Bacterial prostatitis: tactics regimens
The term "prostatitis" determines the presence of inflammation in the prostate gland (PZH). Chronic prostatitis is the most common urological disease that causes the complications of the urogenital tract. Among men aged 20-60 years with chronic prostatitis is observed in 20-30% of cases, and only 5% of them turn for help to the urologist. During the long-term clinical manifestations of chronic prostatitis, as a rule, combined with the symptoms of vesiculitis, and urethritis.
Chronic prostatitis contribute to physical inactivity, decreased immunity, frequent hypothermia, disorders of lymph circulation in the pelvic organs, persistence of bacteria of different species in the genitourinary system. In the age of computer technology, a sedentary lifestyle not only leads to prostatitis, but also to the emergence of problems with the cardiovascular system and musculoskeletal system.
Currently, there are many classifications of chronic prostatitis, but the most complete and practical way is the classification of Us national institutes of health (NIH) published in 1995 According to this classification there are four categories of prostatitis:
- I (NIH category I) acute prostatitis is an acute infection of the pancreas;
- II (NIH category II): CKD – chronic infection of the pancreas, characterized by recurrent infection of the urinary tract;
- III (NIH category III): chronic prostatitis/chronic pelvic pain syndrome – symptoms of discomfort or pain in the pelvic region for at least 3 months. in the absence of uropathogenic bacteria identified by standard cultural methods;
- IIIA: inflammatory chronic pain in the pelvis (abacterial prostatitis);
- IIIB: non-inflammatory syndrome of chronic pelvic pain (prostatodynia);
- IV (NIH category IV): asymptomatic prostatitis detected at surveyed regarding another disease of men no symptoms of prostatitis.
Acute bacterial prostatitis (OBP)
GBS is a severe inflammatory disease and arises spontaneously in 90% of cases or after urological manipulation in the region of the urogenital tract [Wagenlehner F. M. E. et al., 2009].
The statistical analysis of the results of bacterial crops found that in 85% of cases bacterial seeding of the secret of the pancreas are sown Escherichia coli and Enterococcus faecalis. The bacteria Pseudomonas aeruginosa, Proteus spp., Klebsiella spp. are much less common. OBP complications arise quite often accompanied by the development of epididymitis, abscess of the prostate, chronic bacterial prostatitis and urosepsis. The development of urosepsis and other complications can be relieved in a quick and efficientthe appointment of adequate treatment.
Chronic bacterial prostatitis (CKD)
CKD is the most common urological disease in men aged 25 to 55 years, is a nonspecific inflammation of the pancreas. Chronic non-specific prostatitis occurs in approximately 20-30% of men of young and middle age and is often accompanied by violation copulative and reproductive functions. Complaints characteristic of chronic prostatitis, concerned about 20% of men aged 20 to 50 years, but only two-thirds of them seek medical help [Pushkar D. Y., Segal, A. S., 2004; J. Nickel et al., 1999; Wagenlehner F. M. E. et al., 2009].
It is established that CKD is sick 5-10% of men, but the incidence is constantly increasing [Wagenlehner F. M. E. et al., 2009].
Among the causative agents of this disease in 80% of cases, dominated by Escherichia coli and Enterococcus faecalis, can be gram-positive bacteria – staphylococci and streptococci. Coagulase–negative staphylococci, Ureaplasma spp., Chlamydia spp. and anaerobic bacteria localized in the prostate, but their role in the development of the disease still remains the subject of debate and is still not completely clear.
The bacteria that cause prostatitis, can be cultured only in acute and chronic bacterial prostatitis. Antibiotic therapy is the mainstay of treatment, and the antibiotics should have a considerable efficiency.
The choice of antibiotic therapy in the treatment of chronic bacterial prostatitis is quite wide. However, the most effective are antibiotics that can easily penetrate into the prostate and to maintain sufficient concentration for a long enough time. As shown works Drusano, G. L. et al. (2000), levofloxacin at a dosage of 500 mg 1 times/day. creates high concentrations in the prostate secretion, which is maintained for a long period of time. The authors noted positive results using levofloxacin two days before performance in patients radical prostatectomy. Ciprofloxacin oral application also has the property to accumulate in the prostate. The idea of the use of ciprofloxacin was also successfully implemented by many urologists. These patterns of use of ciprofloxacin and levofloxacin before surgery on the prostate is justified. High accumulation of these drugs in the prostate reduces the risk of postoperative inflammatory complications, especially against the background of persistent chronic bacterial prostatitis.
In the treatment of chronic prostatitis, of course, necessary to consider the ability of the penetration of antibiotics into the prostate. In addition, the ability of some bacteria to synthesize biofilms can worsen the results of treatment. Studies of the effectiveness of antibiotics on bacteria have been studied by manyauthors. So, M. Garcia–Castillo et al. (2008) conducted studies in vitro and showed that ureaplasma urealiticum and ureaplasma parvum have good ability to form biofilm, which reduces the effectiveness of antibiotics, particularly tetracycline, ciprofloxacin, levofloxacin, and clarithromycin. However, levofloxacin and clarithromycin effectively exposed to the pathogen, with the ability to penetrate through the formed biofilm. The formation of biological films as a result of inflammatory process hinders the penetration of antibiotic, the reduced effectiveness of its impact on the pathogen [Nickel J. C., Olson M. E., Costerton J. W., 1991].
In the future, Nickel J. C. et al. (1995) showed the ineffectiveness of the treatment model of chronic prostatitis some antibiotics, in particular, norfloxacin. The authors of 20 years ago made the assumption that the effect of norfloxacin is reduced due to the formation of biofilms by bacteria, which should be considered as a protective mechanism. Thus, in the treatment of chronic prostatitis, it is advisable to use products that affect the bacteria, bypassing the formed biofilm. In addition, the antibiotic should be well accumulate in the tissues of the prostate. Given that macrolides, in particular clarithromycin, are ineffective in the treatment of Escherichia coli and enterococci in our study, we opted for the levofloxacin and ciprofloxacin, and evaluated their effect in the treatment of chronic bacterial prostatitis.
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
The etiology of CP and CPPS remains in most cases unclear. However, the analysis of mechanisms of development of the given pathology allows to identify its main causal factors.
- The presence of the infectious agent. DNA–containing bacterial pathogens are often found in the prostate secretion during the examination of patients, which indirectly can indicate pathogenicity in relation to the pancreas. Ability to restore the DNA structure of some pathogens, particularly Escherichia coli, other bacteria of the genus Enterococcus, allows the microorganisms to exist for a long time in a latent state, does not prove itself. This is evidenced by cultural studies. After carrying out antibiotic therapy bacterial seeding of prostate secretion are negative. But after some time, bacteria capable of restoring the DNA–structure, appear in cultural crops again.
- Dysfunction of the regulation of the detrusor. The severity dysuric phenomena can vary in different patients. HP can occur without symptoms. However, the ultrasound confirmed the appearance of residual urinepatients with chronic pancreatitis. This contributes to excessive stimulation of pain neuroreceptors and a sense of incomplete emptying of the bladder.
- Decrease in immunity. Conducted immunological studies in patients with khtb showed significant changes in the immunogram. The number of inflammatory cytokines were statistically increased in the majority of patients. At the same time, the level of anti-inflammatory cytokines was reduced, which was confirmed by the appearance of autoimmune process.
- The appearance of interstitial cystitis. In the works of Schaeffer A. J., Anderson R. U., Krieger, J. N. (2006) showed increased sensitivity potassium intrawaginalnogo test in patients with CP. But the findings are currently being discussed – there is a possibility of an isolated occurrence of pancreatitis and interstitial cystitis.
- The neurogenic factor in the development of unbearable pain. Clinical and experimental data have confirmed the origin of the pelvic pain, the main role in which play the origin of the spinal ganglia that respond to inflammatory changes in the pancreas.
- Venous stasis and lymphedema in the pelvic organs. Patients with the presence of geodinamicheskogo factors appear congestion in the pelvic organs. While there is venous stasis. Confirmed pathogenic link between the development of KHP and hemorrhoids. The combination of these diseases is quite common, which confirms the common pathogenetic mechanism of disease based on the appearance of venous stasis. Lymphedema in the pelvic organs also contributes to the violation of the outflow of lymph from the pancreas, and when combined with other negative factors leads to the development of the disease.
- The influence of alcohol. Effects of alcohol on the reproductive tract not only causes adverse effects on spermatogenesis, but contributes to the exacerbation of chronic inflammatory diseases, including prostatitis.
Asymptomatic chronic prostatitis (bkhp)
Chronic inflammation leads to a decrease in oxygenation of tissue of the prostate that not only changes the indicators of ejaculate, but also causes damage to the structure of the cell wall and DNA of epithelial cells of the prostate. This may be the reason for the activation of neoplastic processes in the pancreas [Nelson W. G. et al., 2004].
Material and methods
The study included 94 patients with microbiologically verified CKD (NIH category II) aged 21 to 66 years. All patients underwent complex urological examination, which included filling the scale of CP symptoms (NIH–CPSI), a study of complete blood count (KLA), microbiological and immunohistochemical study of secretions of the pancreas, PCR–diagnosis to exclude atypical intracellular flora, TRUS of the prostate,uroflowmetry. The patients were divided into two equal groups according to 47 in the 1st group there were 39 (83%), aged 21-50 years, in the 2nd group – 41 (87%). Group 1 in the complex treatment received ciprofloxacin 500 mg 2 times/day. after a meal, the total duration of therapy was 3-4 weeks. The second group received levofloxacin (Leflox) 500 mg 1 time/day, the duration of treatment averaged 3-4 weeks. However, the patients were given anti-inflammatory therapy (candles with indomethacin 50 mg 2 times/day. within 1 week), α–blockers (tamsulosin 0.4 mg 1 times/day.) and physiotherapy (magnetic-laser therapy according to the methodical recommendations). Clinical monitoring was carried out during the entire treatment period patients. Laboratory (bacteriological) quality control treatment was performed after 4-5 weeks. after taking the drug.
Clinical assessment of treatment results was carried out on the basis of complaints, physical examination and ultrasound data. In both groups the majority of patients after 5-7 days of starting treatment showed signs of improvement. Further therapy with the use of levofloxacin (Leflox) and ciprofloxacin showed the effectiveness of the treatment in both groups.
Patients of the 1st group showed a significant reduction and disappearance of symptoms and normalization of leukocytes in the secret of the pancreas, increasing the maximum volumetric flow rate of urine according to uroflowmetry (from 15.4 to 17.2 ml/s). The average score on the NIH–CPSI decreased from 41.5 to 22. Assigned therapy was well tolerated. In 3 patients (6,4%) developed side effects from the gastrointestinal tract (nausea, frustration of a chair), associated with taking antibiotics.
Patients of the 2nd group treated with ciprofloxacin, showed a significant reduction or complete disappearance of complaints. The maximum flow rate of urine according to uroflowmetry increased from 16.1 to 17.3 ml/sec. the Average score on the NIH–CPSI decreased from 38.5 to 17.2. Side effects noted in 3 (6.4%) cases. Thus, valid distinctions based on clinical observations of both groups are received.
In the control bacteriological examination of the 1st group of 47 patients receiving levofloxacin, eradication of the pathogens was achieved in 43 (91.5 per cent).
On the background of treatment with ciprofloxacin the disappearance of the bacterial flora in the prostate secretion was observed in 38 (80%) patients.
To date, fluoroquinolones II and III generations related to antibacterial preparations of wide spectrum of action, continue to be effective antimicrobials for the treatment of urological infections.
Results of clinical studies revealed no significant difference inthe use of levofloxacin and ciprofloxacin. Good tolerability allows you to apply them within 3-4 weeks. However, the data of the bacteriological studies showed the highest antimicrobial efficacy of levofloxacin compared with ciprofloxacin. In addition, the daily dosage of levofloxacin provided by the single administration of a tablet form of the drug, while patients ciprofloxacin should be taken twice a day.
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