Patient's question:
24-year-old male, developed urinary frequency, urgency, and incomplete urination two months ago, with swelling and pain near the anus! Saw a doctor, did ultrasound and urinalysis, both showed normal results, but the prostatic fluid test showed: phospholipid corpuscles 80%, microscopic examination of white blood cells 0~1, microscopic examination of red blood cells 0, diagnosed with prostatitis!Doctor's answer:
Disease Analysis: Prostatitis refers to acute or chronic inflammation caused by specific and non-specific infections of the prostate, leading to systemic or local symptoms. Prostatitis can be classified into non-specific bacterial prostatitis, idiopathic bacterial prostatitis (also known as prostatodynia), specific prostatitis (caused by pathogens such as Neisseria gonorrhoeae, Mycobacterium tuberculosis, fungi, parasites, etc.), non-specific granulomatous prostatitis, prostatitis caused by other pathogens (such as viruses, mycoplasma, chlamydia, etc.), prostatic congestion, and prostatodynia. The presence of phospholipid bodies indicates proper specimen collection.Clinical Advice:
1. Clinical Diagnosis:
- Digital rectal examination reveals a full, enlarged, soft prostate with mild tenderness. In cases of prolonged illness, the prostate may shrink, harden, and become uneven with small hard nodules. Prostatic massage can be used to obtain prostatic fluid for routine examination.
- Prostatic fluid examination: If more than 10 white blood cells are observed per high-power microscopic field in prostatic fluid, and the number of phospholipid bodies decreases, prostatitis can be diagnosed. If bacterial culture is performed simultaneously, a definitive diagnosis and classification of chronic prostatitis can be made. A positive bacterial culture result in prostatic fluid indicates chronic bacterial prostatitis, whereas a negative result suggests chronic non-bacterial prostatitis.
- Ultrasound examination: Disrupted or unclear boundaries in prostate tissue structure may suggest prostatitis.
- Through the above examinations, a diagnosis, differentiation, and classification of prostatitis can be made. Additionally, based on test results, another type of prostatic disease—prostatodynia—can be diagnosed. Clinically, it presents with chronic prostatitis symptoms, particularly pronounced pelvic and perineal pain, but prostatic fluid examination is normal, and bacterial culture yields no growth. Rectal examination may reveal swelling and fullness of the prostate with significant tenderness. When an abscess forms, the prostate gland may appear asymmetrical with localized fluctuation.
2. Preventive Measures:
- During acute phases, prostatic massage should be avoided to prevent the spread of infection to the epididymis, testes, or bloodstream, or to prevent bacteremia.
- Urine discharge can be examined via smear staining and bacterial culture. Urinalysis often shows numerous red blood cells or clusters of pus cells.
- Three-cup test: The first cup of urine appears slightly cloudy with white blood cells, the second cup is clear without white blood cells, and the third cup is cloudy with a large number of white blood cells and pus cells.
3. Etiology and Pathogenesis:
- Prostatitis is a common disease in young and middle-aged males and falls under the category of "lao-lin, jing-zhuo, bai-zhuo" in traditional Chinese medicine.
- It is classified into acute bacterial prostatitis, chronic bacterial prostatitis, and non-bacterial prostatitis. The pathogenesis involves bacterial infection, immune reactions to Staphylococcus epidermidis, joint or anterior uveitis, urethral instrumentation, catheter insertion, upper respiratory or urinary tract infections, sexual dysfunction, or dietary imbalances leading to internal damp-heat retention, turbid essence, and inflammatory swelling or abscess formation.
- Acute symptoms: Chills, fever, nausea, vomiting, frequent or urgent urination, dysuria, turbid urine, constipation, perineal and lower back pain, and prostatic swelling or tenderness.
- Chronic symptoms: Dizziness, lower back pain, frequent or urgent urination, incomplete urination, post-urination discharge of mucus, decreased libido, impotence, premature ejaculation, and testicular swelling or pain.
- Prostatitis is characterized by complex symptoms, prolonged course, stubbornness, and recurrence. Traditional medicine often uses methods to clear damp-heat and resolve toxicity to achieve effective treatment.
4. Differential Diagnosis:
- Prostatodynia: Patients experience persistent urinary frequency, dysuria, and difficulty urinating, along with pain in the perineum, lower abdomen, or lumbosacral region, which worsens after prolonged sitting or cycling. Digital rectal examination shows significant tenderness in the levator ani muscles, but the prostate feels normal without tenderness. Previously, this condition was known as piriformis-levator ani syndrome. Prostatic fluid examination is normal, and bacterial culture yields no growth.
- Prostatic abscess: Often a complication of acute bacterial prostatitis, occurring more frequently in males aged 50–60. Half of the patients experience acute urinary retention, frequent urination, difficulty urinating, rectal discomfort, purulent urethral discharge, or epididymitis. Digital rectal examination reveals an enlarged, soft, and fluctuating prostate on the affected side. Occasionally, a prostatic abscess may rupture into the urethra or rectum, mistakenly diagnosed as a rectal abscess.
- Prostatic calculi: Stones formed within prostatic acini and ducts, associated with chronic prostatitis, prostatic fluid retention, ductal stenosis, or metabolic disorders. Inorganic salts like calcium oxalate, calcium phosphate, or magnesium phosphate deposit on amyloid bodies, epithelial cells, and inflammatory exudates, forming stones. Patients may exhibit symptoms similar to chronic prostatitis, but digital rectal examination detects a grinding sensation in the prostate, pelvic X-rays show positive stone shadows in the symphysis pubis region, and ultrasound reveals bright bands with acoustic shadows at the stone sites.
- Prostatic tuberculosis: Symptoms resemble chronic prostatitis but are often accompanied by a history of urinary tract tuberculosis or other tuberculous lesions. Digital rectal examination shows an irregular nodular prostate, enlarged and hardened epididymis, and in the vas deferens. Direct smear or PCR detection of Mycobacterium tuberculosis in prostatic fluid confirms the diagnosis.
- Prostate cancer: Advanced stages may cause urinary frequency, dysuria, or difficulty urinating, but patients often exhibit systemic symptoms like weight loss, fatigue, anemia, or poor appetite. Digital rectal examination reveals a hard, stone-like mass in the prostate with an uneven surface. Elevated serum prostate-specific antigen (PSA) and acid phosphatase levels are observed. Prostate biopsy detects cancer cells, ultrasound shows an enlarged prostate with irregular or defective boundary echoes and uneven internal echoes, and a bright spot or mass at the tumor site. CT reveals asymmetry in prostate shape, with loss of tissue space between the capsule and seminal vesicles or posterior bladder wall if the tumor invades extracapsularly. CT can determine the extent of prostate cancer invasion.
- Pubic osteitis: Clinically presents with chronic prostatitis symptoms but normal digital rectal examination and prostatic fluid analysis. Key features include significant tenderness at the symphysis pubis, widened symphysis pubis gap (>10 mm), asymmetry in bilateral superior pubic rami (>2 mm), irregular symphysis pubis margins with erosion and reactive bone sclerosis on pelvic X-rays.
- Acute pyelonephritis: More common in females, rare in males. The loin pain caused by acute pyelonephritis is usually unilateral and tender to percussion. In acute prostatitis, loin pain is central in the lumbosacral region, with no tenderness in the renal area. Prostatic fluid contains abundant pus cells, while acute pyelonephritis primarily involves changes in urine characteristics.
5. Treatment and Prognosis:
- Prostatitis, as a common and frequently occurring male disease, is challenging to treat due to unclear etiology, unique anatomical structures, and high prevalence in sexually active populations. Many patients undergo multiple treatments without a definitive cure. However, with advancements in medicine, several treatment methods have shown significant efficacy. With patient confidence and close cooperation with physicians, prostatitis can be cured, allowing for a new life.