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There are many studies on the pathogenesis of benign prostatic hyperplasia, but the etiology is still unknown. At present, it is known that benign prostatic hyperplasia must meet two conditions: normal testicular function and aging. In recent years, the relationship among smoking, obesity and alcoholism, family history, race and geographical environment has also been concerned.
clinical picture
Due to compensation in the early stage of BPH, the symptoms are atypical. With the aggravation of lower urinary tract obstruction, the symptoms become more and more obvious. Clinical symptoms include symptoms of urine storage period, symptoms of urination period and symptoms after urination. Due to the slow progress of the disease, it is difficult to determine the onset time.
1. Symptoms of urine storage period
(1) Frequent micturition and increased nocturia are early symptoms. At first, the number of nocturia increases, but the urine output is not much each time. After detrusor decompensation, chronic urinary retention occurs, which reduces the effective volume of bladder and shortens the interval between urination. If accompanied by bladder stones or infection, the frequency of urination is more and more obvious, accompanied by dysuria.
(2) Urgency and urinary incontinence with lower urinary tract obstruction, 50% ~ 80% of patients have urgency or urge urinary incontinence.
2. Symptoms during urination
Dysuria: with the enlargement of glands, mechanical obstruction and dysuria aggravated, the degree of lower urinary tract obstruction is not proportional to the size of glands. Due to the increase of urethral resistance, the patient's urination began to be delayed, the urination time was prolonged, the range was not far, and the urinary line was thin. The urine is forked, and there is a feeling of endless urine. If the obstruction is further aggravated, the patient must increase abdominal pressure to help urinate. Breathing increases or decreases abdominal pressure, and urine flow is interrupted and drips.
3. Symptoms after urination
Incomplete urine and increased residual urine: Residual urine is the result of detrusor decompensation. When the residual urine volume is large, the bladder is over-inflated, and the pressure is high, which is higher than the urethral resistance, urine will automatically overflow from the urethra, which is called overflow urinary incontinence. Some patients usually have little residual urine, but when they catch cold, drink alcohol, hold their urine, take medicine or have other reasons to cause sympathetic nerve excitement, they may suddenly have acute urinary retention. The symptoms of patients with urinary retention are sometimes good and sometimes bad. Some patients may have acute urinary retention as the first symptom.
4. Other symptoms
(1) Hematuria: The capillaries on the prostate mucosa are congested, and the enlarged glands pull or rub the bladder. When the bladder contracts, it can cause microscopic or macroscopic hematuria, which is one of the common causes of hematuria in elderly men. Cystoscopy, metal catheter catheterization and sudden bladder decompression during acute urinary retention catheterization are easy to cause severe hematuria.
(2) Urinary tract infection Urinary retention often leads to urinary tract infection, with symptoms such as urgency, frequent urination and dysuria. , with dysuria. When secondary upper urinary tract infection occurs, there will be symptoms of fever, low back pain and systemic poisoning. Although patients usually have no symptoms of urinary tract infection, there may be more white blood cells in urine or bacterial growth in urine culture, which should be treated before operation.
(3) Lower urinary tract obstruction caused by bladder stones, especially when there is residual urine, the urine stays in the bladder for a long time and can gradually form stones. When accompanied by bladder stones, there may be urinary line interruption, pain at the end of urination, and urination after changing body position.
(4) Renal function damage is mostly caused by ureteral reflux, and hydronephrosis leads to renal function damage. The main complaints of patients during treatment are often loss of appetite, anemia, elevated blood pressure or drowsiness and unconsciousness. Therefore, for the male elderly with unexplained renal insufficiency symptoms, prostatic hyperplasia should be ruled out first.
(5) Long-term lower urinary tract obstruction may lead to lower abdominal mass caused by bladder diverticulum filling or upper abdominal mass caused by hydronephrosis. Long-term dependence on increasing abdominal pressure to help urinate will lead to hernia, hemorrhoids and proctoptosis.
diagnose
Patients with benign prostatic hyperplasia are often complicated with other chronic diseases because they are elderly patients. Attention should be paid to the general situation of patients, detailed physical examination and laboratory examination, and to the heart, lung, liver and kidney functions. The symptoms of dysuria combined with various tests can be diagnosed clearly.
1.IPSS score
From 65438 to 0995, the International Society of Urology (SIU) introduced the IPSS scoring system, trying to quantify the symptoms for comparison and diagnosis, which can also be used as an evaluation standard after treatment. The system determines the score by answering six questions, with a maximum score of 35. At present, it is considered that the score below 7 is mild, 7 ~ 18 is moderate, and the score above 18 is severe, which requires surgical treatment. IPSS is the best method to judge the severity of symptoms in patients with BPH, and the scoring system can be used for clinical auxiliary diagnosis and treatment.
2. Digital rectal examination
Digital rectal examination is a simple and important diagnostic method, which is performed after bladder emptying. Attention should be paid to the boundary, size and texture of prostate. In the case of benign prostatic hyperplasia, the glands may increase in length or width, or both. Clinically, different methods are used to describe the degree of prostate enlargement.
However, there is a certain error in the estimation of prostate size by rectal digital examination. If the middle lobe protrudes into the bladder, the prostate enlargement is not obvious during rectal digital examination. At the same time, if the rectal digital examination finds suspicious induration on the prostate, biopsy should be done to rule out the possibility of prostate cancer. At the same time, we should pay attention to the contraction function of anal sphincter and exclude neurogenic bladder dysfunction.
3.b-ultrasound examination
The size, shape and structure of prostate were observed by B-ultrasound. Commonly used methods are transrectal and transabdominal ultrasound examination. The former is more accurate but requires high equipment, while the latter is simple and can be popularized.
Transrectal ultrasound can also judge the deformation and displacement of urethra from the sonogram of micturition period, understand the dynamic changes of lower urinary tract obstruction and understand the state after treatment. Abdominal ultrasound is widely used in China, and observing the internal structure of glands is not as good as transrectal ultrasound.
4. Urodynamic examination
Urodynamic examination can objectively evaluate urination function. Maximum urine flow rate, average urine flow rate, urination time and urine volume are of great significance. Maximum urinary flow rate is an important diagnostic index. Attention should be paid to the influence of urine volume on the maximum urine flow rate. When checking, the urine volume of 250 ~ 400 ml is the best urine volume, and the urine volume of 150 ~ 200 ml is the minimum urine volume. For most men over 50 years old, the maximum urine flow rate is 15ml/s, which is normal. When measuring urine flow rate and bladder pressure at the same time, it is helpful to judge the detrusor function and its damage degree, so as to accurately grasp the operation opportunity. After lower urinary tract obstruction, if the detrusor continues to contract, whether it is inhibited or not, it will develop into a bladder with low compliance and high compliance. Although the urinary flow rate can return to normal after operation, the detrusor function is sometimes difficult to recover.
5. Determination of residual urine
Because the bladder detrusor can overcome the increased urethral resistance, there is no residual urine in the early stage of prostatic hyperplasia by compensatory emptying of urine in the bladder, and the existence of lower urinary tract obstruction cannot be ruled out. It is generally believed that the residual urine volume of 50 ~ 60 ml indicates that the bladder detrusor is in an early decompensated state.
It is more accurate to measure residual urine by catheterization after urination. The method of determining residual urine by transabdominal B-ultrasound is simpler, painless and repeatable. But when the residual urine volume is small, the measurement is not accurate enough. Intravenous pyelography (IVP) is a method to observe the residual urine by taking a picture when the bladder is full and after urination. Because it cannot be quantified, it is of little practical value. Isotope concentration measurement, that is, concentration quantification, can be determined according to the solution capacity of different concentrations, which is the most accurate method, but it is expensive and difficult to popularize.
6. Urography
In the case of benign prostatic hyperplasia, the bottom of the bladder can be raised and widened. Intravenous urography shows that the distance between the two ureters increases and the lower part of the ureter is hooked. If hydronephrosis exists, it is bilateral, but the degree of expansion is not necessarily the same. There is obvious filling defect in the bladder area, which is caused by the protrusion of prostate.
7. Cystoscopy
The distance from the seminal vesicle to the bladder neck of a normal person is about 2cm, with a sunken neck and a flat posterior lip. When BPH occurs, the posterior urethra is lengthened, and the shape of the neck changes with the degree of hyperplasia of each lobe, from concave lobe to convex lobe. The urethra is compressed and becomes a seam. The bottom of the bladder sinks, and the distance between the ureteral orifice and the bladder neck becomes wider. The ridge between ureters can be thicker, forming trabecula, chambers or diverticula on the bladder wall.
8. Others
Magnetic resonance imaging has no special value in the diagnosis of benign prostatic hyperplasia, but it is helpful to distinguish early prostate cancer.
The clinical diagnosis of the disease mainly depends on medical history, digital rectal examination and B-ultrasound examination. Cystoscopy can be performed when necessary. It is necessary to further understand whether there is urinary tract dilatation and renal function damage, whether there is neurogenic bladder dysfunction, peripheral neuritis and cardiovascular diseases caused by diabetes, and finally estimate the general situation and decide the treatment plan.
differential diagnosis
1. bladder neck contracture
The patient had symptoms of lower urinary tract obstruction, and no obvious prostate enlargement was found by rectal digital examination. Besides the possibility of glandular lobe process expanding into bladder, the possibility of bladder neck contracture should also be considered. It is generally believed that bladder neck contracture is secondary to inflammatory lesions. The smooth muscle of 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. During cystoscopy, the bladder neck was raised and the posterior urethra and bladder triangle were shortened. Under cystoscope, there was no extrusion deformation of prostate urethra and stricture of internal urethral orifice. However, when the glandular lobe process of simple benign prostatic hyperplasia reaches the bladder neck, it is covered by soft mucosa, the triangular area of bladder sinks and the posterior urethra is prolonged.
Contraction of bladder neck can be accompanied by prostatic hyperplasia. Because the boundary between hyperplastic gland and surgical sac is unclear, it is often difficult to remove, and the gland is obviously smaller than the size predicted by rectal digital examination or B-ultrasound. It is difficult to relieve lower urinary tract obstruction if the constricted bladder neck is not treated at the same time after gland resection.
Treatment can be tried with α-blockers. If the symptoms are severe, recurrent urinary tract infections occur, or urodynamic examination is abnormal, transurethral resection, suprapubic wedge resection of bladder neck or Y-V plasty of bladder neck can be considered.
2. Prostate cancer
Prostate cancer, especially ductal cancer, may be the first symptom of lower urinary tract obstruction. Some patients are accompanied by prostate cancer while BPH, and the serum PSA (prostate specific antigen) is increased, mostly >: 10.0ng/ml. Digital rectal examination showed that the surface of prostate was not smooth and felt like stone. Transrectal biopsy and B-ultrasound guidance are better, and the diagnosis can be made by pathological examination.
3. Neurogenic bladder and detrusor sphincter are not harmonious.
Often manifested as abnormal urination in the lower urinary tract and urinary incontinence. It is necessary to inquire about the history of trauma in detail and check whether there is levator ani reflex, which should be ruled out by urodynamic examination, such as filling bladder manometry, urethral pressure map, pressure/flow synchronous detection, etc.
4. Bladder weakness (bladder wall aging)
The manifestations are urinary retention, abnormal urination in the lower urinary tract and a large amount of residual urine, which should be differentiated from benign prostatic hyperplasia, excluding injury, inflammation, diabetes and other factors, mainly through urodynamic examination. In particular, urethral pressure map, pressure/flow synchronous detection and identification. Cystography showed low bladder pressure and no systolic blood pressure waveform.
treat cordially
The harm of benign prostatic hyperplasia lies in the pathophysiological changes caused by lower urinary tract obstruction. Pathological individuals vary greatly, and not all of them are progressive. Some lesions will not develop to a certain extent, so even if there are mild obstructive symptoms, there is no need for surgery.
1. Watch and wait
For mild symptoms, IPSS score below 7 can be observed and no treatment is needed.
2. Drug therapy
Studies on (1)5α- reductase inhibitors show that 5α- reductase is an important enzyme for the transformation of testosterone into dihydrotestosterone. Dihydrotestosterone plays a role in benign prostatic hyperplasia, so 5α- reductase inhibitor can inhibit prostatic hyperplasia to some extent.
(2) Alpha blockers At present, it is believed that these drugs can improve urodynamic obstruction, reduce resistance and improve symptoms. gottlieb is commonly used.
(3) Progesterone is the most widely used antiandrogen. It can inhibit the cellular binding and nuclear uptake of androgen, or inhibit 5α- reductase to interfere with the formation of dihydrotestosterone. Progesterone drugs include megestrol acetate, cyproterone acetate, chlormadinone acetate and gestrinone caproate. Flubutamide is a non-steroidal antiandrogen, which can also interfere with the cellular uptake and nuclear binding of androgen. After using antiandrogen drugs for a period of time, symptoms and urine flow rate can be improved, residual urine can be reduced, and the prostate can be shrunk. However, after drug withdrawal, the prostate can be enlarged and the symptoms can recur. In recent years, it has been found that these drugs can aggravate blood viscosity and increase the incidence of cardiovascular and cerebrovascular embolism. Luteinizing hormone releasing hormone analogues have a highly selective effect on pituitary gland, making it release LH and FSH. Long-term application can exhaust this function of pituitary gland, reduce the ability of testis to produce testosterone, or even fail to produce testosterone, and achieve the effect of drug castration.
(4) Others include M receptor antagonists, plant preparations and traditional Chinese medicines. M receptor antagonist can relieve excessive contraction of detrusor and reduce bladder sensitivity by blocking bladder M receptor, thus improving the symptoms of BPH patients during urine storage. Plant preparations such as prostaglandin are suitable for the treatment of prostatic hyperplasia and related lower urinary tract symptoms.
To sum up, it is necessary to comprehensively estimate the condition before drug treatment, and also fully consider the side effects of drugs and the possibility of long-term medication. To observe the curative effect of drugs, long-term follow-up and regular urodynamic examination should be carried out to avoid delaying the operation opportunity.
3. Surgical therapy
Surgery is still an important treatment for benign prostatic hyperplasia.
The indications for operation are: ① symptoms of lower urinary tract obstruction, obvious changes in urodynamic examination, or residual urine above 60m; ② The symptoms of bladder instability are serious; ③ Upper urinary tract obstruction and renal function damage have been caused; ④ Recurrent episodes of acute urinary retention, urinary tract infection and gross hematuria; ⑤ Patients with bladder stones. For patients with long-term urinary tract obstruction, obvious impairment of renal function, severe urinary tract infection or acute urinary retention, indwelling urinary catheter should be used to relieve obstruction, and surgery should be performed after infection control and renal function recovery. If urethritis is caused by difficulty in inserting catheter or too long intubation time, suprapubic cystostomy can be changed. The indications of emergency prostatectomy should be strictly controlled.
4. Minimally invasive treatment
(1) Transurethral electrovaporization of prostate is mainly the innovation of electrode metal materials, which makes its biological thermal effect different from the former. Because of its rapid thermal transformation, it can produce a high temperature of 400℃, which can quickly cause tissue vaporization or coagulation and necrosis, and its hemostatic characteristics are extremely obvious. Therefore, clinical application shows that: ① Increase indications: glands over 60g can be performed. ② Clear surgical field of vision: Because of the remarkable hemostatic effect, the washing liquid is clear and easy to operate. (3) Reduction of operation time: Due to the reduction of hemostasis steps, surgical resection is accelerated and operation time is shortened. ④ Reduction of complications: it is not easy to cause water poisoning (thickness of coagulation layer), and the surgical field is clear to reduce accidental injury, which is not easy to cause sphincter and capsule damage. ⑤ Fast postoperative recovery: the irrigation time is shortened.
(2) Transurethral plasmakinetic prostatectomy and transurethral plasmakinetic prostatectomy were performed with plasma bipolar resection system, and transurethral prostatectomy was performed in a manner similar to unipolar TURP.
(3) Cryotherapy can make the frozen prostate tissue necrotic and putrefied, so as to achieve the purpose of frozen prostatectomy. It can be performed through urethra, with simple operation, and is suitable for elderly patients who cannot tolerate other operations. According to literature reports, the symptoms of lower urinary tract obstruction can be alleviated or improved in most patients, and the residual urine is reduced. However, there is blindness in cryotherapy, and the depth and breadth of cryotherapy are not easy to grasp. Transurethral prostatectomy after freezing to remove the remaining hyperplastic tissue after freezing can obviously reduce bleeding.
(4) Microwave therapy uses the principle of thermal coagulation of biological tissues by microwaves to achieve the purpose of treatment. The placement of microwave radiation electrode can be located by rectal ultrasound or transurethral endoscope under direct vision. The latter can avoid the external urethral sphincter accurately and reduce the complications of urinary incontinence.
(5) Laser therapy uses the thermal effect of laser to coagulate, vaporize or remove prostate tissue, which is similar to transurethral surgery. There are surface irradiation, insertion hyperthermia, and laser ablation of glands. The curative effect is affirmative: laser excises glands, crushes tissues and sucks them out of the bladder. Long-term efficacy and cost-effectiveness remain to be seen.
(6) Radiofrequency ablation uses radio frequency waves to produce local thermal effects to coagulate and necrotize prostate tissue.