Arnoldi Eduard K., MD CHRONIC PROSTATITIS: problems, prospects, experience
This book, written by the Assistant Professor of the Department of Urology of the Kharkov Medical University, concentrates on the etiology, pathogenesis, symptoms, diagnosis, and treatment of chronic prostatitis,— one of the most frequently encountered diseases among young.. and middle-aged men.
In our time, the problem of chronic prostatitis has gained significant importance due to the range of ecological, social, and ethico-moral causes, which considerably increased the morbidity. Some data (Yunda I. E., 1987) show, that morbidity of chronic prostatitjs has increased almost in two times during the past decades, and reached the level, which totals nearly half of all men 20—50 years old. This disease is also important in patients, suffering from benign prostatic hyperplasia — age-related illness, which affects significant part of men older 60, in whom prostatitis, not infrequently, exacerbates with ascending infection and (or) hemorrhages the period after surgical and instrumental procedures performed for this reason.
Both diagnosis and treatment strategies in chronic prostatitis should arise from the principle of individual pathogenetic features, which depend on different complex etiogenetic factors (some of them are shown in the corresponding chapter).
Physiological role of the prostate gland is diversified, involving realization of variable reproductive functions, as well as retention of the urine (and, correspondingly, normal urine excretion).
One of the main functions of the prostate consists in production of the secretion, which provides, after ejaculation, dilution of the sperm and mobility of the spermatozoa due to the presence of fructose and zinc citrate. Dilution of the ejaculate is also achieved by action of the proteolytic ferments, produced by the prostate.
The researches, undertaken by Lynn Fraser et al in the London Kings College Biomedical Science Labs, revealed in the spermatic plasma the presence of the FPP (fertilization promoting peptide) produced by the prostate gland. FPP prevents premature acrosomal reaction of the spermatozoa. As was shown by the researches, conducted by P.G.Morosov (1990), considerable percentage of the male infertility is brought about by impaired tissue metabolism in the prostate.
Besides this, the prostate is among important elements of the testosterone production regulating system. Not long ago, the theory of substitutive role of the prostate in age- related impairment of hormone function of the testes was suggested (G.Bartch et al, 1996). In such a condition, as authors assume, the prostate begins the testosterone production. The released testosterone, in its turn, exerts influence upon the prostate, resulting in stimulation of the periurethral gland hypertrophy, that causes prostate adenoma development.
Prostatitis, similarly to pyelonephritis, largely presents the collective term, which includes different in their activity and extent inflammatory processes, developing due to the initiation and stabilization of various structural and functional pathologic changes in the prostate.
It was proved, that allergy and autoimmunization play significant role in the evolution of chronic prostatitis (I.F.Yunda et al, 1975; M.I.Kaplun et al, 1978; V.P.Chernyshev, 1984; N.A.Lopatin et al, 1982).
In this book, the modern complex approaches to the treatment of different forms of prostatitis are described,
including new method of the conservative treatment for calculous inflammation of the prostate. The book deals with some topics, concerning the fertility impairment, related to the prostatitis, an also describes other up-to- date diagnostic and curative methods, employed in chronic prostatitis. There are some problems discussed, pertaining to the interrelation between prostatitis and benign prostate hyperplasia, as well as to the probability of the benign prostate hyperplasia development in such a patient.
Besides this, the presence of prostatitis increases the likelihood of complications after surgical treatment of this disease. It becomes especially important, considering the fact, that chronic prostatitis exists in almost a half of the patients, suffering from benign prostate hyperplasia. Consequently, one may expect, that more than a half of the patients, operated for the benign prostate hyperplasia will be apt to the activation of the urogenital infection in the postoperative period.
Two main factors participate in the etiology of chronic prostatitis: congestive factor, leading to development of the morpho-functional changes of the gland, and infectious factor, which worsens these changes.
The existence of the uroprostatic refluxes plays a distinct role both in pathogenesis of the prostate diseases and in treatment of these disorders. At the same time, these refluxes make it possible for different diagnostic and medicinal substances to penetrate into the surrounding tissues and venous system, achieving the corresponding effects.
Development of the prostatic concrements presents the essential consequence of the uroprostatic reflux (B.N.Holtzov, 1927), though, this is not the only cause of prostatolythiasis.
Endourethral usage of antibacterial, anti-inflammatory, fibrinolytic, and other water-soluble preparations, especially in the combination with Dimexid, allows employment of the urethral refluxes as the factors, facilitating penetration
of the heightened concentrations of the medicinal preparations in treatment of the urethra, penis, and prostate diseases.
Taking into account appropriate for chronic prostatitis elevation of the antibody titer, some investigators consider it necessary to use immunodepressants in order to prevent the autoagressive processes (MJ.Kaplun et al, 1978; O.L.Tyktinski, 1984; I.V.Karpukhin, 1983).
Thus, in the pathogenesis of chronic prostatitis the following main factors may be distinguished: Beginning of the congestive or retentive processes in the prostate, associated with inadequate sexual regimen, sedentary life, concomitant diseases (one of the main causes — habitual constipation), and constitutional features of the vegetative status. Development of the alterative changes in the prostate parenchyma, and, also, decrease of the local or general reactivity, leading to the diminished immunity, or, vice- versa, to the hyperimmunisation with the prostate antigen (simultaneous shifts in the immunologic status are not excluded).
Some external factors should be added, including toxic influence of frequently used alcohol beverages and strong spices, as well as hygienic (cold exposure) factors. Addition (usually per continuitatem) of the pathogenic, or activated conditionally pathogenic flora from the posterior urethra. Existence, on the above-mentioned basis, of the primarily chronic inflammatory process, proceeding with alternating activity, and leading to the gradually developing sclerotic processes in the prostate.
Following changes of the prostate may be reckoned as morpho-functional:
Congestive plethora of the prostate as a result of the frequent sexual excesses, or, on the contrary, on the basis of frustrations. Stasis of the capillary blood circulation leads to the increased volume of the gland within the capsule
limits, which results in compression of the alveolar ducts and impairment of the secretion outflow.
Intrapelvic venous congestion syndrome — IVCS.
Increased, owing to the prevailing sympathetic influence (or by the action of reflex), tonus of the prostatic smooth muscle, which leads to compression of the alveolar ducts.
Atony of the gland without significant morphological changes.
Reduced general prostatic tonus in combination with dilated alveoli, gaped prostatic ducts, and uroprostatic reflux.
Stagnation of contents in the dilated prostatic ducts, as a result of plugging their distal parts by the thickened secretion. These changes may appear in the form of so- called postmassage deformity (altered volume and tonus of the prostate after massage).
Confined prostatic ischemiae, developing due to the continuous compression of the prostate by solid fecal masses in chronic constipation.
Prostatic infarctions, resulting from thrombosis and embolization with consequent purulent inflammation, scarring, and possible development of the diverticula.
Hemorrhages in the prostatic tissue, resulted from the vessel disrupters due to traumas and congestive changes with formation of the “blood cysts”.
Inflammatory edema of the alveolar prostatic duct orifices in posterior urethritis.
Inflammatory changes, pronounced mainly in the lumen of the prostatic ducts without stagnation of the purulent discharges.
Confined inflammatory infiltration of the parenchyma.
Plugging or scarring of the duct orifices with presence of the retentive changes of the prostate duct lumens due to the permanent or persistent impairment of the prostate secretion outflow.
Sequelae after prostatic abscesses, developed on the
basis of impaired secretion outflow, melted inflammatory leukocytic infiltrates and prostatic infarctions. These pathologic changes have the traits of confined sclerotic zones.
Atrophy of the prostatic parenchyma and smooth muscle elements with the cicatro-scierotic transformation of the gland (post-gonorrhea! prostatic sclerosis).
Presence of the separate or multiple prostate diverticula.
Prostatolithiasis with injuries and pressure sores of the alveolar epithelium, and development of the retention and inflammatory changes. Besides, calculi represent secure defense for the inhabiting microflora, protecting it from antibacterial medicinal preparations.
Changes, characterizing specific (tuberculosis, actinomycosis etc.) diseases.
Enumerated pathologic changes may have isolated character, or associate with each other in various combinations.
Hence it appears, that above-named morpho-functional prostatopathiae in most cases create the opportunities for infectioning the prostate. Therefore, etio-pathogenesis of prostatitis has a complex structure, marked by its individuality.
ccordingly, the treatment of prostatitis, besides antibacterial therapy, includes the factors, possibly diminishing expressiveness of the above-mentioned changes, the regimen, preventing their augmentation or recurrence, and also the row of other therapeutic components.
Infection of the prostate may be caused by its own microflora, which lives as a saprophyte in the lower urinary tract (autogenous infection; it is necessary to have some predisposing factors for such a process, because one has certain immunity to these flora), or by extraneous flora (heterogeneous or xenogenous infection), when the immunity to it is abcent.