Prostatic hyperplasia (BPH) is one of the common diseases in middle-aged and elderly men.
Clinical manifestations
(1) Frequent urination, increased nocturia
(2) Urinary urgency, urinary incontinence
(3) Difficulty in urination
(4) Hematuria.
(5) Urinary tract infection with painful urination
(6) Associated bladder stones
(7) Renal function impairment mostly due to ureteral reflux, hydronephrosis leading to renal function destruction
(8) Long-term reliance on increased abdominal pressure to help urination can cause hernias, hemorrhoids and prolapse.
Diagnosis
Patients with prostatic hyperplasia are often combined with
1. IPSS score
In 1995, the International Society of Urology (SIU) introduced the IPSS scoring system, which attempts to quantify symptomatology to facilitate comparison and assist in diagnosis, and can also be used as a post-treatment score up to 35 points, currently considered less than 7 points for mild, 7 to 18 points for moderate, and more than 18 points for severe, requiring surgical management.
2. Rectal examination
Rectal examination is a simple and important diagnostic method, which is performed after the bladder is emptied. The boundaries, size and texture of the prostate should be noted. In the case of prostate enlargement, the gland may be enlarged in length or width, or both. Different methods are used clinically to describe the degree of prostate enlargement.
However, there is some error in estimating the size of the prostate by rectal palpation. If the middle lobe protrudes toward the bladder, enlargement of the prostate gland is not apparent on rectal auscultation. In addition, if a suspicious nodule is found on the prostate during rectal examination, a puncture biopsy should be performed to rule out the possibility of prostate cancer. The contraction function of the anal sphincter should also be noted to rule out neurogenic bladder dysfunction.
3. Ultrasound examination
Ultrasound examination is used to observe the size, shape and structure of the prostate. The common methods are transrectal and transabdominal ultrasonography. The former is more accurate but requires high equipment, while the latter is simple and popular.
Transrectal ultrasound can also be used to determine the deformation and displacement of the urethra from the voiding phase sonogram, to understand the dynamic changes of lower urinary tract obstruction, and also to understand the status after treatment. Transabdominal ultrasound examination is more commonly used in China, and observation of the internal structure of the gland is not as good as transrectal ultrasound examination.
4. Urodynamic examination
Urodynamic examination can provide a more complete and objective evaluation of urinary function. Among them, the maximum urinary flow rate, average urinary flow rate, urination time and urine volume are of great significance. The maximum urinary flow rate is an important diagnostic indicator. Attention should be paid to the influence of urine volume on the maximum urine flow rate results. The best urine volume for this test is 250-400ml, and the smallest volume is 150-200ml. For most men over 50 years of age, a maximum urine flow rate of 15 ml/s is considered normal. When measuring the urinary flow rate, cystometry can be performed simultaneously to help determine the function of the forceps urinaryis muscle and its degree of damage, in order to accurately grasp the timing of surgery. After lower urinary tract obstruction, if the forceps muscle continues to have uninhibited contraction, it will progress to hypo-compliant and hyper-compliant bladder, and although the urinary flow rate can be restored to normal after surgery, the function of the forceps muscle is sometimes difficult to be restored.
5. Residual urine measurement
Since the bladder forced urinary muscle can overcome the increased urethral resistance by compensatory means to empty the urine from the bladder, the absence of residual urine in the early stages of prostatic hyperplasia does not exclude the presence of lower urinary tract obstruction. It is generally believed that a residual urine volume of 50 to 60 ml indicates that the bladder forced urinary muscle is in an early state of loss of compensation.
The determination of residual urine by catheterization after urination is more accurate. The determination of residual urine by transabdominal ultrasound is easier, painless for the patient and can be repeated. However, the measurement is not accurate when the residual urine volume is low. The method of intravenous pyelography, in which one film is taken during bladder filling and one after urination to observe residual urine, is of little practical value because it cannot be quantified. Isotope concentration measurement, i.e., concentration quantification, can be determined according to the method of different concentrations of solution volume, which is the most accurate method, but the cost is high and difficult to popularize.
6. Urography
In the case of prostatic hyperplasia, the bottom of the bladder may be elevated and widened, and the ureteral orifice on both sides may be seen on intravenous urographic films with increased spacing and hook-shaped bending of the lower ureter, if the kidney and ureteral effusion are mostly bilateral, but the degree of expansion may not be uniform. A prominent filling defect is seen in the bladder area, which is caused by the protrusion of the prostate.
7. Cystoscopy
The distance from the seminal frenulum to the neck of the bladder is about 2 cm in normal individuals, with a concave neck and a flat posterior lip. In the case of prostatic hyperplasia, the posterior urethra is prolonged and the shape of the neck changes with the degree of hyperplasia of each lobe, from the disappearance of the concave surface to the projection of the glandular lobe. The urethra becomes fissured by pressure. The base of the bladder is sunken and the ureteral orifice spacing and distance from the bladder neck are widened. The interureteral ridge may be hypertrophic and the bladder wall has trabeculae, small rooms or diverticulae formation.
8. Other
Magnetic resonance imaging has no special value for the diagnosis of prostatic hyperplasia, but can assist in identifying early prostate cancer.
The diagnosis of this condition in clinical practice mainly relies on history, rectal examination and ultrasound examination. Cystoscopy can be performed when necessary, and further investigation is needed to understand the presence of upper urinary tract dilatation and renal impairment, the presence of neurogenic bladder dysfunction, peripheral neuritis due to diabetes mellitus, and cardiovascular disease, and finally to estimate the systemic condition and decide the treatment plan.
Differential diagnosis
1. Bladder neck contracture
The patient has symptoms of lower urinary tract obstruction, but rectal examination does not reveal any significant enlargement of the prostate. In addition to the possibility that the enlarged glandular lobe is protruding into the bladder, the possibility of bladder neck contracture should be considered. It is generally believed that bladder neck contracture is secondary to an inflammatory lesion. The smooth muscle of the bladder neck is replaced by connective tissue and may be accompanied by inflammation. Patients with bladder neck contracture have a long history of lower urinary tract obstruction. On cystoscopy, the bladder neck is elevated and the posterior urethra and bladder triangle are contracted and shortened. Cystoscopy reveals no extruded deformity of the prostatic segment urethra and a narrowing of the internal urethral opening. In contrast, when the simple prostatic hyperplastic lobe protrudes towards the bladder neck, it is covered by soft mucosa, the bladder triangle is depressed, and the posterior urethra is prolonged.
The bladder neck contracture can be accompanied by prostatic hyperplasia, which is often difficult to remove because of the unclear demarcation between the hyperplastic gland and the surgical envelope, and the gland is significantly smaller than those predicted by rectal examination or ultrasound. If the contracted bladder neck is not treated at the same time after removal of the gland, the lower urinary tract obstruction will be difficult to lift.
Treatment can be tried with alpha-blockers. If the symptoms are severe, recurrent urinary tract infections, or abnormal urodynamics, transurethral electrodesis, suprapubic transcystic neck wedge resection or bladder neck Y-Vplasty can be considered.
2. Prostate cancer
Prostate cancer, especially the ductal type, may have lower urinary tract obstruction as its first symptom. In some patients, prostate cancer occurs in conjunction with prostate enlargement, and the serum PSA (prostate-specific antigen) is elevated, mostly >10.0 ng/ml. The surface of the prostate is not smooth and rocky on rectal examination. The diagnosis can be clearly made by rectal biopsy, better guided by ultrasound, and by pathological examination.
3. neurogenic bladder, sphincter of forced urination synergistic disorder
It often manifests as abnormal urination in the lower urinary tract and urinary incontinence. It should be ruled out by urodynamic tests such as filling cystometry, urethral manometry, and simultaneous pressure/flow rate testing.
4. Weak bladder (aging bladder wall)
Presenting with urinary retention, abnormal urination in the lower urinary tract, and large amounts of residual urine should be differentiated from prostatic hyperplasia and should be ruled out by injury, inflammation, diabetes mellitus, etc., mainly also by urodynamic examination. Special urethral manometry with simultaneous pressure/flow rate testing is used to differentiate. Cystoprogram shows low bladder pressure, no systolic pressure waveform, etc.
Treatment
The danger of prostatic hyperplasia lies in the pathophysiological changes that result from causing lower urinary tract obstruction. The pathology varies greatly among individuals and does not always develop progressively. Some lesions do not progress beyond a certain point, so even mild obstruction symptoms do not always require surgery.
1. Watchful waiting
For mild symptoms, IPSS score of 7 or less can be observed without treatment.
2. Drug treatment
(1) 5α-reductase inhibitors Studies have found that 5α-reductase is an important enzyme in the conversion of testosterone to dihydrotestosterone. The 5α-reductase inhibitor can inhibit the hyperplasia of the prostate.
（The actual alpha-blocker is currently believed to improve the urodynamic obstruction and make the resistance drop to improve the symptoms, commonly used drugs such as Gottlieb.
(3) The most widely used anti-androgen drugs are progesterone drugs. It can inhibit the cell binding and nuclear uptake of androgens, or interfere with the formation of dihydrotestosterone by inhibiting 5α-reductase. Among the progesterone drugs are megestrol, cyproterone acetate, chlormadinone acetate, and pregnenolone caproate. Flubutamide is a non-steroidal anti-androgen drug, which also interferes with the cellular uptake and nuclear binding of androgens. It is also found that these drugs can increase blood viscosity and increase the incidence of cardiovascular embolism. The luteinizing hormone-releasing hormone analogs have a highly selective effect on the pituitary gland, causing it to release LH and FSH. long-term application can deplete this function of the pituitary gland and reduce the ability of the testes to produce testosterone, or even fail to produce testosterone and achieve the effect of drug de-testosterone.
(4) Others include M receptor antagonists, botanicals, herbal medicines, etc. M receptor antagonists improve the symptoms of the urinary storage phase in patients with BPH by blocking bladder M receptors, relieving excessive contraction of the detrusor muscle, and reducing bladder sensitivity. Botanical agents such as Pulsatilla are indicated for the treatment of BPH and related lower urinary tract symptoms.
In summary, a comprehensive estimate of the disease should be made before drug treatment is carried out, and the side effects of drugs and the possibility of long-term use should also be fully considered. The efficacy of medication should be observed with long-term follow-up and urodynamic examination should be performed regularly to avoid delaying the timing of surgery.
3. Surgical treatment
Surgery is still an important treatment method for prostatic hyperplasia.
The indications for surgery are: ① there are symptoms of lower urinary tract obstruction, urodynamic examination has been significantly changed, or the residual urine is above 60m; ② serious symptoms of unstable bladder; ③ has caused upper urinary tract obstruction and renal function impairment; ④ repeated episodes of acute urinary retention, urinary tract infection, meatus hematuria; ⑤ complication of bladder stones. For patients with long-term urinary tract obstruction, obvious impairment of renal function, severe urinary tract infection or acute urinary retention, a catheter should be placed first to relieve the obstruction, and then operate after the infection is controlled and renal function is restored. If the insertion of the catheter is difficult or if the long insertion time has caused urethritis, the procedure can be changed to suprapubic cystocentesis and fistula. The indications for emergency prostatectomy should be strictly controlled.
4. Minimally invasive treatment
(1) Transurethral electrical vaporization of the prostate is mainly an innovation in the material science of the electrode metal, which makes its biological thermal effect different from the previous one. Because of the rapid thermal transformation, it can produce 400℃ high temperature, which can rapidly cause tissue vaporization or coagulative necrosis, and its hemostatic characteristics are extremely remarkable, therefore, clinical application shows that: ① the indications are increased: glands above 60g can be performed. ② Clear surgical field: due to the remarkable hemostatic effect and clear flushing fluid, it is easy to operate. ③Decrease in operation time: Surgical resection is accelerated and operation time is shortened because of the reduction of hemostatic steps. ④Reduced complications: less likely to produce water toxicity (thick coagulation layer), clear operative field reduces misinjury, and less likely to produce sphincter and peritoneal injury. ⑤ Quicker postoperative recovery: shorter flushing time.
(2) Transurethral plasma bipolar resection of the prostate and transurethral plasma enucleation of the prostate are performed using a plasma bipolar system and transurethral resection of the prostate in a similar fashion to monopolar TURP.
(3) Cryotherapy involves deep freezing of the prostate gland followed by necrosis and decay of the tissue for the purpose of frozen prostatectomy. It can be performed transurethrally and is simple to perform, and is suitable for patients who are too old to tolerate other procedures. According to the literature, the symptoms of lower urinary tract obstruction can be relieved or improved in most patients, and residual urine is reduced. However, cryotherapy is somewhat blind, and the depth and breadth of freezing are not easy to grasp. The cryotherapy is followed by transurethral resection of the prostate to remove the residual hyperplastic tissue after freezing, which can significantly reduce bleeding.
(4) Microwave therapy uses the principle of thermal coagulation of biological tissues by microwaves to achieve therapeutic purposes. The placement of the microwave radiation pole can be positioned by rectal ultrasound or by urethroscopy under direct vision. The latter allows accurate avoidance of the external urethral sphincter and reduces complications of urinary incontinence.
(5) Laser therapy uses the thermal effect of the laser to coagulate and vaporize or remove prostate tissue in a manner similar to transurethral intracavitary manipulation. There are surface irradiation, insertional thermotherapy, and also excision of the gland using a laser beam. The efficacy of the laser is definitely to enucleate the gland and crush the tissue from the bladder and aspirate it. The long-term efficacy and price performance ratio remain to be observed.
(6) Radiofrequency ablation uses radiofrequency waves to produce a local thermal effect to cause coagulative necrosis of the prostate tissue.