How to diagnose and treat acute prostatitis?
Acute prostatitis is an inflammatory process in the prostate that provokes bacterial infection. The prostate gland plays an important role in the body of a man, since its main function is to produce secretions that make up sperm. Impaired functioning of this gland can occur in men at any age. However, most often, diseases are diagnosed in people from 20 to 50 years old.
- Causes of Acute Prostatitis
- Forms of Acute Prostatitis
- Symptoms of acute prostatitis
- Diagnosis of acute prostatitis
- Complications of acute prostatitis
- Treatment of acute prostatitis
- Prognosis and prevention of acute prostatitis
Causes of Acute Prostatitis
Inflammation in the prostate occurs due to infection of the body with an infection that enters it through the ureter or through the hematogenous route (through the blood). The causative agents of acute prostatitis can be a variety of microorganisms: fungi, streptococci, E. coli, staphylococci, chlamydia, gonococci, pale treponema, viruses, mycobacterium tuberculosis.
However, it is worth noting that in order to start the inflammatory process, it is also necessary to influence predisposing factors on it:
- illegible sexual intercourse, as well as the presence of any chronic inflammatory diseases in the partner (for example, bacterial vaginosis),
- stones in the prostate
- urethral catheters
- complications after surgery on the urethra,
- venous congestion in the pelvic organs due to physical inactivity, hemorrhoids, obesity, paraproctitis,
- the presence of any concomitant pathologies such as alcoholism, diabetes mellitus, acquired immunodeficiency syndrome),
- body hypothermia,
- problems with sexual activity - sexual dysfunction, interruption of sexual intercourse,
- rectal disease
- acute respiratory infections
- violation of the urination process.
Etiology and pathogenesis
Acute prostatitis can be caused by various microorganisms. Most often, prostate tissues are affected by bacteria such as Escherichia coli, Klebsiella, Proteus, Pseudomonas aeruginosa, Enterobacter, Enterococci, Serrations and Staphylococcus aureus. Many of these agents are components of the normal microflora of the body and are constantly present on the skin, in the intestines, etc. However, penetrating the tissues of the prostate gland, they can cause the development of an acute inflammatory process.
Signs and Symptoms
Men suffering from acute prostatitis often complain of fever, chills, fever (even if the body temperature measured under the arm or mouth is normal, the body temperature measured in the anus is often elevated, the difference between rectal temperature and temperature in the armpit, exceeding the usual 0.5 ° C), pain in the lower back, lower back, lower abdomen or perineum, in the pelvis or groin, in the scrotum, anus, rapid urination, n full-time urination (nocturia), dysuria (soreness, pain or burning in the urethra when urinating), as well as signs of general intoxication of the body - weakness, headaches, a feeling of tiredness, fatigue, pain in muscles, joints, bones and other bodily pains . Difficulty urinating, sometimes up to acute urinary retention. Constipation may also occur due to compression of the enlarged prostate gland of the rectum or soreness during bowel movements. Acute prostatitis can be a complication of a prostate biopsy. With a manual examination through the anus, the prostate gland of a patient with acute prostatitis is enlarged, edematous, hyperemic, and sharply painful. In some cases, there are colorless, whitish or yellowish-greenish discharge from the urethra, as well as hemospermia (blood in semen).
An acute infectious and inflammatory process in the prostate gland can give rise to sepsis - a general infection of the blood or an ascending urinary tract infection - cystitis, pyelonephritis. In such cases, the patient's condition is regarded as critical and requires emergency hospitalization. Acute prostatitis is rare.
Acute prostatitis is easily diagnosed due to the typical clinical picture and the presence of severe symptoms, which suggests an acute infectious and inflammatory process in the prostate gland.
The minimum necessary examination volume for the diagnosis of acute prostatitis in case of suspicion of it includes the measurement of rectal temperature and temperature under the arm or in the mouth, examination and palpation of the inguinal and perineal lymph nodes, a general clinical blood test with an expanded leukocyte formula, and a blood test for acute phase proteins inflammation (C-reactive protein, etc.) and for a specific prostatic antigen, general clinical analysis of urine, swabs from the urethra, bacterioscopy and plating antibiotic resistance of swabs taken and spontaneous discharge from the urinary canal, bacterioscopy of urinary sediment and culture of urine or urinary sediment on bacteria with determination of their sensitivity to antibiotics, digital examination of the prostate gland. According to indications, additional examinations are carried out: bacterioscopy of blood and blood culture for bacteria with determination of their sensitivity to antibiotics (if prostatogenic sepsis is suspected), transrectal ultrasound of the prostate gland with puncture of areas suspected of an abscess with appropriate suspicions, CT or MRI of the pelvic organs.
The temperature in the anus with acute prostatitis is usually elevated. The difference between rectal temperature and the temperature under the armpit or in the mouth usually exceeds 0.5 ° C. In the urine or urinary sediment, an increased number of leukocytes is detected. An infectious microorganism can be excreted from urine, blood, smears from the urethra or from secretions arising spontaneously from the urethra. A general clinical blood test for acute prostatitis often reveals shifts typical of acute infectious and inflammatory processes: neutrophilic leukocytosis, often with a shift in the leukocyte formula to the left, and a decrease in the number of eosinophils (eosinopenia up to complete aneosinophilia), less often eosinophilia.
Sepsis as a complication of acute prostatitis is rare, but can be observed in patients with immunosuppression, high fever, severe intoxication, significant severity of common symptoms, such as weakness and weakness, are symptoms suspicious of sepsis and require blood culture on microorganisms.
Massage of the prostate gland as a diagnostic procedure is contraindicated in acute prostatitis and even if acute prostatitis is suspected, since it can cause metastasis of the infection throughout the body and the development of acute sepsis. Since bacteria that are the causative agents of acute prostatitis in this disease are usually easily excreted from urine, urinary sediment and / or blood, from spontaneously flowing secretions or smears from the urethra, massage of the prostate gland and obtaining its secret are completely not required for diagnosis.
The perineum of a patient with acute prostatitis can be painful on palpation. Inguinal and perineal lymph nodes may be enlarged.
Diagnostic palpation of the prostate gland through the anus usually reveals an enlarged, hypersensitive to touch, swollen, painful, hot to the touch, overstretched prostate gland, in which heterogeneities can sometimes be detected - inflammatory seals. Diagnostic palpation of the prostate gland in patients with acute prostatitis is often extremely difficult, and sometimes impossible without analgesia and sedation due to extreme soreness and sensitivity of the prostate gland, as well as due to irradiation soreness and reflex spasm of the anus.
In most cases of acute prostatitis, C-reactive protein and other proteins of the acute phase of inflammation are elevated.
A prostate biopsy for acute prostatitis is not indicated, as it can contribute to the spread of infection or additional infection of the prostate with another type of microorganism. In addition, a biopsy of the prostate as a diagnostic procedure for acute prostatitis is simply not required, since the characteristic clinical signs and symptoms, as well as data from a digital examination of the prostate, blood tests, urine and smears from the urethra can usually make a correct diagnosis without a biopsy. The histological correlate of acute prostatitis is neutrophilic prostate tissue infiltration.
Acute prostatitis is accompanied by a temporary increase in the level of a specific prostatic antigen in the blood, that is, the PSA level rises with acute prostatitis and decreases again, normalizes soon after the resolution of the acute infectious and inflammatory process. Testing for blood PSA levels in uncomplicated acute prostatitis, however, is not required for diagnosis, although it is desirable.
The basis for the treatment of acute prostatitis (Category I NIH prostatitis) is the use of appropriate combinations of antibiotics effective against this pathogen microorganism. The effect of antibiotics in acute prostatitis usually occurs very quickly, within a few days. Nevertheless, antibiotic treatment for acute prostatitis should continue for at least 4 weeks, in order to completely eradicate the pathogen microorganism and prevent possible chronicization of the process (development of chronic bacterial prostatitis or the so-called “chronic prostatitis / chronic pelvic pain syndrome”) . The choice of antibiotics for acute prostatitis should be based on the results of determining the type of microorganism that caused the infection and its individual sensitivity to antibiotics.
In addition, when choosing antibiotics for the treatment of acute prostatitis, several more important factors should be considered. Some antibiotics, such as beta-lactams (excluding amoxicillin) and aminoglycosides, have very poor penetration into the tissues and secretions of the prostate gland, while some other antibiotics, such as fluoroquinolones, macrolides, doxycycline, chloramphenicol, trimethoprim / sulfamethoxazole, have good ability to penetrate into the tissues and secretion of the prostate gland and are able to create high concentrations in it. However, in acute prostatitis, intense inflammation greatly increases the permeability of the hematoprostatic barrier, so this factor (good penetration into the tissues and secretion of the prostate gland) is not as important in choosing the appropriate antibiotic as in chronic prostatitis (categories II, III, and IV according to the NIH classification). In acute prostatitis, as with other sepsisogenic and potentially life-threatening infections, it is more important to give preference to potent bactericidal antibiotics (antibiotics that kill the pathogen), for example, fluoroquinolones, rather than bacteriostatic antibiotics, for example, trimethoprim / sulfamethoxazole or dox. When using antibiotics, which, depending on the dose, can have a bacteriostatic or bactericidal effect (macrolides, chloramphenicol), the dose of the antibiotic must be sufficient to have a bactericidal and not a bacteriostatic effect. This rule of preference for bactericidal antibiotics and the adequacy of doses is especially important in the case of the development of acute prostatitis in a patient with severe immunosuppression.
Patients with acute prostatitis with severe intoxication, fever, poor general condition need emergency hospitalization and intravenous antibiotics. Mild cases of acute prostatitis can also be treated on an outpatient basis. As additional measures of treatment, rest, bed rest (physical activity on the pelvic muscles in acute prostatitis can cause metastasis of the infection and the development of sepsis), the use of analgesics, antipyretics (antipyretic drugs) and anti-inflammatory drugs of the NSAIDs group are recommended. With severe pain, the short-term use of opiates is justified. In acute prostatitis it is very important to drink plenty of fluids, and in severe patients - intravenous hydration (intravenous fluids) and the appointment of diuretics, since copious urine excretion mechanically flushes the urinary tract and prevents the development of ascending urinary infection (cystitis, pyelonephritis), and also reduces intoxication. It is also recommended to use emollients such as paraffin oil, which relieve constipation, relieve the bowel movement, eliminate the need for straining during it, and make this act less painful in acute prostatitis. In order to facilitate the act of urination, antispasmodics and alpha-blockers (such as tamsulosin, doxazosin, prazosin) are recommended. In order to reduce the protective tension of the muscles of the pelvic floor, to reduce the squeezing of the inflamed prostate gland by the tense muscles of the pelvic floor and to reduce soreness, muscle-relaxing remedies can be used, such as baclofen, sirdalud, diazepam, pregabalin or gabapentin. Patients with acute urinary retention are indicated by the imposition of a temporary suprapubic fistula or periodic catheterization of the bladder.
In order to reduce edema and inflammation of the prostate gland and ensure its temporary functional rest, reduce secretion in it, temporarily decrease blood flow in it and reduce the risk of metastasis of the infection, antiandrogens (androgen prostate receptor blockers) are used for a short time, such as cyproterone acetate (previously with this high doses of estrogen, such as synestrol, were used for a short time, as well as small cold enemas (cold to the prostate gland reduces local edema, inflammation drinking and pain, reduces blood flow to the inflamed prostate gland and the risk of metastasis of the infection). However, a decrease in blood flow in the prostate gland with the help of antiandrogens and cold enemas can have negative consequences, reducing the delivery of antibiotics and immunocompetent cells to the prostate gland and thereby slowing down the resolution of the acute inflammatory process and increasing the risk of chronic process with the development of chronic prostatitis, which is why some doctors object the use of these measures in acute prostatitis. Nevertheless, the opposite approach - the use of thermal procedures (warming the prostate gland) and / or therapeutic massage of the prostate gland and / or the appointment of androgens in the acute stage of the process is considered categorically contraindicated due to the risk of metastasis of the infection and the risk of developing septicemia.
The absence of a quick clinical response to antibiotics in acute prostatitis should serve as a basis for suspicion of an abscess of the prostate gland and for the immediate appointment of transrectal ultrasound of the prostate and a test puncture of areas suspected of possible abscess formation. If a prostate abscess is detected, treatment should include not only antibiotics, but also surgical or puncture drainage of the abscess.
It should also be noted that some common microorganisms, often serving as causative agents of acute prostatitis, in particular Escherichia coli, quickly develop resistance to antibiotics and are able to form thick capsules around their cell walls, and are also able to form biofilms that reduce the availability of these bacteria for antibiotics and immunocompetent cells and increasing the duration of survival of the microorganism in the prostate gland and the likelihood of persistent infection and chronicity of the process with the development of chronic bacterial prostatitis. Therefore, when such microorganisms are found in acute prostatitis, antibiotic treatment should be especially persistent and long-term.
General characteristics of the disease
Acute prostatitis is a rapidly developing inflammatory process in the prostate gland. It has four stages of development:
- Catarrhal. At this stage, the gland swells slightly, inflammation affects only the mucous membranes of the excretory ducts of the gland. This period is the most favorable moment for treatment - if you start it at this moment, you can get rid of the disease in less than two weeks. The nature of the inflammation is not purulent, but the resulting edema clogs the ducts, not allowing the secret to leave the gland. Stagnation begins.
- Follicular. As a result of stagnation, bacteria that have entered the body begin their activity already in it. Since the organ consists of cells grouped into lobules and separated by connective tissue, inflammation first affects one part.
- Parenchymal Inflammation passes from one lobule to another, there are many pustules in different parts of the gland.
- Purulent abscess. Pustules merge into one, and a bubble is formed in the gland, filled with purulent contents. Over time, it can burst, pus spreads, falling into the space around the prostate and bladder, urethra or rectum. When an abscess is opened, pus does not come out completely, and this becomes a new round in the inflammatory process.
How quickly the pathological process will develop and how it will end depends on a number of factors: the reasons for which the inflammation appeared, the timeliness and expediency of the treatment.
Complete recovery without any consequences is the most typical outcome. In some cases, a complication in the form of chronic inflammation with the development of chronic bacterial prostatitis or the so-called. "Chronic prostatitis / chronic pelvic pain syndrome." Other complications are also possible: abscesses of the prostate gland, fistula of the prostate gland, sepsis, ascending urinary infection - cystitis, pyelonephritis.
Acute and chronic prostatitis are the most common and socially significant male diseases. In clinical andrology, prostatitis is diagnosed in 30-58% of men who are of reproductive and working age (30-50 years). The course of acute prostatitis is accompanied by disorders of sexual function and fertility, disorders of the psychoemotional state and social maladaptation.
In the development of acute prostatitis, 3 forms are distinguished, which are simultaneously its stages - catarrhal, follicular, parenchymal, abscessed. The disease begins with catarrhal inflammation - changes in the mucous and submucous layer of the excretory ducts of individual lobules of the gland. In the future, swelling of the walls of the ducts contributes to stagnation of the mucopurulent secretion in the follicles of the prostate and the progression of inflammation, in connection with which focal suppuration of the lobules - acute follicular prostatitis can develop.
With multiple lesions of the lobules and diffuse involvement of the parenchymal and interstitial tissue of the prostate in the purulent-inflammatory process, the pathology proceeds to its next stage - parenchymal. In the case of fusion of small abscesses into a large lesion, an abscess of the prostate gland forms, which can open in the urethra, perineum, rectum or bladder.
Clinical manifestations correspond to the stages of the process. Common symptoms include pain, urination disorders and intoxication. In the acute catarrhal stage, heaviness and pain in the perineum are felt. Dysuric disorders are characterized by a painful increase in urination, especially at night. Body temperature remains within normal limits, may be slightly elevated, intoxication is absent.
On palpation, the prostate is not changed or slightly enlarged, somewhat painful. Examination of prostate secretion reveals an increase in white blood cells, an accumulation of mucopurulent threads. Leukocytes appear in the urine when emptying the excretory ducts of the acini. Prostate massage is usually not possible due to soreness. Treatment started in the catarrhal stage of acute prostatitis leads to recovery after 7-10 days.
The follicular form proceeds more clearly, accompanied by dull aching pains in the perineum, radiating to the penis, anus or sacrum. Against this background, urination is painful and difficult, up to the development of acute urinary retention. The act of defecation is also difficult due to severe pain. Due to an increase in body temperature to 38 ° C, the general condition is disturbed. Palpation per rectum is determined by an enlarged, dense, tense, asymmetric prostate, sharply painful in some areas with a digital examination.
Urine collected after palpation of the gland in large quantities contains white blood cells and purulent filaments forming a cloudy sediment. Massage to obtain prostate secretion in the follicular stage of the disease is contraindicated. With vigorous treatment, acute follicular prostatitis can be favorably resolved, otherwise it proceeds to the next, parenchymal stage.
The clinic of acute parenchymal prostatitis is developing rapidly. Pronounced hyperthermia (up to 39-39.5 ° С and higher) with chills, general weakness, appetite suppression, thirst is characteristic. At first, urination is sharply speeded up and difficult, then it can stop completely. Attempts to empty the bladder or intestines are accompanied by intense pain. Excruciating tenesmus, constipation, flatulence develop. The pain spreads to the rectum, has a pulsating character, forces the patient to take a forced position - lying with legs crossed. With the development of reactive inflammation of the rectum, mucus is released from the anus.
Palpation is determined diffusely enlarged, with fuzzy contours of iron, extremely painful at the slightest touch. Massage of the prostate gland in the parenchymal stage is absolutely contraindicated. Sometimes, due to a sharp edema of pararectal fiber and soreness, rectal examination cannot be performed. In urine - pronounced leukocyturia, pyuria. The outcome of acute parenchymal prostatitis can be the resolution of the disease, the formation of an abscess of the prostate or chronic prostatitis.
The purulent form of the disease is accompanied by an abscess of the prostate gland, chills, fever, pain in the perineum and anus, and fever. In some cases, an infection from the prostate gland can also affect the scrotum, causing its swelling and redness. The most serious complication of infection is sepsis.
Symptoms of acute prostatitis
Symptoms depend on the stage of the disease.
During the period catarrhal prostatitis there is a slight discomfort and a feeling of heaviness in the perineum, urge to the toilet at night becomes more frequent. Urination is accompanied by burning and pain. The gland itself has normal or uncritically increased dimensions, palpation examination causes pain. The temperature remains normal or rises slightly. There is no intoxication, overall health is good.
Follicular period has more manifestations. The pain grows, becomes constant, sometimes sharply gives to the penis, sacrum or rectum. Urinary retention appears, as urination is difficult due to acute pain. Defecation is also accompanied by severe pain.
The temperature rises to 38 degrees and keeps at this mark. The prostate gland noticeably increases in size, has a dense consistency, is tense, touching it in some places causes a sharp pain.
Parenchymal prostatitis proceeds very hard. Appetite disappears, chills appear, general weakness. Frequent urination with a short urination is followed by acute urinary retention. Attempts to empty the bladder or intestines become almost impossible due to unbearable pain. It intensifies due to constipation and a full bladder, spreads throughout the perineum, slight relief can only occur in a lying position with legs crossed.
The temperature rises above 39 degrees. Inflammation begins to spread to other organs; mucus is released from the rectum. The prostate gland has a fuzzy outline, enlarged and painful. Palpation may not be possible due to edema.
Abscess formation accompanied by the localization of the point of acute pain - where the abscess appeared. The discharge of urine, stool and gases is extremely difficult, accompanied by severe throbbing pain that spreads to the intestine. The temperature keeps above 39.5 degrees, chills, fever, and sometimes a delusional state appear.
Then relief suddenly comes: the pain goes away, the temperature drops. However, this does not mean that the patient recovered: the fact is that the abscess has burst and urgent procedures are now necessary to cleanse the body of pus, because the negative consequences can be very diverse.
Preventive measures include the absence of unprotected sex (to prevent STIs), thorough hygiene, timely treatment of inflammatory processes in the urinary tract. It is necessary to maintain immunity, not start carious teeth and carefully treat any infectious diseases.
Factors contributing to the development of the disease should also be excluded. To do this, you need:
- have regular sex with one partner,
- avoid hypothermia (both permanent and one-time),
- give up alcohol, smoking and a sedentary lifestyle,
- regularly undergo a routine examination by a urologist,
- do not self-medicate at the first sign of inflammatory processes,
- stick to a balanced diet
- take vitamins, especially during periods of spread of infectious diseases.
Acute inflammation of the prostate occurs due to infections that develop under favorable circumstances. Treatment is with antibiotics, anti-inflammatory drugs, painkillers and vitamins. During therapy, it is important to adhere to a diet and drinking regimen.
Symptoms of a catarrhal form
The catarrhal form of the pathology is manifested by pain in the perineum. Often there are no signs of intoxication in this form of prostatitis. Palpation examination reveals a slight increase in the prostate gland. This stage of the disease is evidenced by data from a laboratory study of the secret, in which an elevated level of white blood cells is detected.
Symptoms of acute form
The symptoms of acute prostatitis in the purulent stage are most intense. This is due to severe intoxication of the patient's body. For this reason, his body temperature rises, his appetite decreases, and chills and fever often occur. Attempts to empty the bladder provoke prolonged and severe constipation.
Complications of acute prostatitis
Incorrect treatment of the disease or its absence at all can lead to serious complications. The most common complication is urinary retention with the formation of residual urine in a volume of more than 100 ml. In this case, the patient is prescribed emergency derivation of urine.
A prolonged inflammatory process often leads to suppuration of prostate tissue and the appearance of an abscess. This complication provokes an extremely serious condition of the patient, because in addition to pronounced signs of intoxication, he may even experience endotoxic shock (hypothermia, drop in blood pressure, decrease in white blood cell count).
If purulent inflammation extends beyond the prostate, paraprostatic phlegmon may occur. Depending on the patient’s state of health, this purulent process can develop into pelvic panphlegmon. The consequences of all quiet pathological processes may be the development of paraproctitis complicated by purulent fistulas.
Antibacterial drugs are prescribed to destroy the pathogen of inflammation. However, before prescribing antibiotic therapy, a thorough bacteriological examination of the patient's urine is necessary. To destroy and prevent the multiplication of pathogenic microbes, the following groups of drugs are prescribed: cephalosporins, aminoglycosides, penicillins, fluoroquinolones. Drug treatment of acute prostatitis also involves the appointment of alpha-blockers (Dalfaz, Prazosin, Omnik, Terazozin, Tamsulosin), which reduce the tone of the bladder, posterior urethra and prostate.
Treatment with rectal suppositories is carried out for 21 days. However, at the end of the first week of treatment, you can notice positive changes:
- immunity increases
- the inflammatory process is significantly reduced,
- urination normalizes
- the pain in the prostate gland disappears.
Microclysters based on hydrogen sulfide and mineral water are an effective method of eliminating the symptoms of the disease. Enema can relieve inflammation, normalize urination, destroy pathogenic microorganisms.
An important role in the treatment of pathology is played by various water procedures - a contrast shower and sedentary baths. For example, baths with aromatic oils help to relax, calm the nerves, and get rid of insomnia. Contrast shower tones, enhances blood circulation, and also normalize metabolism.
Drug treatment can be more effective if you use local medicines - rectal suppositories, enemas, herbal-based baths. Rectal suppositories are of great importance in the treatment of prostatitis: prostatilen, tambucan (based on medicinal mud), prostopin and propolis-d (with bee products), vitaprost (medicines to restore immunity).
An effective non-drug method of treating prostatitis is considered to be prostate massage. It can significantly improve blood circulation in the prostate, which leads to the rapid restoration of damaged tissues and increase resistance to various infections.In addition, massage enhances the effects of drugs. Therefore, it is most effective to prescribe prostate massage along with antibacterial therapy.
Another alternative treatment for the disease is microwave microwave therapy. Exposure of microwave waves to the prostate results in an increase in local temperature in the prostate. During this procedure, there is an acceleration of blood flow, vasodilation, and the involvement of immune cells in the focus of inflammation.