慢性前列腺炎诊断及治疗最新进展

美满®——慢性前列腺炎的理想之选前列腺炎定义急性前列腺炎–一种定位于前列腺的急性感染性疾病，有明显的下尿路感染症状及畏寒、发热和肌痛等全身症状，尿液、前列腺液中白细胞数量升高甚至出现脓细胞定义慢性前列腺炎–在病原体或(和)某些非感染因素作用下，患者出现以骨盆区域疼痛或不适、排尿异常等症状为特征的一组疾病中华医学会泌尿外科学分会。2009年版前列腺炎诊断治疗指南NewNIHcategoryClinicalentityDescriptionIABPAcuteinfectionoftheprostateglandIICBPRecurrentinfectionoftheprostateIIIChronicabacterialprostatitis/CPPSNodemonstrableinfectionIIIAInflammatoryCPPSWhitecellsinsemen,expressedprostaticsecretionsorpost-prostaticmassageurineIIIBNon-inflammatoryCPPSNowhitecellsinsemen,expressedprostaticsecretionsorpostprostaticmassageurineIVAsymptomaticInflammatoryprostatitisNosubjectivesymptoms.InflammationdetectedeitherbyprostatebiopsyorbythepresenceofwhitecellsinexpressedprostaticsecretionsorsemenduringevaluationforotherdisordersNIH/NIDDKclassificationofprostatitissyndrome**WagenlehnerFM,DiemerT,NaberKG,etal.Chronicbacterialprostatitis(NIHtypeII):diagnosis,therapyandinfluenceonthefertilitystatus.Andrologia2008Apr;40(2):100-4ABP=acutebacterialprostatitis;CBP=chronicbacterialprostatitis;CPPS=chronicpelvicpainsyndrome前列腺炎相关研究近况•CP/CPPS的病因及发病机制不明确。许多可能的解释都很脆弱，缺乏严格意义上循证医学的证据。可能的病因及发病机制有：•病原体感染•前列腺内尿液反流•膀胱功能异常•细胞因子介导的免疫反应•激素失衡•神经精神因素•遗传等Microbiology•ThemostcommoncausesofbacterialprostatitisareGram-negativebacteria,mainlystrainsofEscherichiacoli(1).•TheroleofGram-positivebacteriainbacterialprostatitisiscontroversial(2).1、NaberKG,WeidnerW.Chronicprostatitis-aninfectiousdisease?JAntimicrobChemother2000Aug;46(2):157-612、Taylor-RobinsonD.EvaluationandcomparisonofteststodiagnoseChlamydiatrachomatisgenitalinfections.HumReprod1997Nov;12(11Suppl):113-20.Microbiology•Hiddenbacteriamaybeaetiologicallyinvolvedinpatientswithchronicidiopathicprostatitisafterexclusionoftypicalbacterialinfection(3).Detectionofbacteriabymoleculartechniqueshasnotbeenevaluateddefinitively.3、KriegerJN,RileyDE,RobertsMC,etal.ProkaryoticDNAsequencesinpatientswithchronicidiopathicprostatitis.JClinMicrobiol1996Dec;34(12):3120-8.Diagnosis•Symptomsmustbeevaluatedusingstandardisedscores,especiallytheNIHsymptomscore(1).•OtherinvestigativeproceduresincludelaboratorydiagnosisofCBPusingthefour-specimentestforbacteriallocalisation(2),whichmeasuressequentialquantitativebacteriologicalculturesoftheurethra,bladderurineandprostaticsecretions,bothinexpressedprostaticexcretion(EPS)andurineafterprostaticmassage(3).1、LitwinMS,McNaughton-CollinsM,FowlerFJJr,etal.TheNationalInstitutesofHealthchronicprostatitissymptomindex:developmentandvalidationofanewoutcomemeasure.ChronicProstatitisCollaborationResearchNetwork.JUrol1999Aug;162(2):369-75.2、WagenlehnerFM,DiemerT,NaberKG,etal.Chronicbacterialprostatitis(NIHtypeII):diagnosis,therapyandinfluenceonthefertilitystatus.Andrologia2008Apr;40(2):100-4.3、WeidnerW,SchieferHG,KraussH,etal.Chronicprostatitis:athoroughsearchforetiologicallyinvolvedmicroorganismsin1,461patients.Infection1991;19Suppl3:S119-25.Diagnosis•ThekeytodiagnosisisthedemonstrationofleukocytesinEPS,urineafterprostaticmassageand/orejaculatetodifferentiatebetweeninflammatoryandnon-inflammatoryCPPS.Microbiologicalfindings•Afterexclusionofurethritisandbladderinfection,106peroxidase-positivewhitebloodcells(WBCs)permillilitreofejaculateindicateaninflammatoryprocess.Inthiscase,acultureshouldbemadeforcommonurinarytractpathogens,particularlyGram-negativebacteria.Microbiologicalfindings•Aconcentrationof103cfu/mLurinarytractpathogensintheejaculateisindicativeofsignificantbacteriospermia.•Variousmicro-organismsarefoundinthegenitaltractofmenseenininfertilityclinics,usuallywithmorethanonestrainofbacteriapresent(1)1、WeidnerW,KrauseW,LudwigM.Relevanceofmaleaccessoryglandinfectionforsubsequentfertilitywithspecialfocusonprostatitis.HumReprodUpdate1999Sep-Oct;5(5):421-32.Microbiologicalfindings•Ureaplasmaurealyticumispathogeniconlyinhighconcentrations(103cfu/mLejaculate).Nomorethanabout10%ofsamplesanalysedforureaplasmaexceedthisconcentration(1).1、WeidnerW,KrauseW,SchieferHG,etal.Ureaplasmalinfectionsofthemaleurogenitaltract,inparticularprostatitis,andsemenquality.Urolnt1985;40(1):5-9.Whitebloodcells•Theclinicalsignificanceofanincreasedconcentrationofleukocytesintheejaculateiscontroversial(1).Infectionisindicatedonlybyanincreasedlevelofleukocytes(particularlypolymorphonuclearleukocytes)andtheirproducts(e.g.leukocyteelastase)secretedintotheseminalfluid.1、AitkenRJ,BakerHW.Seminalleukocytes:passengers,terroristsorgoodsamaritans?HumReprod1995Jul;10(7):1736-9.Whitebloodcells•Althoughleukocytospermiaisasignofinflammation,itisnotnecessarilyassociatedwithbacterialorviralinfections(1)•Earlierfindingshaveshownthatelevatedleukocytenumbersarenotanaturalcauseofmaleinfertility(2).1、TrumJW,MolBW,PannekoekY,etal.Valueofdetectingleukocytospermiainthediagnosisofgenitaltractinfectioninsubfertilemen.FertilSteril1998Aug;70(2):315-9.2、TomlinsonMJ,BarrattCLR,CookeID.Prospectivestudyofleukocytesandleukocytesubpopulationsinsemensuggeststheyarenotacauseofmaleinfertility.FertilSteril1993Dec;60(6):1069-75.Whitebloodcells•AccordingtoWHOclassification,leukocytospermiaisdefinedas106WBCs/mL.Onlytwostudieshavea