CC BY
50
UDC 616.617-002-08-055.1
THE DYNAMIC ANALYSIS OF URETHRAL MICROCIRCULATION INDEXES IN MEN WITH CHRONIC NON-GONOCOCCAL URETHRITIS AGAINST THE BACKGROUND OF COMPLEX THERAPY
Altai State Medical University, Barnaul
Ya.D. Zheltikova, Yu.S. Kondratyeva, A.I. Neimark
The aim of the study was to assess the impact of the complex effect of vibromagnetotherapy and peloidotherapy on urethral microcirculation in patients with chronic recurrent non-gonococcal urethritis. The effectiveness of treatment was assessed by the combination of clinical, laboratory and instrumental diagnostic methods. To evaluate the microcirculation of the urethra, the laser Doppler flowmetry method was used. The obtained diagnostic data before and after treatment demonstrated more effective normalization of clinical data, urethral microcirculation indices in patients receiving complex treatment with the inclusion of vibro-magnetic therapy and peloidotherapy.
Key words: chronic non-gonococcal urethritis, microcirculation, vibromagnetotherapy, peloidotherapy.
The problem of chronic non-gonococcal urethritis (NGU) has not lost its significance to a large extent due to the torpidity of this disease to the conducted therapy, high frequency of residual urethritis development and high contagiousness [1]. Urethritis is considered persistent or recurrent when the symptoms of urethritis appear in 30-90 days after the treatment of acute NGU. According to various researchers, such state is observed in 10-20% of patients [2]. NGU accounts for 60-65% of urethral inflammatory diseases. Every year in Russia there are registered about 350 thousand NGU cases [3,4]. In 90-93% of cases NGU is caused by pathogenic agents destroying cells of cylindrical epithelium: chlamydia (Chlamydia trachomatis), genital mycoplasmas (Micoplasma hominis, Ureaplasma urealyticum), trichomonads, Candida fungi, herpes simplex virus type I and II. More detailed epidemiological characteristics of NGU are limited by the fact that a part of them lack symptoms and thus, are not registered, while myco-plasmas, acting as NGU causative agents in particular conditions, are resident microflora in 50% of men [5].
One of the important pathogenic constituents of chronic NGU are vascular disorders appearing by long-term inflammatory process. However, low effectiveness of antibacterial therapy, continuous and repeated treatment courses lead to even greater suppression of local immunity and reduction of colonizational resistance of the urogenital tract [6, 7]. Considering modern data on the main causes of NGU development, pathogenetically substantiated is the implementation of therapeutic methods aimed at the elimination of all disease chains.
Research objective: the dynamic assessment of urethral microcirculation state against the background of complex therapy including peloidother-apy and physiotherapy in patients with chronic non-gonococcal urethritis.
Materials and methods
The study included 48 men with chronic non-gonococcal urethritis. Criteria of inclusion: men of reproductive age from 18 to 46 years with diagnosed urethritis and period of illness not less than 6 months, and also with laboratory confirmed urogenital infection.
Criteria of exclusion: patients administrating antibacterial drugs 2 months before the visit to doctor; patients with exacerbation of chronic somatic diseases at the moment of study; patients with syphilis, gonorrhea, HIV infection.
Patients underwent laboratory-instrumental examination, diagnostics of urogenital and viral infections (C.trachomatis, M. genitalium, M.homi-nis, U.urealyticum, HSV2) by means of polymerase chain reaction (PCR "real-time"), microscopic examination of urethral secretions in order to diagnose Tr.vaginalis and Candida fungi.
To evaluate the urethral microcirculation by means of laser Doppler flowmetry (LDF) there was used the laser analyzer of blood microcirculation LAKK-02 (NPP "LAZMA", Russia) (patent № 2605622 "Method of differential diagnosis of urethritis in men"). The helium-neon laser LGN-207B or LGN-208B with the wave length 0,63 mkm is used as a radiant. The power of laser radiation at the input of the lightguide cable constitutes not less than 0,5 mW. The patient was examined in the lying position, the endoscopic tube was introduced directly into the urethra till the transition of the anterior part into the posterior.
In order to enhance the obtaining results all measurements were performed in the same temperature regime of the room, at the same time of the day. After the tube imposition, the indications were registered during 1 minute. These researches in the stated point were evaluated after the calculation of overall average and reflected the rate of basal bloodstream. By means of hard-
ware there were processed the curves immediately after every conducted examination.
The calculation of basal bloodstream parameters was performed in two stages. At the first stage, there were calculated mean values of the perfusion change: M, a and Cv. At the second stage, there were analyzed bloodstream oscillations.
M parameter - is the value of the mean bloodstream within the intervals of time of registration and the arithmetic mean value of microcirculation
- is measured in perfusion units (pf. un.).
The higher M is, the bigger is the level of tissue perfusion. Moreover, the increase of its value can be connected with blood congestion in the venular chain of the microcirculatory bloodstream.
The indicator showing the stream of erythro-cytes, root-mean-square deviation - RMSD - (a) -statistically significant fluctuations of the erythrocyte speed. It is also measured in perfusion units and characterizes temporal variability of microcirculation and fluctuation of the erythrocyte stream. Value a is significant for the evaluation of the microcirculation state, preservation of its regulation mechanisms.
In terms of analysis of calculated parameters it is reasonable to focus on the relation of values M and a, h.e. the coefficient of variation. It characterizes the relation between the tissue perfusion and the value of its variability, and is calculated according to the formula: Cv = a /M*100%.
At the second stage, there is analyzed the amplitude-frequency spectrum (AFS) of perfusion fluctuations. The values of amplitudes of microcirculation fluctuations within particular frequency intervals allow to estimate the vascular tonus and the state of functioning of particular mechanisms of perfusion control. There is used a number of calculated rates: myogenic tonus, neurogenic tonus, rate of shunting and microcirculation efficiency index.
The neurogenic tonus (NT) of precapillary resistant microcirculation vessels is connected with the activity of a-adrenoreceptors (mainly al) of the membrane of clue and partially adjacent smooth muscle cells, and is calculated according to the following formula: NT = a *Pav/An*M, where a - root-mean-square deviation of microcirculation rate, Pv - average arterial pressure, An - maximum value of the perfusion fluctuation amplitude in the neurogenic interval, M - arithmetic mean of the microcirculation rate.
The myogenic tonus (MT) of metarterioles and precapillary sphincters is determined according to the following formula: MT = a *PJAm*M, where a - root-mean-square deviation of microcirculation rate, Pvv - average arterial pressure, Am -amplitude of oscillation of the miogenic interval, M
- arithmetic mean of the microcirculation rate.
The shunting index (SI) is calculated according to the following formula: SI = MT/NT.
The index of microcirculation efficiency (IEM) is determined according to the following formula:
IEM = A.axLF/(AmaxHF+AmaxCF), it characterizes the relation between the bloodstream fluctuations in various areas of the frequency spectrum, where AmaxCF - amplitude of cardiac fluctuations, AmaxLF - amplitude of low fluctuations, AmaxHF -amplitude of respiratory fluctuations.
All men with NGU received standard therapy according to STD treatment recommendations aimed at the causative agent elimination. Upon determining mycoplasmal, chlamydial or ureaplas-mal infection there was prescribed josamycin at a dose of 500 mg orally 3 times a day during 10 days, by trychomonad infection - metronidazole at a dose of 500 mg orally 2 times a day during 7 days or ornidazole at a dose of 500 mg orally 2 times a day during 5 days [8].
At the second stage of treatment, all 48 patients received vibral, thermal and magnetotherapy and pelotherapy. Vibral, thermal and magnetother-apy was performed by means of "AVIM-1" apparatus (OOO "TRIMA, Saratov, RZN license No.FSR 2008/02518). The apparatus presents a disk-shaped instrument with slightly bowed work surface which can be placed on the chair. The procedures were conducted in the sitting position on the apparatus during 15-20 min daily. The vibrator places in the center of work surface was situated between the scrotum and anus. The course included 10 procedures.
The local application of mud onto the penis using sulfide silt therapeutic muds was performed 20-30 min before the procedure of vibral, thermal and magnetotherapy. The magnetic field induction in the working zone (at the distance of 60 mm from the surface)10 mt, vibration amplitude 2-3 mm, frequency of vibration and its character were varied and were chosen by the patient himself depending on the feeling of comfort (50 Hz with random modulation from 0,5 to 8 Hz). The temperature of the working surface 40-55 °C.
The control group consisted of 22 healthy men of reproductive age without diagnosed urogenital infection.
Results and discussion
The efficiency of treatment was estimated on the basis of lack or reduction of pain symptoms, reduction of diuretic disorders. The elimination of causative agents was reached in 46 (95,8%) patients.
After the treatment of patients with chronic non-gonococcal urethritis pain syndrome was not observed in 47 (97,9%) patients, complaints about itching and urethral discomfort were not registered in 45 (93,7%) men, dysuric symptom was not observed in 46 (95,8%) patients.
The evaluation of urethral microcirculation state by means of LDF showed changes of basal
bloodstream parameters in all patients with NGU. The graphical image of urethral basal bloodstream
in a patient with NGU and a healthy man is shown in Figures 1, 2.
Figure 1.
Graphical image of basal urethral bloodstream by NGU
Figure 2.
Graphical image of basal urethral bloodstream of healthy man
Disorders of microcirculation manifested itself mainly through the reduction of tissue perfusion rate, rates of myogenic (0,94±0,03 rel.un.) and neurogenic (0,69±0,01 rel.un.) tonus, bloodstream modulations and coefficient of variation (10,51±0,51%). The control study of LDF after the treatment revealed the following results: the improvement of microcirculation parameters, which approximated to the results of the control group. It happened mainly due to the increase of rates of myo-genic (0,95±0,07 rel.un.) and neurogenic (0,74±0,03 rel.un.) tonus, coefficient of variation (12,4±0,87%), which indicate that combined effect of vibral, thermal and magnetotherapy and pelotherapy leads to the normalization of urethral microcirculation parameters (Table 1).
The analysis of LDF-gram in the urethra after the treatment showed moderate increase of tissue
perfusion M 41,23 ± 0,09 pf.un (before the treatment M - 40,92± 0,04 pf.un.) and bloodstream modulation RMSD - 5,08±0,01 pf.un. (before the treatment RMSD - 4,12±1,23 pf.un.), and also the growth of variation coefficient (Cv) up to 12,3 ±0,04 %.
The examination of urethral AFS after the treatment revealed a significant reduction of the frequency of pulse beats, amplitude of slow fluctuations. The state of bloodstream regulation factors was characterized by the reduction of the passive mechanism of microcirculation regulation and unchanged active rate in relation to the group of healthy men. There was marked a moderate decrease of in-travascular resistance in all fluctuation rhythms, however, it did not reach control values. The values of NT and IEM increased, while MT and SI decreased significantly (Table 2).
Table 1
Mechanisms of urethral bloodstream regulation in patients with chronic non-gonococcal urethritis before and after the treatment
Microcirculation Healthy men (n=22) Before treatment (n=48) After treatment (n=48)
IEM 1,24±0,11 0,95 ± 0,02* 1,12 ± 0,83**
NT 0,77±0,06 0,70 ± 0,04* 0,74 ± 0,02**
MT 0,86±0,11 0,92± 0,12* 0,85 ± 0,02**
SI 1,16±0,06 1,33± 0,05* 1,26± 0,08**
Note. * - differences with the group of healthy men are statistically significant (p<0,05). Note. ** - differences before and after the treatment are statistically significant (p<0,05).
Dynamics o urethral bloodstream AFS oscillations in patients with NGU in the group of comparison
Table 2
Indexes LF Patients with NGU after treatment (n=48) Group of comparison (n=22)
HF CF LF HF CF
Fmax (pf.un.) 3,67±0,05 13,65±0,38* 92,70±0,27* 4,41±0,73 22,76±0,69 85,80±1,03
Amax (pf.un.) 6,91±0,07* 2,80±0,02 0,94±0,01 8,44±0,53 3,27±0,75 1,18±0,21
Amax/3y*100% (%) 35,75±0,73* 24,01±0,70 3,62±0,20* 38,06±0,71 22,90±0,42 5,50±0,08
Amax/M*100% (%) 19,12±0,78 8,92±0,36* 3,01±0,35 18,88±0,60 7,20±0,03 3,31±0,4
Note. * - differences with the group of healthy men are statistically significant (p<0,05).
Conclusion
5. Akovbyan V.A. Non-gonococcal urethritis
Consequently, the combined effect of vibral, thermal and magnetotherapy and pelotherapy in complex treatment of patients with chronic non-gonococcal urethritis leads to the elimination of causative agents in 95,8% of cases, reduction of pain symptoms and dysuric disorders, reduction of discomfort in the urethra, primarily due to the increase of blood perfusion and the bloodstream volume in arterioles, growth of blood flow into the microcirculation system and decrease of hypoxia and tissue ishemization.
References
1. Kulchavenya Ye.V. Modern therapy of patients with chronic urethritis. Russian medical journal. 2005; 25: 15-20.
2. Horner P., Thomas B., Gilroy C., et. al. The role of Mycoplasma genitalium and Ureaplasmaurealyticum in acute and chronic nongonococcal urethritis. Clin Infect Dis. 2001; 7 (32): 995-1003
3. Health of Russian population and activity of healthcare institutions in 2000 (statistical materials) of the Ministry of Health of the Russian Federation. Moscow, 2001.
4. Gomberg M.A., Solovyev A.M., Kovalyk V.P. Non-gonococcal urethritis in men: etiology and substantiation of etiotropic therapy. Lechashchy vrach. 2006; 7: 26-31
in men: etiology, peculiarities of diagnosis and treatment. Reference book of the outpatient doctor. Moscow, 2007.
6. Shahmanesh M., Moi H., Lassau F., Janier M. IUSTI/WHO. 2009 European guideline on the management of male non gonococ-cal urethritis. Int. J. STD AIDS. 2009; 7 (20): 458-464.
7. Kudryavcev Yu.V., Kirpatovskiy V.I., Pere-panova T.S., Hazan P.L. Glycosaminogly-cans stabilizer zinc hyaluronate use in experimental modeling of acute bacterial and interstitial cystitis. Experimental and clinical urology. 2011; (1): 39-44.
8. Federal clinical recommendations. Derma-tovenereology 2015: Skin diseases. Sexually transmitted infections. Moscow, 2016.
Contacts:
Corresponding author - Kondratyeva Yuliya Sergeyevna, Doctor of Medical Sciences, Head of the Department of dermatovenereology, immunology and cosmetology of Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 554578. Email: julia_ jsk@mail.ru
