Treatment of chronic prostatitis on the background of chlamydial infection

Treatment of chronic prostatitis, like many diseases, is often ineffective, since it does not take into account the individual characteristics of the body and is mainly etiotropic, while undeservedly neglecting pathogenetic therapy.

Urogenital chlamydia is a problem that does not lose its relevance. To a large extent, this is facilitated by the intracellular localization and persistence of the pathogen, due to which monotherapy with the most modern antibiotics is not effective enough. The persistence of chlamydia is caused by treatment with drugs that are inactive against this infectious agent, subtherapeutic doses of antichlamydial drugs, and the lack of immunotherapy.

In nature, there are two forms of cell death - apoptosis and necrosis. Apoptosis is the natural dying of a cell at the appointed time by shrinking and fragmentation. Cells that die as a result of apoptosis do not cause harm to surrounding tissues, their fragments are absorbed by macrophages. Inside the macrophages, microorganisms, be they mycobacteria or chlamydia, die. On the contrary, cell necrosis leads to the release of chemically aggressive components of the cytoplasm into the environment and dissemination of microorganisms located in the cell, which leads to the spread of infection. Hence, it is clear how great the role of apoptosis is and the value of drugs that regulate this process.

The biologically active supplement indigal, which has recently appeared on the pharmaceutical market and contains at least 90 mg of pure indole-3-carbinol and at least 15 mg of pure epigallocatechin-3-gallate in each capsule, helps to normalize apoptosis processes, which has been shown in a number of foreign studies. In vitro and in vivo experiments have demonstrated a pronounced inhibitory effect of indole-3-carbinol on prostate cancer cells and a stimulating effect on apoptosis processes. Epigallocatechin-3-gallate, the second component of indigal, reduces cell proliferation, induces apoptosis, and stops inflammatory cascades.

Macrolides are the most active against chlamydia, followed by fluoroquinolones, which also have a bactericidal effect. Among fluoroquinolones, sparfloxacin occupies a special place against intracellular pathogens, the degree of penetration of which into the macrophage is 3 times higher than that of ciprofloxacin and lomefloxacin. In addition, due to the double blocking of the microorganism's DNA, sparfloxacin prevents the development of drug resistance.

In addition to the antibacterial effect and prevention of necrosis, another pathogenetic effect is needed, aimed at accelerated elimination of decay products, relief of inflammation and restoration of local immunoresistance. The herbal preparation Kanefron-N, containing a hydroalcoholic extract of centaury herb, lovage roots and rosemary leaves, has these properties in full.

Drug treatment of chronic prostatitis against the background of chlamydial infection

The aim of the study was to develop and test a treatment regimen for patients with urogenital chlamydia resistant to standard therapy. We observed 14 men with verified urogenital chlamydia. Five of them had predominantly clinical signs of urethritis, and nine had urethroprostatitis. The diagnosis was established within 3 to 11 years, an average of 7.4±1.2 years. The patients received multiple courses of antibacterial therapy, as a result of which six of them developed grade II-III intestinal dysbacteriosis, two developed candidiasis, and four developed toxic-allergic intolerance to macrolide antibacterial drugs. If reinfection was not excluded in 6 men, then 8 of them had no unprotected and/or casual sexual contacts and, therefore, their disease was assessed as chronic and resistant to therapy. Only 2 patients had chlamydial monoinfection. In the remaining 12 patients, the following pathogens were detected in the discharge of the urethra and/or gonads:

• staphylococci - 4 cases;
• enterococci - 2 cases;
• Mycoplasma hominis - 4 cases;
• Ureaplasma - 4 cases;
• streptococcal infection - 1 case;
• E. coli - 1 case.

Most men had more than two infectious agents present at the same time.

To exclude tuberculosis of the genitourinary system, patients underwent a 3-glass urine test before digital rectal examination. In the presence of leukocyturia in the second portion, which was detected in 1 patient, ultrasound of the kidneys, urine culture for Mycobacterium tuberculosis and fluorescent microscopy of smears were performed.

An epidemiological anamnesis was carefully collected, and it was established that none of the patients had previously suffered from tuberculosis, had no contacts with people or animals sick with tuberculosis, and there were no children with Mantoux test deviations in the family. All 14 patients regularly underwent fluorography, the last examination was performed less than 12 months before the visit.

Given the ineffectiveness of the previous therapy, it was decided to choose sparfloxacin as an antibiotic at 200 mg twice a day for 10 days for urethritis and 20 days for urethroprostatitis. The choice fell on sparfloxacin because it:

• bactericidal against chlamydia;
• affects not only actively dividing but also persistent microorganisms;
• has a high ability to penetrate into the cell.

In order to normalize apoptosis, indigal was prescribed at 800 mg twice a day for 2 months, since this period is necessary for the death of the cell infected with chlamydia. To improve the rejection of desquamated epithelium, restore microcirculation and relieve inflammation, patients took canephron-A at 50 drops 4 times a day for 1 month.

The final results were assessed 2 months after the start of the complex therapy. The dynamics of complaints, analysis of prostate secretion by native light microscopy and Gram-stained smear (number of leukocytes, saturation with lecithin grains, presence and type of microflora), spermogram, bacteriological studies, analysis of urethral discharge, prostate ultrasound, examination of urethral scraping and prostate secretion by PCR, and enzyme-linked immunosorbent assay (ELISA) of blood were taken into account.

Upon admission, all 14 men complained of discharge from the urethra - from scanty to profuse, frequent urination (in 8 patients - with burning), including at night, constant aching pain in the perineum (in 6 patients - with irradiation to the scrotum), and sexual dysfunction.

During the initial digital rectal examination, all patients showed a violation of prostate tone, its soreness, and dense foci were palpated in 12 patients. The urethral sponges were edematous and hyperemic in all patients. A large number of leukocytes were found in the prostate secretion (from 43.7+9.2 to a level where counting was impossible), the number of lecithin grains was reduced.

All patients were prescribed the etiopathogenetic therapy described above; all were advised to avoid sun exposure (given the potential phototoxic effect of sparfloxacin), abstain from sexual intercourse (or, as a last resort, use a condom), and drink plenty of fluids. All sexual partners of the patients were also examined and treated to the required extent.

Clinical efficacy was evident from day 5.4±0.2 and was expressed in decreased dysuria, pain and cessation of urethral discharge. By the end of the antibacterial stage of therapy, ^ patients (85.7%) had complete sanitation of the prostate secretion, and the remaining 2 (14.3%) had a significant improvement. After 2 months, only 1 patient (7.1%) had a moderately increased number of leukocytes in the prostate secretion. TRUS performed at the same time showed a pronounced positive dynamics in relation to the echostructure and blood supply to the prostate gland. All patients experienced microbiological purification - no pathogenic microflora was detected either in stained smears, or by the sowing method, or by the DNA diagnostics method. Also, no negative effect of the tested regimen on spermatogenesis was noted - the qualitative and quantitative parameters of the ejaculate did not have reliable differences compared to the initial ones.

The treatment was well tolerated. The patient experienced dyspepsia when taking the drugs on an empty stomach; taking the drug after meals allowed avoiding this side effect without reducing the dose or prescribing additional therapy.

Thus, the combination of sparfloxacin with indigal helps prevent the persistence of intracellular microorganisms and their dissemination, which leads to a rapid decrease in the total population of Chl. trachomatis. Canephron-N provides relief of inflammation, a diuretic effect, accelerated elimination of decay products and desquamated epithelium. The specified combination as a whole ensured clinical and bacteriological cure of patients with urogenital chlamydia resistant to standard therapy in 92.9% of cases.

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Ozone therapy

The effectiveness of ozone therapy was analyzed and its pathogenetic justification as a factor improving hemodynamics and microcirculation was proposed. The study included 72 patients with chronic urethroprostatitis against the background of chlamydial infection, who received identical basic therapy: clarithromycin (fromilid-A), meglumine acridonacetate (cycloferon), wobenzym.

• The first group consisted of 34 patients with chronic urethroprostatitis (clinical symptoms of urethritis and prostatitis were expressed equally) against the background of chronic prostatitis of chlamydial origin. They received complex basic therapy for the treatment of sexually transmitted infections: clarithromycin (Fromilidge), meglumine acridonacetate (Cycloferon), Wobenzym.
• The second group included 20 patients with chronic urethroprostatitis against the background of chronic prostatitis of chlamydial origin. They had predominantly complaints regarding the urinary tract, clinical manifestations of prostatitis were less pronounced. In these patients, basic therapy was supplemented by regional transurethral ozone therapy.
• The third group included 18 patients with chronic urethroprostatitis against the background of chronic prostatitis of chlamydial origin with dominant complaints indicating prostate damage. In this group, basic treatment was supplemented by regional transrectal ozone therapy.
• The comparison group consisted of 11 men aged 21 to 45 years without pathology of the genitourinary system (confirmed by TRUS of the prostate gland and LDF of the urethra and prostate) and with negative results of ELISA and PCR for Chl. trachomatis DNA.

All 72 patients with chronic prostatitis against the background of chlamydia and in the comparison group underwent a study of the microhemodynamics of the urethra and prostate using the LDF and TRUS methods of the prostate before treatment and again within 5-6 weeks after the end of therapy.

The etiological effectiveness of the treatment was assessed 6 weeks after the end of the course of therapy by analyzing scraping material from the urethra and prostate secretion using ELISA and PCR for the following indicators:

• eradication - absence of Ch. trachomatis in control studies;
• lack of effect - preservation of the pathogen in control studies.

The clinical effectiveness of treatment of chronic prostatitis of chlamydial origin was assessed based on the dynamics of the main complaints (pain, dysuria, sexual dysfunction).

For a more complete collection of anamnesis, a questionnaire was used according to the system of total assessment of symptoms in chronic prostatitis (SOS - CP), proposed by O. B. Loran and A. S. Segal (2001), which includes a number of questions on the presence, severity and constancy of symptoms, as well as on the quality of life of patients. The questions are designated by numbers from I to XII and are divided into four groups: pain and paresthesia, dysuria, pathological discharge from the urethra (prostatorrhea) and quality of life. The patient independently answered each question in writing. Questions I and II provided for the possibility of several answer options, which were designated by letters of the generally accepted English alphabet. Each of the positive answers was estimated at 1 point. For questions III through XII, only one answer option is given, estimated from 0 to 3-5 points, that is, from complete absence to the extreme degree of expression of the analyzed indicator.

The questionnaire completed by the patient was analyzed. First, the sum of points scored for the main groups of questions was calculated: pain and paresthesia, dysuria, quality of life. Then, the symptom index (SI - CP) was determined - the sum of points reflecting pain, dysuria and prostatorrhea. Lastly, the clinical index of chronic prostatitis (CI - CP) was established - the sum of SI - CP and the quality of life index. Depending on the severity of clinical manifestations, CI - CP is divided into minor, moderate and significant. Thus, all clinical manifestations of CP are represented by the following digital series:

• pain =;
• dysuria =;
• prostatorrhea =;
• quality of life =
• IS-HP =;
• KI-HP =.

This system was used in 60 patients with chronic prostatitis of chlamydial origin. The questionnaire was understandable to patients, questions and answers excluded ambiguity of their interpretation, and the results obtained were clear.

When collecting the anamnesis, much attention was also paid to previous diseases of the urogenital tract and the health status of the sexual partner.

When examining patients, their constitutional features, the condition of the skin and visible mucous membranes, the severity of secondary sexual characteristics (distribution of hair, subcutaneous fat, skin turgor, scrotal folding and pigmentation) were taken into account. A palpatory examination of the testicles and a digital rectal examination of the prostate were performed. The penis was also palpated to exclude its deformation and pathological changes in the protein membrane. The condition of the surrounding peripheral veins and arteries, especially the lower extremities and scrotum, was physically assessed.

In patients selected for the study, the presence of Chl. trachomatis was confirmed by the complex use of laboratory diagnostic methods ELISA and PCR.

Diagnosis of circulatory and microcirculation disorders was performed using TRUS of the prostate gland with color Doppler imaging using the standard method and LDF of the microcirculation of the urethra and prostate gland; the methods are described in detail in the corresponding section of the monograph.

Method of conducting regional ozone therapy

To carry out regional ozone therapy, a medical ozonizer of the Medozons VM series was used.

The following methods of local ozone therapy were used:

• transurethral ozone therapy. Ozonized olive oil with an ozone concentration of 1200 μg/l, heated to a temperature of 38-39 °C, was introduced into the urethra in a volume of 5-7 ml with an exposure of 10-15 minutes, once a day. The course of treatment was 10 procedures daily;
• transrectal ozone therapy. The procedure consists of introducing 10 ml of ozonized olive oil with an ozone concentration of 1200 mg/l into the rectum, the duration of the procedure is 5 minutes with a subsequent increase in the duration of the procedure to 25 minutes. The procedure should be carried out after a cleansing enema in a prone position. The course of treatment is 10 procedures daily.