Acute bacterial prostatitis

Acute prostatitis is an acute inflammation of the prostate, which is characterized by a certain symptom complex (pain, hyperthermia, dysuria, septic condition). The spectrum of pathogens of acute prostatitis is represented by the same pathogens as in other acute urinary tract infections.

The vast majority are anaerobic non-negative bacteria: Escherichia coli makes up 80% Serratia Pseudomonas, Klebsiella Pseudomonas, Proteus Pseudomonas - 10-15%; non-positive: Enterococcus - 5-10%, Staphylococcus aureus causes the development of acute prostatitis with prolonged drainage of the bladder with a urethral catheter. Other gram-positive bacteria cause the development of the disease against the background of a decrease in immunity (long-term septic condition, acquired immunodeficiency syndrome, tuberculosis and other conditions).

ICD-10 codes

• N41.0. Acute prostatitis.
• N41.8. Other inflammatory diseases of the prostate gland.
• N41.9. Inflammatory disease of prostate gland, unspecified.

Epidemiology of acute prostatitis

Bacterial acute prostatitis accounts for 5-10% of inflammatory diseases of the prostate. The disease occurs mainly in reproductive age (35-50 years).

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What causes acute prostatitis?

Predisposing factors for the development of acute prostatitis include situations that facilitate the penetration of bacterial infection and colonization of prostate tissue:

• promiscuous sexual relations, the presence of chronic inflammatory diseases in the partner (bacterial vaginosis, chronic salpingo-oophoritis, etc.);
• intraprostatic reflux of urine (with functional disorders of the urinary bladder sphincter);
• prostate stones (due to prolonged congestion or as a complication of chronic prostatitis);
• phimosis;
• urethral catheters;
• instrumental interventions on the urethra.

The development of an acute inflammatory process is facilitated by:

• venous congestion (stasis) of the pelvic organs due to hemorrhoids, paraproctitis, obesity and physical inactivity;
• concomitant diseases (diabetes mellitus, acquired immunodeficiency syndrome, alcoholism).

A special place is occupied by bacterial acute prostatitis, which developed against the background of urosepsis, the characteristic clinical picture of which is a lightning-fast course with the development of characteristic complications (prostate abscess, pelvic phlegmon).

There are various ways for infection to enter the prostate.

The most common ways for infection to enter the prostate are:

• canalicular pathway - from the posterior part of the urethra through the excretory ducts of the prostate;
• lymphogenous route - in acute urethritis, "catheter urethral fever";
• hematogenous route - in case of bacteremia.

Pathogenesis of acute prostatitis

Morphological changes in the prostate can be observed during a typical acute inflammatory process. In catarrhal acute prostatitis, the size of the prostate increases due to the expansion of the acini and reactive edema of the interstitial tissue. Further, inflammatory changes quickly develop in the excretory ducts and lobes of the prostate. Their lumen is significantly narrowed or obstructed due to edema of the entire organ.

Only the excretory ducts of the prostatic glands, which open into the posterior part of the urethra, are directly involved in the inflammatory process. The inflammatory process does not extend deeper than the mucous and submucous layers. Impaired contractility of the excretory ducts and their relative narrowing or complete blockage lead to impaired secretion of the glands into the posterior part of the urethra. Stasis of the prostate secretion is noted, the lumen of the ducts and glands is filled with deflated epithelium, leukocytes, and mucous-degenerated bodies. Leukocyte infiltration is in the mucous membrane and submucous membrane. Hemodynamic disorder increases organ edema. Catarrhal acute prostatitis often develops as a result of infection penetration from the posterior part of the urethra. The release of inflammatory-altered secretion into the posterior part of the urethra maintains posterior urethritis.

Follicular prostatitis is the next stage of acute prostatitis. The inflammatory process, spreading, affects the prostatic glands of individual lobes or the entire prostate. Stagnant secretion of the glands in the form of pus is released into the urethra or forms isolated pustules. The glandular tissue is infiltrated, its cellular elements are subject to varying degrees of destructive changes. Hemo- and lymphodynamic disorders increase. With occlusion of the excretory ducts, individual minuses sharply expand. The prostate enlarges.

The transition of the inflammatory process to the interstitial tissue of the prostate indicates parenchymatous acute prostatitis. It should be noted that with contact (post-puncture or postoperative) and hematogenous routes of infection, the parenchymatous stage develops independently. The infection, affecting the interstitium, easily overcomes weak interlobular septa, and the process takes on a diffuse-purulent character. Leukocyte infiltration captures the stromal structures of the organ, leading to compaction and edema of the organ.

The process can capture a lobe of the gland or the entire gland. The parenchymatous stage develops first as a diffuse-focal stage, in which individual foci of purulent inflammation are formed. Then leukocyte infiltration and foci of purulent melting merge with the formation of a prostate abscess. Against this background, the tissue of the gland can melt with the formation of a prostate abscess. If the inflammation captures the fibrous capsule of the prostate or the surrounding tissue, they talk about paraprostatitis. Phlebitis of the paraprostatic venous plexus is a serious complication of acute parenchymatous prostatitis and can cause sepsis. An abscess of the gland sometimes spontaneously opens into the bladder, the back of the urethra, the rectum, and rarely into the abdominal cavity. Its opening into the surrounding pelvic tissue is accompanied by its suppuration. In follicular and parenchymatous acute prostatitis, as a rule, reactive inflammation of the posterior part of the urethra and the neck of the bladder develops, which gives the clinical picture of the disease additional features.

Symptoms of acute prostatitis

Symptoms of acute prostatitis begin acutely, accompanied by frequent, difficult and painful urination in small portions, pain in the perineum, in the anus and suprapubic area, a feeling of pressure in the rectum, discomfort in the genital area. Symptoms of general intoxication join: hyperthermia reaches 39 ° C and more, tachycardia, tachypnea, nausea, chills, up to the development of a septic condition. The addition of chills becomes an obvious sign of a serious disease. Within 20-30 minutes, the chills pass, but general weakness, sweating intensify, fatigue appears.

The intensity of complaints and the degree of clinical manifestations in different patients is not uniform and depends on the form or stage of acute prostatitis, as well as on the anatomical and topographic location of the inflammatory focus in the prostate in relation to the urethra, bladder neck and rectum. Diabetes mellitus, chronic alcoholism, drug addiction can hide the true severity of the disease, which leads to underestimation of the patient's condition. Complaints of pain in acute prostatitis may be absent or limited to painful defecation, a feeling of pressure in the rectum, in the perineum when sitting.

During digital rectal examination, the prostate is significantly enlarged, edematous, and extremely painful; the interlobar groove is not differentiated; fluctuation foci indicate the development of a prostate abscess. With severe pyuria, the urine is cloudy and has a foul odor.

Severe swelling of the inflamed prostate and paraprostatic tissue leads to compression of the posterior part of the urethra, increased difficulty in urination, up to the development of acute urinary retention. In some cases, this serves as a basis for the patient to seek urgent medical care.

Symptoms of acute prostatitis can be very meager, so the disease is not diagnosed in time. Acute prostatitis can pass under the "mask" of common infectious diseases.

Therefore, it should be remembered that any sudden increase in temperature. In a man, with scant other clinical manifestations, requires a digital rectal examination of the prostate.

In catarrhal acute prostatitis, the prostate is either unchanged or slightly enlarged, and moderate pain is noted upon palpation, while in follicular prostatitis, against the background of its moderate enlargement, it is possible to palpate individual sharply painful foci of taut-elastic density over the inflamed lobules. In patients with parenchymatous acute prostatitis, the prostate is sharply tense and painful at the slightest touch. Its density is tight and uniform, and softening is noted when the foci become abscessed.

When the inflammatory process in the prostate spreads to surrounding tissues, the symptoms of acute prostatitis change. When the process involves the paravesical tissue and the wall of the bladder, the clinical manifestations resemble acute cystitis with a sharp increase in the frequency of urination and painful urges to urinate (tenesmus). When the inflammatory process spreads to the wall of the rectum or pararectal tissue, the manifestations of the disease resemble proctitis and paraproctitis with painful defecation, mucus discharge from the rectum, sharp pain in the perineum, painful spasm of the anal sphincter, preventing digital rectal examination.

This examination should be performed with extreme caution, firstly, because of the pain and, secondly, because of the risk of provoking a sharp increase in the resorption of inflammatory exudate and even a direct "breakthrough" of microbial flora and bacterial toxins into the blood. The latter can not only increase general intoxication, but also cause bacterial shock. For the same reasons, prostate massage is strictly prohibited during acute inflammation, including for diagnostic purposes. At the same time, any digital examination of the gland should be used for diagnostic purposes as much as possible, and therefore, when starting it, it is necessary to prepare the necessary test tubes in advance for performing a three-glass test, a three-portion urine analysis and its bacteriological examination.

Classification of acute prostatitis

Acute prostatitis is divided into:

• catarrhal;
• follicular;
• parenchymatous.

Complications of acute prostatitis:

• prostate abscess;
• paraprostatitis,
• phlebitis of the paraprostatic venous plexus.

According to the prevalence of the process, diffuse and focal acute prostatitis are distinguished. The classification of acute prostatitis is relative, since often in the inflammatory process all forms are presented simultaneously or they are successive stages of the development of acute inflammation.

Acute prostatitis consistently passes from catarrhal to follicular and then to parenchymatous form. The time of development of each stage has no strict time limit and depends on the pathogenicity of the microorganism, the state of the body, and concomitant pathological processes.

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Complications of acute prostatitis

A common complication of acute prostatitis is acute urinary retention or difficult urination with residual urine of 100 ml or more, which requires immediate urine derivation. Trocar cystostomy is preferred. A drainage with a diameter of 12-18 CH is installed, the duration of drainage is 7-14 days.

Progression of inflammation can lead to suppuration of the prostate tissue with the formation of an abscess.

Prostate abscess is a purulent melting of the prostate parenchyma with the formation of a pyogenic capsule around the focus, usually a consequence or outcome of acute prostatitis. Much less frequently diagnosed is an idiopathic, primary prostate abscess, which occurs as a result of metastasis of a purulent infection during septicopyemia associated with other purulent-inflammatory diseases. In this case, the anamnesis indicates the existence of a purulent focus (pyoderma, furunculosis, tonsillitis, sinusitis). During examination, these purulent foci can be detected.

Prostate abscess may be suspected when the clinical picture and the severity of the patient's condition with acute prostatitis increase or when the disease rapidly develops with worsening blood tests and increasing signs of intoxication. Prostate abscess, in turn, may be complicated by the development of endotoxic shock (a drop in blood pressure, hypothermia to 35.5 °C, a decrease in the level of leukocytes in the blood below 4.5x10 ⁹ /l), as well as paraprostatic phlegmon.

However, it should also be taken into account that the limitation of the purulent focus (the formation of an abscess in the prostate) can also occur against the background of a subjective improvement in the patient’s condition.

The diagnosis is established by palpation through the rectum, when asymmetry of the enlarged and painful gland, ballottement or fluctuation when pressing on it in a suspicious area are detected. Rarely, it is possible to palpate the pulsation of the pelvic vessels transmitted through the cavity located deep in the prostate (a symptom called Poyon's rectal pulse). An ultrasound of the organ using a rectal sensor allows detection of a purulent cavity in the gland.

Without surgical treatment, the abscess may spontaneously open into the posterior part of the urethra or into the bladder, which is clinically accompanied by visible self-healing. Opening of the abscess into the rectum, perineum, paraprostatic and perivesical tissue is accompanied by the formation of purulent fistulas, phlegmons, which also require surgical treatment.

The detected prostate abscess is urgently opened, the abscess cavity is drained. Prostate abscess drainage is currently performed under ultrasound guidance using transrectal or transperineal access. The choice of method depends on the equipment of the clinic and the preferences of the urologist, but the best approach to prostate abscess is considered to be transperineal access. Under local anesthesia, the abscess is punctured. A drainage tube with a diameter of 6-8 CH is installed in the cavity. The duration of drainage is 5-7 days.

In the absence of ultrasound guidance, the prostate abscess is opened under the control of the index finger of the left hand inserted into the rectum, with which the place of greatest fluctuation is felt. The patient is placed on his back with the legs bent at the hip and knee joints. The operation is performed under general or epidural anesthesia. 2-3 cm in front of the anus to the right or left of the median perineal suture, according to the location of the abscess in one or both lobes, a puncture of the abscess is made with a long needle and syringe. After the puncture and obtaining pus in the syringe, a layer-by-layer incision is made along the needle, the abscess is opened, emptied, the cavity is revised, the course is widened with forceps and drained with a drainage tube, as with ultrasound guidance.

If the abscess is located directly at the wall of the rectum, it can be opened transrectally. The patient's position and anesthesia are the same. Under the control of the index finger of the left hand, the abscess cavity is punctured through the rectum. The abscess should not be completely emptied, as this may complicate its opening. Without removing the needle from the puncture site, a rectal speculum is inserted into the rectum and, under visual control, the abscess wall is opened along the needle for 1-2 cm. Pus is removed by suction. The abscess cavity is inspected with a finger and drained with a drainage tube.

In the postoperative period, narcotic analgesics can be prescribed to delay bowel movement for 4-7 days.

Opening of an abscess may be accompanied by increased intoxication and, in rare cases, even the development of bacterial shock, which requires massive antibacterial therapy and constant monitoring by medical personnel in the postoperative period.

In cases where purulent inflammation extends beyond the prostate capsule, paraprostatic phlegmon occurs. It usually develops in the retrovesical space formed in front by the wall of the urinary bladder, behind by the Denonvilliers aponeurosis and above by the peritoneum, on the sides the retrovesical space is limited by the seminal vesicles and the prostate. Paraprostatic phlegmon is a relatively rare complication of prostate abscess. Symptoms of general intoxication and bacteremia prevail in the clinical picture.

Depending on the patient's immune system and concomitant diseases, particularly diabetes, paraprostatic phlegmon may develop into pelvic panphlegmon or limited purulent foci. Purulent fusion from the retrovesical space easily spreads to the parietal tissue of the small pelvis, causing irritation of the abdominal wall with the development of peritonitis symptoms. Pus may spread downwards around the prostate bed. Spreading through the visceral spaces of the pelvis, the abscess captures the perirectal tissue and opens onto the perineum. This is how paraproctitis with pararectal purulent fistulas occurs. Only timely surgical and antibacterial treatment gives hope for success. In this case, the routes of spread of paraprostatic phlegmon determine the methods of drainage of the small pelvis.

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Diagnosis of acute prostatitis

The diagnosis of acute prostatitis can often be established based on anamnesis and physical examination. Laboratory tests and ultrasonography data usually confirm the diagnosis of acute prostatitis. In differential diagnostics, it is necessary to pay attention to possible chronic inflammation of the pelvic organs (chronic prostatitis, paraproctitis, fistulas of the urethra and bladder).

When diagnosing acute prostatitis, it is necessary to indicate its complications, which can be divided into local and general. Local complications include the development of acute urinary retention, prostate abscess, pelvic phlegmon. General complications include bacteremia, urosepsis, and even bacteriotoxic shock. Local complications require emergency surgery. Acute prostatitis can also lead to the development of acute epididymitis, orchiepididymitis.

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Laboratory diagnostics of acute prostatitis

Laboratory diagnostics of acute prostatitis is an important component in determining the treatment tactics. A general blood test reveals leukocytosis, band shift, increased ESR, which gives grounds to judge the degree of the inflammatory process and purulent-inflammatory intoxication. A single urine test may not reveal any changes, but repeated tests often reveal pyuria and bacteriuria. It is especially important for this purpose to examine the first portion of urine, which washes out pus or altered secretion from the opening excretory ducts of the prostatic glands from the back of the urethra. Since it is impossible to examine the prostate secretion obtained after rectal massage, one has to limit oneself to a four-glass test, in which leukocyturia and bacteriuria are detected in the last portions of urine.

Bacteriological examination of urine reveals typical uropathogenic flora. The results of bacteriological examination of urine (antibioticogram) allow for adjustment of antibacterial therapy. It should also be taken into account that drainage of inflamed areas of the prostate may be disrupted and only periodically restored, and then prostatic secretion mixed with pus enters the back of the urethra. Repeated bacteriological examination of urine increases the likelihood of obtaining accurate information.

With increasing general intoxication, hectic temperature with chills, one should remember the possibility of developing a septic condition and repeatedly perform a cultural study (sowing) of blood, which allows identifying the causative agent of sepsis in the patient.

Considering the major role of neutrophils in the body's response to inflammation, in recent years, immunological reactions in the study of their population have been increasingly widely used clinically. These tests, along with other immunological criteria, allow clinicians to judge the nature and dynamics of the inflammatory process, and most importantly, the danger of the inflammatory process turning into suppuration and the development of sepsis.

Instrumental diagnostics of acute prostatitis

Currently, in urological practice, puncture biopsy of the prostate is increasingly taking up a place in the diagnosis of various diseases. Complications in the form of acute prostatitis account for 1-2% of cases. Such complications are also rarely diagnosed after TUR of the prostate, which, as a rule, arise against the background of an outbreak of nosocomial infection in a medical institution.

Endourethral endoscopic examination methods (urethroscopy, cystoscopy) are contraindicated in acute prostatitis.

Some information can be obtained with excretory urography with a descending cystogram before and after urination. Cystograms can sometimes reveal a filling defect along the lower contour of the bladder due to an enlarged prostate and dilated seminal vesicles, and a descending urethrogram can reveal changes in the posterior part of the urethra and the seminal tubercle (lengthening of the prostatic part of the urethra, enlargement of the filling defect caused by the seminal tubercle). A cystogram after urination can indirectly determine the presence and amount of residual urine.

Due to its prevalence, the most significant and accessible method in the diagnosis of acute prostatitis is ultrasound, TRUS of the prostate is more informative, but has the same contraindications as prostate massage,

When describing prostate ultrasound data, attention is paid to the organ size in three planes, its volume, echostructure (density), expansion of the venous plexus, the state of the intraprostatic sections of the seminal vesicles, and the presence of residual urine in the bladder. Hypoechoic areas in the prostate parenchyma are a sign of a developing abscess.

If residual urine is detected against the background of acute prostatitis, it is necessary to decide in favor of emergency urine derivation - cystostomy.

Treatment of acute prostatitis

Patients diagnosed with acute prostatitis should be hospitalized, preferably in a specialized urology department.

In uncomplicated acute prostatitis, antibacterial treatment of acute prostatitis is usually effective and is carried out stepwise. In case of severe intoxication, drugs are administered intravenously; when the temperature is normalized and the symptoms of acute prostatitis are relieved, a transition to oral administration of drugs is possible. The total duration of drug therapy is at least 4 weeks.

If the body temperature rises to 37.5 °C, there is low leukocytosis, and there are no unfavorable factors (recurrent acute inflammation, diabetes mellitus, old age), treatment is carried out for 10 days; fluoroquinolones can be prescribed on an outpatient basis.

In acute prostatitis, the drugs of choice are:

• fluoroquinolones (levofloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin);
• protected semisynthetic penicillins (ampicillin + sulbactam, amoxicillin + clavulanic acid);
• second-third generation cephalosporins (cefuraxime, cefotaxime, cefaclor, cefixime, ceftibuten), sometimes in combination with aminoglycosides.

Alternative drugs:

• macrolides (azithromycin, clarithromycin, roxithromycin, erythromycin);
• doxycycline.

The most commonly prescribed drugs are:

• levofloxacin intravenously 500 mg once a day for 3-4 days, then orally 500 mg once a day for up to 4 weeks;
• ofloxacin intravenously 400 mg 2 times a day for 3-4 days, then orally 400 mg 2 times a day for 4 weeks;
• pefloxacin intravenously 400 mg 2 times a day for 3-4 days, then orally 400 mg 2 times a day for 4 weeks;
• ciprofloxacin intravenously 500 mg 2 times a day for 3-4 days, then orally 500 mg 2 times a day for up to 4 weeks.

Alternative drugs for acute prostatitis are prescribed less frequently:

• azithromycin orally 0.25-0.5 g once a day for 4-6 weeks;
• doxycycline orally 100 mg 2 times a day for 4-6 weeks;
• erythromycin intravenously 0.5-1.0 g 4 times a day, then orally 0.5 g 4 times a day, for a total of 4-6 weeks.

When using high doses of drugs, vitamin therapy (ascorbic acid, B vitamins) should be prescribed simultaneously, and sufficient fluid intake and excretion should be monitored.

Acetylsalicylic acid and other NSAIDs (piroxicam, diclofenac, the latter can be prescribed intramuscularly, orally, as rectal suppositories and other forms) are useful as anti-inflammatory and pain-relieving agents. In case of unbearable excruciating pain, it is permissible to use narcotic drugs with belladonna, including in rectal suppositories.

In patients with catarrhal and follicular acute prostatitis, in the absence of a tendency for the inflammatory process to progress, physiotherapy, warm sitz baths, and hot microclysters with chamomile decoction are recommended to accelerate the resorption of inflammatory infiltrates in the gland and stimulate the resolution of inflammation.

Experience shows that undiagnosed or late diagnosed acute prostatitis, usually the catarrhal (less often follicular) form, responds successfully to any antibacterial, anti-inflammatory treatment prescribed for another reason (with overdiagnosis of influenza, acute respiratory disease, etc.).

Further management

The doctor’s next task is to achieve long-term remission and prevent complications and possible relapses of the inflammatory process in the prostate.

How to prevent acute prostatitis?

Prevention of acute prostatitis includes the following measures:

• maintaining personal hygiene;
• maintaining sexual hygiene;
• timely treatment of foci of chronic purulent infection, especially in risk groups.

Since the frequency of bladder catheterization in surgical and therapeutic hospitals is 10-30%, and much more often in urological hospitals, preventive measures that can prevent acute prostatitis are especially relevant.

Prognosis of acute prostatitis

The prognosis of acute prostatitis with timely and adequate treatment is generally favorable, but it is not always possible to achieve absolute cure, which is associated with the formation of foci of "dormant" infection in the prostate, to which the complexity of its glandular structure predisposes. Catarrhal acute prostatitis with targeted therapy can be completely cured. After the cure of follicular prostatitis, as a rule, obliterated ducts of individual glands or their groups remain.

They may contain an infectious agent and, due to poor emptying of the secretion, prostate stones may form. These foci of impaired morphology and microcirculation are always considered to be a place of possible onset of relapse of the inflammatory process and the basis of chronic prostatitis. Parenchymatous prostatitis often turns into a chronic form of the disease. The duration of temporary disability is 20-40 days. The danger of acute prostatitis turning into a chronic form of the disease requires dispensary observation of these patients.