Preface
Chronic prostatitis (CP) is a group of diseases characterized by pain or discomfort in the pelvic region and abnormal urination in the prostate gland due to the action of pathogens or certain non-infectious factors. The pathogenesis and physiology of CP, especially non-bacterial prostatits (NBP), are not well understood. It is one of the most common conditions in young adult males and seriously affects the quality of life of adult males. It is now believed that chronic prostatitis is a clinical syndrome consisting of a group of diseases with their own unique etiology, clinical features and regression. In the concept of chronic prostatitis a series of associated clinical symptoms are mainly emphasized, including four basic elements (lower urinary tract symptoms, presence of evidence of inflammation, prostate involvement and lack of evidence of acute inflammation).
This disease belongs to the categories of seminal turbidity, gonorrhea and white turbidity in Chinese medicine. Long-term clinical practice shows that the combination of Chinese and Western medicine has obvious advantages in the treatment of this disease, and the efficacy of combined Chinese and Western medicine treatment is better than that of Western medicine alone or Chinese medicine alone. This disease is one of the characteristics of Chinese medicine treatment, but at present there is a lack of standardized treatment plan in China, because the lack of unified diagnosis and efficacy standards, which hinders the evaluation of the efficacy of the combination of Chinese and Western medicine diagnosis and treatment of chronic prostatitis and the improvement of the level of treatment, so there is an urgent need to develop guidelines for the combination of Chinese and Western medicine treatment of chronic prostatitis. The Chinese Association of Integrative Medicine (CAIM) Men’s Committee has been planning the preparation of the “Guidelines for Integrative Medicine in Chronic Prostatitis in China” since the Huangshan Conference in 2003. In accordance with the principle of evidence-based medicine (EBM), reference to numerous literature, after repeated discussions of the male experts of Chinese and Western medicine, finally completed the development of the “Chinese combined Chinese and Western medicine treatment guidelines for chronic prostatitis” (trial version), it is believed that this guide will provide useful guidance for the clinical workers of Chinese and Western medicine and urology in the diagnosis and treatment of chronic prostatitis and its clinical research. It is believed that this guideline will provide useful guidance to the Chinese and Western urological clinicians in the treatment of chronic prostatitis and clinical research.
The clinical classification of chronic prostatitis is numerous, but the research on the evidence is still based on retrospective analysis such as case studies and expert experience reports, and there are few prospective studies on the evidence, and even fewer using EBM. There is a lack of unified criteria and scientific and objective methods in the identification of evidence, therefore, there is an urgent need to standardize the evidence of chronic prostatitis. This guideline tries to use the literature with high credibility, such as large-scale, multicenter epidemiological reports, and after repeated arguments by experts, finally unifies the consensus on the identification and typing of chronic prostatitis in Chinese medicine.
This guideline has the following characteristics: 1. It combines the latest medical research results and reflects the concept of holistic regulation; 2. It grasps the combination of Chinese and Western medicine in this disease, reflects the characteristics of Chinese medicine in the diagnosis and treatment of this disease, and brings into play the advantages of combining Chinese and Western medicine; 3. 5. repeated discussions during the preparation process and consultation with a large number of clinicians to ensure the practicality, flexibility and operability of the contents of this guideline; 6. adhering to the principle of disease with evidence, i.e., the diagnosis is mainly based on the name of modern medicine, but the treatment still emphasizes the principle of diagnosis and treatment in Chinese medicine.
1, Western medicine diagnosis
(1) The new classification of prostatitis
Type I: equivalent to the traditional classification method of acute bacterial prostatitis (ABP). The onset of the disease is rapid and can be characterized by sudden onset of febrile illness with persistent and obvious symptoms of lower urinary tract infection, elevated white blood cell count in the urine, and positive bacterial culture in the blood or/and urine.
Type II: Corresponds to chronic bacterial prostatitis (CBP) in the traditional classification method. There are symptoms of recurrent lower urinary tract infections, elevated leukocyte counts in EPS/semen/VB3, and positive bacterial culture results. Type III: chronic prostatits/chronic pelvic pain syndromes (CP/CPPS), equivalent to chronic nonbacterial prostatits (CNP) in the traditional classification and prostatodynia (PD), mainly presenting with prolonged, recurrent pain or discomfort in the pelvic region lasting more than 3 months and negative EPS/semen/VB3 bacterial culture results. Based on the results of routine EPS/semen/VB3 microscopy, the type is subdivided into two subtypes, type IIIA (inflammatory CPPS) and type IIIB (non-inflammatory CPPS): patients with type IIIA have elevated numbers of leukocytes in EPS/semen/VB3, and patients with type IIIB have leukocytes in the normal range in EPS/semen/VB3. Type IV: asymptomatory inflammatory prostatitis (AIP), no subjective symptoms, only evidence of inflammation found on examination regarding the prostate.
(2) Clinical symptoms: Patients show varying degrees of urinary frequency, urgency, painful urination, incomplete urination, burning in the urethra, a small amount of white discharge from the urethra in the morning, at the end of urination or during defecation; painful discomfort in the perineum, external genital area, lower abdomen, suprapubic area, lumbosacral and perianal areas. There may also be waiting for urination, weakness of urination, thinning or interruption of the urine line and prolonged urination time. Some patients may also experience dizziness, fatigue, memory loss, abnormal sexual function, ejaculatory discomfort or pain and mental depression. In the diagnosis of chronic prostatitis, the NIH-CPSI is recommended for symptom assessment (Appendix 1). The NIH-CPSI consists of three main parts with nine questions (0-43 points). The first part assesses the site, frequency and severity of pain, and consists of questions 1-4 (0-21 points); the second part is urinary symptoms, assessing the severity of dysuria and urinary frequency, and consists of questions 5-6 (0-10 points); the third part assesses the impact on quality of life, and consists of questions 7-9 (0-12 points).
(3) Physical examination.
a. Local physical examination: check the patient’s lower abdomen, lumbosacral region, perineum, penis, external urethral opening, testes, epididymis and spermatic cord for abnormalities, which helps to make differential diagnosis.
b. Prostate finger examination: texture: full gland, or soft and hard, or nodules, or hard texture; pressure pain: may have limited pressure pain; size: may be mildly enlarged or normal.
(4) Laboratory tests
a. Urine routine analysis and urine sediment examination: urine routine analysis and urine sediment examination are auxiliary methods to exclude urinary tract infection and diagnose prostatitis.
b. Prostate massage fluid (EPS) microscopy: The normal value of WBC count in EPS is used <10/HP, and WBC≥10/HP and disappearance or reduction of lecithin vesicles are abnormal. the amount of WBC count in EPS is controversial, but it is generally believed that WBC count increases in EPS of patients with type II and type IIIA prostatitis, while WBC does not increase in type IIIB. WBC count and The cytoplasm of the macrophages in EPS contains components such as phagocytosed lecithin vesicles or cellular debris that are unique to prostatitis.
c. Pathogenic examination: When the prostate is infected with pathogens such as bacteria, mycobacteria and trichomonas, these pathogens can be detected in the EPS. The methods of sample collection are: (1) four-cup method: VB1 and VB2 for primary and secondary urine, which are localized for urethral and bladder infections, and VB3 and EPS to locate the prostate. However, it is generally less used because it is complex, time-consuming and expensive. (2) The two-cup method is recommended: only the middle urine before prostate massage (VB2) and urine after massage (VB3) are taken, and similar results to the four-cup method can be obtained .
The ultrasound examination of the prostate can be seen as uneven echogenicity, calcification, stones, dilation of the ducts, changes in the seminal vesicles and changes in the pelvic vein congestion, but it is not recommended to use ultrasound findings as a basis for diagnosis. The above-mentioned auxiliary examinations are mainly used to exclude other diseases that may exist in the genitourinary system and pelvic organs.
f. Differential diagnosis: Type III prostatitis needs to be differentiated from BPH, testicular epididymal and spermatic cord disease, overactive bladder, neurogenic bladder, interstitial cystitis, adenocystitis, sexually transmitted diseases, bladder tumors, prostate cancer, anorectal disease, lumbar spine disease, central and peripheral neuropathy, and other diseases that may cause pain and abnormal urination in the pelvic region.
2.Chinese medicine identification
(1) Basic pathogenesis.
The study of the pathogenesis is reflected in three different periods: before the 1960s, damp-heat injection was the main cause; from the 1960s to the end of the 20th century, stasis of blood was the main cause; from the end of the 20th century to the present, the pathogenesis is mostly considered to be damp-heat stasis and liver qi stagnation. The evolution of the pathogenesis of chronic prostatitis is mostly thought to occur in the early stage of damp-heat injection, the middle stage is mostly damp-heat stagnation, and the late stage is mostly accompanied by spleen and kidney deficiency.
(2) Identification and typing.
The evidence of chronic prostatitis is mainly divided into basic and compound evidence. In recent years, the results of a survey on the distribution of chronic prostatitis patterns show that the vast majority of CP are compound patterns, i.e., consisting of two or more basic patterns. The most frequent combinations were The most frequent combination of damp-heat injection plus qi stagnation and blood stasis (1039/1322, 78.59%), and some patients had kidney-yang deficiency (208/1332, 15.73%) in addition to the above two symptoms, which is consistent with traditional and modern TCM understanding. Combined with other epidemiological reports, it fully illustrates that the basic evidence types of chronic prostatitis are: damp-heat injection, qi stagnation and blood stasis, liver qi stagnation, and kidney yang deficiency, while the compound evidence types are damp-heat stagnation and liver-kidney yin deficiency.
The diagnostic criteria of the TCM evidence type: those who have 1 main symptom and 2 secondary symptoms and tongue and pulse, the diagnosis is established. The diagnosis can be quantified during clinical research: according to the principle of 2 points for one main symptom; 1 point for one secondary symptom and 1 point for tongue and pulse, the accumulated score; 5 points are established.
a. Basic types of evidence
(1) Damp-heat injection
Main symptoms: burning and painful urination, frequent and urgent urination.
Secondary symptoms: yellow and short red urine, dripping after urination, white and cloudy urine, damp scrotum, irritability and dry mouth, foul breath and abdominal swelling.
Tongue and pulse: yellow and greasy tongue coating, smooth and solid pulse or stringiness.
(2) Qi stagnation and blood stasis
Primary symptoms: pain in the perineum, or external genital area, or lower abdomen, or suprapubic area, or lumbosacral and perianal areas, and swelling in the above areas.
Secondary symptoms: dripping after urination, stinging pain in urination, dripping urine.
Tongue and pulse: dull tongue or petechiae, petechiae, stringent or astringent pulse.
(3) Liver Qi stagnation
Main symptoms: Pain and discomfort in the perineum, external genital area, lower abdomen, suprapubic area, lumbosacral area and perianal area, pain in the above areas, depression.
Secondary symptoms: dripping urine, chest tightness, anxiety, suspicion and fear of disease.
Tongue and pulse: light red tongue, string pulse.
(4) Kidney Yang deficiency
Main symptoms: fear of cold, weakness or pain in the waist and knees.
Secondary symptoms: dripping after urination, mental depression, impotence or low libido.
Tongue and pulse: pale tongue with thin white coating and sunken or weak pulse.
b. Compound evidence type
(1) Damp-heat stasis
Main symptoms: frequent, urgent, painful urination, difficulty in urination, discomfort or pain in perineum, or anus, milky discharge from urethra.
Secondary symptoms: incomplete urination, residual urine drainage, yellow urine, burning sensation in the urethra; bitter and dry mouth, damp scrotum.
Tongue and pulse: red tongue, yellowish greasy coating, string or slippery pulse.
(2) Liver and kidney yin deficiency
Main symptoms: weakness or pain in the waist and knees, irritable heat in the five hearts, insomnia and dreaminess.
Secondary symptoms: white and cloudy urine like rice slop, short and red urine, seminal emission, premature ejaculation, hypersexuality or Yang strength.
Tongue and pulse: red tongue with little coating, sunken or thin pulse.
c. Other evidence types: cold clotted liver veins, liver depression and fire, liver depression and spleen deficiency, spleen and kidney yang deficiency, deficiency of middle energy, etc. Identification can be based on the TCM elemental points method of identification.