Prostate adenoma - Causes, symptoms and treatment. MF.

Prostate adenoma or prostate adenoma is an outdated term, the disease is currently classified as benign prostatic hyperplasia( BPH).The disease is characterized by the formation of a small nodule or several nodules, which gradually increase. Prostate adenoma, in contrast to prostate cancer, proceeds benignly. This is one of the most common urological diseases of men after 50 years.

Causes of prostate adenoma

The reasons for the development of prostatic adenoma to the end are not clear. The main risk factor for prostatic adenoma is age - the older the man, the higher the risk of developing adenoma. In young men, adenoma of the prostate gland is very rare. This is associated with age-related changes in the endocrine regulation of the male reproductive system due to hyperplasia of the para-urethral glands( in cases of castrated or ospoplennyh men cases of adenoma of the prostate gland is not recorded).

There is no scientifically substantiated link between the onset of prostate adenoma and sexual orientation, sexual activity, smoking, alcohol consumption, transferred venereal and other infectious diseases, chronic prostatitis.

Adenoma develops as a result of the growth of a benign gland tumor that surrounds the urethra in the prostatic urethra under the bladder.

The incidence rate reaches 50% in men after 50 years, increases in later age groups and is the most common cause of bladder dysfunction.

Over 70 years old, 75% of men suffer from prostate adenoma to varying degrees. It is believed that over time it develops in 85% of men.

Symptoms of prostate adenoma

What causes a man with prostatic adenoma to seek medical help? First of all, this is the presence of problems with urination and sexual function, characteristic for this disease. Symptoms of adenoma are divided into obstructive and irritative.

Irritative symptoms as frequent urination, urinary urgency and empty non-withholding of urine( in other words - symptoms of irritation), and they are determined by the degree of functional disorders of the neuromuscular system of the bladder. The man has a need to get up 1-2 times at night, which was never observed before. A significant role in the formation of symptoms of prostate adenoma is the presence of a concomitant inflammatory process in the prostate, occurring in 70-87% of patients. Concomitant chronic prostatitis is manifested by dysuria, and with edema of the prostate gland - difficulty urinating. In addition, its presence leads to an increase in the number of early and late postoperative complications.

Symptoms of prostatic adenoma are associated with symptoms of impaired detrusor function. Now it is revealed that with age, as a result of hemodynamic and hormonal adjustment in men, hypoxia of smooth muscles of the bladder develops. This leads to the so-called instability of the bladder with the corresponding irritative symptoms.

Thus, in the formation of clinical BPH participate pathological processes in the prostate and bladder, and not always related to the actual prostatic hyperplasia. Consequently, not all patients need an operative removal of the hyperplastic benign gland. Moreover, in patients with moderate obstructive symptoms after surgical treatment, no significant improvement occurs.

Clinical manifestations and symptoms of prostate adenoma are extremely diverse and depend on the progression of the disease, physical and mental status, age, social status and medical awareness of the patient. More recently, most doctors believed that the symptoms of adenomas are quite typical and correspond to the 3 stages( compensated, subclinical, decompensated).

The first manifestations of prostate adenoma include a sluggish urine stream and delay in the initial phase of urination, increased urges and the appearance of imperative urges( not resulting in urination), especially at night. Over time, these symptoms increase and there are complaints of difficulty urinating, the need to strain and connect the abdominal muscles to empty the bladder. Because of the decrease in detrusor tone in the bladder cavity, residual urine appears. If the patient does not receive treatment, difficulty urinating becomes a permanent and predominant symptom. The volume of urine with urination gradually decreases from 200-250 to 30-50 ml, the urine stream becomes intermittent, sometimes it is secreted by drop, there is an involuntary, uncontrolled flow of urine through the urethra. Detrusor tone decreases so much that the volume of residual urine reaches a liter and more.

Unfortunately, often men view these symptoms as age-related and do not consult a doctor in a timely manner.

Complications of prostatic adenoma

Numerous complications occur during the course of the disease: hematuria( urine with blood), acute urinary retention, a variety of inflammatory phenomena against the urodynamics of the upper and lower urinary tract.

Hematuria with prostate adenoma occurs quite often and can be micro- and macroscopic, initial, terminal and total. Its origin is associated with venous hypertension in the vessels of the small pelvis and with varicose and sclerotic changes in the veins of the neck of the bladder. When hematuria occurs, stones and bladder tumors must be excluded, as well as tumors of the upper urinary tract.

Acute urinary retention can occur at any stage of the disease. It is usually associated with hypothermia or overheating of the body, alcohol intake or bowel dysfunction.

Inflammatory complications can come to the fore or aggravate the course of the disease. Cystitis and pyelonephritis, arising against a background of progressive disturbance of urodynamics, become chronic and can lead to the development of renal failure. Among other inflammatory complications of prostate adenoma, mention should be made of urethritis, prostatitis, epididymitis and vesiculitis.

The greatest number of patients with prostatic adenoma has mixed symptoms, when urine flow decreases during the day and night, the residual urine and symptoms of chronic kidney failure appear. Therefore, in all cases it is necessary to conduct a complete examination of patients.

Diagnosis of prostatic adenoma

The diagnosis of benign prostatic hyperplasia in typical cases is not difficult. In recent decades, there has been a worldwide trend towards the formation of common principles for the evaluation and interpretation of symptoms of prostate adenoma. In practical urology, the division of symptoms into symptoms of obturation and irrational, that is, symptoms of irritation, is widespread. All obturational symptoms testify to compression of the neck of the bladder and prostatic urethra with an enlarged prostate gland and the impossibility of emptying the latter with the subsequent accumulation of residual urine. The extreme manifestation of this state is paradoxical ishuria. The isolation of obstructive symptoms and the determination of residual urine can serve as a basis for a preliminary presentation of the disease, treatment tactics and prognosis. They should focus on surgical treatment.

Irritative symptoms of prostate adenoma:

increased painful urination, frequent urination at night, imperative urges, inability to retain urine during urge.

Irritative symptoms are usually attributed to changes in the function of the detrusor and the sphincter of the bladder in prostatic adenoma. Irritative symptoms, though significantly reducing the quality of life, are less dangerous and can be significantly reduced with proper conservative treatment. However, as a rule, obstructive and irritative symptoms can be observed to varying degrees in one and the same patient, and there is no direct correlation between the severity of these manifestations and the severity of the condition according to the objective survey.

Obstructive symptoms of adenoma:

is a difficult onset of urination, urine stream in patients is thin, "sluggish" and intermittent. The patient is forced to push to perform urination, notes the feeling of incomplete emptying of the bladder.

The Symptom Score for Prostate Disease( I-PSS) has now been developed, which makes it possible to quantify the extent of their severity by the patient himself. This questionnaire, being extremely simple, received wide support from urologists from many countries around the world. The system of summary assessment of symptoms in prostate diseases( I-PSS) is a questionnaire that is offered to be self-filled to the patient. He should answer 7 clear questions, choosing one of six answers, depending on the severity of each individual symptom from 0 to 5 points. The score can range from 0 to 35 points. According to the results of questioning patients are divided into 3 groups: 0-7 points - with mild symptoms;8-19 points - with moderate symptoms;20-35 points - with severe symptoms.

Compared with the data of the American Association of Urologists, in Russia the percentage of people with severe symptoms predominates.

Physical examination includes mandatory digital rectal examination. Attention is drawn to the size of the gland, the symmetry of the lobes, the presence or absence of seals, tuberosity or smoothness of the surface, painfulness of the study. Rectal examination of the patient is available for every doctor in any conditions. In most men, each lobe of the gland corresponds to the size of the finger nail phalanx. The gland is freely traced by the finger, its consistency is uniform, the boundaries are clear, easily differentiated from surrounding tissues. The surface of the gland is smooth, the mucous membrane of the rectum is mobile, the study is painless. Rectal examination is very important in terms of excluding prostate cancer .It is also very important to perform both external examination and palpation of the abdomen, as often a chronic urinary retention or percussion( tapping fingers) and palpation( palpation) is determined by the bladder.

In detecting benign prostatic hyperplasia, renal function should be assessed: general urine analysis, biochemical blood tests for urea or creatinine, if possible, renal ultrasound to clarify the condition of the upper urinary tract

For further examination in terms of surgical treatment of prostate adenoma, ultrasound examination of the prostate by rectalsensor, uroflowmetry is a non-invasive method of research, which allows one to fairly objectively assess the parameters of urination in a particularpatient, and, according to indications, cystoscopy and intravenous urography.

Treatment of adenoma of the prostate

1. medication
2. minimally invasive( HIFU-therapy)
3. operative( transurethral resection of the prostate, laser vaporization, etc.)

The main method of treatment of prostate adenoma remains operational method. It is indicated to all patients who have an infravesic obstruction, and the success of the operation largely depends on the stage of the disease and the presence of complications. Unfortunately, a very large percentage of patients seek help in the late stages of the disease in the presence of gross violations of urodynamics up to acute urinary retention and renal dysfunction. In such cases, a successful radical operation requires long preparation.

First of all, cystostomy is performed to normalize the outflow of urine - creating an external fistula of the bladder surgically. This simple operation in combination with anti-inflammatory treatment can significantly improve the condition of patients, normalize kidney function and reduce the number of postoperative complications.

Absolute indications for operative treatment of prostate adenoma:

- urinary retention( inability to empty the bladder after at least one attempt at catheterization);
- repeated massive hematuria due to BPH;
- renal failure due to BPH;
- bladder stones due to BPH;
- repeated urinary tract infections due to BPH;
- large diverticula of the bladder, due to BPH.

A radical operation for prostatic adenoma performed by transurethral or open access should be performed routinely after a complete clinical examination.

Many patients are trying by any means to delay the operation, enthusiastically meeting every new remedy for conservative treatment of prostate adenoma. Often they neglect relative indications for surgery and wait for absolute indications, one of which, the most common is acute urinary retention. For this reason, almost every third patient with prostatic adenoma begins treatment with a suprapubic urinary fistula due to acute or chronic urinary retention. The presence of infravesical obstruction is an indication for the surgical treatment of .

The "gold standard" in the treatment of prostate adenoma worldwide is transurethral resection of the prostate gland. The use of epidural anesthesia sharply reduced the number of contraindications for surgical treatment. TUR is performed by patients with a prostate volume of up to 60 cc.see. With a larger volume, which is measured by ultrasound using a rectal sensor, an open operation is shown - adenomectomy.

At one time in the literature there was a thought about the viciousness and inadmissibility of cystostomy, although now we can confidently say that in a number of patients this operation is absolutely shown. It is necessary for the removal of patients intoxicated and sanitizing urinary tract, as well as for preoperative preparation of the patient( heart, lungs, etc.).The effect of cystostomy exceeds all the inconveniences associated with the temporary presence of suprapubic drainage.

When a patient with an acute urinary retention and the diagnosis of adenoma of benign prostatic hyperplasia( after a rectal examination) is consulted, the on-duty surgeon is advised to decide the possibility of a radical surgery in the near future. If there are no contraindications for TUR or adenomectomy, the patient should be directed to a radical operation as soon as possible. It is not recommended to conduct a catheterization of the bladder for more than two days, as there is infection of the urethra and bladder, which significantly complicates the postoperative period. If there are contraindications for performing a radical operation( cardiovascular system, lungs, signs of kidney failure, urinary tract infection), cystostomy, possibly puncture, should be performed and appropriate preoperative preparation should be carried out.

Absolute indications for surgical treatment of prostate adenoma

Surgical intervention remains the best and only option for patients who have developed serious complications of prostate adenoma. However, the analysis of the long-term results after the operation indicates that up to 25% of patients are not satisfied with the treatment, since many symptoms of the disease manifestation remain. Almost every fourth patient after TUR notes frequent urination, 15.5% - do not retain urine, and residual urine is determined in 6.2% of patients. A noticeable decrease in symptoms after surgical treatment is noted mainly in patients with severe forms of the disease and severe obstructive symptoms.

In this regard, the following absolute indications for surgical treatment are determined: urinary retention( impossibility to empty the bladder after at least one attempt at catheterization), repeated massive hematuria due to benign prostatic hyperplasia, renal failure due to adenoma, bladder stones due to adenoma, repeatedurinary tract infections caused by adenoma, large bladder diverticula due to prostate adenoma.

In other cases, conservative treatment may be indicated, one of which is medication.

Medical treatment of prostatic adenoma

The drug treatment of adenoma is mostly symptomatic. To treat benign prostatic hyperplasia, drugs are used:

1. Alpha-adrenoblockers( Omnik, Omnik Okas);
2. 5-alpha reductase inhibitors( Proscar);
3. Plant extracts( Prostamol Uno).
4. Antibiotics( cephalosporins, gentamicin, etc.) with the subsequent administration of probiotics( bifidumbacterin, etc.);
5. Immunostimulants( pyrogenal, rheoferon and others);
6. Preparations that improve blood circulation in the prostate gland( trental) in order to provide the necessary blood flow to create a therapeutic concentration of other drugs in the prostate gland, which is especially important for people with atherosclerosis.

It should be noted that with the asymptomatic course of benign prostatic hyperplasia, the method of "careful waiting" is fully justified, provided that the annual follow-up examination is performed.

Doctor urologist, andrologist Vyatkin K.V.