Symptoms of prostatitis and prostate adenoma in men.

ProstatitisIt is an inflammatory disease of the prostate gland. It is manifested by frequent urination, pain in the penis, scrotum, rectum, sexual disorders (erectile dysfunction, premature ejaculation, etc. ), sometimes urinary retention, blood in the urine. The diagnosis of prostatitis is established by a urologist or an andrologist according to a typical clinical picture, the results of a rectal examination. In addition, ultrasound of the prostate, bakposev of prostatic secretion and urine is performed. Treatment is conservative: antibiotic therapy, immunotherapy, prostate massage, lifestyle correction.

General information

Prostatitis is an inflammation of the seminal (prostate) gland, the prostate. It is the most common disease of the genitourinary system in men. It most often affects patients between 25 and 50 years of age. According to various data, 30-85% of men over the age of 30 suffer from prostatitis. Possible abscess formation of the prostate gland, inflammation of the testicles and appendages, which threatens infertility. The rise of the infection leads to inflammation of the upper genitourinary system (cystitis, pyelonephritis).

Pathology develops with the penetration of an infectious agent that enters the prostate tissue from the organs of the genitourinary system (urethra, bladder) or from a distant inflammatory focus (with pneumonia, influenza, tonsillitis, furunculosis).

Prostate adenoma is a benign neoplasm of the paraurethral glands located around the urethra in its prostatic section. The main symptom of prostate adenoma is a violation of urination due to gradual compression of the urethra by one or more growing nodules. Pathology is characterized by a benign course.

Only a small part of patients seek medical help, however, a detailed examination reveals the symptoms of the disease in every fourth man aged 40-50 years and in half of men aged 50-60 years. The disease is detected in 65% of men aged 60 to 70 years, 80% of men aged 70 to 80 years and more than 90% of men older than 80 years. The severity of symptoms can vary significantly. Studies in the field of clinical andrology suggest that urination problems occur in about 40% of men with BPH, but only one in five patients in this group seek medical help.

Causes of prostatitis

As an infectious agent in an acute process, Staphylococcus aureus (Staphylococcus aureus), Enterococcus (Enterococcus), Enterobacter (Enterobacter), Pseudomonas (Pseudomonas), Proteus (Proteus), Klebsiella (Klebsiella) and Escherichia coli (E. coli) can act. Most of the microorganisms belong to the conditionally pathogenic flora and cause prostatitis only in the presence of other predisposing factors. Chronic inflammation is usually due to polymicrobial associations.

The risk of developing the disease increases with hypothermia, a history of infections, and specific conditions accompanied by congestion in the prostate tissues. There are the following predisposing factors:

• General hypothermia (single or permanent, associated with working conditions).
• A sedentary lifestyle, a specialty that forces a person to be in a sitting position for a long time (computer operator, driver, etc. ).
• Constant constipation.
• Violations of the normal rhythm of sexual activity (excessive sexual activity, prolonged abstinence, incomplete ejaculation during "usual" sexual intercourse without emotional coloring).
• The presence of chronic diseases (cholecystitis, bronchitis) or chronic infectious foci in the body (chronic osteomyelitis, untreated caries, tonsillitis, etc. ).
• Past urological diseases (urethritis, cystitis, etc. ) and sexually transmitted diseases (chlamydia, trichomoniasis, gonorrhea).
• Conditions that cause suppression of the immune system (chronic, irregular stress and malnutrition, regular lack of sleep, overtraining in athletes).

It is assumed that the risk of developing pathology increases with chronic intoxication (alcohol, nicotine, morphine). Some studies in the field of modern andrology show that chronic perineal trauma (vibration, concussion) in motorists, motorcyclists and cyclists is a provoking factor. However, the vast majority of experts believe that all these circumstances are not the real causes of the disease, but only contribute to the exacerbation of the latent inflammatory process in the prostate tissues.

Congestion in the prostate tissues plays a decisive role in the appearance of prostatitis. Violation of capillary blood flow causes an increase in lipid peroxidation, edema, exudation of prostate tissues, and creates conditions for the development of an infectious process.

The mechanism of development of prostate adenoma has not yet been fully determined. Despite the widespread opinion that links the pathology with chronic prostatitis, there are no data confirming the connection between these two diseases. Researchers have found no relationship between the development of prostate adenoma and alcohol and tobacco use, sexual orientation, sexual activity, inflammatory and sexually transmitted diseases.

There is a pronounced dependence of the incidence of prostate adenoma on the age of the patient. Scientists believe that the adenoma develops as a result of hormonal imbalances in men during andropause (male menopause). This theory is supported by the fact that men who are castrated before puberty never suffer from pathology, and very rarely, men who are castrated after it.

Symptoms of prostatitis

acute prostatitis

There are three stages of acute prostatitis, which are characterized by the presence of a certain clinical picture and morphological changes:

• acute catarrhal. Patients complain of frequent, often painful urination, pain in the sacrum and perineum.
• acute follicular. The pain becomes more intense, sometimes radiating to the anus, aggravated by defecation. Urination is difficult, urine comes out in a thin stream. In some cases, there is urinary retention. Subfebrile condition or moderate hyperthermia is typical.
• acute parenchymal. Severe general intoxication, hyperthermia up to 38-40°C, chills. Dysuric disorders, often - acute urinary retention. Sharp, stabbing pains in the perineum. Difficulty in defecation.

chronic prostatitis

In rare cases, chronic prostatitis becomes the result of an acute process; however, as a rule, a primary chronic course is observed. The temperature occasionally rises to subfebrile values. The patient notes a slight pain in the perineum, discomfort during the act of urination and defecation. The most characteristic symptom is scant secretion from the urethra during defecation. The primary chronic form of the disease develops over a considerable period of time. It is preceded by prostatosis (stagnation of blood in the capillaries), gradually turning into abacterial prostatitis.

Chronic prostatitis is often a complication of the inflammatory process caused by the causative agent of a specific infection (chlamydia, trichomonas, ureaplasma, gonococcus). The symptoms of a specific inflammatory process in many cases mask the manifestations of prostate damage. Perhaps a slight increase in pain when urinating, slight pain in the perineum, poor discharge from the urethra during defecation. A slight change in the clinical picture often goes unnoticed by the patient.

Chronic inflammation of the prostate gland can be manifested by a burning sensation in the urethra and perineum, dysuria, sexual disorders, increased general fatigue. The consequence of potency violations (or fear of these violations) often becomes mental depression, anxiety and irritability. The clinical picture does not always include all listed symptom groups, it differs in different patients and changes over time. There are three main syndromes characteristic of chronic prostatitis: pain, dysuria, sexual disorders.

There are no pain receptors in the prostate tissue. The cause of pain in chronic prostatitis becomes almost inevitable due to the abundant innervation of the pelvic organs, participation in the inflammatory process of the nerve pathways. Patients complain of pain of varying intensity, from weak and painful sleep to intense and disturbing sleep. There is a change in the nature of the pain (intensification or weakening) with ejaculation, excessive sexual activity, or sexual abstinence. The pain radiates to the scrotum, sacrum, perineum, sometimes to the lumbar region.

As a result of inflammation in chronic prostatitis, the volume of the prostate increases, compressing the urethra. The lumen of the ureter is reduced. The patient has a frequent urge to urinate, a feeling of incomplete emptying of the bladder. As a rule, dysuric phenomena are expressed in the early stages. Compensatory hypertrophy of the muscular layer of the bladder and ureters then develops. Symptoms of dysuria during this period weaken and then increase again with decompensation of adaptive mechanisms.

In the initial stages, dyspotence can develop, which manifests itself differently in different patients. Patients may complain of frequent nocturnal erections, blurry orgasms, or worsening of erections. Accelerated ejaculation is associated with a decrease in the threshold level of arousal of the orgasmic center. Painful sensations during ejaculation can provoke the rejection of sexual activity. In the future, sexual dysfunctions become more pronounced. In the advanced stage, impotence develops.

The degree of sexual disorder is determined by many factors, including the patient's sexual constitution and psychological mood. Violations of potency and dysuria can be due both to changes in the prostate gland, and to the suggestibility of the patient, who, if he has chronic prostatitis, expects the inevitable development of sexual disorders and urination disorders. Especially often, psychogenic dyspotence and dysuria develop in anxious and suggestible patients.

Impotence, and sometimes the very threat of possible sexual disorders, is difficult for patients to tolerate. There is often a change in character, irritability, hatred, excessive concern for one's own health and even "preoccupation with illness".

There are two groups of disease symptoms: irritative and obstructive. The first group of symptoms includes increased urination, persistent urgency (compelling) to urinate, nocturia, urinary incontinence. The group of obstructive symptoms includes difficulty urinating, delayed onset and increased time of urination, feeling of incomplete emptying, intermittent slow stream urination, straining. There are three stages of prostate adenoma: compensated, subcompensated, and decompensated.

compensated stage

In the compensated stage, the dynamics of the act of urination change. It becomes more frequent, less intense and less free. There is a need to urinate 1-2 times at night. As a general rule, nocturia in stage I prostate adenoma does not cause concern in a patient who associates constant nocturnal awakenings with the development of age-related insomnia. During the day, the normal frequency of urination can be maintained, however, patients with stage I prostate adenoma note a waiting period, especially pronounced after a night's sleep.

Then, the frequency of daytime urination increases and the volume of urine released per urination decreases. There are imperative impulses. The stream of urine, which previously formed a parabolic curve, is slowly discharged and falls almost vertically. Hypertrophy of the bladder muscles develops, due to which the efficiency of its emptying is maintained. There is little or no residual urine in the bladder at this stage (less than 50 ml). The functional status of the kidneys and upper urinary tract is preserved.

undercompensated stage

At stage II of prostate adenoma, the bladder increases in volume, dystrophic changes develop in its walls. The amount of residual urine exceeds 50 ml and continues to increase. During the act of urination, the patient is forced to intensely strain the abdominal muscles and diaphragm, which leads to an even greater increase in intravesical pressure.

The act of urination becomes multiphasic, intermittent, wavy. The passage of urine along the upper urinary tract is gradually disturbed. Muscular structures lose their elasticity, the urinary tract expands. Kidney function is impaired. Patients are concerned about thirst, polyuria, and other symptoms of progressive chronic renal failure. When the compensation mechanisms fail, the third stage begins.

decompensated stage

The bladder in patients with stage III prostate adenoma is stretched, filled with urine, easily determined by palpation and visually. The upper border of the bladder can reach the level of the umbilicus and above. Emptying is impossible even with intense tension of the abdominal muscles. The desire to empty the bladder becomes continuous. There may be severe pain in the lower abdomen. Urine is excreted frequently, in drops or in very small portions. In the future, the pain and the urge to urinate gradually weaken.

A characteristic paradoxical urinary retention develops, or paradoxical iscuria (the bladder is full, urine is constantly excreted drop by drop). The upper urinary tract is enlarged, the functions of the renal parenchyma are impaired due to constant obstruction of the urinary tract, which leads to increased pressure in the pyelocalyceal system. The clinic of chronic renal failure is growing. If medical care is not provided, patients die of progressive CKD.

complications

In the absence of timely treatment of acute prostatitis, there is a significant risk of developing a prostate abscess. With the formation of a purulent focus, the patient's body temperature rises to 39-40 ° C and may become agitated in nature. Hot spells alternate with severe chills. Sharp pains in the perineum make urination difficult and defecation impossible.

Increased prostatic edema leads to acute urinary retention. Rarely, an abscess ruptures spontaneously in the urethra or rectum. When it is opened, cloudy, purulent urine with an unpleasant pungent odor appears in the urethra; when it is opened, the stool contains pus and mucus in the rectum.

Chronic prostatitis is characterized by an undulating course with periods of long-term remissions, during which inflammation in the prostate is latent or manifests with extremely poor symptoms. Patients who are bothered by nothing often discontinue treatment, returning only when complications develop.

The spread of infection through the urinary tract causes the appearance of pyelonephritis and cystitis. The most common complication of the chronic process is inflammation of the testes and epididymis (epdidymis-orchitis) and inflammation of the seminal vesicles (vesiculitis). The result of these diseases is often infertility.

Diagnosis

To assess the severity of prostate adenoma symptoms, the patient is asked to complete a urine diary. During the consultation, the urologist performs a digital examination of the prostate. To exclude infectious complications, sampling and examination of prostatic secretion and smear from the urethra is performed. Additional tests include:

• Ultrasound.In the process of prostate ultrasound, the volume of the prostate gland is determined, stones and areas with congestion are detected, the amount of residual urine, the state of the kidneys and urinary tract are assessed.
• Urodynamic study. Uroflowmetry allows you to reliably judge the degree of urinary retention (urination time and urine flow rate are determined by a special apparatus).
• Definition of tumor markers.To exclude prostate cancer, it is necessary to evaluate the level of PSA (prostate-specific antigen), the value of which should normally not exceed 4 ng / ml. In controversial cases, a biopsy of the prostate is performed.

Cystography and excretory urography for prostate adenoma have been performed less frequently in recent years due to the emergence of new less invasive and safer research methods (ultrasound). Cystoscopy is sometimes done to rule out diseases with similar symptoms or in preparation for surgical treatment.

Treatment of prostatitis

Treatment of acute prostatitis

Patients with an uncomplicated acute process are treated by a urologist on an outpatient basis. With severe intoxication, suspicion of a purulent process, hospitalization is indicated. Antibacterial therapy is carried out. Preparations are selected taking into account the sensitivity of the infectious agent. Antibiotics are widely used that can penetrate the prostate tissue well.

With the development of acute urinary retention at the fne of prostatitis, resort to the installation of a cystostomy, and not a urethral catheter, since there is a danger of the formation of an abscess of the prostate. With the development of an abscess, a transrectal or transurethral endoscopic opening of the abscess is performed.

Treatment of chronic prostatitis

Treatment of chronic prostatitis should be complex, including etiotropic therapy, physiotherapy, correction of immunity:

• antibiotic therapy. The patient is prescribed long courses of antibacterial drugs (within 4-8 weeks). The selection of the type and dosage of antibacterial drugs, as well as the determination of the duration of the course of treatment, are carried out individually. The drug is chosen based on the sensitivity of the microflora based on the results of urine culture and prostate secretion.
• Prostate massage.Gland massage has a complex effect on the affected organ. During massage, the inflammatory secret accumulated in the prostate gland is squeezed into the ducts, then enters the urethra and is removed from the body. The procedure improves blood circulation in the prostate, which minimizes congestion and ensures better penetration of antibacterial drugs into the tissue of the affected organ.
• Physiotherapy.To improve blood circulation, laser exposure, ultrasonic waves and electromagnetic vibrations are used. If it is impossible to carry out physiotherapeutic procedures, the patient is prescribed warm medicinal microclysters.

In long-term chronic inflammation, the consultation of an immunologist is indicated to select the tactics of immunocorrective therapy. The patient receives advice on lifestyle changes. Making certain changes in the lifestyle of a patient with chronic prostatitis is both a curative and preventive measure. The patient is recommended to normalize sleep and wakefulness, establish a diet, engage in moderate physical activity.

conservative therapy

Conservative therapy is carried out in the early stages and in the presence of absolute contraindications to surgery. To reduce the severity of the symptoms of the disease, alpha-blockers, 5-alpha reductase inhibitors, herbal preparations (extract of African plum bark or sabal fruit) are used.

Antibiotics are prescribed to fight the infection that often accompanies prostate adenoma. At the end of the course of antibiotic therapy, probiotics are used to restore normal intestinal microflora. Carry out immunity correction. Atherosclerotic vascular changes that develop in most elderly patients impede the flow of drugs to the prostate gland, so special drugs are prescribed to normalize blood circulation.

Surgery

There are the following surgical methods for the treatment of prostate adenoma:

1. ROUTE(transurethral resection). Minimally invasive endoscopic technique. The operation is performed with an adenoma volume of less than 80 cm3. Not applicable for renal insufficiency.
2. Adenomectomy.It is carried out in the presence of complications, the mass of the adenoma is more than 80 cm3. Currently, laparoscopic adenomectomy is widely used.
3. Laser vaporization of the prostate.It allows you to perform surgery with a tumor mass of less than 30-40 cm3. It is the method of choice for young patients with prostate adenoma, since it saves sexual function.
4. laser enucleation(holmium - HoLEP, thulium - ThuLEP). The method is recognized as the "gold standard" of surgical treatment of prostate adenoma. It allows you to remove an adenoma with a volume of more than 80 cm3 without open intervention.

There are a number of absolute contraindications for surgical treatment of prostate adenoma (decompensated diseases of the respiratory and cardiovascular systems, etc. ). If surgical treatment is not possible, bladder catheterization or palliative surgery is performed: cystostomy, installation of a urethral stent.

Prognosis and prevention

Acute prostatitis is a disease that has a marked tendency to become chronic. Even with timely and proper treatment, more than half of patients end up with chronic prostatitis. Recovery is far from always achieved, however, with correct and consistent therapy and following the doctor's recommendations, it is possible to eliminate unpleasant symptoms and achieve long-term stable remission in a chronic process.

Prevention is eliminating risk factors. It is necessary to avoid hypothermia, alternate between sedentary work and periods of physical activity, eat regularly and fully. For constipation, laxatives should be used. One of the preventive measures is the normalization of sexual life, since both excessive sexual activity and sexual abstinence are risk factors in the development of prostatitis. If symptoms of a urological or sexually transmitted disease appear, you should consult a doctor in a timely manner.