cause symptoms similar to CP, other diseases must be excluded clinically to diagnose CP, so some scholars have compared CP diagnosis to “garbage can diagnosis”. Bacterial culture can not only distinguish bacterial and non-bacterial CP, but also has significance for the differential diagnosis of urethritis and cystitis. At some stage of anal disease, appendix disease, urinary stones, urethral stricture, prostate tumor, ankylosing spondylitis, etc., they may also manifest as chronic pelvic pain or abnormal urination, and should be differentiated accordingly in clinical practice.
Chinese medicine identification and typing
I. Real evidence with stasis
(I) Damp-heat with stasis
External or internal damp-heat is injected into the lower jiao, blocking qi and blood and accumulating in the seminal chamber. The manifestations are frequent urination, urgent urination, burning or astringent pain in the urethra, dripping white, astringent red urine, stabbing pain or astringent pain in the lumbar abdomen or perineum, which may be accompanied by dampness of the scrotum, bitterness of the mouth and dryness of the throat, dry stools or dilute and difficult to solve, burning in the anus, red tongue with yellowish greasy coating, and string or slippery pulse.
(2) Dampness and turbidity with stasis
The lower jiao is trapped by dampness and turbidity, and the qi and blood do not run smoothly and are blocked in the seminal chamber. It can be seen as frequent urination, cloudiness, white turbidity after urination, cold and painful perineum, accompanied by damp and cold scrotum, cold extremities, abdominal froth and dullness, nausea and vomiting, etc. The tongue is large with teeth marks, purple and dark, white smooth or white greasy coating, and sunken and tight or slippery pulse.
(C) Qi stagnation and blood stasis
The liver is out of control, the qi is not smooth, there is no way to move the blood, the qi is stagnant and the blood is stagnant, blocking the seminal chamber. The manifestation is unfavorable urination, pain may reach the chest, accompanied by distension and fullness in the chest, good breath, bitterness in the mouth and not much drinking. The tongue is purple and dark or consists of petechiae and stasis, and the pulse is stringent or astringent.
Deficiency with stasis
(A) Qi deficiency with stasis
Exhaustion and injury to the spleen, deficiency of the spleen in prolonged illness, or deficiency of qi in the heart and liver, and inability to move blood, blocking the lower jiao channels. The manifestations are abdominal cramps, empty pains, stagnant urine, incomplete residual energy, accompanied by less breath and lazy speech, yellowish or white face, etc. The tongue is fat, purple and dark, and the pulse is weak and slow.
(2) Yin deficiency with stasis
Deficiency of kidney yin, delusional movement of phase fire, burning of yin and fluid, and obstruction of the sperm chamber. It may be accompanied by seminal emission, dizziness and tinnitus, fatigue, weakness, red tongue, thin tongue, little or no moss, and fine pulse.
(C) Yang deficiency with stasis
Deficiency of kidney yang, failure of the vital fire, no warmth, deficiency of cold and stagnation, and blockage of the seminal chamber. This can be seen as cold pain in the waist and knees, fear of cold in the vulva, frequent and long urination, cold urine, mostly accompanied by impotence and premature ejaculation, dizziness and tinnitus, depression, fear of cold extremities, etc. The tongue is light and fat, purple and dark, with white moist moss and a sunken and weak pulse.
Chinese medicine treatment
I. Solid evidence with stasis
(I) Damp-heat with stasis
1. Treatment: Clearing heat and dampness, detoxifying and resolving blood stasis.
2. Formula: Bazheng San plus or minus, with the addition of red peony and Wang Bu Liu Xing as appropriate. Qu Mai, Che Qian Zi, Slippery Rock, Gardenia, Rhubarb, Licorice, Red Peony, Wang Bu Liu Xing, Poria, Raw Coix Seed.
(B) Dampness and turbidity with stasis
1, treatment: remove dampness and eliminate stasis, clearing and lowering turbidity.
2, prescription: clearing drink. Atractylodes Macrocephala, Plantago ovata, Poria, Acorus calamus, Phellodendron, Lotus heart, Salvia.
(C) Qi stagnation and blood stasis
1. Treatment: Regulating Qi and activating blood circulation, promoting circulation and relieving pain.
2, formula: Shao abdominal and blood stasis soup plus reduction.
Radix Paeoniae Alba, Radix Angelicae Sinensis, Rhizoma Ligustici Chuanxiong, Rhizoma Wu Lingli, Radix Phellodendron, Radix Cumini, Radix et Rhizoma Yanhuosuo, Radix Myrrh, Radix Achyranthes Bidentatae, Radix Zelen, Radix Sulforaphus, Radix Wang Bu Li Xing.
Second, deficiency with blood stasis
(A) Qi deficiency with stasis
1. Treatment: tonifying the middle and benefiting the qi, raising the yang and lifting the trapped.
2, prescription: tonify the middle and benefit the qi soup with calamus and yujin.
Astragalus, Radix Codonopsis, Radix Angelicae Sinensis, Rhizoma Atractylodis Macrocephalae, Pericarpium Citri Reticulatae, Radix Bupleurum, Acorus Calamus, Radix et Rhizoma Glycyrrhiza.
(II) Yin deficiency with stasis
Treatment: Nourish Yin and tonify the kidney, and at the same time resolve blood stasis.
Remedy: Zhi Bai Di Huang Wan plus Dan Shen, Sheng Long Bone and Oyster.
Zhi Mu, Huang Bai, Shu Di Huang, Cornu Cervi Pantotrichum, Huai Shan Yao, Ze Xie, Mudan Pi, Fu Ling, Dan Shen, Sheng Long Bone, Sheng Oyster.
(C) Yang deficiency with blood stasis
1. Treatment: warming the kidney yang and resolving blood stasis at the same time.
2, prescription: Jin Kui Kidney Qi Pill with Acorus calamus, Yu Jin, Dan Shen, Puzzle Nut, Sha Yuan Zi, Raspberry.
Cinnamon, Radix et Rhizoma, Semen, Radix rehmanniae, Cornus officinalis, Mudanpi, Zedoary, Poria, Acorus calamus, Ulvae japonicae, Salviae miltiorrhizae, Salviae miltiorrhizae, Raspberry.
Other treatments
I. Acupuncture treatment
The acupuncture points are Guan Yuan, San Yin Jiao, Tai Xi, and Hui Yin points as one group; Zhong Ji, Bai Huan Yu, Foot San Li, Yin Ling Quan, and Kidney Yu as one group. Medium intensity stimulation, interval acupuncture 15 minutes, 2 times a day, each group alternating morning and afternoon. 7 days for a course of treatment.
Second, medication sitting bath therapy
According to the clinical diagnosis and classification, different drugs are used in the bath.
1, kidney deficiency and stasis type: Cuscuta, Eucommia, Cornu Cervi Pantotrichum, Radix et Rhizoma, Peony Skin, Radix Paeoniae Alba, Radix Angelicae Sinensis, Salviae Miltiorrhizae, Safflower, Phellodendron, each 10g, water decoction bath, once a day, once for 20 minutes, 30 days for a course of treatment.
3, to the perineum and other local pain: vinegar sizzling Wu Ling fat, Sheng Pu Huang, Yan Hu Suo, Chuan Niu Kne, Wu Yao, Mu Xiang, Chuan Neem, Gao Liang Jiang, Bai Shao, raw licorice 10g each, water decoction, 20 minutes once, 30 days as a course of treatment.
In addition, there are still clinical treatments such as drug point injection, electroacupuncture, ionic herbal penetration, ultrasonic herbal penetration, and herbal enema, which have also proven to be effective and can be chosen appropriately.
Chronic prostatitis blood stasis evidence and progress in the study of blood circulation and blood stasis
The main pathological change of CP is the inflammatory obstruction of the prostatic ducts, which causes poor drainage of the prostatic ducts, which in turn aggravates the inflammatory obstruction of the ducts, resulting in a vicious cycle and repeated attacks, causing CP to linger and be difficult to heal. The chronic pain in the perineum, testicles, inner thighs, lower abdomen and lumbosacral region and the symptoms of urinary frequency, urinary urgency, urinary bifurcation, dripping, painful urination, painful ejaculation and white dripping are consistent with the characteristics of blood stasis in Chinese medicine. The clinical manifestations vary according to the etiology and pathogenesis of the disease, which can be due to actual evil causing stasis or deficiency causing stasis. The site of blood stasis is in the lower jiao-jing ventricle, not only the meridians are blocked, but also the ligaments are affected by blood stagnation; the manifestation of blood stasis in CP is often obvious, and in most cases it is caused by Qi deficiency, kidney deficiency, liver depression, dampness and damp-heat. A large number of basic and clinical trials have confirmed that herbs that activate blood stasis can improve microcirculation and vascular permeability improve blood rheological indicators, promote excretion and absorption of inflammatory secretions, improve and prevent tissue fibrosis around lesions, and promote tissue repair.