Introduction
Prostate hyperplasia is also known as Benign Prostatic Hyperp lasia (BPH), commonly known as prostate hypertrophy. The main clinical symptoms are frequent urination, urgent urination, incomplete urination and difficulty in urination, etc. BPH is a common disease among middle-aged and elderly men over 50 years old, with a prevalence of over 50% in middle-aged and elderly men. According to the autopsy results of men aged 60-70 years, the prevalence of BPH was 75% by visual examination and higher by histopathological examination. The prevalence is higher in the northern region than in the south. As China enters an aging society, the incidence of BPH has a tendency to gradually increase.
Although Chinese medicine does not have the name of prostatic hyperplasia, the knowledge of symptoms related to BPH is scattered in the writings of medical doctors in the past generations, and there are detailed discussions on the evidence and treatment of BPH and its methods and prescriptions, and BPH belongs to the category of “essence of infirmity” in Chinese medicine. Theoretical exposition and clinical practice of TCM in the treatment of BPH, especially the treatment of activating blood circulation and removing blood stasis as an important treatment method of BPH, have formed a wide consensus in academic circles and have achieved positive clinical efficacy.
Etiology and pathogenesis
The prostate gland is like an inverted chestnut, with a 4 cm horizontal diameter, 3 cm longitudinal diameter, and 2 cm anterior and posterior diameter, located below the neck of the bladder, wrapped around the bladder opening and the urethra combined, and this part of the urethra is therefore called the “urethral prostate”. It is possible to say that the prostate gland guards the upper urethra, the prostate gland is ill, urination is affected first. The prostate gland is located at the bottom of the pelvis, above the bladder, below the urethra, in front of the pubic bone, and behind the rectum. The prostate is divided into five lobes, called the anterior lobe, middle lobe, posterior lobe and both lobes, of which the anterior lobe is very small, located between the left and right lobes and the urethra, and is of no clinical importance. The posterior lobe is located behind the middle lobe and both lobes, and is the lobe that is felt during the rectal examination. There is a physiological central sulcus in the middle of it, and during the rectal examination, the prostate is often judged to be enlarged based on whether this central sulcus becomes shallow or disappears. The main areas of the prostate that often produce hyperplasia are the middle lobe and the two lateral lobes.
The enlarged prostate causes obstruction of the bladder neck and the bladder contracts more to overcome the neck resistance causing compensatory hypertrophy of the forceps muscle in the form of trabecular protrusions. The pressure in the bladder cavity increases, and the bladder mucosa can expand outward from the weak spot between the muscle bundles, forming a diverticulum bladder neck obstruction. Continuing to aggravate, urine will remain in the bladder to varying degrees, along with the increase in residual urine, the bladder wall gradually thinned so that the lower end of the ureter obliquely through the bladder wall muscle layer formed by the physiological valve role failed. The urine in the bladder then flows back into the ureter and renal pelvis, causing fluid accumulation in the upper urinary tract on both sides, increasing the pressure in the renal pelvis, causing ischemic atrophy of the renal parenchyma and eventually uremia.
The etiology of BPH is still poorly understood, but the long-established academic consensus is the endocrine hypothesis that the indispensable factors for the pathology are the presence of testes with normal secretory function and ageing. The basis for this is that BPH does not occur in those who have had their testes removed before puberty (e.g. eunuchs); the volume of the prostate gland gradually decreases after the removal of the testes in patients with BPH; biochemical measurements in patients with BPH are often accompanied by abnormal agglutination of the androgen dihydrotestosterone (DHT), which is three to four times higher than normal; endocrine stimulation is available to form an animal model of prostate enlargement; 5-alpha-reduced testosterone (DHT) is also available. In addition, the pathogenesis of BPH is also based on the theory that prostate cells are embryonic reawakening, altered cell population ratios, and peptide growth factors.
In addition, it is also believed that the pathogenesis of BPH is embryonic reawakening of the prostate cells, alteration of the ratio of cell groups, peptide growth factors, etc. According to Chinese medicine, the pathogenesis of this disease is a deficiency of the root cause and the symptoms of the disease.
1, old age and weakness: old age and weakness of Yang, blood transport, cold and damp stagnation, stagnation of Qi and blood is not smooth, then the gland is swollen and hard. Insufficient kidney yang and impaired bladder gasification function result in weak urination or retention of urine. As stated in the “Medical Heart of the Chinese Ginseng and Western Records”, “Deficiency of the yang component and weakness of the qi cannot be pronounced, resulting in unfavorable urination.”
In old age and weakness, the spleen and stomach do not function properly to raise the clear and lower the turbid, so there is no way to pass the article, that is to say, “Insufficient middle qi, urination is changed”.
Old age, physical weakness, indiscretion, or chopping and mourning excessive, color labor injury body, loss of Yin essence, no moistening, phase fire delusion, can also cause frequent urination, dripping incomplete.
2, damp-heat injection: external heat, congestion in the lungs, or damp-heat miasma in the lower jiao, or addicted to spicy food.
3.Qi stagnation and blood stasis: the seven emotions are not in harmony, liver qi is depressed, the drainage is not normal, the wood is not regulated, the qi stagnation is not able to move the blood, the blood stasis is blocked in the bladder and the seminal chamber, and the waterway is blocked.
4, stagnation of essence and blood: prolonged absence from intercourse, or withholding sperm without ejaculation, defeating sperm stagnation, or nourishing too much, flowing into the lower jiao, blocking the sperm chamber and bladder, resulting in retention of urine, Zhang Jingyue said “or defeating sperm, or accumulation of blood, blocking the waterway and blocking”.
The cause of BPH in Chinese medicine is that the upper, middle and lower jiao can all cause the disease. The normal functions of the lung’s propagation and purification, the spleen’s transportation and clearing, and the kidney’s water and warmth are the prerequisites for the smooth flow of urine. However, the root of the pathology is the obstruction of dampness, heat, blood and essence in the bladder and essence chamber, and the obstruction of blood stasis and other evil qi is the core of the pathogenesis of the disease.
[Western medical diagnosis and differential diagnosis
I. Western medical diagnosis
(A) Symptoms
1. Staging: BPH progresses slowly, and the early stage is asymptomatic due to compensatory bladder, or the symptoms are not obvious, called the resting stage of BPH. With the aggravation of lower urinary tract obstruction, the symptoms gradually become obvious, called symptomatic BPH or clinical BPH, the appearance of symptoms is closely related to age, and symptoms usually appear after the age of 50.
2, clinical manifestations: the clinical manifestations of BPH, there are mainly 3 aspects of bladder irritation symptoms, obstruction symptoms, obstruction complications: (1) bladder irritation symptoms: mainly urinary frequency, increased nocturia, urinary urgency or with painful urination, urge incontinence, etc. These symptoms may be related to bladder outlet obstruction, non-obstructive forced urinary muscle instability; among them, the increased number of nocturia is an early symptom of BPH. (2) Obstructive symptoms: mainly include difficulty in urination, hesitation in urination, thinning of urine line, incomplete urination, intermittent urination, final urinary drip, etc. The proliferating gland causes the posterior urethra to lengthen, bend and narrow, or the proliferating middle lobe may protrude towards the bladder neck and form a spherical valve, all of which increase the resistance to urination, of which progressive difficulty in urination is the most important symptom of BPH. (3) Complications of obstruction: serious complications caused by BPH include acute urinary retention, recurrent hematuria, recurrent urinary tract infections, stone production, and renal function impairment or even uremia.
The International Prostate Symptom Score (IPSS), designed as a questionnaire, calculates a score based on answers to seven questions about urinary symptoms to determine the severity of symptoms. The total score ranges from 0 to 35 (asymptomatic to very severe symptoms) and is divided into three types: 0-7 for mild symptoms; 8-19 for moderate symptoms; and 20-35 for severe symptoms.
(B) Physical signs
Anal finger examination of the prostate is a simple but very important examination for BPH, mainly to understand the prostate shape, size, hardness, whether the surface is smooth, whether there are nodules and pressure pain, whether the central groove exists, becomes shallow or disappears, whether the gland is fixed, whether there is a twisting sensation on palpation, etc., and also to understand the anal sphincter, rectum and seminal vesicles. The normal prostate is the size of a chestnut, flat, with clear edges, tough, even and elastic, without nodules or pressure pain, with a slightly depressed central sulcus, symmetrical on both sides of the lobe, and slightly active on the nudge. In the case of prostate hyperplasia, the gland may be enlarged in length and width, with a smooth surface, clear margins, moderately hard and elastic texture, and a shallow, disappearing or elevated central sulcus. Common ways to describe the size of the gland in prostate enlargement: normal size, Ⅰ degree hyperplasia, Ⅱ degree hyperplasia and Ⅲ degree hyperplasia.
In case of urinary retention, a round bulging mass is seen in the middle of the lower abdomen, which can be palpated or palpated with a central turbid zone or with pressure pain, i.e., a full bladder.
(C) Laboratory tests
1, routine urine: routine urine examination in patients with BPH can sometimes be normal, and red blood cells, white blood cells, proteinuria, pusuria and alkaline urine can be seen in urinary tract infection. The presence of hematuria, urine sugar, bilirubin can also be determined through the examination. Urine smear microscopy with culture for bacteria. When collecting urine, it must be done before rectal finger examination to avoid affecting the examination results.
2, blood routine and blood biochemical examination: blood routine white blood cell count and classification has diagnostic significance for concomitant urinary tract infection. The decrease of hemoglobin has a reference value for the degree of uremia.
3, renal function measurement: BPH patients can choose to check the following items according to the specific situation: blood urea nitrogen, creatinine measurement, phenol red excretion test, indocyanine excretion test, urine concentration and dilution test, ordinary or high-dose intravenous urography, etc.
4. Determination of serum prostate-specific antigen (PSA): The prostate is the most important secretion organ of PSA. It is very important to check PSA and free PSA in BPH patients, and it is a routine examination item for BPH patients. PSA is currently the most sensitive tumor marker for prostate cancer, and the purpose of the examination is to exclude the possibility of prostate cancer. In some cases, there may be false positive increase in PSA, such as after prostate massage, after ejaculation, obvious inflammation of the prostate, etc. Therefore, it is necessary to review PSA regularly.
(iv) Special examinations
1. Ultrasonography: Ultrasonography is a quick, inexpensive and effective method for the initial evaluation of patients with prostatic hyperplasia, including transabdominal ultrasound (TAUS) and transrectal ultrasound (TRUS), the latter being more accurate.
2. Urine flow rate: The urine flow rate can assess the severity of urinary tract obstruction in patients with BPH, but since all diseases that cause decreased bladder contraction and urethral obstruction can result in a decreased urine flow rate, this test lacks specificity for the diagnosis of prostatic hyperplasia and must be combined with other tests. As this index is easily influenced by the individual, urine volume and the external environment, it is important to ensure its reliability as the urine flow rate in the case of continuous (≥2) urination of more than 150 ml.
3, urodynamics: this test has two main important implications for patients with BPH: the diagnosis of BPH and the assessment of the surgical outcome.
In addition, urethrography and urethrocystoscopy can be done when necessary or when other pathologies are suspected.
II. Differential diagnosis
(a) Prostate cancer: Prostate cancer is often asymptomatic in the early stages. Although there is no relationship between BPH and prostate cancer development, prostate cancer is often found to have an increased PSA when examining patients with BPH. Pathological examination of prostate puncture biopsy tissue is currently the gold standard for confirming the diagnosis of prostate cancer. Other major tests are: pelvic MRI or CT, ECT bone scan, chest X-ray, and internal ultrasound. The purpose of doing these examinations is mainly to make a comprehensive assessment of the disease, to determine whether the disease is early or advanced, and whether distant organ or lymph node metastasis has occurred.
(b) Bladder cancer: The symptoms of urinary tract irritation and urinary tract obstruction in bladder cancer are easily confused with BPH, but more than 3/4 of patients with bladder cancer have painless hematuria as the first symptom. Urine exfoliative cytology or other urine screening, abdominal plain film and intravenous urography, and cystoscopy can help to confirm the diagnosis.
(C) Neurogenic bladder: a bladder-urethral dysfunction caused by damage to the central nervous system or peripheral nerves that control urinary function. patients with BPH and men with neurogenic bladder both have symptoms of abnormal urination, but the urinary dysfunction in neurogenic bladder often has diminished or lost sensation of bladder distention with defecation dysfunction (such as constipation and fecal incontinence), and may have History of trauma, surgery, diabetes mellitus, poliomyelitis, or drug application. Physical examination may show hyperalgesia and hypotonia or increased tone of the anal sphincter.
Chinese medicine diagnosis and classification
I. Real evidence with stasis
(I) Heat congestion in the lung
Heat congestion in the lung, loss of suction and descent of the lung, unfavorable regulation of water channels, stagnation of the seminal chamber and bladder, unfavorable urination or dribbling, accompanied by dry throat, cough, irritable thirst for drinking, or even shortness of breath, red tongue, yellow fur, slippery pulse.
(II) Damp-heat with stasis
Unfavorable transportation of the middle jiao, damp-heat and turbidity flowing into the lower jiao, or kidney heat moving to the bladder and the jing chamber, burning the fluid and blood, stasis in the jing chamber and bladder, resulting in dribbling of urine, frequency and shortage, burning yellow and red, abdominal urgency and fullness and refusal to press, accompanied by constipation, bitter and sticky mouth, dry mouth and lack of desire to drink, etc. The tongue is red and moist, the tongue is large, the coating is yellow and greasy, and the pulse is slippery.
(C) Phlegm and turbidity with blood stasis
Injury caused by diet of spleen and stomach, or long-standing illness with internal phlegm and turbidity, or a phlegm-damp constitution, with phlegm and turbid evil Qi stagnating in the seminal chamber, resulting in unpleasant dripping of urine and obstruction, accompanied by thirst without desire to drink, dizziness and dizziness, stuffy abdomen, red tongue, fat tongue with teeth marks, white greasy moss, slippery or sunken string pulse.
(IV) Qi stagnation and blood stasis
Depression, or irritability, liver qi stagnation, unregulated qi, no blood flow, resulting in poor urination, weakness in urination, fine urine flow, may be accompanied by distension and pain in the abdomen, or even stabbing pain, purple tongue or petechiae, string or sunken pulse.
Deficiency with stasis
(A) Qi deficiency with stasis
Qi deficiency with stasis, with blood not flowing when Qi fails, resulting in abdominal cramps, desire to urinate but not allowed to come out, or even inability to pass, clear white urine, accompanied by tiredness and laziness, withered face, shortage of breath and lazy speech, fatigue and weakness, not thinking about eating and drinking, pale purple tongue, fat tongue with teeth marks, sunken weak or astringent pulse.
(B) Kidney Yin deficiency with stasis
Old age, depletion of yin and fluid, hyperactivity of phase fire, resulting in urine trickling down, or even no urine, pain in the lower abdomen and pressure, may be accompanied by redness of the cheek in the afternoon, soreness and weakness of the waist and knees, dizziness and tinnitus, dryness of the oropharynx, fever in the hands and feet, tinnitus and deafness, sleeplessness, dry stools, etc., with a dark red tongue and little fluid, thin tongue, little or no moss, and astringent and thin pulse.
(C) Kidney Yang deficiency with stasis
Old age and weakness, lack of yang energy, resulting in difficulty in urination, poor dripping, frequent urination during the day, clear urine, dripping urine, and may be accompanied by weakness of the spirit, coldness of the limbs, soreness of the waist and knees, coldness of the scrotum, coldness of the stem, impotence, etc. The tongue is pale, the tongue is swollen and fat, and the pulse is sunken and weak.
Chinese medicine treatment
I. Real evidence with stasis
(I) Heat-evil congestion of the lung
1. Treatment: Clearing the lung and lowering Qi, and at the same time invigorating Blood.
2. Formula: Qing lung drink with Shengdi and Danshen, etc.
Poria, Phellodendron, Morus alba, Medicago sativa, Radix Platycodon, Radix zedoaria, Radix et Rhizoma, Salviae Miltiorrhizae, Salviae Miltiorrhizae.
(II) Damp-heat with stasis
1. Treatment: Clearing heat and dampness, invigorating blood and promoting drenching.
2, prescription: Bazheng San combined with Guiding Chi San plus Dan Shen and Chuan Niu Kne.
Qu Mai, Q Cun, Che Qian Zi, Slippery Rock, Mountain Gardenia, Rhubarb, Danshen, Chuan Niu Knee, Sheng Di Huang, Bamboo Leaf, Licorice.
(C) phlegm and turbidity with blood stasis
1. Treatment: Eliminate phlegm and disperse knots, activate blood circulation and resolve blood stasis.
2. Formula: Si Hai Shu Yu Wan plus or minus.
Sea clam shell, seaweed, cuttlebone, kombu, Chen Pi, Mu Xiang, Chuan Niu Knee, Atractylodes Macrocephalae, Wu Yao, Lian Lian, and San Ling.
(D) Qi stagnation and blood stasis
1. Treatment: Regulating Qi and invigorating Blood, dispersing nodules and promoting blood circulation.
2. Remedies: Chai Hu Dredging Liver with Shen Xiang San.
Shen Xiang, Shi Wei, Radix Angelicae Sinensis, Chen Pi, White Peony, Slippery Rock, Dong Qu Zi, Wang Bu Liu Xing, Chai Hu, Citrus aurantium, Ocimum sanctum, Glycyrrhiza glabra, Xia Ku Cao.
Second, deficiency with blood stasis
(A) Qi deficiency with stasis
1. Treatment: Tonify the Qi and invigorate the Blood, promote clearing and lowering turbidity.
2, prescription: tonifying the middle and benefiting the qi Tang combined with Chunze Tang and Dan Shen.
Ginseng, Astragalus, Atractylodes, Radix Angelicae Sinensis, Pericarpium Citri Reticulatae, Radix et Rhizoma, Radix et Rhizoma Chai Hu, Osmanthus, Poria, Poria, Salviae.
(B) Kidney Yin deficiency with blood stasis
1, treatment: nourish Yin and tonify the kidney, resolve blood stasis and promote water retention.
2, prescription: Zhi Bai Di Huang Wan combined with pig ling Tang plus Dan Shen, Chuan Niu Knee, Wang Bu Li Xing.
Zhi Mu, Huang Bai, Shu Di Huang, Cornu Cervi Pantotrichum, Yam, Mudan Pi, Ze Di, Poria, Pig Ling, Slippery Rock, Agaricus, Dan Shen, Chuan Niugen, Wang Bu Li Xing.
(C) Kidney Yang deficiency with blood stasis
1. Treatment: Warming Yang, promoting water circulation, resolving Qi and promoting blood circulation.
2, prescription: Jisheng Kidney Qi Pill with Danshen, Wang Bu Liuxing, Baji Tian, Xian Ling Spleen.
Radix et Rhizoma Pseudostellariae, Radix et Rhizoma Cinnamomi, Radix Rehmanniae, Cornus Officinalis, Radix et Rhizoma Yam, Radix Mudanpi, Poria, Radix Zeleniae, Radix Achyranthes Bidentatae, Radix et Rhizoma Carthamus tinctorius, Radix Salviae Miltiorrhizae, Radix et Rhizoma Bidentatae, Radix et Rhizoma Spleen.
Other treatments
1.Acupuncture treatment
Take acupuncture points Guan Yuan, He Gu and San Yin Jiao for damp-heat type; take acupuncture points San Yin Jiao, Zhong Ji and Yin Ling Quan for liver qi stagnation type; take acupuncture points Foot San Li, San Yin Jiao, Guan Yuan and Zhao Hai for lower jiao stasis type prostatic hyperplasia; take acupuncture points Zhong Ji, Yin Ling Quan and Zhao Hai for kidney yin deficiency type; take acupuncture points Zhong Ji, Qi Hai and Zhao Hai for kidney yang deficiency type; take acupuncture points Guan Yuan, Yin Ling Quan, Tai Xi and Foot San Li for spleen and kidney yang deficiency type Take acupuncture points of Foot San Li, Yin Bai, San Yin Jiao, and Qi Hai for spleen spleen deficiency.
The acupuncture points can be left for 10-30 minutes, once a day, 10 times for a course of treatment.
2.Tui na treatment
Massage the small abdomen: point pressure on Qi Hai and Guan Yuan is beneficial to the recovery of bladder function. Slight pressure massage after urination can promote bladder emptying and reduce residual fluid. Regular pressure on lumbar acupoints and with lumbar exercise can release local blood stasis.
3.Physical therapy
Prostate heat therapy, ultrasound therapy, and short wave therapy are commonly used physical therapy methods for BPH. These methods have a role in improving the blood circulation of the prostate tissue and improving the environment of the prostate, and can be used clinically as appropriate.