Prostatic hyperplasia is a common disease in elderly men, the cause of which is due to the gradual enlargement of the prostate gland exerting pressure on the urethra and bladder outlet, clinically manifested as frequent urination, urinary urgency, increased nocturnal urination, and urination effort, and can lead to urinary infections, bladder stones and hematuria and other complications, which have a serious impact on the quality of life of elderly men, and therefore require active treatment, and some patients even need surgery. He Feiping, Department of Urology, Shangyu People’s Hospital Causes of Disease The prostate gland is a male-specific gonadal organ. The prostate gland is like a chestnut, with the bottom facing upward against the bladder, the tip facing downward against the urogenital diaphragm, the front against the pubic symphysis, and the back adjacent to the rectum, so the back of the prostate can be palpated through rectal palpation. Human prostate since birth to puberty, the development of the prostate, growth is slow; after puberty, the growth rate is accelerated, about to the age of 24 years of age to the peak of development, 30 to 45 years of age, the volume of its more stable, and later a part of the people can tend to hyperplasia, the volume of the gland is gradually increasing, if the obvious compression of the urethra of the prostate department, can cause obstruction of bladder outlets and the emergence of urinary difficulties related to the symptoms of the prostatic hyperplasia. Prostatic Hyperplasia. As this kind of hyperplasia is benign, so its full name is Benign Prostatic Hyperplasia (Benign Prostatic Hyperplasia referred to as BPH), the old name for prostate hypertrophy. Prostatic hyperplasia is a common disease in older men, and the pathologic changes of hyperplasia usually begin to occur after the age of 40, with symptoms appearing after the age of 50. At present, the etiology of prostatic hyperplasia is still not very clear, but there are four theories that are quite worthy of attention: 1. The role of sex hormones: the presence of functional testes is necessary for the occurrence of prostatic hyperplasia, the incidence of which increases with age. Testosterone is a sex hormone in the male body. In the prostate gland, testosterone is converted into dihydrotestosterone, which has a stronger ability to act, through the action of 5α-reductase. Dihydrotestosterone promotes an increase in the number of prostate cells, which leads to a gradual increase in the volume of the prostate gland. Inhibition of the 5α-reductase enzyme in the body reduces the production of dihydrotestosterone, and the number of prostate cells decreases, thus reducing the size of the prostate. It is also believed that there is a synergistic effect of estrogen and androgen in the development of prostate enlargement, and that the change in the balance of estrogen and androgen is the reason for the development of prostate enlargement. 2, prostate cells for embryonic reawakening: a study found that the initial pathological changes in prostate hyperplasia, namely the formation of hyperplastic nodules only occur in the prostate gland accounting for 5% to 10% of the region, that is, close to the prostate sphincter of the migratory zone and is located in this sphincter on the inner side of the periurethral region, the initial change in prostate hyperplasia nodules is the hyperplasia of glandular tissues, that is, with the original glandular ducts form a new branch, long into the nearby mesenchyme , after complex re-branching to form a new architectural structure (i.e., nodule), McNeal according to the basic feature of embryonic development is the formation of new structures put forward the theory of embryonic reawakening of prostate hyperplasia, that the formation of prostate hyperplasia nodule is a certain prostate mesenchymal cells in the process of growth of the spontaneous transformation to the state of embryonic development results. 3, peptide growth factors; peptide growth factors for a class of regulation of cell differentiation, growth of peptide substances, some studies have shown that peptide growth factors can directly regulate the growth of prostate cells, and sex hormones only play an indirect role. Currently, peptide growth factors found to play an important role in the process of prostate hyperplasia mainly include: epidermal growth factor (EGF), transforming growth factor α and β, fibroblast growth factor (FGF) and insulin-like growth factor-I, etc., of which basic fibroblast growth factor (bFGF) was proved to have the role of promoting the mitotic effect of almost all the cells in the homogenate of the human prostate gland, and has a role in the development of prostate enlargement. The role of bFGF in the pathogenesis of prostate hyperplasia is being increasingly emphasized. 4. Lifestyle: Obesity is positively associated with prostate size, i.e., the more fat, the larger the prostate. Although the conclusions are less consistent, some existing studies suggest that nutritional elements can influence the risk of BPH and LUTS. Increased total energy, total protein intake, and increased intake of fat, milk and dairy products, red meat, grains, poultry, and starch can potentially increase the risk of prostate enlargement and prostate surgery, whereas vegetables, fruits, polyunsaturated fatty acids, linoleic acid, and vitamin D have the potential to reduce the risk of prostate enlargement. Pathophysiology The prostate gland has the urethra running through the middle of the gland, so to speak, the prostate gland chokes the urethra, so when the prostate gland is diseased, urination is the first thing to be affected. Hyperplasia gradually increases the size of the prostate gland, compressing the urethra and the bladder neck and preventing the bladder from emptying urine. Enhanced contraction of the bladder to overcome the neck resistance causes compensatory hypertrophy of the muscles of the bladder wall, showing trabecular protrusions. With increased pressure in the bladder lumen, the bladder mucosa may bulge outward from the weak spot between the muscle bundles, forming a diverticulum. Bladder neck obstruction continues to aggravate, every time you urinate, the bladder can’t empty the urine completely, after urination, a part of urine remains in the bladder, the existence of residual urine is the basis for the occurrence of urinary tract infections and secondary stones. If not actively treated, prostatic hyperplasia further development, urethral compression gradually aggravated, bladder urinary capacity further decline, the gradual increase of residual urine in the bladder, the bladder pressure rises, so that the urine in the bladder will be refluxed to the ureter and the renal pelvis, resulting in the two sides of the upper urinary tract, the renal pelvis increased pressure, so that the renal parenchyma ischemic atrophy, resulting in renal hypoperfusion. Clinical manifestations Symptoms of prostatic hyperplasia are mainly manifested in two groups of symptoms: one is bladder irritation symptoms; the other is obstructive symptoms due to the obstruction of the urinary tract by the hyperplastic prostate. Bladder irritation symptoms include urinary frequency, urinary urgency, increased nocturia and urge incontinence. Frequent urination is the early signal of prostate enlargement, especially the increase of nocturia is more clinically significant. The emergence of 1 to 2 times of nocturnal urination in the old people who originally do not get up at night often reflects the advent of early obstruction, and the development from 2 times per night to 4 to 5 times per night or even more, indicating the development and aggravation of the lesion. Weakness of urination, thinning of the urinary line and dribbling of urine Due to the obstruction of the hyperplastic prostate, the patient has to use more force to overcome the resistance to urination, so that it is laborious to urinate; the hyperplastic prostate gland deflates the urethra resulting in a thinning of the urinary line; with the progression of the disease, interruption of urination and dribbling of urine after urination may also appear, and so on. When you feel the urge to urinate, you have to stand in the toilet and wait for a long time before the urine comes, and the stream of urine becomes thin, the discharge is weak, the range is not far, and sometimes even from the urethral opening line-like dripping and leaking. Hematuria The enlargement of the prostate gland indicates that there are many blood vessels, and these blood vessels will rupture under increased pressure, resulting in blood in the urine, which is called hematuria, or blood in the urine. Normally, there are no red blood cells in the urine. When the patient’s urine is centrifuged and precipitated and examined under a microscope, if there are more than 5 red blood cells in each high magnification field of view, it is called hematuria. Urinary retention Acute urinary retention can occur in advanced patients with more severe prostate enlargement when the obstruction is severe due to the inability to pass urine due to cold, alcohol consumption, holding urine for too long, or infection. Complications Hydrocele This is due to the hyperplastic prostate pressing on the urethra, and the bladder needs to contract forcefully to overcome the resistance to pass urine out of the body. Over time, the bladder muscles become hypertrophied. If the pressure on the bladder cannot be relieved for a long time, and the residual urine in the bladder gradually increases, the bladder muscles become ischemic and hypoxic, becoming inert and the bladder lumen enlarges. Eventually the urine in the bladder will back up into the ureter and renal pelvis causing hydronephrosis and in severe cases uremia. Infection As the saying goes, “running water does not rot”, but patients with prostatic hyperplasia often have varying degrees of urinary retention, and the residual urine in the bladder is like a pool of stagnant water, and bacterial reproduction may cause infection. Urinary retention and incontinence Urinary retention can occur at any stage of the disease, mostly due to sudden congestion and edema of the prostate gland caused by climate change, alcohol consumption, and exertion. Excessive residual urine can cause the bladder to lose its ability to contract, and the amount of urine retained in the bladder gradually increases. When the bladder is overstuffed, urine will involuntarily overflow from the urethra. This kind of urinary incontinence is called filling incontinence, and such patients must receive emergency treatment. Bladder stones Bladder stones in the elderly are also associated with prostate hyperplasia. Stones do not usually grow in the bladder when the urinary tract is clear. Even if a stone falls from the ureter into the bladder it can be passed in the urine. This is not the case for older people with prostate enlargement. Hernias Prostatic hyperplasia may cause hernias (small bowel gas) and other conditions in older people. Some people with prostate enlargement have difficulty urinating and need to push and hold their breath to pass urine. As a result of the constant straining, the intestines can protrude from weak areas in the abdomen, forming a hernia (small bowel gas), and sometimes the patient develops hemorrhoids and varicose veins in the lower extremities. Hemorrhoids Elevated pressure in the abdomen. It can easily cause hemorrhoids. Hemorrhoids are divided into internal, external and mixed hemorrhoids, which are masses caused by varicose veins in the upper and lower rectal venous plexus on either side of the dentate line. Elevated intra-abdominal pressure, obstruction of venous return and stasis in the upper and lower rectal venous plexuses are important causes of hemorrhoids. Patients may experience bleeding during defecation, prolapse of hemorrhoidal masses, and pain. Therefore, hemorrhoids can often be relieved or even cured after urination difficulty is relieved in patients with prostatic hyperplasia. Urine analysis of examination items Urine routine examination of patients with prostate hyperplasia can sometimes be normal, leukocyturia can be seen when there is a current urinary tract infection, but also to determine whether there is hematuria. Measurement of serum prostate-specific antigen (PSA) PSA is an organ-specific indicator of the prostate, and its elevation can be seen in prostate cancer, prostate hyperplasia, acute urinary retention, prostate inflammation, massage of the prostate, urethral insertion of instruments, and ejaculatory activity prior to the examination of the PSA, etc. Significant elevation of the PSA is seen in prostate cancer, and PSA can be elevated in patients with prostate enlargement, but the magnitude of the increase is relatively high. In patients with prostatic hyperplasia, PSA can also be elevated, but the rise is relatively small. Uroflowmetry This test calculates the rate at which the patient passes urine. Changes in urine flow rate can tell us about overall changes in urinary function, which can be caused by lesions in the prostate, urethra, and bladder. Patients with prostate enlargement should have a decrease in the rate of urine discharge, i.e., a decrease in the urinary flow rate, as the enlarged prostate gland presses on the urethra, which makes urine discharge from the bladder impeded. Uroflow rate test is very important for prostate enlargement patients, no pain, can reflect the severity of the patient’s urinary difficulties, so in the initial diagnosis, treatment and after the treatment can be measured to determine the effectiveness of urinary flow rate. Based on the non-invasive nature and clinical value of this test, it should be measured before, during and after treatment where available. Ultrasound can be used to determine the presence of fluid in both kidneys, the presence of diverticulum formation in the bladder, the size and morphology of the prostate, and the amount of residual urine. Patients with prostatic hyperplasia may experience an increase in the amount of residual urine, and measuring the amount of residual urine can help determine the degree of prostatic hyperplasia. Ultrasonography is the main method to determine the amount of residual urine. After the patient holds his urine for routine bladder and prostate ultrasonography, he gets up to urinate, and after sufficient urination, the bladder is observed again with ultrasonography to measure the amount of residual urine in the bladder after urination. Rectal palpation Enlargement of the prostate with loss or bulging of the median sulcus may be detected, and attention should be paid to the presence of hard nodules and the presence of prostate cancer. Intravenous urography and urethrography Intravenous pyelography should be performed if the patient with prostatic hyperplasia is accompanied by recurrent urinary tract infections, microscopic or microscopic hematuria, suspected hydronephrosis or dilated reflux of the ureter, and urinary stones. It should be noted that intravenous urography is prohibited when the patient is allergic to contrast media or has renal insufficiency. Urethrogram is recommended when urethral stricture is suspected. Diagnostic Points Most commonly seen in older men over 50 years of age. Manifestations include urinary frequency, urinary urgency, increased nocturia, waiting for urination, weak and thin urine stream, dribbling, intermittent urination. Rectal palpation: enlarged prostate, tougher texture, smooth surface, loss of central sulcus. Ultrasonography: can show hyperplastic prostate, increased residual urine. Uroflowmetry: decreased urinary flow rate. Differential diagnosis The disease should be differentiated from urethral stricture, prostate cancer, neurogenic bladder dysfunction. Disease Treatment Currently, prostate hyperplasia is treated with wait-and-see, medication, surgery and minimally invasive treatment. Each treatment option has advantages and risks. It is necessary to choose a reasonable treatment plan for the patient’s specific situation, so that the patient can benefit while trying to avoid complications and risks. Wait-and-see Patients may choose to wait and see if their prostate enlargement has little impact on their quality of life and if they are not significantly distressed. Wait-and-see is not a passive observation of the condition. Rather, it involves assessing the patient’s risk of BPH progression, being alert to complications, and providing health education to improve symptoms through lifestyle modifications. Lifestyle adjustments include drinking an appropriate amount of water and avoiding excessive consumption of caffeinated and alcoholic beverages; patients need to know whether they are also taking medications that may affect urination symptoms, such as diuretics, and adjust them appropriately. Active intervention is needed when patients experience disease progression. Medication Currently, the standard pharmacologic treatment for LUTS/BPH includes alpha1-blockers, 5α-reductase inhibitors, and a combination of the two. Alpha 1 receptor blockers reduce prostate and urethral smooth muscle tone, thereby relieving bladder outlet obstruction, and are currently the first line of treatment for LUTS/BPH. alpha 1 receptor blockers improve symptoms and increase urinary flow rate, but do not affect prostate volume or significantly control disease progression. Symptomatic improvement is perceived in 70% of patients after 2-3 days of α1-blocker use.Adverse effects of α1-blockers mainly include postural hypotension, dizziness, weakness, drowsiness, headache, and ejaculatory disorders. However, the incidence of adverse reactions is low overall and well tolerated by the vast majority of patients. 5α reductase inhibitors reduce the amount of dihydrotestosterone in the prostate by inhibiting the activity of the enzyme 5α reductase in order to reduce the size of the prostate. However, the reduction in prostate volume with 5α reductase inhibitors is slow and symptom relief takes at least 3-6 months. Large-scale clinical studies have confirmed the ability of 5α reductase inhibitors to control the clinical progression of prostate enlargement and reduce the incidence of acute urinary retention.Common side effects of 5α reductase inhibitors include erectile dysfunction, decreased libido, ejaculatory disorders, and breast pain. 5α reductase inhibitors currently in use on the market include finasteride and dutasteride, with finasteride inhibiting only type II 5α reductase and dutasteride inhibiting both type I and type II 5α reductase. In a 12-month study, no significant difference in efficacy was found between finasteride and dutasteride. Patients should be informed before using 5α-reductase inhibitors that 6 months of treatment is required for significant improvement in symptoms and that prostate-specific antigen levels decrease by 50% after 12 months of treatment. Combination therapy with α1-blockers and 5α-reductase inhibitors: The combination of α1-blockers and 5α-reductase inhibitors is effective in relieving symptoms and controlling BPH disease progression more effectively, reducing the risk of acute urinary retention and the associated surgical procedures, and is used primarily in patients at higher risk for progression of prostatic hyperplasia. On the other hand, combination treatments come with higher costs and more side effects. Surgery Advances in drug therapy have led to a significant reduction in the number of patients requiring surgical intervention. However, some patients still require surgical intervention. Currently, surgical treatment is recommended in clinical practice for patients who do not respond well to medication or who refuse to undergo medication when prostate enlargement leads to complications such as recurrent urinary retention, recurrent hematuria, recurrent urinary tract infections, bladder stones, and secondary hydronephrosis of both kidneys. Surgical treatment options include open surgery, endoluminal surgery, and laser surgical treatment. Transurethral resection of the prostate (TURP) is still the “gold standard” of BPH surgical treatment, and after TURP, the majority of patients experience significant improvement in LUTS symptoms. Laser surgery has the advantages of less bleeding and fewer complications, and is suitable for patients who cannot tolerate TURP surgery or have small prostate size, and can achieve better results. With the advancement of technology, laser surgical treatment may gradually replace most of the TURP surgeries. Minimally invasive treatment is a treatment that can be considered for patients who cannot tolerate TURP with high surgical risk and poor efficacy of drug therapy. Currently, minimally invasive treatments commonly used in clinical practice include transurethral needle ablation, transurethral microwave thermotherapy, high-energy focused ultrasound, transurethral prostate ethanol ablation interstitial laser coagulation, and prostate stenting. However, well-designed studies confirming the efficacy of these treatments are lacking. Follow-up All treatments for prostate enlargement should be followed up. The purpose of follow-up is to assess the efficacy of the treatment and to detect any side effects or complications associated with the treatment. The first follow-up visit for patients on watchful waiting and medication may be 6 months after starting treatment, and then once a year. If an exacerbation of the symptoms described above occurs or if a surgical indication arises, a prompt change in the treatment regimen is required. Follow-up includes symptom scores, ultrasound (including residual urine measurements), urinary flow rate, rectal examination, and measurement of prostate-specific antigen. After undergoing all types of surgical treatment, patients should be scheduled for their first follow-up visit at 1 month after surgery. The first follow-up visit focuses on the patient’s overall postoperative recovery and any symptoms that may be associated with the early postoperative period. The treatment effect can be evaluated at 3 months after surgery. The recommended follow-up period after surgery is 1 year. Follow-up also includes symptom scores, ultrasound (including residual urine measurement), urine flow rate, rectal examination, and prostate-specific antigen measurement. Self-care to prevent cold In late fall and early spring, the weather is unpredictable and cold often aggravates the condition. Therefore, patients must pay attention to the cold to prevent cold and upper respiratory tract infections and so on. Absolutely avoid alcohol, less spicy food Drinking alcohol can make the prostate and bladder neck congestion and edema and induce urinary retention. Spicy and irritating food can lead to congestion of the sexual organs, but also make hemorrhoids, constipation symptoms worsen, oppression of the prostate, aggravate urination difficulties. Drinking the right amount of water Drinking too little water will not only cause dehydration, but also unfavorable urination on the flushing effect of the urinary tract, but also easy to lead to the concentration of urine and the formation of insoluble stones. Therefore, in addition to the appropriate reduction of water at night, so as not to overfill the bladder after sleep, should drink more water during the day. Use drugs with caution Some drugs can aggravate urinary difficulties, and when the dose is large, it can cause acute urinary retention, among which there are mainly atropine, belladonna tablets and ephedrine tablets, isopropyl adrenaline and so on.