Prostatitis

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Classification according to ICD-10
N41.0 Acute prostatitis
N41.1 Chronic prostatitis
ICD-10 online (WHO version 2019)

Under prostatitis or prostate inflammation , the inflammation is in the narrower sense prostate (prostate) to understand. In medicine, an extended term has been established according to which "prostatitis" is a syndrome of various complaints in the urogenital system as well as in the area of ​​the pelvic floor and the anus. The symptoms can often not be explained causally by an inflammation of the prostate and differentiated from the differential diagnosis. In women there is a paraurethral gland , which comes from the same embryonic tissue as the prostate . Inflammation of these is believed to cause symptoms of female urethral syndrome and interstitial cystitis .

Symptoms

Clinically relevant courses of prostatitis are characterized by pain. Their extent and intensity can vary from case to case and can lead to severe disability. In the chronic course, the symptoms persist or with intermittent interruptions. Frequently reported are:

  • Alguria (pain and burning sensation when urinating),
  • Pollakiuria (frequent need to urinate)
  • Urinary flow disorders,
  • Pain in the penis, testicles, perineum, anal, groin, pubic and lumbar region,
  • Pain during and especially after ejaculation.

Epidemiology

At the moment only a few surveys on epidemiology are documented, but these already show great clinical and health-political importance. The incidence of the prostate syndrome is accordingly around 2 to 10% of the male population. More men in the United States see a doctor for prostatitis than for BPH or prostate cancer . The complaints usually appear as complex symptoms from which many men suffer chronically over a long period of time. The pressure of symptoms is often comparable to that of angina pectoris , active Crohn's disease or the condition after a heart attack. Epidemiologically, a connection between bacterial prostatitis (chronic or acute) and prostate cancer could be established. In the patient group with prostate cancer , around 10% already had prostatitis, in the control group around 5%. Antibiotic and anti-inflammatory treatment of prostatitis had no influence on the later occurrence of prostate cancer . A connection between chronic prostatitis and fertility (motility, number and health of the sperm cells ) could not be established, but patients with chronic prostatitis suffer statistically more often from erectile dysfunction . Erectile dysfunction is generally not caused by prostatitis.

Diagnosis and classification

There are no clear markers for the diagnosis of prostate syndrome. Basic diagnostics include anamnesis, digital rectal scanning ( palpation ) of the prostate, inflammation and pathogen localization using a 4-glass sample (first urine, midstream urine, prostate expression and urine after prostate massage), ejaculate analysis to determine inflammation (including an antibiogram ), sonography Residual urine measurement to determine functional or anatomical urinary flow disorders, orienting neurological examination. Standardized questionnaires (symptom scores) are used to support the symptom evaluation. Instead of the elaborate 4-glass test, a similarly reliable comparative examination of urine before and after prostate massage is often used in everyday clinical practice.

Under the auspices of the National Institutes of Health (NIH) , a classification of the types of prostatitis was developed, which is used in prostatitis research and increasingly also in urological practice.

  • acute prostatitis (category I)
  • chronic bacterial prostatitis (Category II)
  • chronic abacterial prostatitis / chronic pelvic pain syndrome; short CP / CPPS (Category III)
  • asymptomatic inflammatory prostatitis (category IV).

Pathogenesis and Therapy

In the acute prostatitis is an acute infection of the prostate, of fever , chills, and urinary retention may be accompanied. Bacteria of the type Escherichia coli that live in the intestine are considered to be pathogens . These can be found en masse in urine. The leukocyte and often the concentration of the prostate-specific antigen are increased. The aetiological significance of chlamydial and mycoplasmic species is controversial. For therapy antibiotics , especially fluoroquinolones or possibly tetracyclines , are used.

The chronic bacterial prostatitis is also on the Harnwegsinfekterreger Escherichia coli returned. In addition, Mycobacterium tuberculosis can cause prostatitis in the context of urogenital tuberculosis. Anaerobes, Neisseria gonorrhoeae , Trichomonas vaginalis , viruses and fungal species are only considered to be etiologically relevant in individual cases. Cyclically recurring complaints may be related to the retention or backflow of pathogens in the urinary tract. The causes could be enlarged prostate , neurogenic bladder dysfunction, prostate stones and strictures. The symptoms of chronic bacterial prostatitis are similar to those of the acute form, but are usually less pronounced. Treatment options are antibiotics for 4 to 6 weeks. The success rate is 80% for clarithromycin , 80% for azithromycin , 77% for doxycycline , 40–77% for ciprofloxacin , 75% for levofloxacin , and 62–77% for azithromycin + ciprofloxacin (depending on the ciprofloxacin dose). Due to the apparently slightly lower success rate, the previously preferred co- trimoxazole is now more of a second choice. A combination of antimicrobial treatment with alpha blockers should improve the success of the therapy. The fact that the eradication of the pathogen ultimately leads to an elimination of the painful prostatitis symptoms has not yet been adequately evaluated. There are also no comparisons between antibiotic therapy and placebo. The long-term relapse rate is up to 50%.

To support antibiotic therapies, some authors have recommended accompanying prostate massages. Little data is available on the risk of side effects. In a more recent comparative study, no better treatment results could be achieved than with antibiotics alone.

Abacterial prostatitis / chronic pelvic pain syndrome is the most common form of prostatitis. There are no symptomatic differences to the bacterial form, except that no bacteria relevant as pathogens can be detected. The explanatory models are diverse. They range from an autoimmune disorder to neurogenic inflammation to myofascial pain syndrome. A distinction is made between two categories of the latter: on the one hand, a malfunction of the local nervous system due to past traumatic events and a psychogenic chronic tension in the muscles of the pelvic floor. Due to the chronic stress nerve cells are over-stimulated and thereby the release of the neurokinin substance P stimulated. As shown in animal experiments, this can ultimately lead to inflammation of the urogenital tract.

The possible cause of abacterial prostatitis by bacteria that are difficult to detect is controversial. A Canadian research team led by Keith Jarvi reported at the annual meeting of the American Urological Society (AUA) in 2001 about previously unknown bacterial species Paenobacillus sp. and Proteobacterium sp. in semen and urine of men with CP / CPPS. Frequent findings of bacterial genomic components (16S rRNA) in prostate-specific samples from men with abacterial prostatitis in broad-spectrum PCR tests were also interpreted as an indication of bacterial pathogenesis. In a subsequent study, however, bacterial 16S rRNA was detected with a comparable frequency in tissue samples from men without prostatitis.

In the inflammatory chronic pain syndrome of the pelvis , increased leukocyte concentrations in the prostate secretion / ejaculate , which are interpreted as an indication of inflammation, can be detected. In the non-inflammatory chronic pelvic pain syndrome , no increased leukocyte concentrations are detectable. The pathogenesis of chronic pelvic pain syndrome is unclear. The treatment recommendations hardly differ with regard to the two subtypes. A long-term, highly effective therapy has not been proven. Controlled, randomized studies have shown limited effectiveness for the following agents:

In robust studies, antibiotic therapies have only proven to be helpful for a small proportion of CP / CPPS-IIIa patients. Long-term treatment with fluoroquinolones, which is preferred for bacterial prostatitis, usually does not lead to any symptomatic improvement in chronic pelvic pain syndrome. Pain therapy, such as tramadol , can be considered to treat the pain .

In the context of studies of fertility or cancer prevention, increased leukocyte concentrations in the ejaculate or prostate secretion are often found in men without prostatitis symptoms. Such cases are classified as asymptomatic inflammatory prostatitis . Antibiotics and / or anti-inflammatory substances such as diclofenac and enzymes are often used for treatment. According to the current state of knowledge, the effectiveness of these measures is low.

Alternative therapeutic approaches

Acetylcysteine (ACC) has been researched as a mucolytic in connection with prostatitis for several years. Mucoproteins (see Corpora amylacea ) form a main component of the prostate secretion. The aim here is to remove the blockage of the discharge of secretion and thus to achieve a reduction in tissue pressure (presumed cause of pain) by taking 2 x 600 mg ACC once. The intake is repeated if the symptoms recur. This has been successfully tested by individual patients, but has not yet been clinically proven.

swell

  1. ↑ RF Gittes and RM Nakamura: Female urethral syndrome. A female prostatitis? . In: West J Med. . 164, No. 5, 1996, pp. 435-438.
  2. ^ JN Krieger, SO Ross, DE Riley: Chronic prostatitis: epidemiology and role of infection. In: Urology. Volume 60, Number 6 Suppl, December 2002, pp. 8-12, ISSN  1527-9995 . PMID 12521579 . (Review).
  3. ↑ a b c d Chronic prostatitis - pathogenesis unclear ... Medical practice urology 2/2006 (Dr. Martin Ludwig, Marburg)
  4. ↑ Junyi Jiang, Jinyi Li, Zhang Yunxia, ​​Hong Zhu, Junjiang Liu: The Role of Prostatitis in Prostate Cancer: Meta-Analysis . In: PLoS ONE . tape 8 , no. 12 , December 31, 2013, PMC 3877315 (free full text).
  5. ↑ Nicholas A Daniels, Yea-Hung Chen, Stephen Bent: Antibiotic and anti-inflammatory use and the risk of prostate cancer . In: BMC Research Notes . tape 2 , April 17, 2009, PMC 2672937 (free full text).
  6. ↑ Weihua Fu, Zhansong Zhou, Shijian Liu, Qianwei Li, Jiwei Yao: The Effect of Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP / CPPS) on Semen Parameters in Human Males: A Systematic Review and Meta-Analysis . In: PLoS ONE . tape 9 , no. 4 , April 17, 2014, PMC 3990624 (free full text).
  7. ↑ Zong-Yao Hao, Hong-Jun Li, Zhi-Ping Wang, Jun-Ping Xing, Wei-Lie Hu: The prevalence of erectile dysfunction and its relation to chronic prostatitis in Chinese men . In: Journal of Andrology . tape 32 , no. September 5 , 2011, PMID 21233394 .
  8. ↑ Alexander W. Pastuszak: Current Diagnosis and Management of Erectile Dysfunction . In: Current sexual health reports . tape 6 , no. 3 , September 2014, PMC 4394737 (free full text).
  9. ↑ Chronic pain in the pelvic area - a diagnostic and therapeutic puzzle ( Memento of the original from September 30, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. URO-NEWS • special issue1 · 2003 (O. Moormann, G. Bartsch, H.-P. Caspers) @1@ 2Template: Webachiv / IABot / www.uronews-online.de
  10. ↑ a b Jon Rees, Mark Abrahams, Andrew Doble, Alison Cooper: Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis / chronic pelvic pain syndrome: a consensus guideline . In: Bju International . tape 116 , no. October 4 , 2015, PMID 25711488 .
  11. ↑ Nickel J, Downey J, Feliciano A, Hennenfent B: Repetitive prostatic massage therapy for chronic refractory prostatitis: the Philippine experience . In: Tech Urol . 5, No. 3, 1999, pp. 146-151. PMID 10527258 .
  12. ↑ Use of prostatic massage in combination with antibiotics in the treatment of chronic prostatitis . In: Prostate Cancer Prostatic Dis . 2, No. 3, 1999, pp. 159-162. PMID 12496826 .
  13. ↑ Sengoku A, Yamashita M, Umezu K: [A case of Fournier's gangrene: was it triggered by prostatic massage?] . In: Hinyokika Kiyo . 36, No. 9, 1990, pp. 1097-1100. PMID 2239620 .
  14. ↑ Buse S, Warzinek T, Hobi C, Ackerman D: [Prostate massage with unwanted consequences. Case report] . In: Urologist A . 42, No. 1, 2003, pp. 78-79. PMID 14655640 .
  15. ↑ Ateya A, Fayez A, Hani R, Zohdy W, Gabbar M, Shamloul R: Evaluation of prostatic massage in treatment of chronic prostatitis . In: Urology . 67, No. 4, 2006, pp. 674-678. PMID 16566972 .
  16. ↑ N. Alexacos, X. Pang, W. Boucher, DE Cochrane, GR Sant, TC Theoharides: Neurotensin mediates rat bladder mast cell degranulation triggered by acute psychological stress. In: Urology. Volume 53, Number 5, May 1999, pp. 1035-1040, PMID 10223502 .
  17. ↑ JN Krieger, DE Riley, MC Roberts and RE Berger: Prokaryotic DNA sequences in patients with chronic idiopathic prostatitis . In: J Clin Microbiol. . 34, No. 12, 1996, pp. 3120-3128. PMID 8940458 .
  18. ↑ Keay S, Zhang CO, Baldwin BR, Alexander RB: Polymerase chain reaction amplification of bacterial 16s rRNA genes in prostate biopsies from men without chronic prostatitis . In: Urology . 53, No. 3, 1999, pp. 487-491. PMID 10096371 .
  19. ↑ Dimitrakov JD, Kaplan SA, Kroenke K, Jackson JL, Freeman MR: Management of chronic prostatitis / chronic pelvic pain syndrome: an evidence-based approach , Urology. 2006; 67 (5): 881-888
  20. ↑ Capodice JL, Bemis DL, Buttyan R, Kaplan SA, Katz AE: Complementary and alternative medicine for chronic prostatitis / chronic pelvic pain syndrome . In: Evid Based Complement Alternat Med. . Dec, No. 2 (4), 2005, pp. 495-501. PMID 16322807 .
  21. ↑ RB Alexander, KJigent, AJ Schaeffer, JR Landis, JC Nickel, MP O'Leary, MA Pontari, M. McNaughton-Collins, DA Shoskes, CV Comiter, NS Datta, JE Fowler, RB Nadler, SI Zeitlin, JS Knauss , Y. Wang, JW Kusek, LM Nyberg, MS Litwin: Ciprofloxacin or tamsulosin in men with chronic prostatitis / chronic pelvic pain syndrome: a randomized, double-blind trial. In: Annals of internal medicine. Volume 141, Number 8, October 2004, pp. 581-589. PMID 15492337 .
  22. ↑ JC Nickel, J. Downey, J. Clark, RW Casey, PJ Pommerville, J. Barkin, G. Steinhoff, G. Brock, AB Patrick, S. Flax, B. Goldfarb, BW Palmer, J. Zadra: Levofloxacin for Chronic prostatitis / chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. In: Urology. Volume 62, Number 4, October 2003, pp. 614-617. PMID 14550427 .
  23. ^ "Several inflammatory and reactive alterations of sperm quality seem to be proven; nevertheless, the impact of these findings on male fertility remains in many cases unclear." Weidner W, et al .: Relevance of male accessory gland infection for subsequent fertility with special focus on prostatitis. . In: Hum Reprod Update . 5, No. 5, 1999, pp. 421-432. PMID 10582781 .
  24. ↑ Laborjournal 2007 14 on the ACC hypothesis in chronic prostatitis http://www.kyb.mpg.de/publications/attachments/Laborjournal-2007-14_%5B0%5D.pdf

literature

  • Jürgen Sökeland, Harald Schulze, Herbert Rübben: Urology. 13th edition. Thieme, Stuttgart 2004.
  • Ernst-Albrecht Günthert: Psychosomatic urology. 1st edition. Schattauer, December 2003, ISBN 3-7945-2298-2 (paperback, 156 pages).
  • W. Weidner, PO Madsen, HG Schiefer (Ed.): Prostatitis. Etiopathology, Diagnosis and Therapy. Springer-Verlag, Berlin / Heidelberg 1994, ISBN 3-540-56624-4 / 0-387-56624-4.
  • J. Curtis Nickel: The Prostatitis Manual: A Practical Guide to Management of Prostatitis / Chronic Pelvic Pain Syndrome. 1st edition. Bladon Medical Publishing, 2002, ISBN 1-904218-08-3 .
  • David Wise: A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes. 3. Edition. National Center for Pelvic Pain, 2005, ISBN 0-9727755-2-8 .
  • Florian ME Wagenlehner et al .: Prostatitis and male pelvic pain syndrome: diagnosis and therapy . In: Dtsch Arztebl Int . No. 106 (11) , 2009, pp. 175-183 ( abstract ).

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