1, At present: the treatment strategy for chronic prostatitis should be to improve the patient’s discomfort, the purpose of treatment is not only to reduce the white blood cells of the prostate massage fluid, but more importantly to relieve the patient’s discomfort. The actual fact is that the actual number of white blood cells in the prostate massage fluid is not necessarily proportional to the uncomfortable symptoms, that is, the number of white blood cells is not necessarily heavy; and some patients with serious symptoms are found to have very few or even normal white blood cells in the prostate massage fluid.
2. Not all patients with chronic prostatitis need to receive antibiotic treatment! 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. If the patient’s clinical symptoms do decrease, the original antibiotic can be applied continuously for 4-8 weeks to consolidate the effect.
The first Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, the chief physician and professor of male urology Qiu Yongchao pointed out that the treatment of prostatitis can not be generalized, should be based on typing and individual differences reasonable, standardized treatment, in order to save patients from the disease.
Antibiotic treatment for this type of prostatitis is necessary and urgent. Once the clinical diagnosis is established, antibiotics should be applied immediately. To begin with, antibiotics can be applied intravenously, such as: broad-spectrum penicillin, third-generation cephalosporins, aminoglycosides or fluoroquinolones. After the patient’s systemic symptoms such as fever improve, the patient can be switched to oral medications (e.g., quinolones) for at least 4 weeks. Patients with milder symptoms should also be treated with antibiotics for 2 to 4 weeks.
For acute bacterial prostatitis with urinary retention, suprapubic cystostomy can be used to drain urine, or fine catheterization can be used, but the retention time of the urinary catheter should not exceed 12 hours. Those with abscess formation can be drained by transrectal ultrasound-guided fine needle aspiration, transurethral resection of the prostate abscess or perineal aspiration to drain the pus.
Chronic inflammation: comprehensive treatment to improve symptoms.
Type II prostatitis is the traditional classification of chronic bacterial prostatitis (CBP), which accounts for about 5% to 8% of chronic prostatitis. There are recurrent lower urinary tract infection symptoms lasting more than 3 months, elevated white blood cell count in EPS/seminal fluid/urine after massage of the prostate (VB3), and positive bacterial culture results.
Type III prostatitis is chronic prostatitis/chronic pelvic pain syndromes (CP/CPPS), which is the most common type of prostatitis and accounts for about 90% of chronic prostatitis. The main manifestation is long-term, recurrent pain or discomfort in the pelvic region lasting more than 3 months, which can be accompanied by varying degrees of urinary symptoms and sexual dysfunction, seriously affecting the patient’s quality of life; negative EPS/semen/VB3 bacterial culture results.
Based on the results of routine EPS/semen/VB3 microscopy, this type can be subdivided into IIIA (inflammatory CPPS) and IIIB (non-inflammatory CPPS). Patients with type IIIA have elevated leukocyte counts in EPS/semen/VB3; patients with type IIIB have leukocytes in EPS/semen/VB3 in the normal range. Both subtypes IIIA and IIIB account for about 50% each.
The clinical progressiveness of chronic prostatitis is not clear enough to threaten the life and vital organ function of patients, and not all patients require treatment. The goal of treatment for chronic prostatitis is mainly to relieve pain, improve urinary symptoms and improve quality of life, and efficacy evaluation should be based on symptom improvement.
The first thing is that the general treatment includes health education, psychological and behavioral counseling. Patients should be instructed to abstain from alcohol and spicy stimulating foods; avoid holding urine, being sedentary, keeping warm, and strengthening physical exercise.
Secondly, the three most commonly used medications are antibiotics, alpha-blockers and non-steroidal anti-inflammatory analgesics, while other medications are also effective in relieving symptoms to varying degrees. Currently, the most common first-line drug used in clinical practice for the treatment of prostatitis is antibiotics, but only about 5% of patients with chronic prostatitis have a definite bacterial infection. For patients with type II prostatitis antibiotics should be selected based on bacterial culture results and the ability of the drug to penetrate the prostate. The antibiotics available are fluoroquinolones, tetracyclines and sulfonamides. After the diagnosis of prostatitis, the course of antibiotic treatment is 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. Intraprostatic injection of antibiotics is not a recommended treatment.
In patients with IIIA prostatitis, antibiotic therapy is mostly empirical and based on the theory that certain pathogens that are routinely culture-negative are presumed to have caused this type of inflammation. Therefore, oral antibiotics such as fluoroquinolones are recommended for 2 to 4 weeks, followed by a decision to continue antibiotic therapy based on efficacy feedback. Continuation of antibiotics is recommended only if the patient does experience a reduction in clinical symptoms. The recommended total course of treatment is 4 to 6 weeks. Some patients with this type may have intracellular pathogenic infections such as Chlamydia trachomatis, Ureaplasma lysis or Mycoplasma humanum, which can be treated with oral antibiotics such as tetracyclines or macrolides. For patients with type IIIB prostatitis, antibiotic therapy is not recommended.
Alpha-blockers can improve lower urinary tract symptoms and pain by relaxing smooth muscles in the prostate and bladder and other areas, thus becoming the basic drug for the treatment of type II/III prostatitis, and different alpha-blockers can be chosen depending on the patient’s condition. The main alpha-blockers recommended are: doxazosin, napalmedil, tamsulosin and terazosin, which have shown varying degrees of improvement in patients’ urinary symptoms, pain and quality of life index. The treatment should be aware of adverse effects such as vertigo and postural hypotension caused by these drugs. α-blockers should be treated for at least 12 weeks and can be used in combination with antibiotics for the treatment of type IIIA prostatitis, and the combination should be used for at least 6 weeks.
Non-steroidal anti-inflammatory analgesics are used empirically to treat the symptoms associated with type III prostatitis. Their primary purpose is to relieve pain and discomfort. The therapeutic role of botanical agents in type II and type III prostatitis is increasingly being emphasized as selective therapeutic agents. The pharmacological effects are broad, such as non-specific anti-inflammatory, anti-edema, and promotion of bladder contraction and urethral smooth muscle relaxation. The dosage depends on the patient’s condition and is usually administered on a monthly basis. M-blockers may be used in patients with prostatitis with overactive bladder (OAB) manifestations such as urgency, frequency, and nocturia without urinary tract obstruction.
For patients with chronic prostatitis with combined depression and anxiety and other psychological disorders, treatment with antidepressants and anxiolytics may be an option along with prostatitis. These drugs can improve the patient’s psychological disorder symptoms as well as relieve physical symptoms such as abnormal urination and pain. It is important to pay attention to the prescription regulations and adverse drug reactions of these drugs when applying them. The main antidepressants and anxiolytics available are tricyclic antidepressants, selective 5-hydroxytryptamine reuptake inhibitors and benzodiazepines.
Asymptomatic inflammation: pay attention to the differential diagnosis
The patient has no subjective symptoms, but only evidence of inflammation is found on examination of the prostate (EPS, semen, prostate tissue biopsy and pathology of prostatectomy specimens, etc.). However, if the patient has a combination of elevated serum PSA or infertility, the differential diagnosis should be noted and treated accordingly. If the patient has elevated PSA, antibiotic therapy may be helpful in the differential diagnosis of prostate cancer.