Benign prostatic hyperplasia is an overgrowth of glandular tissue and stroma of the transitional zone of the prostate, leading to an increase in the organ. Prostate adenoma can cause urinary disorders: a weak stream of urine, a feeling of incomplete emptying of the bladder, frequent or nocturnal urges, paradoxical ischuria. The diagnosis is established according to the level of PSA, TRU, uroflowmetry and the IPSS symptom assessment questionnaire. Treatment correlates with the volume of the gland, age, concomitant pathology and the severity of symptoms: waiting tactics, drug therapy, surgical interventions, including minimally invasive techniques are used.
ICD 10
N40 Prostatic hyperplasia
General information
Benign prostatic hyperplasia (prostate adenoma, BPH) is a common global problem faced by one third of men over 50 and 90% of patients who have lived to 85 years. According to statistics, about 30 million men have urogenital dysfunction associated with BPH, and this figure is increasing every year. Pathology is more common in African Americans with initially higher testosterone levels, 5-alpha-reductase activity, growth factors and androgen receptor expression (a population feature). In residents of eastern countries, prostate adenoma is registered less often, which is apparently due to the consumption of a large number of foods containing phytosterols (rice, soy and its derivatives).
Causes
It is obvious that prostate adenoma is a multifactorial disease. The main factor is a change in the hormonal background associated with natural aging with the normal functioning of the testicles. There are many hypotheses explaining the mechanisms of pathology development (the theory of stromal-epithelial relationships, stem cells, inflammation, etc.), however, most researchers consider hormonal theory as fundamental. It is assumed that the age-related predominance of dihydrotestosterone and estradiol stimulate specific receptors in the gland that trigger cell hyperplasia. Additional background risk factors include:
- Overweight/obese. The accumulation of adipose tissue, especially in the abdominal area, is one of the indirect causes of prostate enlargement. This is due to low testosterone levels in obese men. In addition, with hypoandrogenism, the amount of estrogens increases, which increases the activity of dihydrotestosterone, which contributes to hyperplasia.
- Diabetes. High glucose levels and insulin resistance accelerate the progression of BPH. The glucose level in diabetes is higher not only in the blood, but also in all prostate cells, which stimulates their growth. In addition, diabetes mellitus leads to damage to blood vessels, including the prostate gland, which can result in an enlarged prostate. A number of studies demonstrate that among men with diabetes and elevated levels of low-density lipoproteins, BPH is detected 4 times more often.
- Features of nutrition. Eating high-fat foods increases the likelihood of prostate hyperplasia by 31%, and the daily inclusion of red meat in the diet by 38%. The exact role of fatty foods in the occurrence of hyperplastic processes is unknown, presumably, it contributes to hormonal imbalance associated with BPH.
- Heredity. Genetic predisposition is of some importance: if male relatives of the first line were diagnosed early with prostate adenoma with pronounced symptoms, the risk of its development in the next generation of men increases.
Pathogenesis
Testosterone in a man’s body is contained in various concentrations: its level is higher in the blood, less in the prostate. In older men, there is a decrease in testosterone levels, but the level of dihydrotestosterone remains high. A significant role belongs to the prostate-specific enzyme 5-alpha reductase, thanks to which testosterone passes into 5-alpha-dihydrotestosterone. Androgen receptors and DNA of prostate cell nuclei are most sensitive to its action, which stimulate the synthesis of growth factors and inhibit apoptosis (violation of programmed processes of natural death). As a result, old cells live longer, and new cells actively divide, causing tissue proliferation and adenoma growth.
An enlarged prostate contributes to difficulty urinating against the background of narrowing of the prostatic part of the urethra (especially if the growth of adenoma is directed inside the bladder) and increases the tone of smooth muscle fibers of the stroma. At the initial stage of pathology, the condition is compensated by the increased work of the detrusor, which, straining, allows the urine to be evacuated completely.
As the progression progresses, morphological changes appear in the bladder wall: part of the muscle fibers is replaced by connective tissue. The capacity of the organ gradually increases, and the walls become thinner. The mucous membrane also undergoes changes: hyperemia, trabecular hypertrophy and diverticula, erosive ulceration and necrosis are typical. When a secondary infection is attached, cystitis develops. Benign prostatic hyperplasia and urinary stagnation lead to reverse urine flow, cystolithiasis, hydronephrotic transformation of the kidneys and CRF.
Classification
In andrology, several classifications of BPH are accepted. Depending on the volume of the gland (it is determined by ultrasound and measured in cubic centimeters), small (up to 25 cm3), medium (26-80 cm3), large (more than 80 cm3) and giant adenoma (over 250 cm3) are isolated. Guyon ‘s classification distinguishes three clinical stages of BPH:
- Compensation. Dysuric phenomena are absent or expressed slightly, there is no residual urine. Bladder, kidneys without visible signs of pathology.
- Subcompensation. Clinical phenomena are more pronounced, which is caused by the progression of the disease. Residual urine is determined. The upper urinary tract is modified, which is manifested by a violation of the functional ability of the kidneys.
- Decompensation. The functions of the bladder are impaired, there is paradoxical ischuria, severe ureterohydronephrosis, and the addition of CRF.
Benign prostatic hyperplasia symptoms
Symptoms depend on the degree of obstruction of the urethra. If the enlarged prostate squeezes the urethra, there are complaints of frequent urination in small portions, especially at night, a sluggish jet, a feeling of incomplete emptying, regardless of the frequency of urination. As the adenomatous nodes grow, innervation changes, resulting in urgent urges — an uncontrolled desire to urinate, followed by urinary incontinence.
At an advanced stage, paradoxical ischuria develops — the inability to urinate completely with simultaneous leakage of urine in drops, which is associated with atony of the walls of the bladder, as well as detrusor-sphincter dissinergia — the lack of synchronous work between the muscle responsible for expelling urine and relaxation of the urethra sphincter. To empty the bladder, some men are forced to urinate according to the female type ‒ sitting. Clinical manifestations of benign prostatic hyperplasia are non-pathognomonic and can accompany any obstruction, including urethral stricture, diverticulum, tumor, etc., therefore, it is impossible to establish a diagnosis only on the basis of an assessment of symptoms.
Complications
Complications of a hyperplastic prostate can include a number of conditions. Against the background of BPH, acute urinary retention is manifested in 35%. Residual urine tends to crystallize, in this case concretions with secondary inflammation form in the bladder. Increased intravesical pressure contributes to the formation of vesicoureteral reflux, hydronephrosis and CRF. If we consider the complications of prostate adenoma therapy, then there is a possibility of developing urethral strictures after transurethral resection (5-7%), urinary incontinence (1-2%), erectile dysfunction (9-14%), retrograde ejaculation (74-87%), cervical bladder sclerosis (2-4%).
Diagnostics
The diagnosis is made by a urologist or andrologist. Rectal examination is informative only if the location of the tumor is achievable. During finger examination, the prostate is enlarged, homogeneous, painless, its consistency is elastic, the median groove is smoothed. Prostate biopsy is not a routine method and is indicated only if prostate cancer is suspected. A patient with suspected renal dysfunction needs to consult a nephrologist.
There is a special questionnaire designed to assess the severity of symptoms of obstruction of the lower urinary tract. The questionnaire consists of 7 questions related to common symptoms of benign prostatic hyperplasia. The frequency of each symptom is evaluated on a scale from 1 to 5. When summing up, an overall assessment is obtained, which affects the further tactics of treatment (dynamic observation, conservative therapy or surgery): from 0-7 — mild symptoms, 8-19 — average, 20-35 ‒ a serious problem with urination. Instrumental and laboratory diagnostics for BPH include:
- Ultrasound. TRU and transabdominal ultrasound of the prostate and bladder are complementary imaging methods. Ultrasound examination is performed twice — with a filled bladder and after the act of urination, which allows you to determine the amount of residual urine. Asymmetry, density, heterogeneity of the structure, increased blood supply to the prostate indicate adenoma.
- Radiography. With X-ray diagnostics (excretory urography, cystography), it is possible not only to determine the size of the prostate, but also to assess kidney function, developmental abnormalities, diagnose pathologies of the bladder, urethra. The study involves intravenous administration of a contrast agent.
- Urodynamic studies. Uroflowmetry is a simple test to assess the flow of urine, graphically shows the rate of bladder release and the degree of obstruction. The study is performed to determine the indications for surgical treatment and to track the dynamics against the background of conservative therapy.
- PSA research. Prostate-specific antigen is produced by the cells of the organ capsule and periurethral glands. In patients with benign prostatic hyperplasia and prostatitis, PSA levels are elevated. The result is influenced by many factors, so it is impossible to establish a diagnosis based on one analysis.
- Urine tests. In men with prostate adenoma, concomitant inflammation of the bladder and kidneys is often diagnosed, so the OAM pays attention to signs of inflammation — leukocyturia, proteinuria, bacteriuria. Blood in the urine may indicate varicose changes in the vessels of the neck of the bladder, their rupture when straining. With changes, urine is sown on nutrient media to clarify the composition of microbial flora and sensitivity to antibiotics.
Differential diagnosis is carried out with the tumor process of the bladder or prostate, cystolithiasis, trauma, interstitial and radiation cystitis, neurogenic bladder, urethral stricture, prostate sclerosis, meatostenosis, urethral valves, phimosis, prostatitis.
Benign prostatic hyperplasia treatment
Prostate adenoma therapy correlates with the severity of obstructive symptoms and complications, the choice of treatment tactics is influenced by the patient’s age and concomitant pathology. All existing methods of treatment are aimed at restoring adequate urine derivation. Therapy options include:
- Watchful waiting. This tactic is used in men with mild symptoms < 7 on the IPSS scale and in patients with an IPSS score < 8, the presence of symptoms in which is not considered to violate the quality of life in the absence of complications. Once a year, such patients undergo TRU, PSA analysis, and finger examination. Drug therapy is not indicated, as it does not lead to an improvement in well-being and has great risks that can significantly affect the quality of life (for example, erectile dysfunction during treatment with alpha-blockers).
- Drug therapy. With the advent of alpha-blockers, many patients with prostatic hyperplasia have the opportunity to avoid surgery. The drugs relax the muscles in the prostate, urethra and in the neck of the bladder, which is why the strength of the urine stream increases. Drug therapy is performed in patients with severe, moderate and severe urinary disorders from 8 points and above. 5-alpha reductase inhibitors are prescribed to prevent the progression of urinary obstruction symptoms. According to the indications, combination therapy is possible. The inclusion of 5-phosphodiesterase inhibitors in the scheme improves urine flow and has a positive effect on erectile function.
- Surgical treatment. There are several options for surgical interventions: adenomectomy, which refers to radical operations (can be performed both by open access and laparoscopic) and transurethral resection of the prostate gland. Each operation has its own indications, advantages and disadvantages. In severe concomitant pathology, when the probability of an unfavorable outcome is high, epicystostomy is performed as a palliative measure. After normalization of the condition, it is possible to resolve the issue of removing drainage and restoring self-urination.
- Minimally invasive therapy. There are a number of techniques to avoid the adverse effects associated with TRU and adenomectomy. These include laser destruction (vaporization, coagulation) by contact or non-contact method, needle ablation, electrointelligence, transurethral microwave therapy (microwave energy), radiofrequency water thermotherapy, etc. A large volume of the prostate gland is a contraindication to minimally invasive methods of treatment.
Prognosis and prevention
The prognosis for life is favorable, for most patients a long (lifelong) intake of modern medications is sufficient to normalize the function of urination. The need for surgery occurs only in 15-20% of men. After an adenomectomy, the recurrence of the disease does not exceed 5%, minimally invasive techniques do not give a 100% guarantee of healing and can be performed repeatedly. The improvement of the prognosis in the last decade has been facilitated by the introduction of minimally invasive methods of treatment, which minimizes complications that threaten the lives of patients. To normalize erectile function, a consultation of an andrologist-sexologist is necessary.
Data from prostate cancer prevention studies show that a diet low in animal fat and red meat and high in protein and vegetables can reduce the risk of symptomatic BPH. Physical activity for at least 1 hour a week reduces the likelihood of nocturia by 34%.