Patients feel frustrated and helpless and physicians feel frustrated and defeated by a seemingly simple disease – the reasons for this are mainly related to the lack of understanding of the disease and the lack of success in its treatment.
It is now internationally recognized that
The quality of life of patients with chronic prostatitis is similar to that of patients who have had a myocardial infarction, unstable angina or Crohn’s disease! Indeed, most people would not expect such a seemingly small disease to place such a heavy burden on the patient.
Epidemiology
The most prevalent urological disease in men under 50 years of age, and its third most prevalent in men over 50 years of age. The prevalence in the population ranges from 5 to 8.8%.
Etiology and pathogenesis
It may be related to the following factors.
1. pathogenic infections (not only bacteria), the main causative agents include G-bacteria, staphylococci, gonococci, etc. Other unclear pathogens may include mycoplasma, chlamydia, trichomonas, viruses, etc.
2. Increased urethral resistance: Many scholars believe that the symptoms of urinary tract irritation and obstruction in prostatitis may be related to anatomical or physiological lower urinary tract obstruction. It may simply be a bladder neck problem, incoordination of the forced urinary sphincter, urethral stricture, etc.
3. Intraprostatic tubular urinary reflux: Some people have used charcoal powder particles injected into the bladder and later looked for them in the prostate tissue.
4, stones within the prostate: tiny stones sometimes form within the prostate, and if there are bacteria a micro-infection environment is formed; secondly the explanation itself or bacterial metabolites block the prostatic duct causing poor drainage.
5, autoimmune: some scholars have found that there is also an inflammatory response in aseptic prostatitis, possibly secondary to some unidentified antigenic substance, or perhaps an autoimmune response.
7, neuromuscular factors: inflammatory pain is definitely neurological, but there are many hypotheses about non-inflammatory pain, such as presumed nerve reflex pain, but no further confirmation has been obtained.
Classification
Traditional classification
Acute bacterial prostatitis – acute bacterial infection
Chronic bacterial prostatitis – recurrent bacterial infections
Chronic non-bacterial prostatitis: Inflammation caused by non-bacteria
Prostate pain – no laboratory evidence found, but symptoms are obvious
It may seem like a good classification, but it actually ignores a lot of problems and can lead to misunderstandings in treatment.
The new classification
NIH classification and definition of prostatitis
Class I Acute bacterial prostatitis of acute infection of the prostate
Class II Chronic bacterial prostatitis – recurrent prostate infections
Class III Chronic aseptic prostatitis/chronic pelvic pain syndrome (CPPS) without established infection
III A Inflammatory chronic pelvic pain syndrome with WBC in semen/EPS/VB3
III B Non-inflammatory chronic pelvic pain syndrome without WBC in semen/EPS/VB3
Class IV Asymptomatic inflammatory prostatitis without symptoms
The issue of classification received attention at a 1995 NIH briefing on prostatitis, where it was suggested that the classification of this disease should be changed. The newly proposed classification classified patients with obvious bacterial pathogens in EPS or VB3 (initial urine after massage) or both as Class II and those without obvious pathogens in culture as Class III or Chronic Pelvic Pain Syndrome (CPPS), a category further typed as III A and III B based on the presence of inflammatory cells in the prostate specimen.
The NIH subsequently hosted an International Collaborative Prostatitis Network research program and after 3 years of experience found that the new classification method proved practical both clinically and in research.
Diagnosis of Chronic Prostatitis
Symptoms are complex and varied: some physicians once jokingly referred to it as “a big garbage can”. In order to objectively evaluate and quantify the severity of symptoms, many symptom scales have been developed, the best known of which is the NIH Chronic Prostatitis Symptom Scale, which may become the standard in the future.
There are four sections.
1. Pain and discomfort: including the location of pain, frequency of pain episodes, and degree of pain
2. Urinary symptoms: the number of times they occur
3. Impact of symptoms: on work and psychological impact
4.Quality of life
Laboratory tests.
Gold standard Meares-Stamey 4-cup test: This test is a complex and expensive procedure that does not predict changes in symptoms after treatment, and has many false positives and false negatives, but has remained the gold standard for many years because there is no better way so far. The PPMT test is simpler and only collects pre- and post-massage urine.
The presence of additional leukocytes and bacteria in the Post-M specimen is indicative of Class II prostatitis compared to the Pre-M. The presence of leukocytes alone in the Post-M is indicative of Class IIIA, and the absence of both leukocytes and bacteria is indicative of Class IIIB. The diagnostic value of a positive PPMT and the false negative rate are similar to the four-cup test, but the false positive rate is higher than the former. Some of the more traditional scholars advocate the use of VB1 to rule out urethritis. However, in reality many patients with symptoms of chronic prostatitis have both urethritis and prostatitis, and a positive VB1 may lead to bacterial prostatitis being overlooked.
Treatment of Chronic Prostatitis
It is difficult. Why? First, the etiology is complex and cannot be solved by simple antibiotics. Secondly, it is difficult to achieve a completely correct diagnosis and therefore specific and targeted treatment is not always possible. The last and most important point is that the prostate is surrounded by a dense lipid envelope, and the epithelial layer of the prostatic follicle is a lipid epithelium, making it impossible for most drugs to penetrate into the prostate, and even if some of the drugs can enter the prostate, they cannot reach therapeutic concentration, so treatment becomes very difficult.
SMZ has been the first-line drug for the treatment of chronic prostatitis for many years, but the results of long-term follow-up have not been good, with cure rates ranging from 15 to 60 percent, according to different reports. Fluoroquinolones have now become the drug of choice for the treatment of chronic bacterial prostatitis, with significantly better efficacy than SMZ, but long-term effectiveness against recurrence as well as symptom relief has not been further validated. Data on the effectiveness of other antibiotic drugs are not available to date.
Pain medications, however, have little evidence of long-term efficacy. Because the pain of this syndrome differs from other chronic pain such as that caused by malignancy, in which psychological factors are relevant, it has been suggested that combining such drugs with tricyclic antidepressants may be more appropriate for the control of pain in prostatitis syndrome.
Anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs: have a good effect on some patients with non-specific inflammatory prostatitis.
Immunomodulators such as cytokine inhibitors or COX-2 inhibitors: are in development and have some effectiveness, but are not recommended until definitive clinical study results are available.
Valium, for example, is indicated in class IIIB chronic pelvic pain syndrome, especially in cases of confirmed dystocia of the detrusor muscles or spasm of the pelvic or perineal muscles.
Alpha blockers (Alpha-blockers): Prostatitis in some patients is thought to be related to abnormal urinary function and in some cases to the presence of prostatic tubular reflux. Blocking alpha receptors in the bladder neck or prostate area can improve urinary flow rates and theoretically relieve some of the symptoms of prostatitis. There are only very few controlled studies – clinical improvement rates range from 48% to 80%. Phenobianamine, alfuzosin, terazosin, etc.
5-Alpha-Reductase Inhibition (5-Alpha-Reductase Inhibition): Inflammation of the prostate gland epithelium appears to be under hormonal control, so the application of 5-alpha-reductase inhibitors makes the tubules and glandular tissue shrink with the potential ability to improve urinary flow rates, reduce reflux within the prostate, and possibly even reduce inflammation. A typical drug is the current kingpin of prostate enlargement treatment, Phytotherapy, which has been found in some small studies to have a positive effect on class IIIA inflammation, urination, and pain.
Phytotherapy: Various phytoconstituents may have these effects: 5-alpha reductase inhibitory activity, anti-inflammatory effects, improved urinary flow rate, alpha receptor blocking effects, placebo effects, etc. This is a class of drugs with a broad market and a promising future. There is already a pollen preparation abroad that has received a lot of attention, and related in-depth studies are numerous and have yielded positive results. In this regard, China’s herbal medicine is a strong point, but the market is currently mixed with related products, the real effective drugs still need to be discovered and further research.
Allopurinol: Some scholars believe that uric acid salts returning to the prostate can cause an inflammatory response. A placebo-controlled study showed positive results, suggesting a better effect with three months of allopurinol. However, further evaluation did not conclusively prove the efficacy of allopurinol. Therefore, widespread use remains to be seen.
Heat Therapy: There are two main forms of heat therapy for the prostate: transrectal heat therapy and transurethral heat therapy. Many reports in the literature have shown long-term results in some patients. The question, however, is how to decide which patients are suitable for this type of invasive treatment. Heat therapy may accelerate the healing process of chronic inflammation (e.g., fibrosis), but it may also affect or damage the nerves in the prostate, resulting in a “sympathetic blockage of the prostate.
Repetitive Prostate Massage: Once the basic treatment for prostatitis, it was abandoned in the late 1960s due to the development of lower urinary tract bacterial cultures and antibiotics. In recent years, it has regained popularity: firstly, because the commonly used pharmaceutical methods were not effective. Secondly, massage is believed to clear the blockage of the prostate ducts, improve microcirculation and help the penetration of antibiotics.
Surgery: Transurethral bladder neck dissection: may be effective in some patients with proven bladder neck obstruction. Transurethral balloon dilation of the prostate: the conclusions of different authors are controversial. Transurethral resection of the prostate (TURP), radical prostatectomy: both are considered to be used in refractory chronic bacterial prostatitis. In any case, the procedure must be strictly controlled for indications and is not recommended for aseptic prostatitis.
Supportive Therapy: Self-relaxation exercises, lifestyle changes, acupressure, acupuncture, sex, psychological suggestion, etc. sometimes produce good results in some patients or at least help to regulate the psychological condition.
Treatment strategies
Class II: The principle of treatment is adequate long-term antibiotic therapy. There is debate about the exact length of time, with the current preference being for 6 weeks. Surgery is the last option, unless nothing else works. Patients must be willing to accept the complications that come with it and the possibility that symptoms will not resolve after surgery.
Category IIIA: Patients in this category have no clear pathogenic infection in the prostate fluid, but do have elevated WBC. Because the etiology of this category is unknown, it is possible that some patients may have an underlying pathogenic infection, and therefore a 6-week trial of antibiotics is still warranted. If effective, another 6 weeks is recommended. The type of antibiotic used can be similar to class IIA, or antibiotics that include mycoplasma, chlamydia, etc. in the antibacterial spectrum can be considered. If ineffective, then prostate massage, anti-inflammatory drugs, and a-blockers should be considered as the next step.
As mentioned earlier, there may be some underlying pathogens and prostate massage may aid in drug penetration, so antibiotics should be administered concurrently with prostate massage. Prolotherapy, botanicals, and changes in lifestyle may be able to help these patients to some extent. A last resort may be the use of heat therapy, provided they take into account the possibility of complications and perhaps do not relieve the symptoms. For this category of patients, surgery is not indicated.
Category IIIB: The aim of treatment in this category is to relieve symptoms. Despite the absence of WBC or pathogenic bacteria in the specimen, it is prudent to still give one cycle (4 weeks) of treatment before abandoning antibiotics, which will still be effective in a small percentage of patients. After the antibiotics are ineffective, then the problem may not be entirely prostate related. A triple therapy can be used, where the three types of drugs should be combined rather than applied all at once. At this point it is best for the patient to stay home on leave for about two weeks.
If this period is effective, then the pain medication can be replaced with a non-steroidal anti-inflammatory analgesic. Muscarinic drugs can also be tapered, but a-blockers are best maintained for at least 3 months. If this does not work, a range of supportive treatments can be tried. Both physicians and patients must recognize that for category IIIB, the goal of treatment is to relieve symptoms and improve quality of life rather than to cure.
Category IV: Inflammation is often found in prostate specimens from men who do not have symptoms of prostatitis. Treatment is not indicated for most patients in this category. In some cases where inflammation is found on biopsy due to an elevated PSA, it is best to treat with antibiotics rather than prepare for another biopsy. If inflammation is confirmed in the prostate in patients with BPH or prostate cancer, prophylactic antibiotics are strongly recommended prior to endoscopy or surgical treatment. If a patient is seen for infertility and inflammation is found, then a course of antibiotics is warranted.
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