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Prostate Hypertrophy


Information regarding Hyperplasia

Benign Prostate Hypertrophy (Hyperplasia) or simply BPH is the enlargement of the prostate gland. Unfortunately, this is a bit common in men over 50 years old. Recent studies show that more than 50% of men over 50 years do have an enlarged prostate. The symptoms are several and may include constant need to urinate, urinary retention, urgency, urge incontinence, etc. Nevertheless, this prostate enlargement is designated as benign and should not be confused with other types as the one caused by prostate cancer. You can treat BPH with medication.

Some drugs contains alpha1-adrenoceptor blockers (alfuzosin, doxazosin, prazosin, tamsulosin or terazosin) providing a quick relief by acting on the smooth muscle of the prostate and bladder. This is one of the top choices; the only downside is the possible (common) adverse effect that is low orthostatic blood pressure (e.g. dizziness while standing up). The alternative could be 5alpha-reductase inhibitors (Dutasteride or Finasteride). However, these can take up to 6 months to show effects and symptomatic improvement is not guarantee. Moreover, Finasteride and dutasteride may cause decreased libido and ejaculation disorders. In the case of Finasteride, this can also, in some situations, show breast tenderness and enlargement. Surgery is rare here and only indicated in severe cases of BPH.

Benign prostatic hyperplasia is a benign adenomatous proliferation of the periurethral part of the prostate gland. Symptoms correspond to intravesical obstruction - sluggish urine flow, pressure fluctuations, pollakiuria, peremptory urges, nocturnal pollakiuria, feeling of incomplete emptying of the bladder, drop-out urine at the end of urination, imperative incontinence or incontinence during overflow of the bladder and acute urinary retention. Diagnosis is mainly based on data from a digital rectal examination and subjective symptoms, as well as data from cystoscopy, transrectal ultrasound examination, urodynamic examination; Other imaging techniques may also be required. Treatment options include the administration of 5 alpha-reductase inhibitors, alpha adrenoblockers,

Based on two criteria: a prostate volume > 30 ml and a moderate or high index on the symptom scale of the American Urological Association ( Symptom scale of benign prostate hyperplasia of the American Association of Urology ), the rate of BPH in men aged 55–74 years without prostate cancer was 19%. But if the criteria include maximum urination rate10 ml/sec and residual urine volume > 50 ml, the frequency of occurrence becomes equal to only 4%. According to the results of the autopsy, the prevalence of BPH increases from 8% in men aged 31–40 years to 40–50% in men aged 51–60 years and up to more than 80% in men over 80 years of age.

Pathophysiology

In the periurethral region of the prostate, multiple fibroadenomatous nodules develop, apparently arising from the periurethral glands, and not from the true fibro-muscular tissue of the prostate (surgical capsule), which is shifted to the periphery due to the progressive growth of the nodules.

Since the lumen of the prostatic part of the urethra narrows and lengthens, the outflow of urine is progressively difficult. The increase in pressure associated with urination and distention of the bladder can lead to detrusor hypertrophy, the formation of trabeculae, the formation of cellularity and false diverticula. Incomplete emptying of the bladder causes stagnation of urine and predisposes to the formation of calculi and infection. Prolonged urinary tract obstruction, even incomplete, can cause hydronephrosis and impaired renal function.

Clinical manifestations

Symptoms of the lower urinary tract- symptoms of BPH include the constellation of often progressive symptoms, collectively known as lower urinary tract symptoms (LUTS):

  • Frequent urination
  • Urgent urination
  • Nocturia
  • Difficult start of urination
  • Outages

Frequency, urgent urination and nocturia are associated with incomplete emptying and rapid refilling of the bladder. Reducing the diameter and strength of the urine stream leads to insecurity and intermittent urination.

Pain and dysuria are usually absent. As a result, you may experience a feeling of incomplete emptying, installation of urine at the end of urination, urinary incontinence when filling the bladder, or acute urinary retention. The stress required for emptying can cause stagnation in the submucosal veins of the prostatic urethra and the bladder triangle, which can rupture and lead to hematuria. Tension can also quickly cause synocarotid syncope, and over a long period - expansion of hemorrhoidal veins or the appearance of inguinal hernias.

Urinary retention

In some patients, the disease manifests itself suddenly with acute urinary retention with severe discomfort in the abdomen, distention of the bladder. Delays may be preceded by:

  • Long attempts to delay urination
  • Immobilization
  • Cold exposure
  • Taking painkillers, anticholinergics, sympathomimetics, opioids or alcohol

Symptom Rating- Symptoms can be quantified by scores, such as the American Urological Association score, which consists of 7 questions (American Urology Association Symptom Benign Prostate Symptom Scale ). This assessment also allows doctors to track the progression of symptoms:

  • Mild symptoms: scores of 1 to 7
  • Moderate to severe symptoms: scores from 8 to 19
  • Severe symptoms: scores from 20 to 35

Digital rectal examination- In a digital rectal examination, the prostate gland, as a rule, looks enlarged and painless, has an elastic consistency, and in many cases, it lost a middle groove. However, the size of the prostate, determined by digital rectal examination, can be misleading; apparently, a small gland can cause obstruction. A distended bladder can be palpated or percussed during an examination of the abdomen. Dense or hard areas may indicate prostate cancer.

Diagnostics

Digital rectal examination, General analysis and urine culture, Prostate-Specific Antigen Level, and Sometimes uroflowmetry and ultrasound of the bladder.

Symptoms of the lower urinary tract for BPH can also be caused by other diseases, such as infection or prostate cancer. Moreover, BPH and prostate cancer may be present simultaneously. Despite the fact that pain on palpation is characteristic of inflammation, the data of a digital rectal examination for BPH and cancer are often the same. Although stony, hard, lumpy, asymmetrically enlarged prostate glands can be palpated with cancer, most patients with cancer, BPH, or a combination of both diseases have an enlarged prostate with normal consistency. Thus, patients who have symptoms or are palpated by pathological changes in the prostate should be examined.

Typically, a general urine test and urine culture are performed, and the level of the prostate-specific antigen (PSA) is also measured. In men with moderate or severe obstructive symptoms, it is possible to perform uroflowmetry (an objective measurement of urine volume and speed of urination) and determine the volume of residual urine by ultrasound examination of the bladder. Urination rate15 ml/sec allows you to think about obstruction and the volume of residual urine > 100 ml - about chronic urinary retention.

PSA level

Interpreting PSA study results can be difficult. PSA levels are moderately elevated in 30–50% of patients with BPH, depending on the size of the gland and degree of obstruction, and are elevated in 25–92% with prostate cancer, depending on the volume of the tumor.

In patients without cancer, serum PSA levels> 1.5 ng / ml usually indicate a prostate volume of ≥ 30 ml. If PSA levels are elevated (levels > 4 ng / ml), further discussion / joint decision-making regarding other studies or biopsy is recommended.

For men under the age of 50 and at high risk of developing prostate cancer, a lower threshold level (PSA > 2.5 ng/ml) may be used. Other indicators may be informative, including the PSA level growth rate, the ratio of free/bound PSA, and other parameters. (A full discussion of screening and diagnosis of prostate cancer can be found in another section on this site).

Other types of research

A transrectal biopsy is usually performed under ultrasound guidance; this procedure is usually only indicated if prostate cancer is suspected. With transrectal ultrasound, it is possible to determine the volume of the prostate.

Assessment of the need for the further examination should depend on the clinical situation. The need for imaging studies (for example, CT, IVU) with the use of contrast agents is rare, except in the case of a patient with UTI with fever or severe obstructive symptoms that have been present for a long time. Pathology of the upper urinary tract, usually caused by intravesical obstruction, includes an upward displacement of the distal ureters (like a fishhook), expansion of the ureters and hydronephrosis. If the study of the upper urinary tract is necessary due to the presence of pain and an increase in creatinine, it is possible to give preference to ultrasound, so it relieves the patient from radiation exposure and nephrotoxic effects of the contrast agent.

Alternatively, men whose PSA levels indicate the need for further testing can undergo multi-parameter MRI, which is more sensitive (albeit less specific) than transrectal biopsy. Limiting biopsies to areas that were considered suspicious in multi-parameter MRI can reduce the number of prostate biopsies and diagnoses of clinically insignificant prostate cancers, and possibly increase the likelihood of diagnosing clinically significant prostate cancers.

Treatment

Exclusion of anticholinergics, sympathomimetics, and opioids. The use of alpha-adrenergic blocking agents (e.g. terazosin, doxazosin, tamsulosin, alfuzosin), 5-alpha reductase inhibitors (finasteride, dutasteride) or, in the presence of concomitant erectile dysfunction, a type 5 tadalafil phosphodiesterase inhibitor. Transurethral resection of the prostate or alternative ablation procedure

Urinary retention

Acute urinary retention requires immediate drainage of the bladder. Initially, they try to hold a regular urinary catheter, if this fails, it may be effective to use a catheter with a curved end. If it is not possible to carry out such a catheter as well, flexible cystoscopy or insertion of thin catheters and guides (strings and dilators that gradually open the lumen of the urethra; it may be performed by a urologist) may be necessary. If transurethral manipulations are unsuccessful, percutaneous suprapubic drainage of the bladder can be used.

Drug therapy

With partial obstruction with subjective symptoms, it is necessary to stop taking all anticholinergics and sympathomimetics (many are available without a prescription) and opioids; any inflammation requires the use of antibiotics.

In patients with mild to moderate obstructive symptoms, alpha-blockers (e.g., terazosin, doxazosin, tamsulosin, alfuzosin) can help reduce urination disorders. 5-alpha reductase inhibitors (finasteride, dutasteride) can cause a decrease in the size of the prostate and the severity of urination disorders for several months, especially in patients with an increased (> 30 ml) gland volume. Combined treatment with drugs of both groups is more effective than monotherapy. For men with concomitant erectile dysfunctiontaking, tadalafil daily can help alleviate both conditions. Many over-the-counter and alternative medicine drugs are advertised for the treatment of BPH, but not one of them, including the well-studied drug with palm extract Serena, has been shown to be more effective than placebo.

Surgery

Surgical treatment is used when patients do not respond to drug therapy or when they develop complications, such as recurrent UTIs, urinary calculi, severe bladder dysfunction or dilation of the upper urinary tract. Transurethral resection of the prostate (TURP) is a standard technique. Erectile function and urinary retention are usually preserved, although about 5-10% of patients complain of violations in the postoperative period, most often retrograde ejaculation. The frequency of erectile dysfunction after TURP is 1–35%, and the incidence of urinary incontinence- 1-3%. However, technological advances, such as the use of bipolar resectocystoscopes, which allow washing with saline, significantly improved the safety of TURP, preventing hemolysis and hyponatremia.

About 10% of men undergoing TURP need a second procedure for 10 years, as the prostate continues to grow. As an alternative to TURP, various laser ablation techniques are used. Large prostates (usually > 75 g) usually require open surgery using a suprapubic or retro-pulmonary approach, although some newer methods, such as Holle laser enucleation of the prostate (HoLEP), can be performed transurethrally. All surgical treatments require postoperative drainage of the bladder with a catheter for 1–7 days.

Other treatments

Alternatives to TURP include microwave thermotherapy, electro-vaporization, various laser techniques, high-intensity focused ultrasound, transurethral needle ablation, radiofrequency vaporization, injection therapy with heated water under pressure, urethral plastic surgery, steam injection therapy and the installation of intraurethral stents. The conditions under which preference should be given to these methods have not been completely determined, but those that are performed in the doctor’s office (microwave thermotherapy and radiofrequency procedures) are used more often and do not require the use of general or local anesthesia. Their ability to change the natural course of BPH with long follow-up periods is currently being studied.

Key points

  • BPH is a widespread disease that is closely associated with age-related changes but does not always cause symptoms.
  • Acute urinary retention can develop with hypothermia, prolonged attempts to postpone urination, immobilizing or using anesthetics, anticholinergics, sympathomimetics, opiates or alcohol.
  • Examination of patients is carried out using a digital rectal examination and, as a rule, a general analysis of urine, urine culture and determination of the PSA level.
  • In men with BPH, anticholinergics, sympathomimetics, and opioids should be excluded.
  • Alpha-blockers (e.g., terazosin, doxazosin, tamsulosin, alfuzosin), 5 alpha-reductase inhibitors (finasteride, dutasteride) or, with concomitant erectile dysfunction, tadalafil can be used to stop the unpleasant symptoms of obstruction.
  • Consideration should be given to conducting TURP or other amputation techniques if BPH causes complications (for example, recurring calculi, bladder dysfunction, dilatation of the upper urinary tract) or if the disturbing symptoms are resistant to drugs.