Congestive prostatitisis a disease process in the prostate gland caused by congestion. Pathogenic flora is not detected; Microscopic examination of prostatic secretions, semen, and urine may reveal leukocytes. Symptoms include constant aching pain in the perineum, dysuria. Diagnostics are based on the results of bacterial culture of biomaterial and TRUS. There is no single treatment regimen for congestive prostatitis; massage, physiotherapy, antimicrobial drugs and alpha-blockers are prescribed. An individual approach is needed, taking into account existing symptoms. If conservative treatment fails, surgery is possible.
general informations
Prostatitis can be infectious, caused by the presence of pathogenic microflora, or stagnant, associated with blood congestion, retention of ejaculate and prostatic secretions. Congestive or congestive prostatitis (vegetative urogenital syndrome, prostatosis) is an obsolete name. Modern specialists in the field of urology most often use the term "chronic pelvic pain syndrome without inflammatory response" (CPPS). Prostatitis occurs in 25% of men aged 35-60 years, inflammation caused by congestive processes accounts for 88-90% of the total number of cases. The potentially congestive form of the disease is supported by pathogens that are in the L form, fixed on biofilms and not detected by routine methods.
Causes
The causes of congestive prostatitis can be associated both with the gland itself and with extraprostatic factors. The exact etiology is not known, it is probably due to stagnation of secretions in the prostate or is a consequence of venous congestion in the pelvic organs and scrotum. Some urologists consider the condition psychosomatic. The boundary between bacterial and abacterial inflammation is very arbitrary; with immunosuppression of any origin, due to the addition of secondary microflora, the process becomes infectious. Congestive prostatitis is caused by:
- Internal urological causes. Functional or structural pathology of the bladder: cervical obstruction, inability of the external sphincter to relax during bowel movements, impaired detrusor contractility contribute to urinary retention and, due to compression of the vessels, to blood stagnation. Prostate hyperplasia and cancer, urethral stricture and obstructive bladder stones are also considered potential causes of venous congestion.
- Compression. Blood circulation is hindered due to compression of the venous plexus by a retroperitoneal tumor, metastases and intestinal loops full of feces (constipation). The vessels of the genitourinary plexus dilate, blood flow slows down, tissues suffer from oxygen starvation and are replaced by non-functional structures. Some of the blood is deposited and is cut off from circulation.
- Behavioral factors. Refusal of sexual activity, irregular ejaculation, and the use of interrupted sexual intercourse as a means of preventing unwanted pregnancies cause blood flow and swelling of the prostate tissue. During ejaculation, this gland is not completely drained. Constant masturbation can lead to congestive prostatitis, because. . . For the development of an erection, a blood supply to the genitals is necessary.
Predisposing factors include low physical activity, hypothermia and overheating, poor nutrition with a predominance of spicy and smoked foods. Alcohol and nicotine affect the tone of the vascular wall, disrupt redox processes and permeability, causing swelling. The main prerequisites for the formation of congestive prostatitis with effect on all organs of the male genital area (vesicles, testicles) are considered anomalies of the vascular system of the pelvis - valve insufficiency, congenital weakness of the venous wall.
Pathogenesis
The peripheral area of the prostate gland is made up of ducts that have a poorly developed drainage system, which prevents the outflow of secretions. As the prostate enlarges with age, patients develop reflux of urine into the prostatic tubes. It has been noted that many men suffering from prostatitis are more prone to allergies. Scientists believe that such patients may also suffer from autoimmune inflammation caused by a previous infection.
Urinary reflux is favored by urethral strictures, bladder dysfunction and BPH. Backflow of even sterile urine leads to chemical irritation and inflammation. Fibrosis of the tubules begins, creating the conditions for prostatolithiasis, which increases intraductal obstruction and stagnation of secretions. Inadequate drainage of the acini triggers an inflammatory reaction, increased swelling is accompanied by the appearance of symptoms. The condition is aggravated by congestion (stagnation) of blood in the pelvis.
Classification
The general classification of prostatitis includes acute (I) and chronic (II) bacterial forms. Category III includes subtype IIIa – CPPS with inflammation and IIIb – CPPS without it. Congestive prostatitis is considered a manifestation of CPPS with absence of inflammatory response (IIIb). There is a clinical differentiation that takes into account the pathogenetic and morphological characteristics of the disease:
- First stage.Characterized by the predominance of processes of exudation, emigration, arterial and venous hyperemia, with consequent damage to the microcirculation and destruction of the glandular tissue. These changes are recorded during the first years after the onset of the disease. The clinical picture in the first phase is more pronounced.
- Second phase.The initial processes of connective tissue proliferation develop and symptoms diminish. Due to the formation of thrombi, microcirculation suffers, which aggravates sclerosis. At this stage, most patients experience sexual dysfunction: erection and intensity of orgasm weaken, premature ejaculation develops or, vice versa, the man experiences difficulties in achieving orgasm.
- Third phase. Severe fibrosclerotic changes are typical. It has been shown that the proliferation of connective tissue is stimulated not only by inflammation, but also by the ischemia that accompanies congestive prostatitis. Complaints of difficulty urinating are typical and the involvement of the kidneys in the pathological process is noted.
Symptoms of congestive prostatitis
The pathology manifests itself with a variety of symptoms. Most patients describe the pain as a constant discomfort in the perianal area, scrotum or penis. Some notice increased perineal pain when sitting. The radiation of pain is variable: to the lower back, inside the thighs, to the coccyx. Swelling of the gland often makes it difficult to begin urination and weakens urine flow. A type of congestive inflammation against the background of vascular pathology is often accompanied by hemospermia - the appearance of blood in the sperm.
Symptoms of bladder irritation include frequent urgency and urge urinary incontinence. With long-term pathology, depressive disorders develop. It is still debatable whether psycho-emotional characteristics lead to discomfort in the perineum or, conversely, pain caused by swelling of the prostate affects the mental state of a man. An increase in temperature with chills indicates the transition of abacterial congestive prostatitis to infectious and the need to start pathognomonic treatment.
Complications
Congestive prostatitis with the addition of microflora can become acute bacterial. Neighboring organs and structures may be involved in the inflammatory process: vesicles, bladder, testes. The role of the prostate gland is to produce fluid for sperm; it normally has a special composition that has a protective function for male germ cells. Insufficient quantities of nutrients and changes in the biochemical properties of prostatic secretions inevitably affect the quality of ejaculate; men with congestive prostatitis are more often diagnosed with infertility.
With severe swelling of the organ, part of the urine after urination remains in the bladder, which leads to the formation of pathological reflux of urine in the ureters and renal collecting system. Persistent hydronephrosis and pyelonephritis with impaired renal function may occur in response to reflux. 50% of men develop sexual dysfunctions: painful ejaculation, dyspareunia, uncomfortable nocturnal erections, which worsen the quality of life and negatively affect the couple's relationship.
Diagnostics
Determining the origin of symptoms is essential for effective treatment of congestive prostatitis, therefore various questionnaires have been developed to facilitate the diagnosis: I-PSS, UPOINT. These questionnaires are available in Russified form and are used by urologists and andrologists in their practice. To exclude myofascial syndrome, consultation with a neurologist is indicated. Upon palpation the prostate appears enlarged, moderately painful; the congestive nature of the disease is evidenced by varicose veins of the rectum. The diagnosis of congestive prostatitis includes:
- Lab test. A microscopic and cultural examination of the prostate juice is performed. A slight increase in the number of leukocytes under the microscope and negative bacterial culture results confirm bacterial congestive inflammation. PCR tests are performed to exclude the sexually transmitted nature of the disease. In the third portion of urine after massage, a more pronounced leukocyturia is detected. To exclude bladder cancer, urine cytology can be performed; in patients older than 40-45 years a PSA blood test is justified.
- Visual search methods. The main instrumental diagnostic method remains TRUS, ultrasound of the bladder. Cystourethrography findings are informative in confirming bladder neck dysfunction, revealing intraprostatic and ejaculatory reflux of urine and urethral stricture. In case of pronounced weakening of the jet, uroflowmetry is performed. Pelvic floor muscle tension is assessed using a videourodynamic study.
Differential diagnosis is carried out with bladder carcinoma, BPH, interstitial cystitis. Similar manifestations are observed in genitourinary tuberculosis and urethral stricture, as these nosologies are also characterized by lower abdominal pain, symptoms of dysuria and difficulty urinating. Congestive prostatitis is distinguished from bacterial prostatitis; furthermore, all pathological processes accompanied by CPPS in men must be excluded.
Treatment of congestive prostatitis
The patient is recommended to normalize his sexual life, as regular ejaculation helps to drain the acini and improve microcirculation. Interrupted or prolonged sexual intercourse that causes congestion is not acceptable. Numerous products have been identified that increase the chemical aggressiveness of urine: their consumption leads to an increase in the symptoms of congestive prostatitis. Spices, coffee, marinades, smoked foods, alcoholic and carbonated drinks should be limited, or better yet excluded. Treatment of congestive inflammation of the prostate gland can be conservative and surgical.
Conservative therapy
The treatment regimen is selected individually, depending on the prevailing symptoms. In many patients, improvement occurs after taking antibacterial drugs, which is explained by incomplete diagnosis of latent infections. In case of slow urinary flow and requiring effort, alpha-blockers are prescribed. Urinary urgency is neutralized with anticholinergic drugs. 5-alpha reductase inhibitors have been shown to reduce the severity of clinical manifestations by reducing the response of macrophages and leukocytes and their migration into the inflammatory zone.
Pain relievers, nonsteroidal anti-inflammatory drugs, and muscle relaxants can help relieve pain and muscle spasms. It is reasonable to include in the therapeutic regimen drugs that normalize microcirculation – phlebotonics (venotonics). If the stagnant process supports androgen deficiency, hormone replacement therapy is resorted to. Patients with anxiety-hypnotic and depressive disorders are advised to consult a psychiatrist who will select the optimal antidepressant.
With congestive inflammation of the prostate, physiotherapeutic procedures help to normalize men's health. They use laser and magnetic therapy, electrophoresis, etc. Thermal treatments help alleviate the symptoms of dysuria and improve sexual function: intake of alkalizing mineral waters, applications of paraffin and mud, massaging showers. In some patients, normalization of well-being is noted when performing physical therapy to reduce tension in the pelvic muscles. Prostate massage does not replace natural ejaculation, but improves blood circulation and drainage of the organ.
Minimally invasive treatment methods
If conservative therapy is unsuccessful, high-tech interventions are considered: transurethral resection of the prostate, ablation with high-intensity focused ultrasound. The most effective is transrectal hyperthermia, a non-invasive method based on the principle of thermal diffusion (the prostate is exposed to unfocused microwave energy). Heat increases tissue metabolism, reduces symptoms of congestion and has a neuroanalgesic effect. Data on the effectiveness of the procedures in treating congestive prostatitis are limited.
Prognosis and prevention
The prognosis for life is favorable, but chronic pelvic pain is difficult to treat. Sometimes congestive prostatitis resolves spontaneously over time. A long-term circulatory disorder leads to sclerosis of the glandular tissue, which is manifested by a deterioration of spermogram parameters. The prognosis of congestive prostatitis largely depends on the patient's compliance with all recommendations and lifestyle changes.
Prevention involves playing sports, avoiding heavy lifting, normalizing sexual intercourse and avoiding the consumption of coffee and alcohol. When working in a sedentary manner, it is recommended to take breaks to do physical exercises and use a cushion. Loose underwear and pants are preferable. Patients are observed by a urologist with periodic evaluation of prostatic secretions for inflammation and ultrasound and, if necessary, receive antibacterial treatment and prostate massage sessions.