Prostatitis is a clinical syndrome characterized by pain in the perineum, pelvis, suprapubic area, external genitalia and varying degrees of urinary and ejaculatory symptoms, some patients may also exhibit varying degrees of erectile dysfunction, depression and even infertility. The course of prostatitis is variable, very few are acute and most are chronic. A small percentage (5-10%) are associated with bacterial infections (with clear evidence of bacterial infection), and most of the etiology is inconclusive and not even related to the prostate itself.
The International Prostatitis Collaborative Network, formed by the National Institutes of Health (NIH), proposed a new definition and classification system for prostatitis syndrome in 1995. This system is now widely accepted and recommended by the international academic community as the basic framework for the study and treatment of prostatitis.
NIH Prostatitis Syndrome Classification and Definition.
I Acute bacterial prostatitis: acute infection of the prostate
II Chronic bacterial prostatitis: recurrent infection of the prostate
III chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS): no verifiable presence of infection
IIIA inflammatory CPPS: presence of leukocytes in semen, prostatic fluid (EPS) or urine after prostate massage (VB3)
IIIB non-inflammatory CPPS: no evidence of inflammation in semen, EPS, or VB3
IV asymptomatic inflammatory prostatitis: no subjective symptoms, diagnosed by prostate biopsy or the presence of leukocytes in prostate fluid/semen during the diagnosis of other diseases
Acute Bacterial Prostatitis (Type I)
Acute bacterial prostatitis is an acute infection of the prostate and lower urinary tract caused by Gram-negative bacilli (E. coli is the most common), enterococci and Staphylococcus aureus, and is a serious systemic disease.
Diagnostic criteria
I. Symptoms
(i) Symptoms of urinary tract infection: urinary frequency, urgency, painful urination and difficulty in urination, sometimes acute urinary retention may occur.
(ii) Symptoms of prostatitis: pain in the lumbosacral region, perineum, penis, and even rectum.
(iii) Symptoms of bacteraemia: chills and fever, and sometimes joint and muscle pain.
Second, physical signs
(i) Local signs of prostate: rectal palpation reveals smooth surface of prostate, swelling, increased tension, obvious tenderness, and fluctuating sensation can be palpated in case of abscess formation.
(ii) Bacteraemia signs: elevated body temperature and tachycardia.
Laboratory tests
(i) Middle urine (VB2) analysis, culture and drug sensitivity test: active bacteria and white blood cells can be detected in urine, and bacterial culture can find pathogenic bacteria (colony count >105/ml).
(ii) Blood routine, culture and drug sensitivity test: elevated leukocyte count in blood and possible positive findings in bacterial culture.
(iii) Prostate massage: Prostate massage is not advisable when suffering from acute bacterial prostatitis. The pain during prostate massage is intense and can promote bacteremia. In addition, most of the pathogenic bacteria can be isolated from the urine, and there is little value in performing prostate fluid examination.
The standard of treatment
Cure criteria.
I. Systemic and local symptoms and signs disappeared.
The laboratory tests showed no evidence of bacterial infection in the urinary tract and prostate, and no evidence of inflammation in the semen, EPS or VB3.
III. Normal routine blood leukocyte count and negative blood culture.
Chronic prostatitis (type II and III)
Patients with chronic bacterial prostatitis often have recurrent and recurrent lower urinary tract infections caused by the same pathogenic bacteria (same as acute bacterial prostatitis, still E. coli is most common). In the interval between symptomatic bacteriuria, lower urinary tract bacterial cultures may demonstrate that the prostate infection is the source focus of this recurrent infection.
Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) refers to the presence of discomfort or pain in the pelvic region, but the presence of pathogenic bacteria cannot be detected by standard microbiological methods, and may be associated with urinary symptoms and sexual dysfunction of varying degrees, usually over a 3-month duration. CP/CPPS accounts for more than 90% of patients with symptomatic prostatitis, and the etiology is unknown; factors other than the prostate cannot be ruled out as The cause of CP/CPPS is unknown and does not exclude the possibility that factors other than the prostate are important.
Diagnostic criteria
I. Mandatory evaluation items
(i) Medical history: Patients with chronic bacterial prostatitis mostly have a history of acute bacterial prostatitis, recurrent lower urinary tract infections or effective antibacterial medication. Both chronic bacterial and non-bacterial prostatitis can have variable and varying degrees of discomfort or pain in the perineum, lumbosacral region, external genitalia and during ejaculation, and symptoms of urinary urgency, frequency, nocturia, painful urination and difficulty in urination. The duration of the disease was more than 3 months.
(ii) Physical examination (including rectal examination): there are usually no objective physical signs and there may or may not be prostate tenderness. The purpose of physical examination is mainly to exclude other diseases.
(iii) Urinalysis/culture: used to screen for hematuria and possible lower urinary tract infection. If there is a positive finding, the next step in the consultation and treatment plan may need to be adjusted.
II. Recommended tests
(i) Meares-Stamey four-cup method or two-cup test before and after prostate massage: The four-cup method is the gold standard for identifying chronic bacterial prostatitis, inflammatory and non-inflammatory CP/CPPS, but this method is time-consuming, cumbersome and rarely used in clinical work. After excluding UTI, the two-cup method of examination before and after prostate massage proposed by NickelJC can be used. For patients with a history of recurrent urinary tract infections or obvious signs of infection, the four-cup method is still appropriate. The criteria for the four-cup method (the criteria for the two-cup method also refer to the relevant content of this standard) are as follows.
1. If the colony count in EPS or VB3 is 10 times or more than that of VB1, the prostate is considered to have a bacterial infection.
2, polymorphonuclear leukocytes (PMNL) count ≥ 10/HPF (×400) in EPS, or PMNL count 10/HPF or more in VB2 and VB1, can establish the diagnosis of inflammatory CP, and vice versa for non-inflammatory CP.
3. If the colony counts of the four-cup specimen are similar and high, apply furadantin and penicillin (these drugs can inhibit or eliminate bacteria in the urethra and bladder, but not in the prostate) after treatment, then perform the four-cup method of examination.
(ii) Chronic prostatitis symptom assessment: Symptom assessment using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) is recommended to understand the severity of symptoms and the impact on the patient’s quality of life, and also to facilitate evaluation of the effectiveness of treatment.
(iii) Urine flow rate or residual urine measurement: It can provide information on the functional status of the lower urinary tract.
(iv) Urine cytology examination: it is suitable for patients with microscopic hematuria or urinary irritation symptoms.
III. Selective examination items
(i) Semen analysis and culture: applicable to infertile patients with chronic prostatitis.
(ii) Urethral swab culture: for patients with a history of STD and/or signs of UTI.
(iii) Urodynamic examination: including pressure-flow rate measurement, imaging urodynamics and electromyography (Flow-EMG), for patients with symptoms of unexplained voiding obstruction.
(iv) Cystoscopy: for patients with hematuria, suspicious urine cytology, irritative and obstructive voiding symptoms, and abnormal urodynamics. It can detect underlying, severe lower urinary tract disease.
(v) Transrectal prostate ultrasound: for patients in whom previous treatment has failed and whose history and physical examination suggest the presence of other causes. It may detect prostate abscesses or cysts as well as abnormalities of the seminal vesicle glands and ejaculatory ducts.
(vi) Pelvic imaging: including ultrasound, CT, MRI, with the same indications as transrectal ultrasound.
(vii) PSA assay: for patients with abnormal rectal fingers prostate or age >50 years.
Curative criteria
Cure criteria.
I. Disappearance of symptoms.
ii. No evidence of inflammation in semen, EPS or VB3.
III. For chronic bacterial prostatitis, there must also be no evidence of prostate and urinary tract infection.
Asymptomatic inflammatory prostatitis (type IV)
Diagnostic criteria
Asymptomatic inflammatory prostatitis can be diagnosed by having one of the following two
I. A prostate biopsy reveals diffuse or focal infiltration of single nucleated cells (lymphocytes, monocytes and plasma cells) in the stroma surrounding the gland or ducts, but should not include lymph nodules scattered in the stroma.
Second, the presence of leukocytes in EPS or semen (refer to the diagnostic criteria for inflammatory CP).
Therapeutic criteria
This type of prostatitis generally does not require treatment. Treatment may be considered when suspected to be related to sexual dysfunction, infertility or elevated PSA. The efficacy criteria may refer to chronic prostatitis.