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Diagnostics of the chronic prostatitis
Medical expert of the article
So, at the first meeting with the patient it is necessary to carefully collect an anamnesis, including epidemiological. Classic domestic medicine JV. Botkin assured that correctly collected anamnesis - 90% of the diagnosis. One can not confine oneself to a brief question whether the patient has suffered from venereal diseases, it is necessary to specify in detail about each disease, to find out whether the sexual partner of the patient is currently receiving any therapy for sexually transmitted diseases. Our time is epidemically unsuccessful for tuberculosis, accordingly, we must certainly clarify whether the patient did not suffer from this disease, as well as his relatives, friends, co-workers, etc.
It is necessary to find out when the signs of the disease appeared, suddenly they appeared or their intensity gradually increased, with what the patient associates their appearance, which causes deterioration, and what facilitates the condition. The doctor should establish a regime and intensity of sexual life, the permissibility of anal sex, especially without a condom, the number of sexual partners, methods of contraception. Do not consider the last question an idle curiosity - sometimes the answer to it is key. For example, a patient has a new sexual partner who uses a vaginal cream for the purpose of contraception, for which the patient has an allergy. More intense than usual, sexual life plus a local allergen can provoke dysuria, ache in the testes and pain in the head of the penis - typical signs of prostatitis, which in this case there.
But the anamnesis is collected, all the weighed symptoms are known. Patients with prostate adenoma at this stage are asked to fill out a special questionnaire - the International prostate symptom score (IPSS) symptom scale. Attempts at times to work similar questionnaires for patients on chronic prostatitis were met by the urological community without enthusiasm until the NIH in the Chronic Prostatitis Clinical Research Network published a scale of the symptom index of chronic prostatitis that describes the main manifestations of the disease: pain, urination disorder, and also takes into account the quality of life. This scale is a questionnaire with nine questions that the patient must answer on his own. Very simple calculations proved to be useful both in practical and in scientific work. IPCN suggested in all scientific studies to use this scale for objective comparison and comparability of data.
After collecting anamnesis and systematization of clinical manifestations, we proceed to examine the patient. And here there is a lot of controversy and controversy regarding the necessary tests and the sequence of manipulations.
Diagnosis of chronic prostatitis: a 4-cup test
In 1968, Meares and Stamey proposed a so-called 4-cup test. Often, its adapted modification is used, which, however, does not eliminate any of the drawbacks inherent in this method. So, the scheme of the test is as follows. The patient is invited to see a urologist on condition that the examinee does not urinate for 3-5 hours with the usual amount of liquid consumed. Before performing the test, ask to thoroughly wash the glans penis with soap with exposure to the foreskin (it is left in this state until the test is completed). The patient is offered to release a small (10-20 ml) portion of urine into the sterile tube (this is the first portion of the urine), then continue urinating into a separate container - approximately 100-150 ml (an average aliquot that is not subject to analysis and not taken into account) and fill the second sterile tube (10 ml). After stopping urination, the doctor performs a massage of the patient's prostate. The received secret is the third portion of the test. The fourth is the self-released urine residue after the massage. Meares and Stamey investigated the first portion of urine to exclude urethral contamination; the second portion determined the presence or absence of inflammation in the bladder and kidneys. The third portion is the secret of the prostate, and the fourth portion of urine rinses the rest of the secret from the mucous membrane of the urethra. Each portion should be examined microscopically and bacteriologically.
The diagnosis of bacterial chronic prostatitis is raised only if the number of leukocytes in the secretion of the prostate or in the urine after massage of the prostate is at least 10 times higher than in the urine from the first and second portions.
Although this is a detailed procedure and is recognized as the "gold standard" of diagnosis and has become, in fact, a urological dogma, in fact, experts do not use this test. There are many reasons and explanations, but the main argument is this: the use of this complex, expensive and time-consuming procedure does not play a significant role in tactics and treatment strategies. The effectiveness, sensitivity and specificity of a 4-glass sample have never been evaluated by anyone, however, this test is for some reason considered a "gold standard" and has been used, contrary to common sense, for many decades. This opinion is shared by many specialists, in particular the universally recognized expert in prostatology issues Nickel J.S.
Interpretation of the results of the 4-cup test on Meares and Stamey
- The first portion is positive, the second and third are negative - Inflammation of the urethra - urethritis
- The first and second portions are negative, the third is positive - Inflammation of the prostate - prostatitis
- All three portions of urine are positive - Urinary tract infection (cystitis, pyelonephritis)
- The first and third portions are positive, the second is negative - Urethritis and prostatitis or only prostatitis
ABOUT. Laurent et al. (2009) note: "The multistage localization test Meares-Stamey, or its equally informative (in the sense of an equally uninformative) simplified two-port version, considered to be the most important method for diagnosing chronic prostatitis, can have a diagnostic value in no more than 10% of patients with an infectious form of CP (NIH-I1).
In order not to reject the methodology of Meares and Stamey is unfounded, it is necessary to give a logical explanation to the arguments against. First, the test is difficult. If you release a little urine in a special dish and continue urinating in another dish, it's easy to stop urinating, leaving some amount of urine in the bladder, not every man is capable of. In addition, stop urinating by urinating - means to communicate turbulence to the laminar flow and provoke reflux of urine into the prostatic ducts, which, as is known, is fraught with the development of chemical burns, inflammation and prostatolythiasis. Moreover, the patient is not given instructions to urinate continuously, therefore, before the second portion, he also compresses the sphincter, which can promote the squeezing of both leukocytes and microflora into the urine. Finally, this is a very laborious procedure requiring a separate cabinet.
In foreign literature, attempts to adapt a 4-cup test are reflected, for example, pre- and post-massage test-PPMT with microscopy and urine culture obtained before and after the prostate massage were suggested. PPMT was offered as a screening procedure; The classic 4-glass test was performed only in the case of detection of uropathogenic microflora or an increased number of leukocytes, and if there were indications - to exclude urethritis.
Diagnosis of chronic prostatitis: a 3-cup test
However, in real conditions this test has only a minor, auxiliary value. The 3-glass test is much simpler and more informative, when the patient is offered to urinate approximately in equal portions in three containers in sequence, without interrupting the jet. The first portion reflects the state of the urethra, the second - the kidneys and the bladder.
The presence of pathological elements in the third portion indicates a poor prostate, since this portion is contaminated with the contents of the prostate, which, as the external sphincter of the bladder, contracts at the end of urination. It is very important that a 3-cup test should be performed before a digital rectal examination in order to get some idea of the state of the upper urinary tract. Some guidelines recommend limiting the 2-glass test, but this is clearly not enough - this technology does not allow you to assess the state of the urinary tract: the first portion will contain flushing from the urethra, and the second will be contaminated with the secretion of the prostate.
Algorithm for the diagnosis of chronic prostatitis
The doctor of a polyclinic or a hospital should be guided by the following algorithm for examining a patient with suspected chronic prostatitis:
- anamnesis collection;
- examination and physical examination of external genitalia;
- 3-cup urine sample;
- rectal examination with secretion, followed by Gram staining and light microscopy;
- general urine analysis after prostate massage;
- the analysis of an ejaculate (under indications);
- bacteriological studies (including on mycobacterium tuberculosis) with the determination of the sensitivity of the detected microflora to antibacterial drugs;
- ultrasound (ultrasound) of the kidneys;
- Prostate laparoscopic dopplerography;
- uroflowmetry (according to indications);
- DNA diagnosis of sexually transmitted infections and mycobacteria tuberculosis by polymerase chain reaction (PCR) of the urethra scraping and prostate secretion;
- determination of the level of PSA in the blood plasma of men over 45;
- prostate biopsy (according to indications) with pathomorphological and bacteriological examination of biopsy specimens, as well as with DNA diagnostics;
- with a tendency to a continuously-recurrent type of flow, ascending urethrography is indicated.
The given list of manipulations is sufficient to establish the diagnosis in the overwhelming number of patients, if necessary, it can be supplemented with computed tomography, optimally multispiral as well as urethroscopy, laser doppler flometry (LDF), but, as a rule, these research methods are of scientific interest.
Let us dwell in more detail on some of the nuances of the above diagnostic manipulations.
It is necessary to emphasize once again the importance of continuous urination when collecting urine for a 3-cup sample (the patient must definitely give clear unambiguous instructions).
Examination and palpation of the external genitalia of the patient is often neglected, and completely in vain, since it is during these manipulations that head hypopsy, varicocele, scrotal hernia, edema of the testicles, epididymitis or orhoepididymitis, testicular anemia, hypoplasia of the testicles, fistula of the scrotum and perineum, papillomas and condylomas of the urethra, which the patient himself did not pay attention to, namely, these conditions and determined the clinical picture
Recently, there was a sad tendency (not only in Russia, but also abroad) to refuse a digital rectal examination, substituting for his TRUS, while instead of the secret of the prostate they limit themselves to analyzing the ejaculate. This is a profoundly evil practice. First, the information obtained by palpation of the prostate is irreplaceable, TRUZI only supplements it. Secondly, in the ejaculate contains the secret of only those lobules of the prostate, the excretory ducts of which are free, and the most affected lobules need to be squeezed out mechanically - both due to the atony of their smooth muscles, and because of purulent necrotic plugs. It is not always possible to get a secret with a massage, for various reasons. So it can happen with fibrosis or sclerosis of the prostate, after ejaculation passed on the eve (therefore, the ejaculate for the study is collected after the secret is obtained), with severe soreness of the gland. In this case, the patient is offered to urinate a small portion immediately after digital rectal examination and treat the flush as an analog of the secretion of the prostate gland.
The obtained secret is placed on a slide, covering the drop with a cover glass, after which the preparation is sent to the laboratory for light microscopy. Another drop is collected in a sterile tube and immediately sent to a bacteriological laboratory; to obtain reliable results between the intake of material and sowing should not take more than an hour. Next, the third drop is gently smeared over the glass and left to dry - this drug will be subsequently colored according to Gram. After that, from the urethra, scraping is taken for DNA diagnosis by the PCR method of intracellular infections and sexually transmitted viruses. This material can be frozen, but it should be remembered that after thawing it must be urgently started in the diagnostic process, repeated freezing is unacceptable. So, the main thing - if the secret has not been obtained, for all tests, the flushing of the urethra after
For comparison, one can cite the approach of Chinese doctors to managing patients for chronic prostatitis. 627 urologists from 291 hospitals in 141 Chinese cities were interviewed. Age fluctuations are 21-72 years, on average - 37 years.
Only a few hospitals in China have specialized urological units, so most doctors work in university clinics. 75.2% of respondents had experience of more than 5 years. 64.6% of specialists believed that the main cause of chronic prostatitis was a non-bacterial infection (inflammation); 51% admitted that the infection was an etiotropic factor, 40.8% considered psychosomatic disorders important. The range of diagnostic manipulations used by Chinese urologists in the examination of patients for chronic prostatitis is presented below:
- Microscopy of prostate secretion - 86.3%
- Seeding secret on the microflora - 57.4%
- General examination, including digital rectal examination - 56.9%
- Urinalysis - 39.8%
- Ultrasound - 33,7%
- Psychological testing - 20,7%
- Blood test, including PSA - 15.5%
- Spermogram - 15.2%
- Uroflowmetry - 12.1%
- Prostate biopsy - 8.2%
- X-ray methods - 2.1%
A 4-cup test was used by only 27.1% of urologists in its practice, and a 2-cup test was 29.5%. According to the NIH classification, 62.3% of the specialists diagnosed, but 37.7% divided the patients into: bacterial chronic prostatitis, non-bacterial chronic prostatitis and prostatodynia.
The lion's share in the drug treatment is accounted for by antibiotics (74%), of which fluoroquinolones predominate (79%). Macrolides (45.7%) and cephalosporins (35.2%) are used in less than half of cases, a-adrenoblockers are prescribed by 60.3% of urologists (70.3% of them use a-adrenoblockers only with symptoms of obstruction and 23% - always, regardless of the clinical picture), phytopreparations - 38.7%, traditional Chinese medicine - 37.2% of specialists. When antibiotics are prescribed, 64.4% of the respondents are based on bacteriological examination data, 65.9% of the patients have sufficient leukocytes in the exprimates of the sexual glands and 11.4% prescribe antimicrobial agents always, regardless of the results of the laboratory examination.