The main cause of chronic bacterial prostatitis is pathogenic infection, mainly retrograde infection, the pathogens are mainly Staphylococcus spp, often with a history of repeated episodes of urinary tract infection or persistent presence of pathogenic bacteria in the prostate massage fluid.
The pathogenic factors are also mainly pathogenic infections, but the body is more resistant or/and pathogen virulence is weak, to retrograde infection, the pathogens are mainly Staphylococcus spp, followed by Escherichia coli, rod-shaped bacilli and Enterococcus spp. Prostate stones and urinary reflux may be important reasons for the persistence of pathogens and recurrence of infection.
1, chronic non-bacterial prostatitis
The etiology is very complex and its main cause may be the result of a combination of pathogenic infection, inflammation and abnormal pelvic floor neuromuscular activity and immune abnormalities.
(1) Pathogenic infection In this type of patient, although routine bacterial examination fails to isolate the pathogen, it may still be associated with some specific pathogens: such as anaerobic bacteria, L-type Aspergillus, nanobacteria, or Chlamydia trachomatis and mycoplasma infections. It is also possible to detect up to 77% of local prokaryotic DNA in this type of patient; some clinical “aseptic” prostatitis with chronic inflammation, recurrent or aggravated, may be related to these pathogens. Other pathogens such as parasites, fungi, viruses, trichomonas, and Mycobacterium tuberculosis may also be important causative factors for this type, but the lack of reliable evidence has not yet led to a unified opinion.
Many patients with prostatitis have a variety of urodynamic changes, such as reduced urinary flow rate, functional urinary tract obstruction, and dysfunction of the detrusor-urethral sphincter synergy. These functional abnormalities may only be a clinical phenomenon, and their nature may be related to various underlying pathogenic factors.
(3) Psycho-psychological factors Studies have shown that more than half of the patients with persistent prostatitis have significant psycho-psychological factors and personality traits changes. For example, anxiety, depression, hypochondria, hysteria, and even suicidal tendencies. These changes in mental and psychological factors can cause plant nerve dysfunction, resulting in posterior urethral neuromuscular dysfunction, leading to pain in the pelvic region and dysfunctional urination; or cause changes in the function of the hypothalamic-pituitary-gonadal axis and affect sexual function, further aggravating the symptoms, eliminating mental tension can make the symptoms ease or heal. However, it is not clear whether psychosomatic changes are the direct cause or secondary manifestations.
(4) Neuroendocrine factors Patients with prostate pain are often prone to fluctuations in heart rate and blood pressure, indicating that they may be related to autonomic responses. Their pain has the characteristics of visceral organ pain. Local pathological stimulation of the prostate and urethra triggers spinal reflexes through the afferent nerves of the prostate, activates astrocytes in the lumbar and sacral medulla, nerve impulses send out impulses through the genitofemoral and ilioinguinal nerves, and sympathetic nerve endings release norepinephrine, prostaglandins, calcitonin gene-related peptides, and substance P, causing vesicourethral dysfunction, and cause abnormal activity of perineal and pelvic floor muscles, and persistent pain and involvement pain in the corresponding areas other than the prostate.
(5) Abnormal immune response Recent studies have shown that immune factors play a very important role in the development and evolution of type III prostatitis. Changes in the levels of certain cytokines, such as IL-2, IL-6, IL-8, IL-10, TNF-α and MCP-1, can occur in the prostatic fluid and/or seminal plasma and/or tissues and/or blood of patients, and IL 10 levels are positively correlated with the pain symptoms in patients with type III prostatitis, and the application of immunosuppressive therapy has some effect.
(6) Oxidative stress theory Under normal circumstances, the production, utilization and removal of oxygen free radicals in the body are in a dynamic balance. Prostatitis patients with excessive production of oxygen free radicals or/and the role of the free radical scavenging system is relatively reduced, thus reducing the body’s ability to respond to oxidative stress, oxidative stress products or/and by-products increase, may also be one of the pathogenesis.
(7) Pelvic-related disease factors Some patients with prostatitis are often accompanied by dilated venous plexus in the peripheral zone of the prostate, hemorrhoids, varicose veins of the spermatic cord, etc., suggesting that the symptoms of some patients with chronic prostatitis may be related to pelvic venous congestion and blood stagnation, which may also be one of the causes of prolonged treatment.
2. Classification
The naming of chronic prostatitis belongs to the old classification system, in which prostatitis is divided into: acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), chronic non-bacterial prostatitis (CNP), prostate pain (PD). Chronic prostatitis is divided into: chronic bacterial prostatitis and chronic non-bacterial prostatitis, both of which are equivalent to the NIH typing of prostatitis with type II and type III respectively.
3, clinical performance
1, chronic bacterial prostatitis
There are repeated episodes of lower urinary tract infection symptoms, such as urinary frequency, urinary urgency, painful urination, burning sensation in urination, difficulty in urination, urinary retention, and discomfort in the posterior urethra, anus, and perineal area. The duration is more than 3 months.
2.Chronic non-bacterial prostatitis
The main manifestation is pain in the pelvic region, which can be seen in the perineum, penis, perianal area, urethra, pubic bone or lumbosacral area. The abnormal urination can be manifested as urinary urgency, frequency, painful urination and increased nocturia. As chronic pain remains untreated, patients have a reduced quality of life and may have sexual dysfunction, anxiety, depression, insomnia and memory loss.
4.Diagnosis
Chronic prostatitis: detailed history, comprehensive physical examination (including rectal examination), routine urine and prostate massage fluid examination are required. The NIH Chronic Prostatitis Symptom Index is recommended for scoring symptoms. The “two-cup method” or “four-cup method” is recommended for pathogen localization testing.
To make a definitive diagnosis and differential diagnosis, the following tests are available: semen analysis or bacterial culture, prostate-specific antigen, urine cytology, transabdominal or transrectal ultrasound (including residual urine measurement), urine flow rate, urodynamics, CT, MRI, urethral cystoscopy, and prostate puncture biopsy.
Specific diagnostic methods.
1, Medical history taking.
2.Physical examination
Rectal examination can understand the size and texture of the prostate, the presence or absence of nodules, the presence or absence of pressure pain and its extent and degree, the tension of the pelvic floor muscles, the presence or absence of pressure pain in the pelvic wall, and massage the prostate to obtain prostatic fluid.
3. Laboratory tests
(1) Routine examination of prostate massage fluid (EPS) Normal EPS has leukocytes HP, lecithin vesicles evenly distributed throughout the visual field, pH 6.3-6.5, erythrocytes and epithelial cells are absent or occasionally seen. When leukocytes >10/HP and the number of lecithin vesicles is reduced, there is a diagnostic significance.
(2) Routine urine analysis and urine sediment examination Routine urine analysis and urine sediment examination are auxiliary methods to exclude urinary tract infection and diagnose prostatitis.
(3) Bacteriological examination Chronic prostatitis is recommended “two cup method” or “four cup method” pathogen localization test.
(4) Other pathogens include Chlamydia trachomatis and mycoplasma.
4.Instrument examination
(1) Ultrasound Although ultrasound examination of patients with prostatitis can reveal uneven prostate echogenicity, prostate stones or calcification, and dilated periprostatic plexus, there is still a lack of specific performance of ultrasound for diagnosing prostatitis, and it is not possible to use ultrasound for typing prostatitis.
(2) Urodynamics
(1) Urine flow rate. Urine flow rate examination can give a general idea of the patient’s urination status and help to differentiate prostatitis from diseases related to urination disorders;
②Urodynamic examination, which can detect bladder urethral dysfunction.
(3) CT and MRI have potential applications for identifying pelvic organ lesions such as seminal vesicles and ejaculatory ducts, but the diagnostic value for prostatitis itself remains unclear.
5.Differential diagnosis
Chronic prostatitis lacks an objective and specific diagnostic basis. The clinical diagnosis should be made differently from diseases that may cause pain in the pelvic region and abnormal urination, and the presence or absence of bladder outlet obstruction and abnormal bladder function should be clarified in patients with predominantly abnormal urination. Diseases to be differentiated include benign prostatic hyperplasia, 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, and central and peripheral neuropathy.
Patients whose symptoms are not relieved after treatment should be selected for further examination, depending on the specific situation, except for the above-mentioned diseases.
6.Treatment
Chronic bacterial prostatitis treatment is based on oral antibiotics, choosing sensitive drugs for a course of 4 to 6 weeks, during which the patient should be evaluated for stage efficacy. If the efficacy is not satisfactory, other sensitive antibiotics can be used instead. Alpha-blockers can be used to improve urinary symptoms and pain. Botanicals, NSAIDs and M-blockers can also improve the associated symptoms.
Chronic non-bacterial prostatitis: oral antibiotics can be given for 2 to 4 weeks and then the decision to continue antibiotic therapy is based on their efficacy feedback. Alpha-blockers are recommended to improve urinary symptoms and pain. Phytochemicals, NSAIDs and M-blockers are also available to improve urinary symptoms and pain.
The goal of treatment for chronic prostatitis is mainly to relieve pain, improve urinary symptoms and improve quality of life, and the evaluation of efficacy should be based on symptom improvement.
1, general treatment
The patient should self psychological guidance, maintain a cheerful and optimistic attitude towards life, should abstain from alcohol, avoid spicy and stimulating food; avoid holding urine, sedentary and long time cycling, horseback riding, pay attention to warmth and strengthen physical exercise.
2.Drug treatment
The most commonly used drugs are antibiotics, alpha-blockers, plant preparations and non-steroidal anti-inflammatory analgesics, and other drugs also have different degrees of efficacy in relieving symptoms.
(1) Antibiotics Currently, the most commonly used first-line drugs in clinical practice for the treatment of prostatitis are antibiotics, but only about 5% of patients with chronic prostatitis have a definite bacterial infection.
Chronic bacterial prostatitis: antibiotics are chosen based on bacterial culture results and the ability of the drug to penetrate the prostate. After the diagnosis of prostatitis is confirmed, the course of antibiotic therapy is 4 to 6 weeks, during which the patient should be evaluated for stage efficacy. Intraprostatic antibiotic injections are not recommended as a treatment.
Chronic non-bacterial prostatitis: antibiotic therapy is mostly empirical and is based on the theory that certain pathogens that are routinely culture-negative are presumed to cause this type of inflammation. Therefore, oral antibiotics such as fluoroquinolones are recommended for 2 to 4 weeks, and then the decision to continue antibiotic therapy is based on feedback on efficacy. Continuation of antibiotics is recommended only when there is a definite reduction in clinical symptoms. The recommended total course of treatment is 4 to 6 weeks.
(2) Alpha-blockers Alpha-blockers improve lower urinary tract symptoms and pain by relaxing smooth muscles in the prostate and bladder, and are therefore the basic treatment for type II/III prostatitis.
Different alpha-blockers can be chosen depending on the patient’s condition. The main recommended alpha-blockers are: doxazosin, napalmedil, tamsulosin and terazosin, etc. The results of controlled studies have shown that the above-mentioned drugs have different degrees of improvement on patients’ urinary symptoms, pain and quality of life index.
(3) Botanical preparations The therapeutic role of botanical preparations in type II and III prostatitis is gaining attention as recommended therapeutic drugs. Botanical preparations mainly refer to pollen-based preparations and plant extracts, which have a wide range of pharmacological effects, such as non-specific anti-inflammatory, anti-edema, and promoting bladder contraction and urethral smooth muscle relaxation. The recommended botanical preparations are: Pulsatilla, sabal palm and its infusion, etc. Due to the large number of varieties, their dosage depends on the specific condition of the patient, and the course of treatment is usually measured in months. Adverse reactions are small.
(4) Non-steroidal anti-inflammatory analgesics Non-steroidal anti-inflammatory analgesics are empirical drugs used to treat symptoms associated with type III prostatitis. Their main purpose is to relieve pain and discomfort.
(5) M-blockers M-blockers (e.g., tolterodine) can be used to treat patients with prostatitis who exhibit symptoms such as urinary urgency, frequency and nocturia but no urinary tract obstruction.
(6) Antidepressants and anxiolytics For patients with chronic prostatitis who have a combination of depression, anxiety and other mood disorders, you can choose to use antidepressants and anxiolytics to treat the prostatitis at the same time. These medications can improve the patient’s mood disorder symptoms as well as relieve physical symptoms such as abnormal urination and pain. It is important to be aware of the prescription regulations and adverse drug reactions to these drugs when applying them. The main antidepressants and anxiolytics available are selective 5-hydroxytryptamine reuptake inhibitors, tricyclic antidepressants and other drugs.
(7) Chinese herbal medicine It is recommended that the Chinese herbal medicine treatment of prostatitis be carried out in accordance with the relevant norms of the Chinese Medicine Association or the Society of Integrative Medicine.
3.Other treatments
(1) Prostate massage Prostate massage is one of the traditional treatment methods. Studies have shown that proper prostate massage can promote prostate duct emptying and increase local drug concentration, thus relieving the symptoms of patients with chronic prostatitis, so it is recommended as an adjuvant therapy for type III prostatitis. Type I prostatitis patients are prohibited.
(The actual fact is that the actual pelvic floor muscles are not as good as they should be. Biofeedback combined with electrical stimulation therapy can relax and harmonize the pelvic floor muscles and relax the external sphincter, thus relieving the perineal discomfort and urinary symptoms of chronic prostatitis.
(The main purpose of this is to increase the blood circulation in the prostate tissue and accelerate the metabolism, which helps to reduce inflammation and eliminate tissue edema and relieve pelvic floor muscle spasm. It has a short-term effect on relieving symptoms, but the long-term effect is unclear. It is not recommended for unmarried and infertile people.
(4) Prostate injection therapy/transurethral prostate perfusion therapy Efficacy and safety have not been confirmed.