The pathogenesis and pathophysiology of CP, especially non-bacterial prostatitis (NBP), is not well understood. This disease belongs to the category 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.
Western medicine diagnosis
1, the new classification of prostatitis
Type I: that is, acute prostatitis (ABP), with an acute onset, accompanied by persistent and obvious symptoms of lower urinary tract infection, elevated number of white blood cells in the urine, positive bacterial culture in the blood and/or urine. Type II: chronic bacterial prostatitis (CBP) with recurrent lower urinary tract infection symptoms, elevated leukocyte count in prostatic fluid (EPS) or semen or post-massage urine (VB3), and positive bacterial culture results.
Type III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), equivalent to chronic non-bacterial prostatitis (CNP) and prostatodynia (PD) in the traditional classification, mainly presenting with long-term, recurrent pain or discomfort in the pelvic region for more than 3 months, and negative bacterial cultures of EPS or semen or VB3;
According to the routine microscopic examination of EPS or semen or VB3, this type is subdivided into two subtypes: type IIIA (inflammatory CPPS) and type IIIB (non-inflammatory CPPS), i.e. type IIIA patients have elevated white blood cell count in EPS or semen or VB3, while type IIIB patients have white blood cells in EPS or semen or VB3 in the normal range. Type IV: asymptomatic prostatitis, no subjective symptoms, only evidence of inflammation found during the examination of the prostate.
2. Clinical symptoms
The patient shows 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; perineum, external genital area, lower abdomen, suprapubic area, lumbosacral and perianal swelling and pain. 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, discomfort or painful ejaculation, and depression, etc. When diagnosing chronic prostatitis, the NIH2CPSI is recommended for symptom assessment.
The NIH2CPSI consists of three main parts with 9 questions (0-43 points). The first part assesses the location, frequency and severity of pain, and consists of questions 1-4 (0-21 points); the second part assesses the severity of dysuria and frequency of urination, 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
(1) Local physical examination: check the patient’s lower abdomen, lumbosacral region, perineum, penis, urethral orifice, testes, epididymis, spermatic cord, etc. for any abnormalities, which can help in differential diagnosis.
(2) Prostate finger diagnosis: texture: gland full, or hard or soft, or nodules, or hard; pressure: may have limited pressure pain; size: may be mildly enlarged or normal.
4.Laboratory tests
4.1 Routine urinalysis and urine sedimentation examination
The urine routine and urine sediment examination is an auxiliary method to exclude urinary tract infection and diagnose prostatitis.
4.2 Prostate fluid (EPS) examination
The number of WBCs in EPS is controversial, but it is generally believed that the number of WBCs in EPS increases in patients with type II and type IIIA prostatitis, while WBCs do not increase in type IIIB. The WBC count does not necessarily correlate with the severity of symptoms. The WBC count correlates with the severity of symptoms, and the cytoplasm of the macrophages in EPS contains components such as phagocytosed lecithin vesicles or cellular debris, which are unique to prostatitis.
4.3 Pathogenic examination
When the prostate is infected with pathogens such as bacteria, mycobacteria and trichomonas, these pathogens can be detected in the EPS. (1) Four-cup method: VB 1 and VB 2 for primary and intermediate urine, which are useful for localizing urethral and bladder infections, and VB 3 and EPS for localizing the prostate. However, because of its complicated, time-consuming and costly operation, it is generally used less often. (2) The two-cup method is recommended: only the middle urine (VB 2) and the post-massage urine (VB 3) are taken before the prostate massage, which can obtain similar results as the four-cup method.
5, auxiliary tests
The main tests are B ultrasound, uroflow rate, urodynamics, cystoscopy, urethroscopy, CT and MRI, etc. B ultrasound can reveal echogenicity of the prostate, calcification, stones, dilated ducts, changes in the seminal vesicles, and changes in pelvic vein congestion, but it is not recommended to use the B ultrasound findings as a basis for diagnosis. The above auxiliary examinations are mainly used to exclude other diseases that may exist in the genitourinary system and pelvic organs.
6. Differential diagnosis
Type III prostatitis needs to be differentiated from 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, central and peripheral neuropathy, and other diseases that may cause pain and abnormal urination in the pelvic region.
Chinese medicine identification
1. Basic pathogenesis
The evolution of the pathogenesis of chronic prostatitis is mostly thought to be due to damp-heat injection in the early stage of the disease, damp-heat stagnation in the middle stage, and spleen and kidney deficiency in the late stage.
2. Identification and typing
The evidence of chronic prostatitis is mainly divided into basic and compound evidence. The epidemiological reports of chronic prostatitis are the following: damp heat, blood stagnation, liver qi stagnation, deficiency of kidney yang, and the complex type of damp heat and stagnation, liver and kidney yin deficiency.
2.1 Basic evidence types
2.1.1 Damp-heat infusion
Main symptoms: burning and astringent pain in the urine, urinary frequency and urgency. Secondary symptoms: yellow and short red urine, dripping after urination, white and cloudy urine, dampness of the scrotum, irritability and dryness of the mouth, foul breath and abdominal swelling. Tongue and pulse: yellow and greasy tongue coating, slippery or stringy pulse.
2.1.2 Qi stagnation and blood stasis
Main 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: dribbling after urination, stinging pain in urination, dripping urine. Tongue and pulse: dull tongue or petechiae, petechiae, stringent or astringent pulse.
2.1.3 Liver qi stagnation
Main symptoms: perineum, or external genital area, or lower abdomen, or suprapubic area, or lumbosacral and perianal swelling and discomfort, the above parts seem to be painful but not painful, depression. Secondary symptoms: dysuria, chest tightness, anxiety, suspicion and fear of disease. Tongue and pulse: light red tongue, string pulse.
2.1.4 Kidney Yang deficiency
Main symptoms: fear of cold, softness 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.
2.2 Combination of evidence
2.2.1 Damp-heat stagnation
Main symptoms: frequent urination, urgent urination, painful urination, difficulty in urination, discomfort or pain in the perineum or anus, milky discharge from the urethra. Secondary symptoms: incomplete urination, residual urination, 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.
2.2.2 Liver and kidney yin deficiency
Main symptoms: softness or pain in the lumbar and knees, irritable heat in the five hearts, insomnia and dreaminess. Secondary symptoms: white and cloudy urine like rice slop or short red, seminal emission, premature ejaculation, hypersexuality or Yang strength. Tongue and pulse: red tongue with little coating, sunken or thin pulse.
2.3 Other symptoms
Cold clotting in the liver, liver depression and fire, liver depression and spleen deficiency, spleen and kidney yang deficiency, deficiency of middle energy, etc. The symptoms can be identified according to the TCM identification factor points method.
Treatment
Treatment principle: The main goal of the comprehensive treatment of chronic prostatitis with TCM and TCM is to improve the symptoms. In addition to individualized treatment, we also pay attention to the quality of life and correction of poor lifestyles.
1, general treatment
Patients should abstain from alcohol, avoid spicy and stimulating food; avoid holding urine, sedentary, pay attention to warmth, and strengthen physical exercise. Should avoid impure sex and frequent sexual excitement, encourage moderate sexual life. The regular prostate massage treatment can also significantly relieve the patient’s discomfort. Biofeedback therapy is also good for relieving pelvic floor and perineal discomfort and pain caused by pelvic floor perineal muscle tension and spasm.
2 .Western medicine treatment
The three most commonly used drugs are antibiotics, alpha 2 blockers and non-steroidal anti-inflammatory analgesics, and other drugs also have different degrees of efficacy in relieving symptoms.
2.1 Antibiotics
The most common first-line drug used in the clinical practice of treating prostatitis is antibiotics, but only about 5% of patients with chronic prostatitis are found to have a definite bacterial infection. If the results are not satisfactory, you can switch to other sensitive antibiotics. The treatment of intraprostatic injection of antibiotics is not recommended.
Theoretically, it is assumed that certain pathogens that are currently undetectable in routine cultures are responsible for the inflammation. Therefore, oral fluoroquinolone antibiotics are recommended for 2-4 weeks, and then the decision to continue antibiotic therapy is based on the feedback of the efficacy, and only when the patient’s clinical symptoms do decrease is it recommended to continue antibiotics, and the total recommended course is 4-6 weeks. Some patients may have pathogens such as Chlamydia trachomatis, Mycoplasma solium or Mycoplasma humanum, and may be treated with oral antibiotics such as macrolides.
Type III B: antibiotic treatment is not recommended.
2.2 Alpha 2 receptor blockers
The main reason for this is that it can relax the smooth muscles of the prostate and bladder and improve the symptoms and pain in the lower urinary tract, which makes it the basic drug for the treatment of type II or III prostatitis. The choice of alpha 2 blockers can vary according to the individual patient. The treatment should be aware of adverse effects such as vertigo and postural hypotension caused by these drugs. The alpha 2 blockers can be combined with antibiotics for the treatment of type IIIA prostatitis, and the combined course of treatment should be at least 6 weeks.
2.3 Non-steroidal anti-inflammatory analgesics
The main purpose of these drugs is to relieve pain and discomfort.
3. Other drugs
The use of botanicals, M2-blockers, antidepressants and anxiolytics can also be used according to clinical conditions.
4.TCM diagnosis and treatment
4.1 Damp-heat injection
Treatment: Clear heat and dampness. Combination of Chinese and Western medicine: Type III can be treated with traditional Chinese medicine alone and, if necessary, with western medicine. Under the premise of diagnosis and treatment, western medicine can be selected according to specific conditions to improve the efficacy, such as when VB 3 bacterial culture positive, oral fluoroquinolone antibiotic treatment is recommended for at least 4-6 weeks; Type IIIA oral fluoroquinolone antibiotics for 2-4 weeks, the patient’s clinical symptoms have been reduced, then recommended to continue antibiotic treatment, the total course of treatment for 4-6 weeks; Type IIIB western medicine treatment can also be used according to the need for alpha 2 receptor blockers as needed.
4.2 Qi stagnation and blood stasis
Treatment: Move the Qi and activate the Blood… The main symptom of Qi stagnation and blood stasis is pain. Type III is treated with Chinese medicine alone, and western medicine can be added if necessary. Alpha 2 blockers and non-steroidal anti-inflammatory analgesics can be used. If necessary, antibiotics can be used.
4.3 Liver Qi Stagnation
Treatment: De-stress the liver and relieve depression. Combination of Chinese and Western medicine ideas: this type of evidence can be treated with Chinese medicine alone, in the more serious mental symptoms, such as anxiety, depression, etc., according to the clinical needs of the choice of antidepressants and anti-anxiety drugs. The appropriate use of alpha 2 blockers and non-steroidal analgesics can help improve the efficacy.
4.4 Deficiency of kidney yang
Treatment: Tonify the kidney and strengthen Yang. Combination of traditional Chinese and Western medicine: to support the righteousness and dispel the evil.
4.5 Dampness and heat stagnation
Treatment: Clearing heat, relieving dampness, resolving stasis and relieving pain. Combination of Chinese and Western medicine: Type II can be treated with Chinese and Western medicine, Type III can be treated with Chinese medicine alone, and Western medicine can be added if necessary. Under the premise of diagnosis and treatment, fluoroquinolone antibiotics can be used for oral administration if there is clear infection. Alpha 2 blockers and non-steroidal anti-inflammatory analgesics can also be used according to clinical needs.
4.6 Yin deficiency of liver and kidney
Treatment: Nourish Yin and clear heat.
5.External treatment
(1) Chinese herbal medicine decoction 50-100 mL at 37-38 ℃ after bedtime bowel movement.
(2) Chinese medicine ion introduction, Chinese medicine sitz bath, Chinese medicine fumigation, Chinese medicine paste can also achieve therapeutic effect.
6.Acupuncture treatment
The acupuncture has a good effect on the painful symptoms of chronic prostatitis. Recommended acupuncture points: Zhongji, Guangyuan, Qihai, or take the second, upper, middle, lower, Huiyin, Huiyang and other points alternate treatment
7.Physiotherapy
7.1 Heat therapy
The main use of the heat generated by a variety of physical methods to promote the blood circulation of the prostate tissue, is conducive to the elimination of tissue edema, relieve the pelvic floor muscle spasm, has a certain effect on the relief of symptoms. The use of microwave, radiofrequency, laser and other physical means via the urethra and perineum route is not supported by evidence-based medical evidence. It is not recommended for unmarried and infertile people.
7.2 Prostate massage
The prostate massage can promote prostate blood circulation, gland emptying, promote drainage, and thus relieve the symptoms of patients with chronic prostatitis, so it is recommended as an adjuvant therapy for type II and III prostatitis, and combined with other treatments can effectively shorten the course of the disease.
Health Education
1, psychological factors
The actual fact is that it is not related to acute prostatitis.
2, urinary tract infection
The main cause of acute bacterial prostatitis (type I) and chronic bacterial prostatitis (type II) is pathogenic infection, and retrograde infection of the urinary tract is the main pathway of prostate infection pathogens, and studies have found that the incidence of prostatitis is significantly higher after sexually transmitted diseases, indicating that urinary tract infection is closely related to the development of prostatitis.
3, lifestyle
The epidemiological case-control study found that fixed sitting position, alcohol abuse, and prolonged urinary retention are risk factors for the development of chronic prostatitis.
4, Chinese medicine health care
The first thing you need to do is to make sure that you have a good diet. The actual fact is that you can find a lot of people who are not able to get a good deal on this. The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things.
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