Chronic prostatitis/chronic prostatodynia (CP/CPPS), known as type III prostatitis, is the most common type of prostatitis in clinical practice, accounting for approximately 25% of all urological visits [1]. CP is mainly characterized by irregular pain in the perineum, suprapubic arch, scrotum and urethra, often accompanied by urinary dysfunction and sexual dysfunction. Tension pain. The diagnosis of type IIIB prostatitis can be made when the duration of symptoms is greater than 3 months and the leukocyte count in the semen/VB3/EPS on microscopic examination is within the normal range. Statistics on the incidence of CP/CPPS are more scattered and the data vary relatively widely.
The incidence of CP/CPPS worldwide is about 9%-16% [2], and a large sample survey of the incidence of CP/CPPS in China in recent years showed that the incidence of CP in China is 4.5% and the incidence of CPPS is 8.5%, with type IIIB prostatitis accounting for about 90%-95%. There are many possibilities for the cause of type IIIB chronic prostatitis, including: chemical inflammation, pelvic muscle spasm, immune dysfunction, psychological factors, neuroinflammation, oxidative stress factors, etc. However, the exact pathogenesis of type IIIB prostatitis remains unclear. Clinical studies have found that patients with chronic prostatitis often present with mental disorders dominated by anxiety and depression. The relationship between the two has received more attention from scholars at home and abroad. The current status of research on type IIIB prostatitis and mental disorders is now reviewed.
1, type IIIB prostatitis mental disorder performance
The similarity lies in the fact that the adverse mental affect caused by CP/CPPS is anxiety, depression, fear and hypochondriasis, with generalized anxiety and depression predominating. Patients often complain of somatic discomfort and they view problems with a lack of confidence. The difference is that patients with generalized anxiety or depression are predominantly female, have no objective anxiety or object of concern, have fears and anxieties but no specific fears or perceptions, and are depressed in a way that is disproportionate to their situation.
In contrast, CP/CPPS patients are men who often exhibit extreme low self-esteem and lack of masculinity. The subject of anxiety is chronic somatic discomfort, and the content of fear is often hypogonadism, prostate cancer changes, etc. There is also a clear link between the degree of depression of the patient and the severity of the disease. miller [10] concluded that an important feature of patients with CP/CPPS is excessive mental tension and concern for changes in their condition. Wu Lixin et al. applied the Zung Anxiety Scale (SAS) and Depression Scale (SDS) to investigate the psycho-spiritual status of 1426 patients with chronic prostatitis, delineated by SAS ≥ 50 and SDS ≥ 53, and found that 23.6% of patients with chronic prostatitis had anxiety symptoms and 21.7% had depressive symptoms when compared with the domestic norm.
Nickel et al. used the QOL Somatic Symptom Rating Scale (SF12-PCS) and the Psychiatric Symptom Rating Scale (SF12-MCS) to score 253 patients with chronic prostatitis and found that the more severe the patients’ somatic symptoms the lower the SF12-MCS score and the more pronounced the manifestation of anxiety and depressive symptoms. blackolck [13] et al. based on different research groups’ psychometric measurements of CPPS The data were analyzed and summarized based on the psychometric results done by different research groups on patients with CPPS and concluded that patients with prostate pain prefer to actively state their anxiety-related somatic discomfort and pain and exhibit overstressed types of behavior. Korean scholars, after conducting statistics on chronic prostate patients in the military, found that low self-esteem and lack of masculinity showed a positive correlation with sexual function symptoms in patients with chronic prostatitis.
2. The relationship between mental disorders and type IIIB prostatitis
2.1 The influence of mental factors on the development of type IIIB prostatitis
While recognizing that type IIIB prostatitis can cause mental disorders, more and more scholars are realizing that mental factors also play an important role in the pathogenesis of CP. The pathogenesis of both type IIIB prostatitis and psychiatric disorders is currently unclear [15], so it is still based on the original doctrine to explain the relationship between the two.
The chemical inflammation theory suggests that the autonomic nerves, after being stimulated by adverse mental factors such as anxiety, depression, panic, and stress, significantly increase excitability and develop a dysfunction of the vegetative nerves, leading to a significant increase in prostatic glandular secretion. The above changes cause spasm of the periurethral sphincter and pelvic floor muscles, bladder neuromuscular dysfunction, and the increased intraurethral pressure in the prostatic department causes urine to reflux into the prostatic ducts, causing inflammation of the prostatic ducts and surrounding tissues, which eventually triggers chemical prostatitis. Xie Hui et al [16] summarized domestic and international studies and proposed the psycho-neurotransmitter-neurological loop, explaining the process of forming prostatitis as psychological factors acting on the vegetative nerves through this loop, causing urethral and bladder muscle dysfunction, resulting in increased a-receptor excitability, creating high pressure in the urethra and causing urine reflux to form inflammation.
The neuroinflammatory theory also provides a new perspective to explain the role of psychosomatic factors in the pathogenesis of CP. black [17] suggested that a state of chronic anxiety and depression promotes increased release of substance P, neuropeptide, from peripheral nerve endings. The relative increase of these substances can activate macrophages to release various inflammatory transmitters and trigger local inflammation. This idea can explain the different symptoms and sites of onset in patients with type IIIB prostatitis. The most important thing is that the patient’s body is not only a good source of information, but also a good source of information.
2.2 Influence of psychological factors on the course of type IIIB prostatitis
There is a strong intrinsic link between the psychiatric symptoms of the patient and the disease throughout the development of CP/CPPS symptoms to disease regression. There is a significant correlation between three variables: the severity of psychiatric symptoms, the effectiveness of prostatitis treatment, and the improvement or decline in the patient’s quality of life.Tripp [18] et al. concluded that psychiatric symptoms such as anxiety and depression are factors that negatively influence the effectiveness of CP/CPPS treatment.
Zhao [19] concluded that anxiety and depression are common psychiatric symptoms in CP/CPPS patients, and that chronic anxiety and depression can reduce the effectiveness of CP treatment and affect the course of the patient’s illness, increasing the psychological burden and the duration of the illness, resulting in a significant decrease in the patient’s quality of life. The adverse psychological experience leads to a gradual change in the perception and judgment of CP patients, and with the prolongation of the disease and the worsening of symptoms, stress and anxiety are further aggravated. Aubin [20] studied 72 patients with CPPS and 98 healthy individuals and concluded that patients with CPPS have depressive symptoms and to some extent, as their depressive symptoms increase, their sexual frequency and erectile function decrease, leading to a certain degree of low self-esteem. Low self-esteem leads to a decrease in social sociability and lack of masculinity in CP patients making them less evaluated by social groups.
Both can lead to a significant decrease in the social support received by CP patients. Foreign scholar Nickel [21] concluded that there is a significant positive correlation between the social support received by patients with chronic prostatitis and their own quality of life, and that a decrease in the quality of life level increases the patient’s anxiety and depression scores. Since some patients with chronic prostatitis also exhibit hypochondriasis, making repeated visits to the doctor, examinations and over-treatment, while significantly increasing their own economic burden. According to statistics, the average cost of CP treatment for Chinese CP patients is $1151 per year [22], and the higher direct and indirect costs of treatment impose a significant financial burden on patients. The heavy financial burden as well as the prolonged nature of the disease itself increases the psychological stress of patients and progressively decreases their compliance with treatment, forming a vicious circle under the effect of multiple adverse factors.
3.The causes and mechanisms of psychiatric disorders
The clinical findings show that generalized anxiety, depression and type IIIB prostatitis have a high co-morbidity rate, but the etiology and pathogenesis of mental disorders are still unclear. Studies suggest that pathopsychological factors, neurobiological factors, and genetic factors form the basis of the pathogenesis of mental disorders [23], and the role of organismal inflammation and adverse biological behaviors in the pathogenesis has also received much attention from scholars.
3.1 Pathopsychological factors
The pathophysiological basis of the disorder can be formed by adverse personality tendencies, adverse psychosocial environment, negative somatic factors, and negative life stressful events.Rietveld et al. suggested that chronic central nervous system disorders and chronic somatic disorders can be important causes for the development of anxiety and depression. The sexual dysfunction, decreased interest in life, and reduced daily activities that may accompany the course of type IIIB prostatitis can lead to marital disharmony in the family, and the high treatment costs associated with long-term treatment of the disease increase the financial burden on the patient. Such negative stressful events play an important role in promoting the development of mental disorders. The patient will gradually develop and reinforce the misconception that the disease is a serious physical illness, and may even lead to prostate cancer due to prolonged untreated disease.
The above factors work together and interact with each other to form the pathological psychological basis of the psychiatric disorder.
3.2 Neurobiological basis Foreign psychiatrists have put forward various hypotheses about the biological factors that cause generalized anxiety and depression. The most important hypotheses are neurotransmitter hypothesis and neuroendocrine disorder hypothesis.
The neurotransmitter hypothesis suggests that the neurobiological basis for anxiety and depression is the abnormal metabolism of neurotransmitters such as 5-hydroxytryptamine (5-HT) and norepinephrine in the brain. Patients with depressive episodes have decreased 5-HT precursors tryptophan, increased 5-HT degradation, and appear to have decreased 5-HT functional activity. In patients with anxiety, 5-HT secretion and regulation are disturbed and 5-HT receptor activity is decreased, especially in the septal nucleus and its projection system. During the anxiety state, Ne metabolites in the cerebrospinal fluid increase and the regulation of secretion is disturbed.
The neuroendocrine disorder hypothesis suggests that abnormalities in the function of the hypothalamic-pituitary-adrenergic axis (HPA)/thyroidal axis (HPT)/growth hormone axis (HPS) are responsible for psychiatric symptoms. Among them, abnormal HPA function is of most interest to psychiatrists. antonijevic [26] found that depressed patients present with excessive plasma cortisol secretion, altered circadian rhythm of secretion, and disturbance of negative feedback regulation of cortisol, suggesting that abnormal HPA function is the pathochemical basis of depressive episodes.
Rodney et al, selected 45 CPPS patients and 20 healthy individuals for a controlled trial, first applied the BSI scale to assess psychiatric symptoms, and then drew blood at 9 different time points on 2 consecutive days to examine blood levels of adrenocorticotropic hormones. The BIS score was found to be significantly higher in CPPS patients than in the control group (P<0.001), and the rate of secretion and the percentage of increase in adrenocorticotropic hormone at morning rise were significantly higher than in the control group (P<0.05), suggesting that the HPA dysfunction seen in CPPS patients can cause depressive disorders in CPPS patients.
3.3 The effect of inflammation on mental disorders
In recent years, it has been suggested that inflammation in the organism has an important role in causing depression and anxiety.Miller [28] suggested that inflammatory responses can act on the brain to cause changes in mental behavior by promoting the release of inflammatory cytokines and activating immune cells. Certain inflammatory cytokines and their signaling pathways have significant effects on the synthesis, release and reuptake of neurotransmitters such as 5-HT, dopamine and glutamate. By activating the ureline pathway, inflammatory factors lead to a massive conversion of the 5-HT precursor tryptophan to ureline, and a large number of reactive metabolites are produced. These reactive metabolites can significantly affect dopamine and glutamate regulation in the brain.
Inflammatory cytokines act on the basal ganglia and anterior cingulate cortex of the brain to produce anxiety, panic, and depression through their effects on the neurotransmitter system.Raison [29] suggested that inflammatory states can increase the risk of depression and that depression can also lead to the development of local inflammation in patients, suggesting that inflammatory states have an important role in producing mental disorders.Gimeno [30], in a follow-up after analyzing data on serum inflammatory markers C-reactive protein and IL-6 in 3339 volunteers over a 12-year period, found that people with increased inflammatory markers were more likely to suffer from depression, suggesting that the inflammatory state of the organism may be related to the development of depression.
3.4 Influence of adverse biological behavior
Larkin [31] et al. suggested that somatic diseases produce psychiatric symptoms and exacerbate them as a result of a combination of adverse biological behavior, pathopsychological factors, and altered physiological internal environment, and after analyzing and summarizing the relevant data, they proposed a disease cycle chain of adverse biological behavior-altered physiological internal environment-somatic diseases-clinical symptoms-psychiatric symptoms-adverse biological behavior. Patients’ reduced activity, decreased compliance, and increased bad habits such as smoking and alcohol abuse lead to alterations in the physiological internal environment and the formation of local inflammation, triggering chronic prostatitis. After the onset of chronic prostatitis, clinical symptoms, distress from organ dysfunction and changes in mood, the initial formation of mental symptoms. Anxiety and depression disorders cause activity to continue plus decline, treatment attitudes change, and bad habits increase, eventually leading to a vicious cycle that leads to increased mental symptoms.
3.5 Genetic factors
Genetic factors have recently been proven to play an important role in the development of psychiatric disorders, but whether genetic factors have a significant effect on the development of anxiety, depression and other psychiatric symptoms caused by type IIIB prostatitis, the current research data are not perfect, and it is necessary to conduct hike studies on such patients, molecular genetic studies, twin and foster child control studies.
4.Factors affecting psychiatric symptoms
The authors believe that many factors can influence the regression of psychiatric symptoms in patients with CP/CPPS, including personality, age, disease duration, leukocyte count in prostate fluid, CPSI, sexual function status, economic life stress, social support, and literacy. However, the magnitude of the correlation between these factors and mental disorders remains academically controversial. Foreign scholars found that patients with introverted personality had significantly higher anxiety and depression scores than those with extroverted personality; patients with long duration of illness and more severe somatic symptoms and concomitant symptoms had more significant anxiety; patients with high social support and high literacy had lower psychiatric symptom scores and better treatment results.
Domestic scholars have also done a lot of research in this area. Wu Lixin found that the degree of anxiety and depression in CP patients correlated with disease detection rate, disease duration, duration of symptom presence, and sexual function status. In a univariate analysis, introverted personality, fatigue, low economic income, life and work stress, and sleep deprivation were found to be associated with the occurrence of anxiety and depression, and age, occupation, education, and marital status were not associated with the onset of anxiety and depression. Some scholars’ findings also differed from the above findings.
Sun Huabin et al. used the SDS questionnaire, Medical Coping Questionnaire MCM on 116 patients with chronic prostatitis and showed that the yield score of chronic prostatitis with education level above high school was significantly higher than that of junior high school and below, P<0.01, suggesting that the incidence of depression was related to education level. The reason for the difference in the results of the two studies is on the one hand the difference in the number of patients sampled in the two studies, and on the other hand although the assessment scales for depression are the same, there may be differences in the training received by the assessors and the survey methods used in the two studies.
5. Treatment of mental disorders due to type IIIB prostatitis
Type IIIB prostatitis is currently considered to be the most difficult prostatitis to treat, and symptom relief remains the main treatment modality today. The idea of a social-psychological-biomedical model has been widely accepted in the world, and it has become a trend to treat the disease while targeting appropriate interventions to the patient’s psychological factors. In the treatment of type IIIB prostatitis, more and more scholars have started to pay attention to the treatment of psychosomatic symptoms. However, studies have shown that controlling anxiety and depressive symptoms in patients with CP/CPPS is more difficult than in patients with anxiety and depressive episodes alone [33]. The main modalities of psychological intervention are currently pharmacotherapy, psychocognitive therapy, and psychosocial support therapy. Biofeedback therapy, which has gained considerable attention in recent years, has also achieved more excellent treatment results.
5.1 Pharmacological treatment
In the treatment of chronic pain, antidepressants have been widely used to control patients’ psychiatric symptoms. Tricyclic drugs have long been used clinically to intervene in the psychiatric symptoms associated with chronic somatic pain with good efficacy [34-35]. However, the side effects of tricyclic antidepressants on the vegetative nervous system and cardiovascular system are large, and they tend to cause urinary difficulties, decreased sexual function, and cardiac arrhythmias. These side effects may aggravate the symptoms of CP/CPPS patients and reduce patient compliance in treatment. Therefore, selective 5-hydroxytryptamine reuptake inhibitors (SSRIs), which have fewer side effects and higher receptor selectivity, are increasingly favored by clinicians for the control of psychiatric symptoms associated with type IIIB prostatitis.
Six classes of SSRIs, fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, and escitalopram, are more widely used in clinical practice. They regulate the effective concentration of 5-HT in the synaptic gap by inhibiting the reuptake of 5-HT by presynaptic neurons in the central nervous system, so that the concentration and metabolism of 5-HT are within a reasonable range, thereby controlling the emergence of anxiety and depressive states. After collecting data from 1980 to 2011, Thaler statistically analyzed the results of 13 antidepressant treatments for patients with depression accompanied by anxiety, insomnia, and pain, and concluded that SSRIs are comparable to traditional tricyclic drug treatments, but SSRIs have significantly lower affinity for dopamine, histamine, cholinergic, and adrenergic receptors, virtually avoiding extrapyramidal side effects, and significantly reduced the incidence of adverse events such as urinary retention, constipation, and arrhythmias. Since the drug regulates the metabolism of 5-HT, it has the effect of treating both anxiety and depressive symptoms, making it more convenient for the treatment of patients with anxiety and depression co-morbidities.
RA lee [37] found that treatment with sertraline was effective in reducing prostate symptom level score (PSS) and onset frequency score (PSF) as well as anxiety and depression score (HAD) in CPPS patients after clinical observation and data analysis of the experimental group given sertraline for 13 weeks and the control group of CPPS patients given placebo. This suggests that sertraline is effective in controlling psychiatric symptoms and improving somatic symptoms in patients with type IIIB prostatitis.
5.2 Cognitive therapy
The physician conducts purposeful de-escalation based on a comprehensive understanding of the patient’s psychological situation. Explain to the patient in detail the process of the occurrence and development of chronic prostatitis, clarify the prognosis for most patients, and give the patient a relatively clear understanding of the entire disease and treatment. Correct the misconceptions that patients have formed from misleading propaganda in the media and society that having chronic prostatitis means that sexual dysfunction will definitely occur in the future and that there is a high chance of cancer, etc. Reduce unnecessary psychological stress on patients by adding positive and positive guidance. Make patients realize that there is a strong connection between their thoughts, emotions and symptoms.
5.3 Psychosocial support
Because patients have different psychosocial burdens, they have different levels of concern about their prognosis. Psychosocial support therapy is a treatment modality that educates and guides the patients separately after a comprehensive analysis of themselves, their relatives and the economy. By introducing successful cases with similar backgrounds as the patient’s, it builds up the patient’s confidence to accept the examination and adhere to the treatment, and encourages the patient to arrange his or her work, life and study with a normal mind and not to focus on the disease. It is also important to educate the patient’s relatives and instruct them, especially their sexual partners, to give the patient courage and family warmth to overcome the disease and eliminate their psychological fears, worries and anxiety. In the economic aspect, introduce the patients to the necessity and rationality of the drugs used in the treatment, point out some exaggerated and misleading propaganda in the society for the people with chronic prostatitis, reduce the economic burden of the patients, so that the patients can have enough financial ability to adhere to the full course of treatment.
5.4 Biofeedback therapy
Biofeedback therapy is a bio-behavioral treatment method that has emerged in recent years. It emphasizes that patients first observe their own physiological activities, and adjust their own bad physiological activities according to the findings. Throughout the treatment process, the ability to strengthen and control the activities of internal organs is constantly enhanced, so as to reduce and eliminate the adverse physiological processes of the body. Biofeedback therapy is a kind of cognitive-behavioral therapy (CB) that combines behavioral and psychological treatment into one. It is a cognitive-behavioral (CB) treatment. The treatment is done by guiding the patient to clearly understand his or her condition and psychological state, and to know that the symptoms that cause him or her distress are closely related to his or her thoughts and emotions at that time. Based on this understanding, one changes one’s poor physiological situation and transforms one’s thought condition in order to achieve relief of mental and physical symptoms. The treatment process emphasizes repeatedly strengthening the patient’s motivation to improve their physiological and mental conditions with increasing the patient’s confidence to successfully overcome the disease.
Because biofeedback therapy can create conditions for treatment at any time, it has the advantages of being noninvasive and low cost, and these advantages happen to be conducive to adherence to treatment for patients with relatively high psychological and economic burdens, so it has strong generalizability.Nickel [38] et al. found that after analyzing and summarizing data from studies of the National Health Study in the United States, the use of cognitive-behavioral therapy to treat patients with CP/CPPS for 8 weeks later, patients’ anxiety, pain symptoms, and life therapy were significantly improved, suggesting that CB therapy is expected to be an effective tool for clinical treatment of CP/CPPS. In China, Ye Zhangqun et al [39] used biofeedback therapy on 62 patients with type 3B CPPS and achieved an overall effective rate of 96.7% (60/62).
6. outlook
To further study the relationship between type IIIB prostatitis and psychiatric disorders and to recognize the pathogenesis of psychiatric disorders and type IIIB prostatitis, deeper multidisciplinary cooperation is needed. The diagnosis of the disease requires further refinement of the classification of psychiatric disorders in patients with type IIIB prostatitis, improvement of relevant neuroendocrine and biochemical examinations, and large-scale randomized controlled studies and family lineage studies. Only in this way can we gain a deeper understanding of the deeper relationship between the two and suggest new ideas for further treatment of type IIIB prostatitis. There are many methods and modalities for the treatment of psychosomatic symptoms, however, at present, due to time and technical limitations, it is not possible to achieve large-scale psychological interventions for prostatitis patients in clinical settings, so there are not many large sample studies using psychological interventions for the treatment of type IIIB chronic prostatitis.
The extent of the role of psychotherapy in the treatment of type IIIB prostatitis still requires more data to support the study, especially with the involvement of a psychologist. The face-to-face psychological intervention model is more difficult to promote on a large scale due to the limitations of clinical time and physician capacity. The use of modern software and networks for standardized psychological interventions can achieve a large sample size, expanded distribution of study groups, rapid information update and dissemination, and research.