Prostate enlargement is a common disease in elderly men, the cause of which is the gradual enlargement of the prostate gland on the urethra and bladder outlet pressure, clinical manifestations of frequent urination, urinary urgency, increased urination at night and urinary effort, and can lead to urinary system infections, bladder stones and hematuria and other complications, the quality of life of elderly men has a serious impact, so it needs to be actively treated, and some patients even need surgery.
Etiology of the disease
The prostate is a male-specific gonadal organ. The prostate is like a chestnut, with the bottom facing up against the bladder and the tip facing down against the urogenital diaphragm, with the front against the pubic symphysis and the back adjacent to the rectum, so the back of the prostate can be palpated by rectal palpation.
The prostate gland is slow to develop and grow from birth until puberty; after puberty, the growth rate accelerates to about 24 years of age, and its volume is more balanced between 30 and 45 years of age, after which some people can tend to proliferate, the gland volume gradually increases, and if it obviously presses on the urethra of the prostate, it can cause obstruction of the bladder outlet and symptoms related to urinary difficulties, namely prostatic hyperplasia. This is known as prostatic hyperplasia. This is a benign lesion, so the full name is Benign Prostatic Hyperplasia (BPH), formerly known as prostate hypertrophy. This is a common disease in older men, and the pathological changes of hyperplasia usually begin after the age of 40, with symptoms appearing after the age of 50.
The cause of prostate hyperplasia is still not well understood, but there are four theories that deserve considerable 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 the sex hormone in the male body. In the prostate gland testosterone is converted into dihydrotestosterone with stronger action ability through the action of 5α-reductase. Dihydrotestosterone can promote the increase of prostate cells, making the prostate volume gradually increase. If you have a good idea of what you’re looking for, you’ll be able to get a good idea of what you’re looking for. It is also believed that there is a synergistic effect of estrogen and androgen in the developmental changes of prostate enlargement, and that the change in the balance of estrogen and androgen is the reason for the occurrence of prostate enlargement.
2, prostate cells for embryonic re-awakening: some studies have found that the initial pathological changes of prostate hyperplasia, namely the formation of hyperplastic nodules only occur in the area accounting for 5% to 10% of the prostate gland, namely the migratory zone close to the prostate sphincter and the periurethral zone located on the inner side of this sphincter, the initial change of prostate hyperplastic nodules is the proliferation of glandular tissue, that is, the formation of new branches with the original glandular ducts, growing into the nearby interstitium The first change in prostatic hyperplasia nodules is the proliferation of glandular tissue, i.e. the formation of new branches that grow into the nearby mesenchyme, and after complex re-branching to form new structures (i.e. nodules).
The main peptide growth factors found to play an important role in the development of prostate hyperplasia include: epidermal growth factor (EGF), transforming growth factor alpha and beta, fibroblast growth factor (FGF) and insulin-like growth factor-Ⅰ, etc. Among them, basic fibrillogenic growth factor (bFGF) has been shown to have a mitogenic effect on almost all cells in human prostate homogenates, and has a role in the development of prostate hyperplasia. The role of bFGF in the pathogenesis of prostate enlargement is receiving increasing attention.
4. lifestyle: obesity is positively correlated with prostate volume, i.e. the more fat, the larger the prostate volume. Although the findings are less consistent, several existing studies suggest that nutritional elements can influence the risk of BPH and LUTS. Increased intake of total energy, total protein, 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 is crossed by the urethra in the middle, so to speak, and the prostate gland chokes the urethra, so urination is the first thing to be affected by a diseased prostate. The enlarged prostate gland gradually increases in size, compressing the urethra and bladder neck and preventing the bladder from emptying the urine. The enhanced contraction of the bladder to overcome the neck resistance causes compensatory hypertrophy of the muscles of the bladder wall, which appear as trabecular protrusions. The pressure in the bladder cavity increases and the bladder mucosa may bulge outward from the weak spot between the muscle bundles to form a diverticulum. The obstruction of the bladder neck continues to worsen, and each time you urinate, the bladder cannot empty the urine completely, and a portion of the urine remains in the bladder after urination. The presence of residual urine is the basis for the occurrence of urinary tract infections and secondary stones. If not actively treated, the prostate enlargement further develops, the pressure on the urethra gradually increases, the bladder’s ability to urinate further decreases, the residual urine in the bladder gradually increases, the pressure in the bladder rises, so that the urine in the bladder flows backwards to the ureter and renal pelvis, causing fluid accumulation in the upper urinary tract on both sides, and the pressure in the renal pelvis increases, causing ischemic atrophy of the kidney parenchyma, resulting in renal hypofunction.
Clinical manifestations
The symptoms of prostate enlargement are mainly manifested as two groups of symptoms: one is bladder irritation; the other is obstructive symptoms arising from the blockage of the urinary tract by the enlarged prostate.
1, bladder irritation symptoms
Urinary frequency, urinary urgency, increased nocturia and urge incontinence. The frequency of urination is an early sign of prostate enlargement, especially the increase in the number of nighttime urination is more clinically significant. The original elderly who do not get up at night appear to urinate 1 to 2 times at night, often reflecting the onset of early obstruction, while 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.
2, weakness of urination, thinning of the urine line and dripping of urine
The patient has to use more force to overcome the resistance to urination because of the obstruction of the enlarged prostate, so it is hard to urinate; the enlarged prostate deflates the urethra and makes the urine line thinner; as the disease develops, there may be symptoms such as interruption of urination and dripping after urination. When you feel the urge to urinate, you have to stand in the toilet and wait for a while before the urine comes, and the urine stream becomes thin, the discharge is weak, and the distance is not far, and sometimes it even drips down from the urethra in a thread-like manner.
3. Hematuria
The enlarged prostate indicates that there are many blood vessels, and these vessels will rupture when the pressure increases, making the urine with blood that is hematuria, also known as urine blood. In normal circumstances, there are no red blood cells in the urine. Medically, after the patient’s urine is centrifuged and precipitated and examined with a microscope, if there are more than five red blood cells in each high magnification field, it is called hematuria.
4.Urinary retention
In advanced patients with heavy prostatic hyperplasia, acute urinary retention can occur when the obstruction is severe due to cold, alcohol, holding urine for too long or infection, which leads to the inability to discharge urine.
5, complications hydrocele
This is due to the hyperplastic prostate gland pressing on the urethra, the bladder needs to contract hard to overcome the resistance to expel urine out of the body. Over time, the bladder muscles will become hypertrophic. 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, become inert and the bladder cavity expands. Eventually the urine in the bladder will back up into the ureter and renal pelvis causing hydronephrosis and in severe cases uremia.
6.Infection
As the saying goes, “running water does not rot”, but patients with prostate hyperplasia often have varying degrees of urinary retention. The residual urine in the bladder is like a pool of stagnant water, and bacterial reproduction may cause infection.
7. Urinary retention and incontinence
The urinary retention can occur at any stage of the disease, mostly due to climate change, alcohol consumption, exertion that causes sudden congestion and edema of the prostate. Excessive residual urine can cause the bladder to lose its ability to contract, and the urine retained in the bladder gradually increases. When the bladder over-expands, urine will unconsciously overflow from the urethra, and this phenomenon of urinary incontinence is called filling incontinence, and such patients must receive emergency treatment.
8.Bladder stones
Bladder stones in the elderly are also associated with prostatic hyperplasia. With a clear urinary tract, stones do not usually grow in the bladder. Even if a stone falls from the ureter into the bladder it can be expelled with urine. This is not the case for older people with prostate enlargement.
9. Hernia
Prostate enlargement can cause diseases such as hernia (small bowel gas) in the elderly. Some people with prostate enlargement have difficulty urinating and need to strain and hold their breath to pass urine. As a result of frequent straining, the intestines protrude from the weak areas of the abdomen, forming a hernia (small intestine gas), and sometimes patients also develop hemorrhoids and varicose veins in the lower extremities.
10. Hemorrhoids
The pressure in the abdomen is elevated. It can easily cause hemorrhoids. Hemorrhoids are divided into internal, external and mixed hemorrhoids, which are masses caused by varicose veins of the upper and lower rectal plexus on both sides of the dentate line. Elevated intra-abdominal pressure, obstructed venous reflux, and stasis in the venous plexus above and below the rectum are important reasons for the occurrence of hemorrhoids. Patients may experience bleeding during defecation, prolapsed hemorrhoid masses, and pain. Therefore, hemorrhoids can often be relieved or even heal themselves after the difficulty in urination is lifted in patients with prostate enlargement.
Urinalysis of examination items
The routine urinalysis of patients with prostatic hyperplasia can sometimes be normal, and white cell urine can be seen when there is a present urinary tract infection, and the presence or absence of hematuria can also be determined.
1. Measurement of serum prostate-specific antigen (PSA)
The PSA is an organ-specific indicator of the prostate gland, 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 PSA test.
2. Urine flow rate test
This test is able to calculate the rate at which the patient’s urine is expelled. Changes in the urine flow rate can tell the overall changes in the patient’s urinary function. The causes of these changes include lesions in the prostate, urethra and bladder and other organs. In patients with prostate enlargement, the enlarged prostate gland should compress the urethra, causing obstruction of bladder urine drainage, which is manifested by a decrease in the rate of urine drainage, i.e., a decrease in urine flow rate. The urine flow rate test is very important for patients with prostate enlargement, it is painless and can reflect the severity of the patient’s difficulty in urination, so the urine flow rate can be measured at the initial diagnosis, during and after treatment to determine the efficacy of the treatment. The test is non-invasive and clinically valuable, and should be measured before, during and after treatment where available.
3.Ultrasound examination
It is possible to find out whether there is fluid in both kidneys, whether there is diverticulum formation in the bladder, the size and shape of the prostate, and to determine the amount of residual urine. The amount of residual urine can be increased in patients with prostate enlargement, and measuring the amount of residual urine can help determine the degree of prostate enlargement. Ultrasound is currently the main method of measuring residual urine. After holding urine for a routine bladder and prostate ultrasound, the patient gets up to urinate, and after adequate urination, the bladder is observed again with ultrasound to measure the amount of residual urine in the bladder after urination.
4.rectal palpation
Prostate enlargement, disappearance or bulging of the middle groove can be found. Attention should be paid to the presence of hard nodules and the presence of prostate cancer.
5.Intravenous urography and urethrography
If a patient with prostatic hyperplasia also has recurrent urinary tract infections, microscopic or meatus hematuria, suspected hydronephrosis or dilated ureteral reflux, or urinary stones an intravenous pyelogram should be performed. It should be noted that intravenous urography is prohibited when the patient is allergic to the contrast agent or has renal insufficiency. Urethrography is recommended when urethral stricture is suspected.
Diagnostic points
Most commonly seen in older men over 50 years of age. It manifests as frequent urination, urgent urination, increased nocturia, waiting for urination, weak and thin urine stream, urine dripping and intermittent urination.
1. rectal palpation: enlarged prostate, tougher texture, smooth surface and disappearance of the central groove.
2. ultrasonography: it may show enlarged prostate with increased residual urine.
3. urine flow rate examination: decreased urine flow rate.
4. Differential diagnosis: the disease should be differentiated from urethral stricture, prostate cancer, and neurogenic bladder dysfunction.
Disease treatment
At present, the treatment options for prostatic hyperplasia include wait-and-see, medication, surgery and minimally invasive treatment. Each of these treatment options has advantages and risks. It is necessary to choose a reasonable treatment plan for the patient’s specific situation to benefit the patient while avoiding complications and risks as much as possible.
Wait and see
If prostate enlargement has a low impact on the patient’s quality of life and there is no significant distress, the patient may choose to wait and see. Rather than passively observing the condition, wait-and-see requires assessing the patient’s risk for BPH progression, being alert for complications, and providing health education to improve symptoms through lifestyle modifications. Lifestyle adjustments include drinking appropriate amounts of water and avoiding excessive consumption of caffeinated and alcoholic beverages; patients need to be informed if they are also taking medications that may affect urinary symptoms, such as diuretics, and adjusted appropriately. Active intervention is needed when patients experience disease progression.
Pharmacological treatment
Currently, the standard pharmacological treatment for LUTS/BPH includes: α1 receptor blockers, 5α reductase inhibitors, and a combination of both.
Alpha 1 blockers are currently the first line of treatment for prostate enlargement as they reduce prostate and urethral smooth muscle tone, thereby relieving bladder outlet obstruction. alpha 1 blockers improve symptoms and increase urinary flow rates, but do not affect prostate volume or significantly control disease progression. After 2-3 days of using alpha1 blockers, 70% of patients can feel improvement in their symptoms. Adverse effects of alpha1 blockers include postural hypotension, dizziness, weakness, drowsiness, headache and ejaculation disorders. However, the overall incidence of adverse reactions is low and well tolerated by the majority of patients.
5α reductase inhibitors reduce the amount of dihydrotestosterone in the prostate by inhibiting the activity of 5α reductase in order to reduce prostate volume. However, the reduction in prostate volume is slow with 5α reductase inhibitors, and symptom relief takes at least 3-6 months. Large clinical studies have confirmed that 5α-reductase inhibitors can 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. Currently marketed 5α reductase inhibitors include finasteride and dutasteride, with finasteride only inhibiting 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 need to be informed before using 5α-reductase inhibitors: 6 months of treatment is required to achieve significant improvement in symptoms; prostate-specific antigen levels decrease by 50% after 12 months of treatment.
Combination therapy with α1-blockers and 5α-reductase inhibitors: Combination therapy with α1-blockers and 5α-reductase inhibitors is effective in relieving symptoms and in more effectively controlling the progression of BPH disease, reducing acute urinary retention and the associated risk of surgery, mainly in patients at higher risk of progression of prostatic hyperplasia. On the other hand, combination therapy also carries a higher cost and more side effects.
Surgical treatment
Advances in drug therapy have led to a significant decrease in the number of patients requiring surgical intervention. However, a proportion of patients still require surgical treatment. Currently, surgical treatment is recommended for patients who do not respond well to medication or who refuse medication when prostate enlargement leads to complications such as recurrent urinary retention, recurrent hematuria, recurrent urinary tract infections, bladder stones and secondary bilateral hydronephrosis.
Surgical treatment options include open surgery, endoluminal surgery, and laser surgical treatment. The majority of patients have significant improvement in their LUTS symptoms after TURP, which remains the “gold standard” of surgical treatment for BPH. The laser surgery has the advantages of less bleeding and fewer complications, and is suitable for patients who cannot tolerate TURP surgery or have a small prostate. As technology advances, laser surgery may gradually replace most TURP procedures. Minimally invasive treatment is a treatment option to consider for patients with high surgical risk who cannot tolerate TURP and whose drug therapy is not effective. 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 effectiveness of the treatment and to detect side effects or complications associated with the treatment.
The first follow-up for patients on watchful waiting and medication may be 6 months after starting treatment and annually thereafter. If an exacerbation of these symptoms occurs or if surgery is indicated, a prompt change in the treatment plan is required. Follow-up includes: symptom scores, ultrasound (including residual urine measurement), urinary flow rate, rectal examination and prostate-specific antigen measurement.
After all types of surgical treatment, the patient should be scheduled for the first follow-up visit at 1 month after the procedure. The first follow-up visit will focus on the patient’s overall postoperative recovery and any symptoms that may be associated with the early postoperative period. The effect of treatment can be basically evaluated at 3 months after surgery. The recommended follow-up period after surgery is 1 year. The 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
1. From late fall to early spring, the weather is unpredictable and the cold often aggravates the condition. The actual fact is that the actual person has to be aware of the cold, prevent the cold and upper respiratory tract infections, etc.
2, absolutely no alcohol, less spicy food. The actual fact is that you can get a lot more than just a few of the most popular and most popular products. The actual fact is that you can find a lot of people who have been in the business for a long time.
4. Drink the right amount of water. The actual fact is that you will not only cause dehydration, but also detrimental to the flushing effect of urination on the urinary tract, which can also easily lead to the formation of insoluble stones by concentrating urine. 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.
5, careful use of drugs. Some drugs can aggravate the difficulty of urination, and in large doses can cause acute urinary retention, including mainly atropine, belladonna tablets and ephedrine tablets, isopropyl adrenaline, etc.