What is Benign Prostatic Hyperplasia?

Benign benign prostatic hyperplasia (BPH) is one of the common diseases of middle-aged and elderly men, and the incidence of aging is increasing with the global population. The incidence of benign prostatic hyperplasia increases with age, but clinical symptoms may not necessarily be present when there is a hyperplastic lesion. The incidence is higher in urban areas than in rural areas, and ethnic differences also affect the degree of proliferation.

Basic Information

Causes of Benign Prostatic Hyperplasia

There are many studies on the pathogenesis of benign prostatic hyperplasia, but the etiology has not yet been elucidated. May be due to the balance between epithelial and mesenchymal cell proliferation and apoptosis, other related factors: androgen and its interaction with estrogen, the interaction of prostate mesenchymal and glandular epithelial cells, growth factors, inflammatory cells, Neurotransmitters and genetic factors. It is known that benign prostatic hyperplasia must have a functioning testicle and age. In recent years, the relationship between smoking, obesity and alcoholism, family history, ethnicity and geographical environment has also been noticed.

Clinical manifestations of benign prostatic hyperplasia

In the early stages of benign prostatic hyperplasia, due to compensation, the symptoms are atypical. As the lower urinary tract obstruction worsens, the symptoms gradually become obvious. Clinical symptoms include symptoms during storage, symptoms during urination, and symptoms after urination. Due to the slow progression of the disease course, it is difficult to determine the onset time.

Urine storage symptoms

The main symptoms of this period include frequent urination, urgency, incontinence, and increased nocturia.

(1) Frequent urination and increased nocturia are early symptoms, and the number of nocturia increases, but the amount of urine output is not large. After decompensation of the bladder detrusor, chronic urinary retention occurs, thereby reducing the effective capacity of the bladder and shortening the interval between urination. If accompanied by bladder stones or infections, urinary frequency becomes more pronounced and is accompanied by dysuria.

(2) In the case of urinary urgency and urinary incontinence, 50% to 80% of patients have urgency or urgency incontinence.

2. Symptoms of urination

Symptoms during this period include urinary urination, difficulty urinating, and intermittent urination.

With the enlargement of the glands, the mechanical obstruction worsens, and the difficulty of urination increases. The degree of lower urinary tract obstruction is not proportional to the size of the glands. Due to the increase in urethral resistance, the patient's urination onset was delayed, the urination time was prolonged, the range was not far, and the urine line was thin and weak. Bifurcation and endless urination. If the obstruction worsens, the patient must increase abdominal pressure to help urinate. Breathing increases or decreases abdominal pressure, interruptions in urine flow, and dripping.

3. Symptoms after urination

Symptoms during this period include endless urination, dripping after urination, and so on.

Endless urine and increased residual urine: Residual urine is the result of decompensation of the bladder detrusor. When the residual urine volume is large, the bladder is over-inflated and the pressure is high, which is higher than the urethral resistance, the urine will overflow from the urethra on its own, which is called overflow urinary incontinence. Some patients usually do not have much residual urine, but acute cold retention may occur suddenly when they are exposed to cold, alcohol, urination, taking medication, or have other reasons for sympathetic nerve excitement. The symptoms of urinary retention in patients can be good or bad. Some patients may have acute urinary retention as the first symptom.

4. Other symptoms

(1) Hematuria: capillary congestion and small blood vessels dilate on the prostate mucosa and are stretched by enlarged glands or rubbed against the bladder. When the bladder contracts, it can cause microscopic or gross hematuria. Cystoscopy, metal urinary catheterization, and sudden decompression of the bladder during acute urinary retention catheterization can easily cause severe hematuria.

(2) Urinary tract infections Urinary retention often leads to urinary tract infections, which may include symptoms such as urgency, frequent urination, and difficulty urinating, accompanied by dysuria. When the upper urinary tract infection is secondary, fever, low back pain, and systemic poisoning may occur. Although the patient usually has no symptoms of urinary tract infection, there may be more white blood cells in the urine, or bacterial growth in the urine culture, and it should be treated before surgery.

(3) Urinary tract obstruction under bladder stones , especially when there is residual urine, the urine stays in the bladder for a longer time, and stones can gradually form. When accompanied by bladder stones, urinary line interruption, pain at the end of urination, and urination after changing position can be seen.

(4) Renal damage is mostly due to ureteral reflux and hydronephrosis leading to the destruction of renal function. The main complaints of patients at the time of consultation are loss of appetite, anemia, increased blood pressure, or lethargy and unconsciousness. Therefore, benign prostatic hyperplasia should be ruled out first for male patients with unexplained renal insufficiency symptoms.

(5) A long-term lower urinary tract obstruction may result in a lower abdominal mass due to bladder diverticulum filling or an upper abdominal mass due to hydronephrosis. Long-term reliance on increased abdominal pressure to help urinate can cause hernias, hemorrhoids, and prolapse.

Benign prostatic hyperplasia

External genital examination

Excludes narrowing of the outer urethra or other diseases that may affect urination (eg phimosis, penile tumor, etc.).

2. Digital Rectal Examination (DRE)

Digital rectal examination is a simple and important diagnostic method that needs to be performed after the bladder is emptied. Attention should be paid to the boundaries, size and texture of the prostate. In benign prostatic hyperplasia, the glands can grow in length or width, or both. Different methods are used to describe the extent of prostate enlargement.

There is a certain error in the digital rectal estimate of prostate size. If the middle lobe protrudes toward the bladder, the prostate gland enlargement is not obvious during digital rectal examination. At the same time, if a suspicious induration is found on the prostate by digital rectal examination, a biopsy should be performed to rule out the possibility of prostate cancer. The proportion of patients with DRE abnormality who are finally diagnosed with prostate cancer is 26% to 34%, and the positive rate of them increases with age. At the same time, attention should be paid to the contractile function of the anal sphincter to exclude neurogenic bladder dysfunction.

3. Examination of the local nervous system (including movement and sensation)

Examination of the perianal and perineal peripheral nervous system to indicate the presence of neurogenic bladder dysfunction due to neurogenic disease.

4. Urine routine

To determine whether patients with lower urinary tract symptoms ((Lowerurinarytractsymptoms, LUTS)) have hematuria, proteinuria, pyuria, and urine sugar.

5.B-ultrasound

Observe the size, shape and structure of the prostate, whether there is abnormal echo, the degree of protrusion into the upper arm, and the residual urine volume (Postvoidresidualvolume). Common methods include transrectal and abdominal ultrasound. The former is more accurate but requires high equipment, the latter is simple and popular.

Transrectal B-ultrasound can also be used to measure the volume of the prostate, to judge the deformation and displacement of the urethra from the urinary sonogram, to understand the dynamic changes of lower urinary tract obstruction, and to understand the state after treatment. Transabdominal B-ultrasound is more common in China. Observing the internal structure of the glands is not as good as transrectal B-ultrasound.

6. Residual urine determination

Because the detrusor of the bladder can overcome the increased urethral resistance and empty the urine in the bladder by means of compensation, the absence of residual urine in the early stage of benign prostatic hyperplasia cannot exclude the existence of lower urinary tract obstruction. It is generally believed that a residual urine volume of 50 to 60 ml indicates that the detrusor of the bladder is in an early decompensated state.

Residual urine measurement is more accurate after urination. The method of measuring residual urine by transabdominal B-ultrasound is more simple, the patient is painless, and can be repeated. But when the residual urine volume is small, the measurement is not accurate enough. Intravenous pyelography is a method of observing residual urine during the bladder filling period and after urination, which is of little practical value because it cannot be quantified. The isotope concentration measurement, that is, the concentration quantification, can be measured according to the method of different concentration solution volumes, which is the most accurate method, but the cost is high and it is difficult to popularize.

7. Other

Magnetic resonance imaging has no special value in the diagnosis of benign prostatic hyperplasia, but it can help identify early prostate cancer. If necessary, urodynamic tests and urography can be performed.

The clinical diagnosis of this disease mainly depends on the history, digital rectal examination and B-ultrasound. Cystoscopy can be performed when necessary, and further understanding of the presence of upper urinary tract dilatation and renal impairment, neurological bladder dysfunction, peripheral neuritis and cardiovascular disease caused by diabetes, and finally estimation of the general situation and decision treatment plan.

Diagnosis of benign prostatic hyperplasia

Patients with benign prostatic hyperplasia often have other chronic diseases because they are elderly patients. At the time of diagnosis, we should pay attention to the overall condition of the patient, conduct detailed consultation, physical examination, and laboratory tests, and pay attention to heart, lung, liver, and kidney functions. Difficulty of urination combined with various examinations can confirm the diagnosis.

1.IPSS score

In 1995, the International Society of Urology (SIU) introduced the IPSS scoring system in an attempt to quantify symptomology for comparison and assistance in diagnosis, and can also be used as a post-treatment evaluation standard. The system determines the score by answering 6 questions, up to 35 points. At present, it is considered that a score of 7 or less is mild, a score of 7 to 18 is moderate, and a score of 18 or more is severe, requiring surgical treatment. IPSS is currently the best internationally recognized method for judging the severity of symptoms in patients with BPH, but it is mainly a subjective reflection of the severity of lower urinary tract symptoms in patients with BPH. This scoring system can be used at work to assist diagnosis and treatment.

2. Ask a medical history

(1) Characteristics, duration and accompanying symptoms of lower urinary tract symptoms;

(2) history of surgery and trauma, especially pelvic surgery or trauma;

(3) Know previous history, including history of sexually transmitted diseases, diabetes, neurological diseases, and heart disease that may be related to nocturia;

(4) History of medication, to know whether the patient is currently or in the near future taking drugs that affect the function of bladder exit or cause LUTS;

(5) General condition of the patient.

Differential diagnosis of benign prostatic hyperplasia

Bladder neck contracture

Patients with symptoms of lower urinary tract obstruction, digital rectal examination did not find a significant increase in prostate, in addition to the increase of the glandular lobe process to the bladder, the possibility of bladder neck contracture should be considered. It is generally believed that bladder neck contractures are secondary to inflammatory lesions. Bladder neck smooth muscle is replaced by connective tissue, which can be accompanied by inflammation. Patients with bladder neck contractures have a long history of lower urinary tract obstruction. During cystoscopy, the neck of the bladder is elevated and the posterior urethra and triangle of the bladder contract. Cystoscopy showed no compression deformation of the urethra of the prostate segment, and the inner urethra narrowed. When the simple benign prostatic hyperplasia lobes approach the neck of the bladder, they are covered by soft mucosa, the bladder triangle is depressed, and the posterior urethra is prolonged.

Bladder neck contractures can be accompanied by benign prostatic hyperplasia. Due to the unclear boundary between the proliferative glands and the surgical envelope, removal is often difficult, and the glands are significantly smaller than those predicted by digital rectal examination or B-ultrasound. If the contracture of the bladder neck is not treated at the same time after the glands are removed, it is difficult to relieve the lower urinary tract obstruction.

Treatment can try alpha-blockers. If the symptoms are severe, recurrent urinary tract infections, or abnormal urodynamic tests, transurethral resection, suprapubic bladder neck wedge resection, or bladder neck YV plasty can be considered.

2. Prostate cancer

Prostate cancer, especially ductal cancer, may be the first symptom following urinary tract obstruction. In some patients, benign prostatic hyperplasia is accompanied by prostate cancer, and serum PSA (prostate-specific antigen) is increased, more than 10.0ng / ml. Digital rectal examination of the prostate surface is not smooth, rocky feel. Transrectal biopsy, B ultrasound guidance is better, and the diagnosis can be confirmed by pathological examination.

3. Neurological bladder and detrusor sphincter synergy

Often manifested in lower urinary tract dysuria, urinary incontinence and other manifestations. You need to ask for a history of trauma in detail, check for anal levator reflexes, and exclude them by urodynamic tests, such as filling cystometry, urethral pressure map, and simultaneous pressure / flow rate detection.

4. Weak bladder (aging of bladder wall)

It is characterized by urinary retention, abnormal urination in the lower urinary tract, and a large amount of residual urine. It should be distinguished from benign prostatic hyperplasia. Factors such as injury, inflammation, and diabetes should be excluded. It is also mainly through urodynamic examination. Special urethral pressure map, simultaneous detection of pressure / flow rate to identify. Bladder pressure map shows low bladder pressure and no systolic pressure waveform.

Benign Prostatic Hyperplasia Treatment

The danger of benign prostatic hyperplasia lies in the pathophysiological changes caused by lower urinary tract obstruction. The pathological individual is very different, and not all of them develop progressively. Some lesions no longer develop to a certain extent, so even if there are mild obstruction symptoms, surgery is not required.

Watch and wait

Symptoms are mild. IPSS scores below 7 can be observed without treatment.

2. Drug treatment

(1) 5-reductase inhibitors are suitable for the treatment of patients with BPH who have increased prostate volume with moderate and severe lower urinary tract symptoms. Studies have found that 5-reductase is an important enzyme for the conversion of testosterone to dihydrotestosterone. Dihydrotestosterone has a role in benign prostatic hyperplasia, so the use of 5-reductase inhibitors can inhibit the proliferation to a certain extent.

(2) 1-receptor blockers are suitable for BPH patients with moderate and severe lower urinary tract symptoms. At present, it is believed that such drugs can improve urinary tract dynamic obstruction, reduce resistance to improve symptoms, and commonly used drugs include gortrin. Common side effects of these drugs include dizziness, headache, fatigue, drowsiness, orthostatic hypotension, and abnormal ejaculation.

(3) Others include M receptor antagonists, plant preparations, Chinese medicine, etc. M receptor antagonists alleviate excessive contraction of the detrusor muscle and reduce bladder sensitivity by blocking the M receptor of the bladder, thereby improving the symptoms of patients with BPH during storage. Botanical preparations such as Pu Shi Tai are suitable for the treatment of BPH and related lower urinary tract symptoms.

In summary, a comprehensive estimate of the condition should be made before drug treatment, and the side effects of the drug and the possibility of long-term use should also be fully considered. Observing the efficacy of the drug should be followed up for a long time, and regular urodynamic tests should be performed to avoid delaying the timing of the operation.

3. Surgical treatment

Surgery is still an important treatment for benign prostatic hyperplasia. It is applicable to patients with BPH who have moderate to severe LUTS and have significantly affected the quality of life. The classic surgical methods include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy. TURP is still the "gold standard" for BPH treatment.

The surgical indications are: symptoms of lower urinary tract obstruction, urodynamic examination has changed significantly, or residual urine above 60m; severe unstable bladder symptoms; has caused upper urinary tract obstruction and renal function damage; multiple times Acute urinary retention, urinary tract infection, gross hematuria; complicated by bladder stones. Combining inguinal temples, severe hemorrhoids, or prolapse of the anus, and those who are unable to achieve lower urinary tract obstruction without clinical judgment can not achieve the treatment effect. For patients with long-term urinary tract obstruction, renal function has been significantly impaired, patients with severe urinary tract infection or acute urinary retention should be indwelling catheter to remove the obstruction, the infection is controlled, and renal function is restored before surgery. If urinary tractitis is difficult due to difficulty in inserting a urinary catheter or a long time to intubate, a suprapubic bladder puncture may be performed. The indications for emergency prostatectomy should be strictly grasped.

4. Minimally invasive treatment

(1) Transurethral electrovaporization of the prostate (TUVP) is suitable for patients with BPH who have poor blood coagulation function and small prostate volume. It is another option for TUIP or TURP. It is mainly the innovation of electrode metal materials that makes its biological thermal effect different from the former. Due to the rapid thermal transformation, it can produce high temperature of 400 , which can cause tissue vaporization or coagulative necrosis, and its hemostatic characteristics are extremely significant. Therefore, clinical application shows: Increased indication: glands above 60g can be implemented. The surgical field is clear: Because the hemostatic effect is significant, the irrigation solution is clear, which is convenient for surgery. Reduction of operation time: As the hemostatic steps are reduced, surgical resection is accelerated and the operation time is shortened. Reduction of complications: It is not easy to produce water poisoning (thick coagulation layer), clear surgical field reduces accidental injuries, and it is not easy to produce sphincter and capsule damage. Fast recovery after operation: The flushing time is shortened.

(2) Transurethral prostate plasma bipolar resection (TUPKP) and transurethral plasma prostate enucleation (TUKEP) use a plasma bipolar resection system and perform a transurethral prostatectomy in a similar way to unipolar TURP surgery. The main advantages of TUPKP include less intraoperative and postoperative bleeding, reduced blood transfusion rate, and shorter postoperative catheterization and hospital stay; TUKEP removes the prostate within the capsule, which is more in line with the anatomy of the prostate, has more complete resection of the prostate hyperplasia, The postoperative recurrence rate is low and the intraoperative bleeding is low. .

(3) Microwave treatment is suitable for patients who are ineffective in drug treatment (or unwilling to take medication for a long time) and are unwilling to undergo surgery, and high-risk patients with repeated urinary retention who cannot undergo surgery. It is based on the principle of thermal coagulation of biological tissues by microwave to achieve the purpose of treatment. Microwave emitters can be placed by rectal ultrasound or directly under urethoscope. The latter can accurately avoid the external urethral sphincter and reduce the complications of urinary incontinence.

(4) Laser treatment The common feature of laser surgery is that the intraoperative blood loss is relatively small, especially suitable for patients with high risk factors, such as advanced age, anemia, and impaired vital organ function. The laser thermal effect is used to coagulate and vaporize or remove prostate tissue in a similar way to transurethral cavity operation. There are surface irradiation, insertion of hyperthermia, and removal of glands by laser beam. The curative effect is affirmatively, the glands are removed by laser enucleation, and the tissue is crushed and sucked out from the bladder. The long-term curative effect and price-performance ratio remain to be seen.

5. Other

(1) Transurethral Needle Ablation (TUNA) is a simple and safe treatment method, suitable for high-risk patients with prostate volume <75ml, who cannot undergo surgery, and is not recommended as a first-line treatment for general patients.

(2) Stents are metal (or polyurethane) devices placed in the urethra of the prostate through an endoscope. To relieve the symptoms of lower urinary tract caused by BPH. It is only suitable for high-risk patients with repeated urination and can not undergo surgery, as an alternative treatment method for catheterization. Common complications include stent displacement, calcification, stent occlusion, infection, and chronic pain.