Ⅳ型前列腺炎对精液质量的影响及纳米银治疗作用的研究
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摘要
慢性前列腺炎是男性泌尿生殖系统中非常常见的疾病。然而慢性前列腺炎与男性不育的关系已经争论多年。多年前,外国的一些学者报导了慢性前列腺炎与精液的质量、功能不正常有关,而另一些学者报导了慢性前列腺炎、前列腺痛患者的精子密度、活动能力、形态方面与对照组没有区别。更有个别学者认为精液与前列腺按摩液(EPS)方面作为炎症标志的白细胞计数升高对精子总数、密度、活动力、形态和精子成活率方面没有不利影响。而在中国的学者调查发现,男性不育患者中慢性前列腺炎的发生率较高39.1%。对于这些相互矛盾的结果有一个可能的解释就是对于慢性前列腺炎传统的分类诊断是否适合。1995年美国国立卫生研究院(National Institutes of Health, NIH)根据当时对前列腺炎的基础和临床研究情况,制定了一种新的分类方法：工型：相当于传统分类方法中的ABP(急性细菌性前列腺炎acute bacterial prostatitis, ABP)。Ⅱ型：相当于传统分类方法中的CBP(慢性细菌性前列腺炎(chronic bacterial Pprostatitis,)Ⅲ型：慢性前列腺炎/慢性骨盆疼痛综合征(chronic prostatitis/chronic pelvic pain syndromes, CP/CPPS),相当于传统分类方法中的CNP(慢性非细菌性前列腺炎(chronic nonbacterial prostatitis, CNP)、和PD(前列腺痛prostatodynia, PD)。根据EPS/精液/VB3常规显微镜检结果,该型又可再分为ⅢA(炎症性CPPS)和ⅢB(非炎症性CPPS)两种亚型：ⅢA型患者的EPS/精液/VB3中白细胞数量升高；ⅢB型患者的EPS/精液/VB3中白细胞在正常范围。Ⅳ型：无症状性前列腺炎(asymptomatory inflammatory prostatitis, AIP)。无主观症状,仅在有关前列腺方面的检查(EPS、精液、前列腺组织活检及前列腺切除标本的病理检查等)时发现炎症证据。
Ⅳ型前列腺炎由于患者本身无前列腺炎的相关症状,常常被临床医师所忽视,往往是在门诊不育的筛查时无意中发现。近年来男性不育发病率不断上升,前列腺炎对男性生育能力的影响再次引起了广泛的关注。Ⅳ型前列腺炎在不育的患者中发病率相当高,但关于Ⅳ型前列腺炎对精液质量影响及其机制、治疗的方法等方面的研究并不多,本研究通过调查Ⅳ型前列腺炎对精液质量主要参数的影响,探讨EPS中白细胞水平与精液质量主要参数的相关情况；探讨EPS、精浆中细胞因子、精浆中性粒细胞弹性蛋白酶、精浆抗精子抗体的水平及其影响精液质量的机制；探讨Ⅳ型前列腺炎患者前列腺组织结构特点及使用纳米银凝胶联合前列腺按摩治疗Ⅳ型前列腺炎的效果及作用机制。
随着医学科技水平不断提高,前列腺炎与不育的关系也不断地被研究证实。目前已经表明,慢性前列腺炎可影响男性生殖系统功能,是导致男性不育、性功能障碍的重要病因之一。但对于引起不育的机制,不同类型的前列腺炎有不同的表现与结果。明确不同类型的前列腺炎对生殖功能的影响,对指导临床治疗有重要意义。通过此项研究,阐明Ⅳ型前列腺炎对精液质量参数的影响,及与患病年龄、作用时间的关系；明确EPS中白细胞水平与精液质量主要参数的相关情况；通过了解EPS、精浆中细胞因子、精浆中性粒细胞弹性蛋白酶、精浆抗精子抗体的水平,揭示其影响精液质量的机制及Ⅳ型前列腺炎可能的发病机制。进而找出其合理的治疗方法。目前男性不育约占不育不孕的40%。很多少、弱、畸精患者早期通过寻找病因及适当的治疗后成功自然受孕,但有些前列腺炎患者特别Ⅳ型,因其无症状,患者往往未能及时就诊,当发现时精液质量已受严重影响,不易恢复。若因此而作试管婴儿的费用每例约2～3万元(成功率约30～40%),若能提前给其提供生育上的指导,则可为患者节约医疗费用,为社会节省大量的医疗资源。
第一章：Ⅳ型前列腺炎对精液质量的影响
第一节：Ⅳ型前列腺炎对精液指标的影响
目的：
研究Ⅳ型前列腺炎对精液量、精子密度、活动力、存活率、形态、pH、柠檬酸、果糖及前列腺液、精液中白细胞、精子膜功能的影响。
材料方法：
2010年1月至2011年1月,中山市人民医院门诊230例Ⅳ型前列腺炎患者年龄20～65岁,平均年龄：33.41±9.37岁。80例健康志愿者作为对照组,21～45岁,平均年龄32.18±6.49岁。全部病人进行标准的评估,包括直肠指检、显微镜检、尿及精液的细菌培养。精液分析包括：精液量、精子密度、活动力、存活率(伊红染色)、形态、pH值、柠檬酸和果糖的浓度。前列腺液(EPS)及精液中白细胞检测采用髓过氧化物酶染色法,精子膜功能检测采用精子低渗肿胀试验。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎对精液指标的影响
Ⅳ型前列腺炎患者的精子活动能力、精子畸形百分率、液化时间等指标及精子低渗肿胀试验,与对照组相比差异有显著性(P<0.001)。而精液pH值、精子活率、精子密度等指标,两组相比差异无显著性(P>0.05)。
2Ⅳ型前列腺炎对精液柠檬酸、果糖、精液量的影响
20～35岁病例,Ⅳ型前列腺炎组与对照组相比,差异无统计学意义(P>0.05)。36～65岁病例,两组比较差异有统计学意义(P<0.05)。
3前列腺按摩液中白细胞的水平与精子质量的关系
将Ⅳ型前列腺炎患者按前列腺按摩液中的白细胞水平分组A组：WBC(+++)及B组：WBC(+++～++++)。两组在精子活动能力、精子畸形百分率、液化时间等方面,两组比较差异有统计学意义(P<0.001)。
结论
Ⅳ型前列腺炎对精液的液化时间、精子活动能力、正常形态、质膜完整性等主要参数有影响,并与患者年龄相关。前列腺按摩液中WBC水平与精液的质量呈负相关。
第二节：Ⅳ型前列腺炎对精液中细胞因子、中性粒细胞弹性蛋白酶及精浆抗精子抗体的影响
目的：
研究Ⅳ型前列腺炎对精液中细胞因子、中性粒细胞弹性蛋白酶及精浆抗精子抗体的影响。
材料方法：
在此前研究的230例Ⅳ型前列腺炎患者中随机抽取60名患者,年龄21-46岁,平均年龄34.31±8.30岁。50例健康志愿者作为对照组,年龄21-43岁,平均年龄32.28±5.3岁。分别检测两组病例前列腺液及精液中的细胞因子(TNF-α、IL-1β、IL-6)及精浆中性粒细胞弹性蛋白酶(NE)、精浆抗精子抗体。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎患者前列腺按摩液、精液中TNF-α和IL-1β、IL-6均显著高于对照组(P<0.01)。前列腺按摩液中TNF-α、IL-1β、IL-6与前列腺按摩液中WBC数量存在正相关关系,与精液的液化时间、A级活动能力、正常形态呈负相关。而对照组各指标间不存在相关关系。
2Ⅳ型前列腺炎患者精浆中性粒细胞弹性蛋白酶浓度显著高于对照组(P<0.01)。
3Ⅳ型前列腺炎患者精浆抗精子抗体检测MAR阳性率显著高于对照组(P<0.01)。结论
Ⅳ型前列腺炎患者的精液质量异常可能与前列腺按摩液、精浆中的细胞因子改变有关,其中可能包含了感染与免疫的双重作用。前列腺按摩液、精浆中的细胞因子、中性粒弹性蛋白酶与前列腺液中白细胞水平呈正相关,白细胞升高可能是感染与免疫共同作用的结果。
第二章：纳米银治疗慢性前列腺炎的动物实验及临床研究
第一节纳米银对慢性前列腺炎大鼠模型病理形态学及超微结构的影响
目的：
通过建立慢性前列腺炎大鼠模型,探讨纳米银对慢性前列腺炎病理形态学及超微结构的影响。
材料方法：
24只大鼠随机分为对照组、大肠杆菌前列腺炎组、衣原体支原体组、衣原体支原体+纳米银组,每组6只。建模6周后处死大鼠,取前列腺组织分别观察病理形态学(HE染色)及透射电镜下前列腺上皮细胞内超微结构改变。
结果：
1对照组前列腺腺上皮立方或高柱状,腺腔内见粉染分泌物,未见炎症细胞浸润及纤维组织增生。大肠杆菌组前列腺组织明显异常变化,腺泡萎缩,腺体管闭塞,皱襞明显减少或消失,腺泡无分泌物,大量炎细胞浸润,伴有组织坏死。衣原体支原体组前列腺病理变化为腺腔内粉染分泌物减少甚至消失,腺泡萎缩,腺体管腔变小,甚至闭塞,间质疏松水肿,少量淋巴细胞浸润,可见少量浆细胞,血管扩张充血,周围也有淋巴细胞浸润,还可观察到成纤维细胞,偶有炎性肉芽肿性病变。衣原体支原体+纳米银组较衣原体支原体有明显改善,虽然前列腺组织腺腔内见粉染分泌物稍减少,间中可见淋巴细胞浸润,但未见成纤维细胞及炎性肉芽肿性病变。
2对照组腺上皮细胞表面有微绒毛,细胞间可见连接,胞浆中含有丰富的线粒体、内质网轻度扩张,细胞中以及细胞顶部有散在的内含颗粒的分泌泡,细胞核椭圆。大肠杆菌组前列腺腺上皮细胞肿胀崩解,胞质中可见大量的浅色分泌泡,可见电子密度高的大肠杆菌。衣原体支原体组腺上皮细胞表面微绒毛较稀疏,细胞间可见连接,胞浆中含有丰富的线粒体、内质网,细胞中有少量散在的内含颗粒的分泌泡。衣原体支原体+纳米银组前列腺腺上皮内超微结构基本正常。
结论
在慢性前列腺炎大鼠模型上证明纳米银凝胶经直肠给药治疗由衣原体支原体感染引起的Ⅳ型前列腺炎是一个良好的治疗方法。
第二节纳米银经直肠给药途径治疗Ⅳ型前列腺炎的可行性与临床疗效观察
目的：
探讨直肠给药途径治疗Ⅳ型前列腺炎的可行性,并观察纳米银经直肠给药途径治疗Ⅳ型前列腺炎的临床疗效。
材料方法：
1Ⅳ型前列腺炎患者230例行经直肠的前列腺超声检查,观察慢性炎症在前列腺中的分布趋势。
2血清PSA升高及年龄50岁以上的Ⅳ型前列腺炎患者8例行前列腺穿刺活检,观察慢性炎症在前列腺中的分布情况。
3Ⅳ型前列腺炎患者60例随机分为两组,两组在治疗前的年龄、精液质量指标等方面差别无统计学意义,60例均无接受抗菌素治疗。A组为前列腺按摩对照组共30例,每周作前列腺按摩2次。B组为纳米银联合按摩治疗组共30例,每晚睡前纳米银抗菌凝胶3m1经直肠给药,另外每周作前列腺按摩2次,按摩前直肠注入纳米银抗菌凝胶3ml,然后按摩治疗约3-5分钟。连续治疗12周后,分别检测两组精液质量主要参数、治疗组前列腺按摩液中细胞因子(TNF-α和IL-1β、IL-6)及精浆抗精子抗体检测MAR、精浆中性粒细胞弹性蛋白酶NE作前后比较,同时记录、比较不良反应。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎的B超影像学特点炎症分布特点主要表现为以下几种类型：各回声均匀型：本组13例(5.6%)；外周区回声欠均匀型本组113例(49.1%)；增大低回声型本组96例(41.7%)；结节钙化型本组8例(3.6%)可见Ⅳ型前列腺炎的病变多集中在外周区为主。
2Ⅳ型前列腺炎的病理组织学特点：所有病例的前列腺内都存在炎症细胞浸润,炎症细胞浸润主要在前列腺外周区和尿道周围腺体分布最多。
3除精浆抗精子抗体外,纳米银联合按摩治疗组病例治疗前后的精液液化时间、活动能力、正常形态、前列腺按摩液中细胞因子(TNF-α、IL-1β、IL-6)、精浆中性粒细胞弹性蛋白酶NE、精浆抗精子抗体等指标的相比较,均有明显改善,差异有统计学意义(P<0.05)。纳米银联合按摩治疗组疗效优于前列腺按摩对照组(P<0.05)。前列腺按摩对照组病例在治疗前后以上指标相比较,差异无统计学意义(P>0.05)。
结论：
Ⅳ型前列腺炎的病变主要在前列腺外周区与尿道周围为主。纳米银凝胶联合按摩治疗方法可明显改善Ⅳ型前列腺炎患者精液的质量。
[Object]:The chronic prostatitis is one kind of common diseases in the masculine urogenital system. However, the relations between chronic prostatitis and the sterile have been already argued for many years. Relationship between the seminal quality, dysfunction and the chronic prostatitis had been reported. But the others suggested no distinction to be presence in sperm density, power, the morphology changes between the chronic prostatitis patient's and control group. Furthermore, it had been reported that the white blood cell level of seminal fluid and the prostate gland fluid, which is a symbol as the inflammation, had no relation with the total sperm, the density, power, the shape and the sperm survival rate. Some Chinese date showed that approximate 39.1% male sterility patients had been diagnosed as the chronic prostatitis at the same time.
In 1995 the National Institutes of Health convened a consensus conference to re-evaluate the utility of the existing classification system. The result was a refinement of the traditional classification of prostatitis syndromes that allowed for standard inclusion criteria for participants in clinical trials for chronic nonbacterial prostatitis and prostadynia. The new system also has four categories. CategoryⅠ, acute bacterial prostatitis, refers to a combination of lower urinary tract and systemic infectious symptoms such as fever and chills. CategoryⅡ, chronic bacterial prostatitis, is characterized by culture-documented recurrent urinary tract infection combined with symptoms of acute or chronic pelvic pain without the systemic component demonstrated in categoryⅠ. CategoryⅢ, known as chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS), lacks an infectious component and is subcategorized as inflammatory or non-inflammatory based on the findings of leukocytes in a urine sample and expressed prostatitic secretions. Symptoms, however, can be similar to those found in categoriesⅠandⅡand include perineal or low back pain, lower urinary tract symptoms and painful ejaculation. The existence of pelvic pain is a requirement for diagnosis of categoryⅢprostatitis regardless of the level of urinary symptoms. Due to the differences in presenting symptoms among patients, the National Institutes of Health-Chronic Prostatitis Symptoms Index (NIH-CPSI) was created to quantify and determine the effects of the presenting symptoms for categoryⅢpatients. The NIH-CPSI asks questions that are tabulated into three domain scores:(1) pain, (2) urinary symptoms and (3) quality of life. The index can be helpful in differentiating the levels of CP-CPPS while also quantifying an individual's quality of life. A limitation of the index is that it was validated by a population of mostly white, educated men and may not be as useful in other patient populations. Category IV refers to asymptomatic inflammatory prostatitis. It is usually found incidentally through biopsies of patients being evaluated for benign prostatic hypertrophy (BPH) or an elevated prostate-specific antigen (PSA). It has been estimated that categoryⅣprostatitis may affect one-third of all patients who present with prostatitis.
Ⅳ(symptomless prostatitis) as a result of non-prostatitis's related symptom affaired the patient himself, to be neglected frequently by clinician, But often to be discovered in outpatient service sterile screening by chance. Recently, the sterile patient disease incidence rate is raising up and the chronic prostatitis has been thinked as one of the major factors of the masculine potentia generandi. Symptomless prostatitis incidence rate is quite high in the sterile patient, but the research reports concern on situation and mechanism, therapeutics of seminal fluid quality influence, which induced by symptomless prostatitis (Ⅳ), are rare. In our study, the main parameter's influence of seminal fluid quality in symptomless prostatitis patients, the relation between white blood cell level and main parameter of seminal fluid quality in prostate gland fluid, the cytokines of prostate gland fluid and seminal fluid, seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body level of seminal plasma and its mechanism involve in seminal fluid quality, had been investigated. Furthermore, we explored the effect and the function mechanism of nanometer silver gelatin combine with the prostate gland massage in symptomless prostatitis's patients.
Significance:Developing with the scientific research method's increasingly progress, relation between prostatitis and the sterile is confirmed unceasingly and clearly. It had been reported that about 60-70% male sterility patients were caused by chronic prostatitis and chronic prostatitis could affect the male reproductive system function. Different chronic prostatitis has the different situation and the consequence. It is very important to make clear the different type chronic prostatitis and deciding the treatment to cure the reproduction function influence. In our study, seminal fluid quality parameter, patient's age, response time will be explored. The relation between the white blood cell level in the prostate gland fluid and the main parameter of seminal fluid quality, various cytokine of prostate gland fluid and seminal fluid, Seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body level of Seminal plasma will be discussed to reveal its possible morbidity mechanism involve in seminal fluid quality and its reasonable method of treatment. About 40% of dysgenesis and infertility suffered from male sterility in recent papers. Making Material and method:
60 categoryⅣprostatitis patients, age 21～46 years old, mean age 34.31±8.30 years old and 50 control group volunteers, age 21～43 years old, mean age 32.28±5.3 years old. In the distinction examination of patients' prostatic fluid, the seminal fluid and the cytokine, TNF-α, IL-1β, IL-6, and Seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body of seminal plasma examines. The data indicated by x±s, and the chi-square test, the t-test were be used with the SPSS 13.0 software. Result:
1. The levels of TNF-α, IL-1βand IL-6 in prostatic fluid and the seminal fluid in categoryⅣprostatitis patients were higher than that of control group. And they had negative correlation with the seminal fluid liquefied time, class A sperm motility and the normal sperm shape, P<0.01.
2. The concentration of seminal plasma neutrality grain of elastic proteinase in categoryⅣprostatitis patients was higher than that of control group, P<0.01.
3. The positive rate of anti-sperm immune body of seminal plasma in categoryⅣprostatitis patients was higher than that of control group, P<0.01.
Conclusion:
Seminal fluid quality of the categoryⅣprostatitis patients may be concern with the changed of cytokine in the prostatic fluid and seminal plasma. It maybe caused by the infection and the immunity. The levels of the cytokine, neutrality grain of elastic proteinase in the categoryⅣprostatitis patients have positive correlation with the levels of white blood cell level in prostatic fluid and seminal plasma. The high level of white blood cell in the prostatic fluid and seminal plasma maybe the result of the infection and immunity.
Chapter 2:The effect of nanometer silver treatment in chronic prostatitis with animal model and clinical experience. Prat1. The study of pathomorphology and ultrastructural changes with the treatment of nanometer silver in rat chronic prostatitis model.
Objective:To study the nanometer silver effect of pathomorphology and ultrastructural changes in rat prostatitis model.
Material and method:
24 rats were random divided into 4 groups. Group A (control group, n=6), Group B(escherichia coli, n=6), Group C(chlamydia and mycoplasma, n=6), Group D(chlamydia and mycoplasma and nanometer silver, n=6). The pathological sections and the ultrastructural changes of rat prostates had been observed by optics microscope and transmission electron microscope after 6 weeks treatment.
Result:
1. In the optics microscope, in Group A, prostate gland epithelium like cubic or columnar, glandular secretions were pink dyed by feosin. No inflammatory cells and fibrous tissue proliferation.
In Group B, acinar atrophy, glandular tube occlusion, fold reduced or disappeared significantly, no acinar secretion, inflammatory cell infiltration accompanied by tissue necrosis.
In Group C, pathological changes include glandular secretions reduced and disappeared, acinar atrophy, gland lumen shrink and occlusion, interstitial edema, a few of lymphocytic infiltration, showing a small amount of plasma cells, blood vessels dilatation and congestion, prostate gland secretions were also surrounded by lymphocytic infiltration which pink dyed by feosin, fibroblasts observed also, occasional inflammatory granulomatous lesions.
In Group D, the pathological changes had significant improvement, although the prostate gland secretions reduced, lymphocytes infiltration was observed occasionally, no fibroblasts and inflammatory granulomatous lesions.
2. The changes of ultrastructural changes.
In Group A, microvillus on epithelial cell surface, the cytoplasm contained abundant mitochondria, endoplasmic reticulum expanded slightly, secretory vesicles contained granular, nuclei shape liked oval.
In Group B, prostate gland epithelial cell disintegrated with swelling, a large number of light-colored secretory vesicles in the cytoplasm can be seen, showing high electron density E. coli.
In Group C, sparse microvillus on epithelial cell surface, connections between cells can be observed, cytoplasm rich in mitochondria, endoplasmic reticulum, cells containing a small amount of secretory vesicles with scattered particles.
In Group D, prostate gland epithelial ultrastructure was almost normal.
Conclusion:
The treatment of nanometer silver is a effective management in chlamydia mycoplasma prostatitis rat model.
Prat 2. The feasibility and the effect of nanometer silver treatment in chronic prostatitis patients.
Objective:To study the feasibility and the effect of nanometer silver treatment in chronic prostatitis patients.
Material and method:
1.230 categoryⅣprostatitis patients had accepted transrectal ultrasound examination. The data had been collected to analynize the inflammation distributed character in these patients.
2.8 categoryⅣprostatitis patients, age above 50 years old and with high blood serum PSA level, had accepted prostate gland puncture.6 needles puncture in the flank boundary area and the prostate tissue were observed by pathological specialist.
3.60 categoryⅣprostatitis patients were divided into two groups. Control group,30 cases, only accepted prostate gland massage twice each week. Nanometer silver treated group,30 cases, treated with nanometer silver 3ml through rectum every night, and accepted prostate massage twice per week for 12weeks. The main parameter of seminal fluid quality and the cytokine, TNF-α, IL-1βand IL-6, anti-sperm immune body of seminal plasma, seminal plasma neutrality grain of elastic proteinase of seminal fluid were detected. The data indicated by x±s, and the chi-square test, the t-test were be used with the SPSS 13.0 software.
Result:
1. The inflammation distributed character by ultrasonic iconography in categoryⅣprostatitis patients' indicated as follow. Type A (echoes well-distributed),13 cases in this group(5.6%). Type B(echo un-well-distributed in periphery area),113 cases in this group (49.1%). Type C(increasing echo),96 cases in this group (41.7%). Type D(tubercle calcification),20 cases in this group (3.6%).
2. The infiltration of inflammatory cell in the prostatic tissue had been observed in all cases. the inflammatory cell primarily distributed in periphery region and the circum-urethra area.
3. Except anti-sperm immune body of seminal plasma, the sperm liquefied time, power, shape, the cytokine, TNF-α, IL-1βand IL-6, seminal plasma neutrality grain of elastic proteinase of seminal fluid had been significant improved in nanometer silver treated group, P<0.05. The effect of nanometer silver treated group was better than that of the control group, P<0.05. The categoryⅣprostatitis patients could not get the significant benefit by prostatic massage, P>0.05.
Conclusion:
The pathological change of categoryⅣprostatitis patients is mainly around prostate gland periphery area and circum-urethra. The nanometer silver gelatin combined massage treatment may improve the seminal quality in categoryⅣprostatitis patient.
Ⅳ型前列腺炎由于患者本身无前列腺炎的相关症状,常常被临床医师所忽视,往往是在门诊不育的筛查时无意中发现。近年来男性不育发病率不断上升,前列腺炎对男性生育能力的影响再次引起了广泛的关注。Ⅳ型前列腺炎在不育的患者中发病率相当高,但关于Ⅳ型前列腺炎对精液质量影响及其机制、治疗的方法等方面的研究并不多,本研究通过调查Ⅳ型前列腺炎对精液质量主要参数的影响,探讨EPS中白细胞水平与精液质量主要参数的相关情况；探讨EPS、精浆中细胞因子、精浆中性粒细胞弹性蛋白酶、精浆抗精子抗体的水平及其影响精液质量的机制；探讨Ⅳ型前列腺炎患者前列腺组织结构特点及使用纳米银凝胶联合前列腺按摩治疗Ⅳ型前列腺炎的效果及作用机制。
随着医学科技水平不断提高,前列腺炎与不育的关系也不断地被研究证实。目前已经表明,慢性前列腺炎可影响男性生殖系统功能,是导致男性不育、性功能障碍的重要病因之一。但对于引起不育的机制,不同类型的前列腺炎有不同的表现与结果。明确不同类型的前列腺炎对生殖功能的影响,对指导临床治疗有重要意义。通过此项研究,阐明Ⅳ型前列腺炎对精液质量参数的影响,及与患病年龄、作用时间的关系；明确EPS中白细胞水平与精液质量主要参数的相关情况；通过了解EPS、精浆中细胞因子、精浆中性粒细胞弹性蛋白酶、精浆抗精子抗体的水平,揭示其影响精液质量的机制及Ⅳ型前列腺炎可能的发病机制。进而找出其合理的治疗方法。目前男性不育约占不育不孕的40%。很多少、弱、畸精患者早期通过寻找病因及适当的治疗后成功自然受孕,但有些前列腺炎患者特别Ⅳ型,因其无症状,患者往往未能及时就诊,当发现时精液质量已受严重影响,不易恢复。若因此而作试管婴儿的费用每例约2～3万元(成功率约30～40%),若能提前给其提供生育上的指导,则可为患者节约医疗费用,为社会节省大量的医疗资源。
第一章：Ⅳ型前列腺炎对精液质量的影响
第一节：Ⅳ型前列腺炎对精液指标的影响
目的：
研究Ⅳ型前列腺炎对精液量、精子密度、活动力、存活率、形态、pH、柠檬酸、果糖及前列腺液、精液中白细胞、精子膜功能的影响。
材料方法：
2010年1月至2011年1月,中山市人民医院门诊230例Ⅳ型前列腺炎患者年龄20～65岁,平均年龄：33.41±9.37岁。80例健康志愿者作为对照组,21～45岁,平均年龄32.18±6.49岁。全部病人进行标准的评估,包括直肠指检、显微镜检、尿及精液的细菌培养。精液分析包括：精液量、精子密度、活动力、存活率(伊红染色)、形态、pH值、柠檬酸和果糖的浓度。前列腺液(EPS)及精液中白细胞检测采用髓过氧化物酶染色法,精子膜功能检测采用精子低渗肿胀试验。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎对精液指标的影响
Ⅳ型前列腺炎患者的精子活动能力、精子畸形百分率、液化时间等指标及精子低渗肿胀试验,与对照组相比差异有显著性(P<0.001)。而精液pH值、精子活率、精子密度等指标,两组相比差异无显著性(P>0.05)。
2Ⅳ型前列腺炎对精液柠檬酸、果糖、精液量的影响
20～35岁病例,Ⅳ型前列腺炎组与对照组相比,差异无统计学意义(P>0.05)。36～65岁病例,两组比较差异有统计学意义(P<0.05)。
3前列腺按摩液中白细胞的水平与精子质量的关系
将Ⅳ型前列腺炎患者按前列腺按摩液中的白细胞水平分组A组：WBC(+++)及B组：WBC(+++～++++)。两组在精子活动能力、精子畸形百分率、液化时间等方面,两组比较差异有统计学意义(P<0.001)。
结论
Ⅳ型前列腺炎对精液的液化时间、精子活动能力、正常形态、质膜完整性等主要参数有影响,并与患者年龄相关。前列腺按摩液中WBC水平与精液的质量呈负相关。
第二节：Ⅳ型前列腺炎对精液中细胞因子、中性粒细胞弹性蛋白酶及精浆抗精子抗体的影响
目的：
研究Ⅳ型前列腺炎对精液中细胞因子、中性粒细胞弹性蛋白酶及精浆抗精子抗体的影响。
材料方法：
在此前研究的230例Ⅳ型前列腺炎患者中随机抽取60名患者,年龄21-46岁,平均年龄34.31±8.30岁。50例健康志愿者作为对照组,年龄21-43岁,平均年龄32.28±5.3岁。分别检测两组病例前列腺液及精液中的细胞因子(TNF-α、IL-1β、IL-6)及精浆中性粒细胞弹性蛋白酶(NE)、精浆抗精子抗体。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎患者前列腺按摩液、精液中TNF-α和IL-1β、IL-6均显著高于对照组(P<0.01)。前列腺按摩液中TNF-α、IL-1β、IL-6与前列腺按摩液中WBC数量存在正相关关系,与精液的液化时间、A级活动能力、正常形态呈负相关。而对照组各指标间不存在相关关系。
2Ⅳ型前列腺炎患者精浆中性粒细胞弹性蛋白酶浓度显著高于对照组(P<0.01)。
3Ⅳ型前列腺炎患者精浆抗精子抗体检测MAR阳性率显著高于对照组(P<0.01)。结论
Ⅳ型前列腺炎患者的精液质量异常可能与前列腺按摩液、精浆中的细胞因子改变有关,其中可能包含了感染与免疫的双重作用。前列腺按摩液、精浆中的细胞因子、中性粒弹性蛋白酶与前列腺液中白细胞水平呈正相关,白细胞升高可能是感染与免疫共同作用的结果。
第二章：纳米银治疗慢性前列腺炎的动物实验及临床研究
第一节纳米银对慢性前列腺炎大鼠模型病理形态学及超微结构的影响
目的：
通过建立慢性前列腺炎大鼠模型,探讨纳米银对慢性前列腺炎病理形态学及超微结构的影响。
材料方法：
24只大鼠随机分为对照组、大肠杆菌前列腺炎组、衣原体支原体组、衣原体支原体+纳米银组,每组6只。建模6周后处死大鼠,取前列腺组织分别观察病理形态学(HE染色)及透射电镜下前列腺上皮细胞内超微结构改变。
结果：
1对照组前列腺腺上皮立方或高柱状,腺腔内见粉染分泌物,未见炎症细胞浸润及纤维组织增生。大肠杆菌组前列腺组织明显异常变化,腺泡萎缩,腺体管闭塞,皱襞明显减少或消失,腺泡无分泌物,大量炎细胞浸润,伴有组织坏死。衣原体支原体组前列腺病理变化为腺腔内粉染分泌物减少甚至消失,腺泡萎缩,腺体管腔变小,甚至闭塞,间质疏松水肿,少量淋巴细胞浸润,可见少量浆细胞,血管扩张充血,周围也有淋巴细胞浸润,还可观察到成纤维细胞,偶有炎性肉芽肿性病变。衣原体支原体+纳米银组较衣原体支原体有明显改善,虽然前列腺组织腺腔内见粉染分泌物稍减少,间中可见淋巴细胞浸润,但未见成纤维细胞及炎性肉芽肿性病变。
2对照组腺上皮细胞表面有微绒毛,细胞间可见连接,胞浆中含有丰富的线粒体、内质网轻度扩张,细胞中以及细胞顶部有散在的内含颗粒的分泌泡,细胞核椭圆。大肠杆菌组前列腺腺上皮细胞肿胀崩解,胞质中可见大量的浅色分泌泡,可见电子密度高的大肠杆菌。衣原体支原体组腺上皮细胞表面微绒毛较稀疏,细胞间可见连接,胞浆中含有丰富的线粒体、内质网,细胞中有少量散在的内含颗粒的分泌泡。衣原体支原体+纳米银组前列腺腺上皮内超微结构基本正常。
结论
在慢性前列腺炎大鼠模型上证明纳米银凝胶经直肠给药治疗由衣原体支原体感染引起的Ⅳ型前列腺炎是一个良好的治疗方法。
第二节纳米银经直肠给药途径治疗Ⅳ型前列腺炎的可行性与临床疗效观察
目的：
探讨直肠给药途径治疗Ⅳ型前列腺炎的可行性,并观察纳米银经直肠给药途径治疗Ⅳ型前列腺炎的临床疗效。
材料方法：
1Ⅳ型前列腺炎患者230例行经直肠的前列腺超声检查,观察慢性炎症在前列腺中的分布趋势。
2血清PSA升高及年龄50岁以上的Ⅳ型前列腺炎患者8例行前列腺穿刺活检,观察慢性炎症在前列腺中的分布情况。
3Ⅳ型前列腺炎患者60例随机分为两组,两组在治疗前的年龄、精液质量指标等方面差别无统计学意义,60例均无接受抗菌素治疗。A组为前列腺按摩对照组共30例,每周作前列腺按摩2次。B组为纳米银联合按摩治疗组共30例,每晚睡前纳米银抗菌凝胶3m1经直肠给药,另外每周作前列腺按摩2次,按摩前直肠注入纳米银抗菌凝胶3ml,然后按摩治疗约3-5分钟。连续治疗12周后,分别检测两组精液质量主要参数、治疗组前列腺按摩液中细胞因子(TNF-α和IL-1β、IL-6)及精浆抗精子抗体检测MAR、精浆中性粒细胞弹性蛋白酶NE作前后比较,同时记录、比较不良反应。数据以x±s表示,计数资料采用x2检验,计量资料采用t检验,用spss13.0软件包进行统计分析。
结果：
1Ⅳ型前列腺炎的B超影像学特点炎症分布特点主要表现为以下几种类型：各回声均匀型：本组13例(5.6%)；外周区回声欠均匀型本组113例(49.1%)；增大低回声型本组96例(41.7%)；结节钙化型本组8例(3.6%)可见Ⅳ型前列腺炎的病变多集中在外周区为主。
2Ⅳ型前列腺炎的病理组织学特点：所有病例的前列腺内都存在炎症细胞浸润,炎症细胞浸润主要在前列腺外周区和尿道周围腺体分布最多。
3除精浆抗精子抗体外,纳米银联合按摩治疗组病例治疗前后的精液液化时间、活动能力、正常形态、前列腺按摩液中细胞因子(TNF-α、IL-1β、IL-6)、精浆中性粒细胞弹性蛋白酶NE、精浆抗精子抗体等指标的相比较,均有明显改善,差异有统计学意义(P<0.05)。纳米银联合按摩治疗组疗效优于前列腺按摩对照组(P<0.05)。前列腺按摩对照组病例在治疗前后以上指标相比较,差异无统计学意义(P>0.05)。
结论：
Ⅳ型前列腺炎的病变主要在前列腺外周区与尿道周围为主。纳米银凝胶联合按摩治疗方法可明显改善Ⅳ型前列腺炎患者精液的质量。
[Object]:The chronic prostatitis is one kind of common diseases in the masculine urogenital system. However, the relations between chronic prostatitis and the sterile have been already argued for many years. Relationship between the seminal quality, dysfunction and the chronic prostatitis had been reported. But the others suggested no distinction to be presence in sperm density, power, the morphology changes between the chronic prostatitis patient's and control group. Furthermore, it had been reported that the white blood cell level of seminal fluid and the prostate gland fluid, which is a symbol as the inflammation, had no relation with the total sperm, the density, power, the shape and the sperm survival rate. Some Chinese date showed that approximate 39.1% male sterility patients had been diagnosed as the chronic prostatitis at the same time.
In 1995 the National Institutes of Health convened a consensus conference to re-evaluate the utility of the existing classification system. The result was a refinement of the traditional classification of prostatitis syndromes that allowed for standard inclusion criteria for participants in clinical trials for chronic nonbacterial prostatitis and prostadynia. The new system also has four categories. CategoryⅠ, acute bacterial prostatitis, refers to a combination of lower urinary tract and systemic infectious symptoms such as fever and chills. CategoryⅡ, chronic bacterial prostatitis, is characterized by culture-documented recurrent urinary tract infection combined with symptoms of acute or chronic pelvic pain without the systemic component demonstrated in categoryⅠ. CategoryⅢ, known as chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS), lacks an infectious component and is subcategorized as inflammatory or non-inflammatory based on the findings of leukocytes in a urine sample and expressed prostatitic secretions. Symptoms, however, can be similar to those found in categoriesⅠandⅡand include perineal or low back pain, lower urinary tract symptoms and painful ejaculation. The existence of pelvic pain is a requirement for diagnosis of categoryⅢprostatitis regardless of the level of urinary symptoms. Due to the differences in presenting symptoms among patients, the National Institutes of Health-Chronic Prostatitis Symptoms Index (NIH-CPSI) was created to quantify and determine the effects of the presenting symptoms for categoryⅢpatients. The NIH-CPSI asks questions that are tabulated into three domain scores:(1) pain, (2) urinary symptoms and (3) quality of life. The index can be helpful in differentiating the levels of CP-CPPS while also quantifying an individual's quality of life. A limitation of the index is that it was validated by a population of mostly white, educated men and may not be as useful in other patient populations. Category IV refers to asymptomatic inflammatory prostatitis. It is usually found incidentally through biopsies of patients being evaluated for benign prostatic hypertrophy (BPH) or an elevated prostate-specific antigen (PSA). It has been estimated that categoryⅣprostatitis may affect one-third of all patients who present with prostatitis.
Ⅳ(symptomless prostatitis) as a result of non-prostatitis's related symptom affaired the patient himself, to be neglected frequently by clinician, But often to be discovered in outpatient service sterile screening by chance. Recently, the sterile patient disease incidence rate is raising up and the chronic prostatitis has been thinked as one of the major factors of the masculine potentia generandi. Symptomless prostatitis incidence rate is quite high in the sterile patient, but the research reports concern on situation and mechanism, therapeutics of seminal fluid quality influence, which induced by symptomless prostatitis (Ⅳ), are rare. In our study, the main parameter's influence of seminal fluid quality in symptomless prostatitis patients, the relation between white blood cell level and main parameter of seminal fluid quality in prostate gland fluid, the cytokines of prostate gland fluid and seminal fluid, seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body level of seminal plasma and its mechanism involve in seminal fluid quality, had been investigated. Furthermore, we explored the effect and the function mechanism of nanometer silver gelatin combine with the prostate gland massage in symptomless prostatitis's patients.
Significance:Developing with the scientific research method's increasingly progress, relation between prostatitis and the sterile is confirmed unceasingly and clearly. It had been reported that about 60-70% male sterility patients were caused by chronic prostatitis and chronic prostatitis could affect the male reproductive system function. Different chronic prostatitis has the different situation and the consequence. It is very important to make clear the different type chronic prostatitis and deciding the treatment to cure the reproduction function influence. In our study, seminal fluid quality parameter, patient's age, response time will be explored. The relation between the white blood cell level in the prostate gland fluid and the main parameter of seminal fluid quality, various cytokine of prostate gland fluid and seminal fluid, Seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body level of Seminal plasma will be discussed to reveal its possible morbidity mechanism involve in seminal fluid quality and its reasonable method of treatment. About 40% of dysgenesis and infertility suffered from male sterility in recent papers. Making Material and method:
60 categoryⅣprostatitis patients, age 21～46 years old, mean age 34.31±8.30 years old and 50 control group volunteers, age 21～43 years old, mean age 32.28±5.3 years old. In the distinction examination of patients' prostatic fluid, the seminal fluid and the cytokine, TNF-α, IL-1β, IL-6, and Seminal plasma neutrality grain of elastic proteinase, anti-sperm immune body of seminal plasma examines. The data indicated by x±s, and the chi-square test, the t-test were be used with the SPSS 13.0 software. Result:
1. The levels of TNF-α, IL-1βand IL-6 in prostatic fluid and the seminal fluid in categoryⅣprostatitis patients were higher than that of control group. And they had negative correlation with the seminal fluid liquefied time, class A sperm motility and the normal sperm shape, P<0.01.
2. The concentration of seminal plasma neutrality grain of elastic proteinase in categoryⅣprostatitis patients was higher than that of control group, P<0.01.
3. The positive rate of anti-sperm immune body of seminal plasma in categoryⅣprostatitis patients was higher than that of control group, P<0.01.
Conclusion:
Seminal fluid quality of the categoryⅣprostatitis patients may be concern with the changed of cytokine in the prostatic fluid and seminal plasma. It maybe caused by the infection and the immunity. The levels of the cytokine, neutrality grain of elastic proteinase in the categoryⅣprostatitis patients have positive correlation with the levels of white blood cell level in prostatic fluid and seminal plasma. The high level of white blood cell in the prostatic fluid and seminal plasma maybe the result of the infection and immunity.
Chapter 2:The effect of nanometer silver treatment in chronic prostatitis with animal model and clinical experience. Prat1. The study of pathomorphology and ultrastructural changes with the treatment of nanometer silver in rat chronic prostatitis model.
Objective:To study the nanometer silver effect of pathomorphology and ultrastructural changes in rat prostatitis model.
Material and method:
24 rats were random divided into 4 groups. Group A (control group, n=6), Group B(escherichia coli, n=6), Group C(chlamydia and mycoplasma, n=6), Group D(chlamydia and mycoplasma and nanometer silver, n=6). The pathological sections and the ultrastructural changes of rat prostates had been observed by optics microscope and transmission electron microscope after 6 weeks treatment.
Result:
1. In the optics microscope, in Group A, prostate gland epithelium like cubic or columnar, glandular secretions were pink dyed by feosin. No inflammatory cells and fibrous tissue proliferation.
In Group B, acinar atrophy, glandular tube occlusion, fold reduced or disappeared significantly, no acinar secretion, inflammatory cell infiltration accompanied by tissue necrosis.
In Group C, pathological changes include glandular secretions reduced and disappeared, acinar atrophy, gland lumen shrink and occlusion, interstitial edema, a few of lymphocytic infiltration, showing a small amount of plasma cells, blood vessels dilatation and congestion, prostate gland secretions were also surrounded by lymphocytic infiltration which pink dyed by feosin, fibroblasts observed also, occasional inflammatory granulomatous lesions.
In Group D, the pathological changes had significant improvement, although the prostate gland secretions reduced, lymphocytes infiltration was observed occasionally, no fibroblasts and inflammatory granulomatous lesions.
2. The changes of ultrastructural changes.
In Group A, microvillus on epithelial cell surface, the cytoplasm contained abundant mitochondria, endoplasmic reticulum expanded slightly, secretory vesicles contained granular, nuclei shape liked oval.
In Group B, prostate gland epithelial cell disintegrated with swelling, a large number of light-colored secretory vesicles in the cytoplasm can be seen, showing high electron density E. coli.
In Group C, sparse microvillus on epithelial cell surface, connections between cells can be observed, cytoplasm rich in mitochondria, endoplasmic reticulum, cells containing a small amount of secretory vesicles with scattered particles.
In Group D, prostate gland epithelial ultrastructure was almost normal.
Conclusion:
The treatment of nanometer silver is a effective management in chlamydia mycoplasma prostatitis rat model.
Prat 2. The feasibility and the effect of nanometer silver treatment in chronic prostatitis patients.
Objective:To study the feasibility and the effect of nanometer silver treatment in chronic prostatitis patients.
Material and method:
1.230 categoryⅣprostatitis patients had accepted transrectal ultrasound examination. The data had been collected to analynize the inflammation distributed character in these patients.
2.8 categoryⅣprostatitis patients, age above 50 years old and with high blood serum PSA level, had accepted prostate gland puncture.6 needles puncture in the flank boundary area and the prostate tissue were observed by pathological specialist.
3.60 categoryⅣprostatitis patients were divided into two groups. Control group,30 cases, only accepted prostate gland massage twice each week. Nanometer silver treated group,30 cases, treated with nanometer silver 3ml through rectum every night, and accepted prostate massage twice per week for 12weeks. The main parameter of seminal fluid quality and the cytokine, TNF-α, IL-1βand IL-6, anti-sperm immune body of seminal plasma, seminal plasma neutrality grain of elastic proteinase of seminal fluid were detected. The data indicated by x±s, and the chi-square test, the t-test were be used with the SPSS 13.0 software.
Result:
1. The inflammation distributed character by ultrasonic iconography in categoryⅣprostatitis patients' indicated as follow. Type A (echoes well-distributed),13 cases in this group(5.6%). Type B(echo un-well-distributed in periphery area),113 cases in this group (49.1%). Type C(increasing echo),96 cases in this group (41.7%). Type D(tubercle calcification),20 cases in this group (3.6%).
2. The infiltration of inflammatory cell in the prostatic tissue had been observed in all cases. the inflammatory cell primarily distributed in periphery region and the circum-urethra area.
3. Except anti-sperm immune body of seminal plasma, the sperm liquefied time, power, shape, the cytokine, TNF-α, IL-1βand IL-6, seminal plasma neutrality grain of elastic proteinase of seminal fluid had been significant improved in nanometer silver treated group, P<0.05. The effect of nanometer silver treated group was better than that of the control group, P<0.05. The categoryⅣprostatitis patients could not get the significant benefit by prostatic massage, P>0.05.
Conclusion:
The pathological change of categoryⅣprostatitis patients is mainly around prostate gland periphery area and circum-urethra. The nanometer silver gelatin combined massage treatment may improve the seminal quality in categoryⅣprostatitis patient.
引文
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