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慢性前列腺炎/慢性骨盆疼痛综合症

慢性非细菌性前列腺炎
(Chronic nonbacterial prostatitis)
类型urologic chronic pelvic pain syndrome[*]、慢性前列腺炎
分类和外部资源
医学专科泌尿外科
ICD-10N41
DiseasesDB10801
MedlinePlus000524
eMedicine437745
[编辑此条目的维基数据]

慢性非细菌性前列腺炎（Chronic nonbacterial prostatitis）或慢性前列腺炎/慢性骨盆疼痛综合症（chronic prostatitis/chronic pelvic pain syndrome ）又称类前列腺炎综合征，是会导致男性盆腔疼痛（英语：Pelvic pain）的一种疾病，是前列腺炎中找不到致病生物体类型的总称，涵盖找不到致病生物体的慢性前列腺炎各类型和前列腺痛；其特征是患者主述腰骶、会阴、外生殖器、尿道各种主观不适难忍，迁延难愈。没有明确的尿道感染病史。部分类前列腺炎综合征患者尿流率图曲线见齿型波，最大尿流率正常；平均尿流率时间相对延长。

此病应与其他类型的前列腺炎区分，如慢性细菌性前列腺炎、急性细菌性前列腺炎[1][2]。此外，这种疾病以前被称为前列腺疼痛（prostatodynia）。

症状

慢性前列腺炎/慢性骨盆疼痛综合征的主要特征是骨盆或会阴疼痛，且没有尿路感染的迹象[3]，并持续超过3个月[4]——此乃关键症状。它的症状可能会时好时坏。痛楚的程度可以从轻微的，以至使人虚弱。痛楚可散发至背部和直肠，令人坐下时感到不舒服。可于会阴、睾丸、阴茎前端、耻骨或膀胱这些区域上感到痛楚[5]。排尿困难、关节痛、肌肉痛、不明原因的乏力、腹痛、阴茎灼痛也是时常会出现的症状。尿频和尿急可能是暗示患者患的是间质性膀胱炎（发炎的是膀胱，而不是前列腺）。由神经和肌肉介导的射精后疼痛，仍是其一大特点[6]，此特点可用以把慢性前列腺炎/慢性骨盆疼痛综合症患者与良性前列腺增生症区分。有些患者报告说自己性欲低下、性功能障碍和勃起困难。

原因

神经、压力和荷尔蒙

慢性前列腺炎/慢性骨盆疼痛综合症是免疫、神经和内分泌系统与心理因素之间的相互作用导致[7]。该病背后的理论包括压力令下丘脑-垂体-肾上腺轴功能失调，和肾上腺皮质激素（内分泌）异常[8][9]，以及出现神经源性炎症（英语：Neurogenic inflammation）[10][11][12]、肌筋膜疼痛症候群[13][14]。在后两类，是由于过去的创伤、感染或焦虑性格导致局部神经系统的失调，慢性无意识地绷紧骨盆(受神经细胞释放物质（如物质P（英语：Substance P））的调节)亦会导致炎症。前列腺（和泌尿生殖道其它部分：膀胱、尿道、睾丸）亦能因长期活化在骨盆神经端部的肥大细胞而发炎。类似压力诱发的生殖泌尿炎症已经在其他哺乳动物实验中发现[15]。然而，前列腺炎组织学检查与国立卫生研究院的慢性前列腺炎症状指数之间没有关联[16]。

细菌感染学说曾在这一领域长时间占居主导地位，但于2003年在华盛顿大学由李博士（Dr Lee）和理查德·伯杰（Richard Berger）教授带领的研究显示细菌感染并不重要。该研究发现，三分之一正常男性或患者前列腺都有类近的细菌数量[17]。这一观点得到了西北大学泌尿外科主任和教授安东尼·谢弗博士（Dr Anthony Schaeffer）赞同，在2003年的泌尿外科杂志中，他指出“这些数据表明，细菌在慢性骨盆疼痛综合症的病情发展中并不扮演一个显著角色[18] 。”；并在一年后与他的同事发表他的研究，显示抗生素对慢性前列腺炎/慢性骨盆疼痛综合症基本上是无用的[19][20]。由于这些研究报告的发表，UCPPS的病因研究重点已经从感染转移到神经肌肉、行为、心理和遗传这些方面去研究（UCPPS：慢性前列腺炎/慢性骨盆疼痛综合症、间质性膀胱炎/膀胱疼痛综合症），其中强调下尿路和其他生理系统之间的相互作用[21]。现在的研究把UCPPS视为一种全身性疾病[21]。为佐证这项提议，2005年的研究表明，压力是与第三类前列腺炎慢性前列腺炎/慢性骨盆疼痛综合症）相关的[22]。

与间质性膀胱炎/膀胱疼痛综合症重叠

一些研究人员认为，慢性骨盆疼痛综合症是间质性膀胱炎/膀胱疼痛综合症的一种形式。2007年，美国国立糖尿病消化与肾病研究所（英语：National Institute of Diabetes and Digestive and Kidney Diseases）开始把间质性膀胱炎/膀胱疼痛综合症和慢性前列腺炎/慢性骨盆疼痛综合症组合，统称泌尿系统慢性盆腔疼痛综合症(Urologic Chronic Pelvic Pain Syndromes )。对间质性膀胱炎/膀胱疼痛综合症有效的治疗，如槲皮素[23]，在慢性前列腺炎/慢性骨盆疼痛综合症中同样有一些疗效[24]。最近的研究集中在基因组学和蛋白质组学方面的相关条件[25]。

患者可能在膀胱充盈时出现疼痛，这也是膀胱疼痛综合症的典型症状[26]。

气候

环境温度在病情上也扮演一个角色。患者很多时候会报告说寒冷引起症状加重，热力则很多时候会被报告说改善症状[27]。这则显得寒冷是可以引发导致慢性前列腺炎/慢性骨盆疼痛综合症的过程的因素之一[28]。寒冷也会导致症状加重和复发[28][29]。一项调查表明，居住在寒冷气候下的芬兰北部的男性前列腺炎症状的发生率比在世界其它地方报告的数字高[30]。

食物过敏

有证据表明，食物过敏和不耐受可能在慢性前列腺炎/慢性骨盆疼痛综合症方面起了加重病情的作用，也许是肥大细胞的介导机制所致。也有一些证据表明在一些患者的泌尿系统慢性盆腔疼痛综合症（如间质性膀胱炎/膀胱疼痛综合症和慢性前列腺炎/慢性骨盆疼痛综合症）与麸质不耐（英语：Non-celiac_gluten_sensitivity）有关[31][32][33]。因此，患者通过识别问题食品然后把其从饮食中消除可能对减轻症状有帮助。但这方面的研究较为缺乏。

诊断

没有确切的对慢性前列腺炎/慢性骨盆疼痛综合症的诊断测试。这是一种所知甚少的病症。尽管它占所有前列腺炎诊断的90％-95％[34]。它可在任何年龄的男性中被发现，35-45岁为男性发病的高峰[35]。慢性前列腺炎/慢性骨盆疼痛综合症可以根据前列腺液分泌物中的脓细胞水平，分为炎症（分类ⅢA）或是非炎症（分类ⅢB），但这些子类别在临床上用途有限。在分类为炎症的情况下，尿液、精液、其它从前列腺流出来的液体包含脓细胞（死去的白血细胞或白细胞）；而分类为非炎症的情况下，并无发现脓细胞存在。最近的研究质疑分类Ⅲa和Ⅲb之间的区别，因为如果脓细胞和更细微的迹象（如所测量的细胞因子）被忽略，这两类都表明是炎症[36]。

2006年，中国的研究人员发现，患有Ⅲa和Ⅲb型的男性在其前列腺按摩液（EPS）均具有抗炎细胞因子TGFβ1（英语：TGFβ1）和促炎细胞因子干扰素伽玛的显著升高迹象(与对照组相比)。因此，这些细胞因子的测量可用于诊断第Ⅲ型前列腺炎[37]。2010年的研究发现，神经生长因子（英语：Nerve growth factor）也可以用作作为一种生物标志物来测量[38]。

对于慢性前列腺炎/慢性骨盆疼痛综合症患者，尿液分析并以此表示前列腺分泌物中白细胞是有争议的，因为确定炎性和非炎性之间的差异是没有任何作用[39]。血清PSA测试、前列腺常规影像、沙眼衣原体和脲测试对患者并不能提供任何好处[39]。

>50％慢性骨盆疼痛综合症患者存在前列腺外腹部/骨盆压痛，但只有7％的痛楚受到控制[40]。健康男性在其精液发现的细菌比患有慢性骨盆疼痛综合症的男性略多[41]。在无症状的对照人群中，白细胞和细菌培养阳性的高发病率引起了人们对临床应用4-glass test作为慢性前列腺炎/慢性骨盆疼痛综合症诊断工具的疑惑[41]。美国泌尿外科医生使用4-glass test目前是十分罕见，经常使用它的只有4％[42]。

患上慢性前列腺炎/慢性骨盆疼痛综合症的男性一般人更容易患上慢性疲劳综合症[43]和大肠激躁症。

有些实验测试可能在未来有用的，包括测量精液和前列腺液的细胞因子水平的测试。各种研究已表明在慢性前列腺炎/慢性骨盆疼痛综合症中，炎症标记物会增加，如细胞因子[44]、髓过氧化物酶[45]、趋化因子[46][47]的水平升高。

鉴别诊断

有些状态也有与慢性前列腺炎类似的症状，膀胱颈部肥大和尿道狭窄可能由于尿液返流引起相似的症状，可以通过膀胱镜和尿动力学测试排除[48][49][50]。

命名法

慢性前列腺炎/慢性骨盆疼痛综合症有时会区分做IIIa型（炎症）和IIIb型（非炎症）[51]，取决于脓胞（白细胞）是否可以在患者的前列腺液分泌物（EPS）中找到。一些研究者质疑这种分类的有效性并呼吁抛弃four-glass test[52]。

2007年，美国国立糖尿病消化与肾病研究所（英语：National Institute of Diabetes and Digestive and Kidney Diseases）以研究为目的，开始使用“泌尿系统慢性盆腔疼痛综合症”此一伞式术语，指与膀胱（即间质性膀胱炎/膀胱疼痛综合症）和前列腺（即慢性前列腺炎/慢性骨盆疼痛综合症）有关的疼痛综合症[53]。

此疾病的旧版术语是前列腺痛和非细菌性前列腺炎。

治疗

慢性骨盆疼痛综合症是很难治疗的[54]。

心理治疗和物理治疗

第三类前列腺炎可能除了焦虑情绪外，并没有任何的触发因素。且患者经常伴有强迫症、恐慌症或其他焦虑光谱的问题[55][56][57]。这理论上会令骨盆区域出现敏化状态，令肌肉循环性地紧张，并提高神经反馈。目前的治疗方案在很大程度上集中于使紧张的盆腔或肛门部位（通常被称为激痛点)放松，方法包括直肠按摩、对该区域进行物理治疗和放松疗法，以减少致病的压力。


有氧运动可以帮助那些没患上慢性疲劳综合症或不会由运动加剧痛苦症状的慢性前列腺炎/慢性骨盆疼痛综合症患者[58]。据报告，针灸也对一些患者有帮助[59]。慢性非细菌性前列腺炎（第III类），也被称为慢性前列腺炎/慢性骨盆疼痛综合症，这使得大多数男性被诊断为“前列腺炎”。一最近已经公布了个称为“斯坦福大学治疗方案（英语：Wise–Anderson Protocol）”[13][14][60]的治疗方案，其包括：

  • 药物治疗（使用三环类抗抑郁药和苯二氮卓）
  • 心理治疗(矛盾放松(paradoxical relaxation)训练，专门针对盆腔疼痛，早在20世纪期间由埃德蒙·雅各布森发展的一种渐进式放松技术)
  • 物理疗法(盆底和腹部肌肉的激痛点释放疗法，而且进行瑜伽式的练习，以放松盆底和腹部肌肉为目的)[13][14]

生物反馈理疗对学习如何控制盆底肌肉可能是有帮助的[61][62][63][64]。生物反馈对青春期的慢性前列腺炎治疗是良好的疗法（主要是治疗排尿问题）[65]。

药理治疗

许多药物可用于治疗这种疾病。α-受体阻滞剂（英语：Alpha blocker）或抗生素似乎是最有效的。非甾体抗炎药如布洛芬，提供的益处则较少[66]。

  • 用抗生素治疗是有争议的。有些抗生素已发现对病情有好处[66]；但有些人质疑抗生素的效用[67]。抗生素已知具有抗炎特性，因此这被认为说明了它们的部分功效并建议用于治疗慢性骨盆疼痛综合症[18]。抗生素如喹诺酮类，四环素类和大环内酯类缺乏没有感染的直接抗炎性质。阻断细胞因子如白细胞介素1族、白细胞介素-8、肿瘤坏死因子，都在男性慢性前列腺炎患者的精液和列腺按摩液中发现升高的现象[68]。
  • α-受体阻滞剂(坦索罗辛、阿夫唑嗪)对慢性骨盆疼痛综合症的有效性备受质疑，2006年的一项荟萃分析发现，他们在持续至少3个月的治疗中度有益[69]
  • 雌激素再吸收抑制剂，例如美帕曲星（英语：Mepartricin），能改善排尿、减少神经疼痛，提高慢性非细菌性前列腺炎患者的生活质量[70]。
  • 还没有在临床试验中经妥善评价，但有轶事证据支持的药物包括：加巴喷丁、苯二氮䓬类和阿米替林[71]。

外科手术

经尿道针切除前列腺（英语：Transurethral needle ablation of the prostate）已在实验被证明无效[72]。

流行病学

慢性骨盆疼痛综合症的每年人口患病率为0.5％[73]。38％初级卫生保健提供者表示他们从来没有见过慢性前列腺炎/慢性骨盆疼痛综合症患者[74]。然而，暗示慢性前列腺炎/慢性骨盆疼痛综合症的总患病率为6.3％[75]。

预后

近年来，慢性前列腺炎/慢性骨盆疼痛综合症的预后出现改善，归因于多峰治疗、植物疗法，旨在通过激痛点释放和控制焦虑，使骨盆神经平静下来，还有治疗慢性疼痛[76][77][78]。

著名病例

参考资料

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外部链接

男性骨盆和生殖器疾病（N40–N51，600–608）
内部
睾丸
附睾
前列腺
外部
阴茎
其他
描述
疾病
治疗
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慢性前列腺炎/慢性骨盆疼痛综合症
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