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Symptoms of the development of benign prostatic hyperplasia

• Age over 40 years.
• Hypertonic disease.
• The presence of diabetes.

• the first - harbingers;
• the second is subcompensated;
• the third is decompensated.

• the process of reverse flow of urine;
• violation of the kidneys;
• the formation of kidney stones;

• the stream of urine is rather weak;

• frequent calls at night.

• traces of blood in the urine;
• urinary incontinence;
• the quality of the blood deteriorates;
• general fatigue, weakness;
• hydronephrosis;
• kidney pathology.

• unbalanced diet;
• diabetes;
• excess weight;
• bad ecology;
• hormonal imbalance.

• structural phenomena in the urethra;
• bladder cancer;
• infections;
• atypical prostatitis;

• identification of PSA in the blood;
• Ultrasound of the abdominal organs;
• ISI kidneys and bladder;
• transrectal ultrasound.

General urine analysis.

Ultrasound examination of the prostate transabdominal, transrectal: the volume of the gland, residual urine (>

Prostate cancer.


Tumors of the small pelvis.

Hematuria.

Bladder stones.
Hydronephrosis.

Risk factors: age >
Hematuria.
Prostate specific antigen >10 ng/mL.

1. Medical treatment
2. Operative methods of treatment
3. Non-operative methods

Medical treatment

Operative methods of treatment

Cryodestruction.

Hormonal changes in a man cause the development of grade 1 BPH, and understanding what it is, what factors affect its development and what to do if diagnosed, you can eliminate the disease without serious negative health consequences.

Benign prostatic hyperplasia of the 1st degree (BPH) is a common disease of men of puberty. It is characterized by the growth of tissues of the glandular epithelial layer of the prostate or its stromal components. Subsequently, multiple benign formations - tumors - are formed in the prostate gland. Increasing in size, they begin to compress the urethra, and the disease begins to manifest itself as a violation of urination.

Unlike prostate cancer, BPH is benign and does not metastasize, and therefore does not pose a threat to life. However, when a disease occurs, it is necessary to constantly regulate the level of prostate-specific antigen in the blood serum, since it is a marker of the transformation of a tumor into a malignant one.

It is not known for certain what causes the disease. Factors affecting the development of BPH are:

• Age over 40 years.
• Hormonal changes in the body. As men age, testosterone production decreases, and the synthesis of female hormones, estrogen, increases. An imbalance between female and male hormones causes benign changes in prostate tissue.
• hereditary factor. The likelihood of the disease increases if a man's father or grandfather had BPH in his family.
• Constant hypothermia, especially during winter fishing, diving.
• Overweight. If a man's weight in kg is divided by the square of his height in meters, you get a value called the body mass index (BMI). With a BMI over 30, you should work on weight loss.
• Varicose veins of the small pelvis.
• Hypertonic disease.
• The presence of diabetes.
• Bad habits, malnutrition (excess in the diet of fatty, salty, spicy foods), sedentary lifestyle.

Having one of the predisposing factors to the development of the disease, it is recommended that a man undergo an annual preventive examination in order to prevent the growth of adenoma to a health-threatening size.

The development of the disease is staged. In total, there are 3 stages in the development of prostatic hyperplasia:

• the first - harbingers;
• the second is subcompensated;
• the third is decompensated.

If the adenoma has not been treated, the second and third stages of the disease develop, which are characterized by serious urination disorders that require urgent catheterization. Untimely treatment of the disease is fraught with the development of renal failure. Therefore, already at the 1st stage of BPH, it is necessary to consult a doctor.

The question remains unresolved: how to recognize the development of prostate adenoma at stage 1, is it possible to treat the disease?

The initial stage of the disease can last from 1 to 10 years. The 1st degree prostate adenoma itself is so small that it does not cause pain or a deterioration in the quality of life. Its detection is possible if it squeezes neighboring organs of the urinary system. This provokes the occurrence of symptoms of BPH:

• more frequent urination during the day and at night;
• less intense urine output;
• a decrease in the amount of urine excreted with a single trip to the toilet;
• problems with holding back the detrusor contraction, the desire to urinate urgently;
• excretion of urine in a vertical stream;
• the need for straining the abdomen to excrete urine at the beginning or at the end of the act of urination.

If discomfort occurs, a doctor should be consulted. Self-diagnosis is unacceptable, since prostatitis of the 1st degree, an early stage of prostate cancer, has similar signs.

Prostate adenoma of the 1st degree does not entail violations of the functioning of the urinary tract or kidneys. The volume of urine that does not come out when going to the toilet at the initial stage of the disease can be either insignificant, not causing discomfort, or absent altogether.

As a consequence of the development of hyperplasia of prostate cells, complications may occur:

• inflammation of the tissues of the prostate gland (prostatitis);
• diverticula (saccular protrusions) of the bladder;
• the process of reverse flow of urine;
• incomplete emptying of the bladder, which is chronic;
• violation of the kidneys;
• the formation of kidney stones;
• progressive expansion of the pelvis in the kidneys (hydronephrosis).

Only a doctor can identify the disease when using methods for diagnosing BPH, and it is the manifestations of complications caused by the disease that can lead to the suspicion of developing an adenoma.

When contacting a doctor with complaints of impaired urination, a digital rectal examination of the prostate is performed. Then, to clarify the diagnosis and determine the exact size of the organ, diagnostic methods are used:

• Ultrasound - is performed in one of two ways: through the anterior wall of the abdomen or transrectal method (TRUS). The second method is more informative and allows you to differentiate benign and malignant tumors, clarify the stage of BPH. The volume of urine remaining in the bladder after emptying is also subject to assessment. At the initial stage of adenoma development, its volume is close to the norm, equal to 25 ml.
• Uroflowmetry - determination of the speed of urine flow using a device - uroflowmeter. For the procedure, a patient with a full bladder urinates into a tank equipped with sensors to record the jet flow rate, urine volume, degree of flow acceleration, urination time, urination waiting time. As a result, the device generates a graph - a uroflowgram, according to which the doctor evaluates the state of the urinary system.
• Cystoscopy. This method involves examining the bladder using a special tube equipped with a camera and a light source. It is inserted into the urethra, and the camera captures the condition of the organs of the urinary system.
• Excretory contrast urography is an examination method in which contrast is injected into the patient's blood and a series of x-rays are taken to record the condition of the kidneys.

In addition to instrumental diagnostic methods, to assess the degree of development of BPH, laboratory tests of blood, urine, prostatic secretion are used, a blood test is performed for the content of prostate-specific antigen to assess the risk of prostate cancer.

For grade 1 BPH, drug treatment is preferable.

Prostate adenoma does not disappear during treatment. The only way to get rid of it is through surgery. However, at the initial stage of the development of the disease, if prostate hyperplasia does not cause pain, discomfort and disruption of the urinary system, treatment is carried out with drugs:

1. Alpha - adrenergic blockers (Uroxatral, Flamax, Gitrin, Rapaflo). Under the influence of drugs, the smooth tissues of the prostate and bladder are relaxed. In this case, there is an increase in the flow of urine and complete emptying of the bladder. The drugs are taken orally 1-2 times a day. Drug treatment can cause side effects in the form of a headache, a decrease in blood pressure, and a deterioration in potency.
2. 5-alpha reductase inhibitors (Avodart, Proscar). Drugs reduce the effect of androgens on the prostate. This leads to a slowdown in the growth of the prostate, and sometimes to its reduction. Improvement in the patient's condition is observed after 6-12 months of continuous use of drugs. Treatment with such drugs is well tolerated by patients, however, during the first year of their use, there may be a deterioration in erection and sexual desire, impaired ejaculation, and a slight increase in the mammary glands. Drugs are recommended to be used only with an enlarged prostate. Men planning to replenish the family should refrain from taking them, and pregnant women should avoid contact with tablets containing dutasteride or finasteride (5-alpha reductase inhibitors).

If drug treatment fails, a prostate resection procedure is used, balloon dilatation is used to expand the urinary canal, a stent (cylindrical structure) is installed to prevent further narrowing of the urinary canal.

If BPH of the 1st degree is detected, it is necessary to adjust the diet, eat more foods containing the substance "lycopene": tomatoes, persimmons, watermelon, grapefruit. In combination with olive oil and avocado, lycopene is well absorbed and prevents cancer. In the fight against prostate adenoma, products containing selenium and zinc help. These include: seafood (oysters, salmon, mackerel, tuna), legumes, buckwheat and oatmeal, pumpkin seeds, mushrooms, celery and parsnips. It is also necessary to limit the consumption of alcohol.

Benign prostatic hyperplasia is an increase in the size of an organ that does not correspond to the norms of physiology and anatomy. Most experts are inclined to believe that the gradual enlargement of the prostate is a completely natural mechanism for the aging of the gland. Half of the male population over 65 years of age has hypertrophy, expressed to one degree or another.

In men older than 40 years, this pathology is less common. An increase in the size of the gland indicates a clear imbalance in the male body.

The prostate is a small secretory organ located near the bladder and rectum. Partially, the prostate gland covers a fragment of the urethra. The glandular organ produces a secret that enters the seminal fluid.

Prostate hyperplasia in men after 40 years is a non-cancerous enlargement of the prostate that develops under the influence of male hormonal substances. A gradual increase in the body threatens even men with excellent health. Pathological enlargement of the prostate due to its anatomical features leads to deformation of the fragments of the urethra. The outflow of urine is disturbed. Patients begin to pursue irritative and obstructive symptoms.

The size of the organ itself does not affect the clinical picture. Sometimes even very large hyperplasia phenomena do not cause symptoms, and very slight deviations from the norm lead to unpleasant consequences. It all depends on how quickly the pathology develops, whether it affects the organ completely or partially.

In the vast majority of cases, men over 60 years of age who do not experience much discomfort do not need radical treatment. However, all patients aged 40-55 require adequate therapy.

The structure of the prostate is formed by glandular elements and stroma. With hyperplasia, it is the muscle fibers and the connective tissue that increase most of all.

Male sex hormones have a positive effect on the development of pathology. They are not the main cause of the development of the disease, however, without these biologically active substances, further growth of the gland is impossible.

In young and adulthood, high testosterone levels have a beneficial effect on the functioning of the prostate. However, after the age of 40, an excess amount of male hormones has a twofold effect. Old age and hormonal levels are a specific "foundation" for the development of hyperplasia.

Pathological growths compress the urethra, adversely affect the functional features of the bladder.

Progressive obstruction causes the following symptoms:

• the stream of urine is rather weak;
• the bladder never empties completely;
• the beginning of the process of urination is difficult.

In addition to obstructive phenomena, patients are worried about irritative symptoms:

• constant irritation of the tissues of the urethra provokes constant urge to go to the toilet with an unproductive act of urination;
• the urge to go to the toilet is almost impossible to suppress, and the bladder itself is rarely full;
• frequent calls at night.

If the prostate enlargement occurs rather quickly, and pathological changes negatively affect the general health of a man, the following clinical manifestations are observed:

• traces of blood in the urine;
• burning during urination;
• tendency to infections and constant inflammatory processes;
• urinary incontinence;
• the quality of the blood deteriorates;
• general fatigue, weakness;
• the appearance of bladder diverticula;
• hydronephrosis;
• kidney pathology.

There is very little information in medical documentary sources about which course of the disease is considered the most common and natural. It is not known for certain in which cases the growth of prostate tissue occurs in a forced and uncontrollable way, and in which situations the disease does not threaten with special complications.

Statistical data show that in 45% of patients, minor hyperplasia remains at the initial level for quite a long time and does not threaten with serious consequences. However, 10-25% of all cases require adequate therapy and surgery.

It has already been stated that hyperplasia occurs in men over 65 with high testosterone levels.

However, there are a number of factors that can provoke further tissue growth:

• genetic predisposition;
• unbalanced diet;
• pathological hypertension;
• diabetes;
• excess weight;
• bad ecology;
• hypertrophied androgen receptors;
• hormonal imbalance.

Any conditions associated with urinary incontinence or the inability to fully release urine for a long time should be amenable to therapy. It is worth contacting a specialist at the first appearance of blood in the urine. Also, you can’t do without medical help if the hypertrophied prostate gland has become inflamed and turned into a source of pathogenic microflora.

If urinary retention is accompanied by severe pain, most likely, obstructive renal failure develops in the body. This is an extremely serious pathological condition, which can only be removed by qualified specialists in a modern hospital.

Benign prostatic hyperplasia is relatively easy to diagnose. To do this, the doctor collects a complete history, conducts a full examination and prescribes a number of laboratory and, if necessary, instrumental tests.

It is important to carefully study the clinical picture in order to exclude other possible pathologies.

At the first stages of diagnosis, prostatic hyperplasia can be confused with such diseases:

• structural phenomena in the urethra;
• bladder cancer;
• infections;
• atypical prostatitis;
• disorders in the urinary system from neurological disorders that appear due to strokes, sclerotic processes or Parkinson's disease;
• diabetes mellitus with an atypical course.

After conducting a digital rectal examination, the doctor can already determine the approximate size of the prostate and the degree of hyperplasia. The patient needs to pass a complete urinalysis, undergo studies that will help calculate the rate of urine flow, as well as a series of activities to study renal function.

Depending on the data obtained during the initial examination, the diagnostician may prescribe a number of auxiliary diagnostic procedures:

• urodynamic study by flow/pressure type;
• identification of PSA in the blood;
• Ultrasound of the abdominal organs;
• ISI kidneys and bladder;
• transrectal ultrasound.

Prostatic hyperplasia requires constant monitoring by doctors. Medical therapy and surgery are welcome.

Often drugs are used to eliminate swelling and inflammation. Alpha blockers and 5 alpha reductase inhibitors are widely used. Prostatectomy and transurethral resection of the gland are acceptable if the patient suffers from pain, excretory dysfunction, and urethral obstruction.

"Wrong judgments are inevitable in the practice of the art of medicine, which to a greater extent consists in balancing probabilities" W. Osler

Difficulty urinating: weak, intermittent urine stream, straining when urinating, dripping at the end of urination.
Frequent (nighttime) urination, urgency, urinary incontinence.
IPSS International Prostatic Symptoms Scale: 0-7 points - mild, 8-19 points - moderate, 20-35 points - severe symptoms.

Digital rectal examination.
Prostate specific antigen (general, free): assessment of cancer risk, prostate volume, and risk of acute urinary retention.
Plasma creatinine, glomerular filtration rate.
General urine analysis.
Neurological examination.
Uroflowmetry: Graphical recording of the characteristics of the urine stream.
Ultrasound examination of the prostate transabdominal, transrectal: the volume of the gland, residual urine (> 200 ml - the effect of treatment is worse).
Ultrasound examination of the kidneys.
Urethrocystoscopy: exclusion of other diseases, before invasive treatment.

Transrectal ultrasound of the prostate

CAUSES OF INFRAVESICAL OBSTRUCTION

Prostate cancer.
Prostatitis (bacterial, granulomatous).
Obstructive diseases of the bladder neck (contracture, fibrosis).
Sclerosis of the prostate.
Obstruction of the urethra (stricture, tumors).
Tumors of the small pelvis.
Neurogenic disorders of the bladder (detrusor sphincter dyssynergia).
Inflammation, tumors of the paraurethral glands.

Hematuria.
Acute urinary retention.
Inflammatory complications: cystitis, pyelonephritis, urethritis, prostatitis, epididymitis, vesiculitis.
Bladder stones.
Bladder diverticula.
Hydronephrosis.
Decreased kidney function: acute kidney injury, chronic kidney disease.

Dynamics of the frequency of malignant neoplasms in men and women (ACS)

Siegel R, et al. Cancer J Clin. 2016;66:7–30.

SIGNS OF PROSTATE CANCER (ACS)

Risk factors: age >65 years, family history of prostate cancer in grade 1 relatives, smoking.
Hematuria.
Prostate specific antigen >10 ng/mL.
The proportion of free prostate specific antigen 30–40 ml): finasteride 5 mg 1 time, dutasteride 0.5 mg 1 time.
Combination of an alpha-blocker and a 5-alpha reductase inhibitor.
Bladder catheterization in acute urinary retention: no more than 2 days.
Transurethral dissection (incision) of the prostate gland: prostate volume

Established 1 standard for the treatment of prostate hyperplasia

There are a large number of treatments for benign prostatic hyperplasia. They are versatile and highly effective. These methods can be divided into three groups:

1. Medical treatment
2. Operative methods of treatment
3. Non-operative methods

At the first symptoms of prostate adenoma, drug treatment is used.

Treatment is aimed at improving blood circulation in the pelvic organs, inhibiting the growth of hyperplastic prostate tissue, reducing concomitant inflammation of the prostate tissue and surrounding tissues (bladder), eliminating constipation, reducing or eliminating urinary stasis, facilitating urination and eliminating secondary infection of the urinary tract.

The patient is recommended a mobile lifestyle, a decrease in fluid intake before bedtime. Also, the patient is prohibited from drinking alcohol, smoking, eating spicy, spicy foods. Replacement therapy with male sex hormones is prescribed only if there are obvious laboratory and clinical signs of age-related androgen deficiency. In parallel, treatment of complications is prescribed - pyelonephritis, prostatitis and cystitis.

In acute urinary retention, the patient is urgently hospitalized for bladder catheterization.

Medical treatment

Basically, two types of drugs are used to treat prostate adenoma:

1. Alpha-1-blockers. These drugs relax the smooth muscles of the prostate and bladder neck, preventing urethral obstruction and making it easier for urine to pass. Their action can be short or prolonged.
2. 5-alpha reductase blockers. Drugs in this group prevent the formation of dihydrotestosterone (a biologically active form of testosterone), which helps to reduce the size of the prostate gland and counteracts urethral obstruction.

Operative methods of treatment

In severe cases, with the ineffectiveness of drug therapy, they resort to surgical intervention. It consists in excision of hyperplastic tissue - adenomectomy, or total resection of the prostate gland - prostatectomy. In this case, there are two types of operations: 1. Open (transvesical adenomectomy) - with access through the wall of the bladder. They are used in advanced cases, they are more traumatic, but provide a complete cure for the disease. 2. Minimally invasive operations (with a minimum amount of surgical intervention) - without an incision, through the urethra, using modern video endoscopic technology.

The modern "gold standard" for the treatment of benign prostatic hyperplasia is holmium laser enucleation of the prostate. With the help of a special high-power laser, endoscopic (without incisions, through the urethra) exfoliation of the hyperplastic prostate tissue into the bladder cavity is performed, after which the adenomatous nodes are removed. This technique has the same efficiency as open adenomectomy. At the same time, the number of complications is significantly less than with other methods of treatment.

Embolization of the arteries of the prostate gland is an endovascular operation, the essence of which is the blockage of the arteries of the prostate gland with particles of a special medical polymer. It is performed under local anesthesia, access through the femoral artery.

Non-surgical treatments include:

Balloon dilatation of the prostate gland (expansion of the narrowed area by inflating the balloon inserted into the urethra);

Installation of prostatic stents in the area of ​​narrowing;

The method of thermotherapy or microwave coagulation of the prostate;

High Intensity Focused Ultrasound;

Transurethral needle ablation;

Cryodestruction.

One of the most common diseases that occur in men, doctors consider prostate adenoma. Until now, it was this term that was commonly used everywhere, but recently another formulation has become more popular: benign prostatic hyperplasia (BPH).

Benign prostatic hyperplasia - this is the term recognized by most experts around the world, as it more fully expresses the essence of the disease and its histological structure.

Different age groups of the male half of humanity demonstrate different prevalence of BPH. The incidence in the group of patients aged 40-50 years is approximately 50%. Among men aged 50-60 years, about 60% suffer from this disease. Patients in the age category of 70 years and older are prone to illness in 85% of cases. Therefore, with increasing age, the likelihood of developing the disease increases.

At the same time, in the course of histological examination, signs of prostatic hyperplasia were also detected in 30-40-year-old men. Among the reasons that provoke the development of this disease, there are, first of all, hormonal changes occurring in the body. At the same time, no relationship of BPH with sexual activity, dietary habits, or race has been identified.

The prostate gland is an organ that surrounds the urethra at the very base of the bladder. The prostate synthesizes a secret that, during ejaculation, is released into the urethra, and then ejected with semen. The activity of the prostate gland is determined by the amount of "male" hormones - androgens.

Hyperplasia of the prostate is called the growth of prostate tissue, an increase in its volume. In the case when such a pathology is observed only with the tissues of this gland, and there are no metastases to other organs, we are talking about benign hyperplasia - it is usually called prostate adenoma.

Benign hyperplasia can be described in another way: there is no degeneration of gland cells, only their number increases. The gland increases in volume, which causes disturbances in the functioning of adjacent organs.

If the growth of the prostate occurs with the formation of metastases that spread to other organs, then we are talking about prostate cancer, and not about BPH. In this case, prostate cells degenerate into cancer cells, which spread through the bloodstream and lymph, and then penetrate into other organs.

As mentioned, the state of the prostate gland is greatly influenced by the hormonal background. As long as the "male" and "female" hormones are in a stable balance in the male body, nothing threatens the healthy state of the prostate. But very often, usually after 40 years, the hormonal background of the body fluctuates very often and strongly. If the body produces more "male" androgens than necessary, the process of growth of prostate tissue may begin.

The formation of prostate adenoma is accompanied by the appearance of "nodules" - growth zones. Over time, there are more "nodules", the size of the gland increases, and it squeezes the urethra more and more. At the initial stage of the disease, a man notices changes in the nature of urination: the urine stream no longer has the usual strong pressure, the urge to urinate more and more often (this happens more often at night).

When the gland grows further, it puts even more pressure on the bladder and squeezes the urethra even more. Because of this, the walls of the bladder and urethra stretch and lose their tone. The bladder can no longer excrete all the accumulated fluid, and the last portion of it, which is called residual urine, remains in it.

This condition provokes the development of infectious processes. There is a violation of the volition of urination, that is, there may be an involuntary exit of urine or it will be delayed. Urine may come out in very small portions, it may contain blood, it may be with a changed color and smell. The man is no longer able to complete the full process of emptying the bladder.

Due to disturbances in the functioning of the bladder, disturbances in the functioning of the kidneys begin, which leads to pathological changes in all metabolic processes of the body. A person begins to experience frequent dizziness, appetite disturbances, general weakness appears. The psyche suffers greatly: the man becomes oppressed and irritable. If you do not start timely treatment of adenoma, it will provoke the appearance of acute urinary retention, the development of severe renal failure, and then the most unfavorable prognosis.

All the described stages of prostatic hyperplasia do not replace each other too quickly, they can last for several years. It is very important to immediately consult a doctor when the first signs of prostate hyperplasia appear. After all, if the diagnosis is made at an early stage, and treatment is carried out immediately, then the fewer health problems will arise.

In order for the diagnosis to be made as accurately as possible, it is necessary to undergo a thorough examination. It all starts with an examination, in particular, with rectal palpation of the prostate. Then, to obtain more accurate results, you will need to undergo a transrectal ultrasound and transabdominal ultrasound, cystoscopy, uroflowmetry. Laboratory tests, in particular, PSA, a prostate-specific antigen, should help to adequately assess the patient's condition (they will also help to distinguish between benign and malignant hyperplasia). If complications are present, the doctor may prescribe x-ray methods.

Treatment of prostatic hyperplasia is aimed at minimizing the pressure exerted by the prostate tissue on the bladder and urethra. In some cases, it is quite enough to make lifestyle changes and prescribe medications to normalize the hormonal state of the body.

All men suffering from prostatic hyperplasia should lead an active lifestyle and not give up physical activity. It is also important to adhere to a healthy diet, that is, to minimize the consumption of smoked, fatty and fried foods. It is necessary to control the amount of fluid consumed, this is especially true for the second half of the day and the time before bedtime.

Prescribed medications can have a dual effect. The strength of some may be aimed at relaxing the muscles of the walls of the bladder and urethra, which contributes to an easier outflow of urine. One of these drugs is "Zokson". The action of other drugs will reduce the activity of androgens that stimulate prostate hyperplasia. These drugs include Penester.

The tissue of the prostate gland can also be influenced using hardware methods, such as ultrasound or cryotherapy. During the application of such methods, the structure of the prostate tissue is disrupted, as a result of which it stops its growth.

It is also possible to mechanically expand the urethra with the help of special stents, which normalizes the outflow of urine. If required, surgical treatment can be performed. At home, you can carry out herbal medicine, which is based on the use of plant extracts. It must be said that this method does not differ in powerful efficiency, although the dwarf palm extract relieves swelling of the prostate and has an anti-inflammatory effect.

Established 1 standard for the treatment of prostate hyperplasia

There are a large number of treatments for benign prostatic hyperplasia. They are versatile and highly effective. These methods can be divided into three groups:

1. Medical treatment
2. Operative methods of treatment
3. Non-operative methods

At the first symptoms of prostate adenoma, drug treatment is used.

Treatment is aimed at improving blood circulation in the pelvic organs, inhibiting the growth of hyperplastic prostate tissue, reducing concomitant inflammation of the prostate tissue and surrounding tissues (bladder), eliminating constipation, reducing or eliminating urinary stasis, facilitating urination and eliminating secondary infection of the urinary tract.

The patient is recommended a mobile lifestyle, a decrease in fluid intake before bedtime. Also, the patient is prohibited from drinking alcohol, smoking, eating spicy, spicy foods. Replacement therapy with male sex hormones is prescribed only if there are obvious laboratory and clinical signs of age-related androgen deficiency. In parallel, treatment of complications is prescribed - pyelonephritis, prostatitis and cystitis.

In acute urinary retention, the patient is urgently hospitalized for bladder catheterization.

Medical treatment

Basically, two types of drugs are used to treat prostate adenoma:

1. Alpha-1-blockers. These drugs relax the smooth muscles of the prostate and bladder neck, preventing urethral obstruction and making it easier for urine to pass. Their action can be short or prolonged.
2. 5-alpha reductase blockers. Drugs in this group prevent the formation of dihydrotestosterone (a biologically active form of testosterone), which helps to reduce the size of the prostate gland and counteracts urethral obstruction.

Operative methods of treatment

In severe cases, with the ineffectiveness of drug therapy, they resort to surgical intervention. It consists in excision of hyperplastic tissue - adenomectomy, or total resection of the prostate gland - prostatectomy. In this case, there are two types of operations: 1. Open (transvesical adenomectomy) - with access through the wall of the bladder. They are used in advanced cases, they are more traumatic, but provide a complete cure for the disease. 2. Minimally invasive operations (with a minimum amount of surgical intervention) - without an incision, through the urethra, using modern video endoscopic technology.

The modern "gold standard" for the treatment of benign prostatic hyperplasia is holmium laser enucleation of the prostate. With the help of a special high-power laser, endoscopic (without incisions, through the urethra) exfoliation of the hyperplastic prostate tissue into the bladder cavity is performed, after which the adenomatous nodes are removed. This technique has the same efficiency as open adenomectomy. At the same time, the number of complications is significantly less than with other methods of treatment.

Embolization of the arteries of the prostate gland is an endovascular operation, the essence of which is the blockage of the arteries of the prostate gland with particles of a special medical polymer. It is performed under local anesthesia, access through the femoral artery.

Non-surgical treatments include:

Balloon dilatation of the prostate gland (expansion of the narrowed area by inflating the balloon inserted into the urethra);

Installation of prostatic stents in the area of ​​narrowing;

The method of thermotherapy or microwave coagulation of the prostate;

High Intensity Focused Ultrasound;

Transurethral needle ablation;

Cryodestruction.

Main points

• benign hyperplasia prostate (BPH)- non-cancerous enlargement of the prostate.
• It is believed that this disease is part of the normal aging process.
• 50% of men over 60 have clinically significant BPH.
• Prostate cancer and this disease are not connected in any way.
• Symptoms are not necessarily progressive and may change.
• Medical treatment can be very effective.
• Transurethral resection of the prostate (TURP) remains the "gold standard" in the treatment of benign prostatic hyperplasia.

Description

The prostate is a walnut-shaped gland located directly below the

bladder

and in front of the rectum. It covers the upper part from all sides

(urethra), which is a tube that starts from the bladder and opens outward.

The prostate produces a portion (±0.5 ml) of seminal fluid containing nutrients. The bladder neck and prostate form a genital sphincter that provides antegrade ejaculation and eruption of seminal fluid outward, rather than backward, into the bladder.

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate. Its development depends on male hormones: testosterone and dihydrotestosterone. Over time, the disease of varying severity affects all men, even those whose testicles and prostates function normally.

Enlargement of the prostate leads to deformation of the urethra, due to which the flow of urine from the bladder is disturbed, and obstructive or irritant (irritative) symptoms appear.

The size of the prostate does not directly affect the severity of symptoms. Sometimes very large prostate disease is asymptomatic, while small prostate disease is characterized by very severe symptoms.

Clinically significant BPH is present in 50% of men aged 60-69 years. Of this number, ±50% are in need of treatment. The risk that a man will have to resort to prostate surgery in his lifetime is 10%.

The prostate gland consists of glandular structures and stroma. The second element contains smooth muscle fibers and connective tissue. With BPH, all components of the prostate increase, but the stroma, nevertheless, is relatively larger than the rest.

For the growth of the gland, male hormones (testosterone and dihydrotestosterone) are needed. They are not the root cause of the appearance of benign hyperplasia, but without them its development is impossible.

Aging and male hormones are the only confirmed risk factors that can trigger the development of BPH. Every male with a healthy prostate and normally functioning testicles develops this disease if he lives long enough.

The testicles produce 95% of the testosterone in the body. In the prostate gland, this hormone is converted into dihydrotestosterone, to which it is more sensitive than to testosterone. An enzyme called 5-alpha reductase is an intermediate link in the chain of transformation of testosterone into its active form. It is contained exclusively in the secretion of the male gonad. 5-alpha-reductose can be controlled with medications (see "Treatment" section).

Over time, dihydrotestosterone stimulates the formation of growth factor in the prostate, which, in turn, leads to an imbalance between cell growth and their programmed death (apoptosis).

The result of all this is a slow, progressive, enlargement of the prostate gland. Such a clinically pronounced disease is present in the vast majority of older men, however, in itself it does not necessarily cause symptoms or lead to complications.

Symptoms may occur because BPH directly affects the prostate or bladder outlet, resulting in an obstruction (see "Symptoms" below).

BPH may be accompanied by the absence or presence of symptoms. They occur due to mechanical compression of the urethra by an enlarged prostate, secondary bladder changes due to obstruction, or complications of BPH.

Obstruction (blockage) of the bladder outlet can lead to various consequences, such as thickening and instability of the bladder muscles. The instability is thought to cause irritant (irritative) symptoms.

In addition, the narrowing of the lumen of the urethra can lead to insufficient contraction of the muscles of the bladder, or further aggravate their condition. The result of this disorder on the face is obstructive symptoms and insufficient emptying of the urinary bladder. Although the natural aging process is responsible for the appearance of these symptoms, it is the obstruction that will exacerbate both signs of the withering of the male body.

Obstructive symptoms:

• weak stream of urine;
• feeling of incomplete emptying of the bladder;
• intermittent stream of urine;
• Difficulty initiating urination (delay);
• tension during urination.

Irritant (irritative) symptoms:

• Frequency (frequent going to the toilet);
• Urgency (strong urge to urinate that is difficult to suppress);
• Nocturia (the need to wake up at night to empty the bladder).

Symptoms indicating the presence of complications:

• Blood in the urine (hematuria): BPH can cause blood in the urine. However, this disease cannot be considered the culprit of bleeding, unless other, more serious reasons for this have already been excluded.
• Urinary tract infection with symptoms such as burning during urination, pain in the bladder area, fever and frequent urination.
• Urinary retention (complete inability to go to the toilet).
• Urinary incontinence (urinary leakage due to an overfilled bladder that does not empty properly).
• Kidney failure (fatigue, weight loss, increase in total blood volume (hypervolemia), etc.).

Only ±50% of men with a histologically confirmed diagnosis of benign prostatic hyperplasia will develop symptoms. Enlargement of the male gonad does not always lead to obstruction or symptoms.

The clinical syndrome (symptoms and signs) associated with prostate enlargement is known by various names including BPH, LUTS (lower urinary tract symptoms), prostatism, and urinary tract obstruction.

50% of men aged 51-60 and 90% over 80 have histological BPH. However, only 25% of fifty-five-year-olds and 50% of seventy-five-year-old men will be bothered by symptoms reminiscent of an enlarged prostate.

The natural course of development of untreated BPH is variable and unpredictable. There is little reliable information in the medical literature on this subject. But what is clear is that prostatic hyperplasia is not necessarily a progressive disease.

Many studies have shown that in about 30% of patients, symptoms may improve or go away with time. In 40% of men, they remain the same, and in 30% they worsen. In 10% of patients who did not resort to medical care, urinary retention will appear in the future. And 10-30% of patients who reject medicine will eventually need surgery for an enlarged prostate.

Potentially possible risk factors:

• western food;
• high blood pressure;
• diabetes;
• overweight;
• industrialized environment;
• increased androgen receptors;
• imbalance of testosterone and estrogen levels.

Any healthy man who lives long enough will fall prey to prostate hyperplasia. Time and male hormones (dihydrotestosterone and testosterone) are the only risk factors whose influence on the development of BPH has been established.

Prostate cells are much more sensitive to dihydrotestosterone than to testosterone. An enzyme, 5-alpha-reductase, which is unique to the prostate, converts testosterone to dihydrotestosterone. Those representatives of the strong half of humanity who were castrated in their youth or suffer from a lack of 5-alpha reductase do not experience BPH.

Recent research suggests that there is a likely genetic link to BPH. The risk of surgery for a man increases four times if his next of kin was operated on for this disease. The genetic link is especially strong for men with large prostates before the age of 60.

Some medical research has found that the number of male hormone receptors (androgen receptors) can be increased in BPH cells. And the role of the environmental factor, as well as nutrition, overweight and the industrialized environment, is not fully understood.

The incidence among Eastern men (especially Japanese) is low. Their regional diet is rich in phytoestrogens and may have a protective effect.

In this scenario, the bladder never empties properly, which can lead to obstructive kidney failure and other complications such as infections or stones.

It is not worth associating the appearance of blood with an enlarged prostate until other, more serious causes (bladder cancer) can be ruled out.

Every man over the age of 50 should have an annual screening for prostate cancer. Blacks, who are at higher risk of developing this type of cancer, and men with a genetic predisposition to it, should start getting regular screenings at age 40. The goal of annual prostate exams is to diagnose prostate cancer at an early stage, when it can still be cured.

As a rule, at an early stage, prostate cancer is asymptomatic. If a man has ever had gonadal surgery for BPH (namely, transurethral resection or open prostatectomy), this does not mean that he is no longer at risk of developing prostate cancer.

Prostate cancer usually starts in the outer part of the prostate that is not removed during surgery for BPH.

You may be asked to complete a questionnaire that will help you assess the severity of your symptoms (using the Prostate Symptom Score). During the physical examination, a digital examination of the rectum will be done.

The healthcare provider will usually order a urinalysis and may ask you to urinate into a device to measure the flow rate. Shortly before a visit to the doctor, it is better not to empty the bladder.

The symptoms of BPH are divided into obstructive and irritant (see "Symptoms" section). It is impossible to make a diagnosis based on symptoms alone, since many diseases mimic the symptoms of BPH. A thorough medical history can help identify other conditions than BPH that are causing the symptoms.

Diseases similar to BPH:

• urethral stricture (narrowing of the lumen of the urethra in the penis);
• bladder cancer;
• bladder infection;
• prostatitis (chronic infection of the prostate);
• neurogenic bladder (dysfunction of this organ due to neurological disorders such as stroke, Parkinson's disease or multiple sclerosis);
• diabetes.

Urethral stricture can occur as a result of previous injuries, the use of technical means in treatment (referring to the catheter), or infections (gonorrhea). Blood in the urine may indicate the presence of bladder cancer. Burning and pain when urinating may indicate an infection or stones.

Diabetes may be a possible cause of frequent urination and insufficient emptying, as it affects bladder muscles and nervous system function.

A scoring scale is used to assess the severity of prostate symptoms. It helps to determine whether further evaluation of the patient's condition is necessary or whether treatment should be initiated. The American Urological Association Symptom Index is the most commonly used assessment method.

Symptoms are classified according to the total score: 1-7 points - mild symptoms, 8-19 - moderate and 20-35 - severe. If the disorders are mild, then in most cases no treatment is needed. With moderate signs, treatment is required, and in the case of severe manifestations of the disease, surgical intervention is most often resorted to.

During this examination, the doctor assesses the general health of the patient and feels the abdominal cavity for the presence of a full bladder. A digital examination of the rectum is performed in order to determine the size, shape and consistency of the prostate gland. To do this, the doctor inserts the finger of a gloved hand into the rectum. The prostate lies adjacent to the anterior intestinal wall and can be easily palpated in this way. This procedure is slightly unpleasant, but does not cause pain. In BPH, the enlargement is smooth and uniform, while in prostate cancer it is nodular and irregular.

Unfortunately, prostate size alone is poorly correlated with symptoms or obstruction. It happens that men with large prostates show no symptoms and no obstruction occurs, and vice versa, small prostatic hyperplasia can be characterized by severe obstruction with symptoms and / or complications.

An enlarged prostate in itself is not an indication for treatment. The size of the prostate of patients who actually need therapy may influence the choice of treatment. A neurological examination is indicated if the medical history suggests that the cause of the symptoms may be neurological.

In order to eliminate all doubts about the correctness of the diagnosis, check for other causes of symptoms, confirm or refute obstruction and find complications associated with it, special studies are prescribed.

The minimum list of examinations required to diagnose BPH:

• medical history, including symptom severity index (see above);
• physical examination including digital rectal examination (see above);
• Analysis of urine;
• urine flow rate;
• evaluation of renal function (serum creatinine).

Additional tests:

• urodynamic study "pressure-flow";
• determination of the level of prostate-specific antigen (PSA) in blood serum
• ultrasound examination of the abdominal organs;
• ultrasound of the kidneys, ureter and bladder;
• transrectal ultrasound of the prostate.

A simple urine test can be done in the office using a test strip. If it indicates a possible infection, a urine culture is taken. If blood has been found in the urine, further testing should be done to rule out other causes of this symptom.

To determine the rate of urine flow, the patient is asked to urinate into a special machine that produces an indicator. Most devices measure urine volume, maximum flow rate, and the amount of time it takes for the bladder to empty. In order for the result to be accurate, at least 125-150 ml of urine is needed at a time.

The most useful parameter is the maximum urine flow rate (Qmax), measured in milliliters per second. Despite the fact that the mentioned parameter is an indirect sign of urinary tract obstruction, it appears that the presence of this disorder is confirmed in the majority of patients whose urine flow rate is less than 10 ml/sec. At the same time, those whose urine flow rate exceeds 15 ml/sec show no signs of obstruction.

Moreover, patients with low values ​​measured before undergoing surgery feel better after it, compared with those with higher urinary flow rates. It must be understood that a low value of this parameter does not indicate what exactly is the cause of a weak urine flow - obstruction or impaired function of the bladder muscle.

The level of creatinine is determined in the serum of the taken blood sample. The result obtained gives an idea of ​​how the kidneys function. Creatinine is one of the waste products excreted by the kidneys. If the level of this substance is elevated due to urinary tract obstruction, then it is better to drain the bladder with a catheter, which will allow the kidneys to recover before starting prostate surgery.

The pressure-flow urodynamic study is the most accurate method to determine the presence of urinary tract obstruction. Bladder pressure and urine flow pressure are measured simultaneously. Obstruction is characterized by high pressure and low flow. This is an invasive test, for which sensors are inserted into the bladder and rectum. Many scientists do not recommend this procedure for patients with severe prostate symptoms. At the same time, such a study is indispensable if there are doubts about the diagnosis.

Indications for urodynamic study:

• any neurological disorder, such as a seizure, Parkinson's disease, and multiple sclerosis;
• acute symptoms, but normal urinary velocity (>15 ml/sec);
• long-term diabetes;
• previous failed prostate surgery.

The level of prostate-specific antigen (PSA) in the blood serum increases in the presence of BPH. There are controversies associated with the use of this test to detect prostate cancer. The American Urological Association, like most urologists, recommends that serum PSA levels be checked every year in patients over 50 years of age, whose life expectancy is 10 years.

Representatives of the black race and men with a genetic predisposition to prostate cancer should undergo such a study, starting at the age of 40. PSA levels rise before prostate cancer becomes clinically apparent. Thanks to this, it is possible to establish an early diagnosis and start timely treatment.

Abdominal ultrasound may be helpful in detecting hydronephrosis (enlargement) of the kidneys and determining the volume of urine that remains in the bladder after the patient has defecated. This indicator does not directly explain the appearance of other symptoms and signs of prostatism, and on its basis it is impossible to predict the outcome of surgery.

It is also not known whether a large residual volume of urine indicates impending bladder or kidney problems. Most experts believe that it is necessary to more closely monitor patients with a high value of this indicator if they prefer non-surgical therapy.

Renal failure with obstruction results from progressive enlargement of the kidneys (hydronephrosis). Ultrasound examination of patients with elevated serum creatinine levels can determine whether the insufficiency is caused by obstruction or other factors.

Transrectal ultrasound of the prostate is not always done in patients with benign hyperplasia. But still, during this examination, you can very accurately measure the volume (size) of the prostate. The main function is to help do a biopsy of the gland in case of suspected cancer of this organ.

Follow-up, drug therapy and surgery are the main treatment options. Patients who are unsuitable for surgery and who have not received positive results from drug treatment are placed in permanent catheters, intermittent (periodic) self-catheterization, or an internal urethral stent (read below). Complications arising from BPH are usually an indication for surgery. Therefore, patients with complications are not treated by dynamic observation or medications.

To improve the symptoms of BPH, consider these recommendations. Drink alcohol and caffeinated drinks in moderation, especially in the late evening before going to bed. Tranquilizers and antidepressants weaken the muscles of the bladder and prevent complete emptying. Cold and flu medicines usually contain decongestants that increase the tone of the smooth muscles in the bladder neck and prostate, causing symptoms to worsen.

Phytotherapy is the use of plant extracts for medicinal purposes. Recently, this method of treating the symptoms of BPH has attracted the attention of the press. The most popular extract was the dwarf palm (also known as saw palmetto). The mechanism of action of herbal medicine is unknown, and its effectiveness has not been proven. It is believed that the extract of this plant has an anti-inflammatory effect that reduces swelling of the prostate, and inhibits hormones that control the growth of prostate cells. It is possible that the positive results obtained from the use of plants are only a consequence of the placebo effect.

There are two groups of drugs that have shown their effectiveness in the treatment of benign prostatic hyperplasia. These are alpha blockers and 5-alpha reductase inhibitors.

Alpha blockers The prostate gland and bladder neck contain a large number of smooth muscle cells. Their tone is under the control of the sympathetic (involuntary) nervous system. Alpha receptors are nerve ending receptors. Alpha blockers are drugs that block alpha receptors, thereby lowering the tone of the muscles of the prostate and bladder neck. As a result, the rate of urine flow increases and the symptoms of prostate disease improve. Alpha receptors are also found in other parts of the body, particularly in the blood vessels. Alpha blockers were originally developed to treat high blood pressure. Not surprisingly, the most common side effect of these medications is orthostatic hypotension (dizziness caused by a drop in blood pressure).

The list of commonly used alpha blockers includes:

• prazosin;
• doxazosin;
• terazosin;
• tamsulosin.

The last drug is a selective α1A-adrenoceptor blocker, designed specifically to inhibit the alpha receptor subtype, located mainly in the bladder and prostate.

Alpha-blockers are effective in treating patients with a residual urine volume of less than 300 ml, and who do not have an absolute (vital) indication for surgery. Most studies have shown that symptoms have been reduced by 30-60% with these drugs, and urine flow has moderately increased. All of the above alpha-blockers, taken in therapeutic dosages, have the proper effect. The maximum result is achieved within two weeks, and persists for a long time. 90% of patients tolerate the treatment well. The main reasons for stopping treatment are dizziness due to hypotension and lack of efficacy. Direct studies, the subject of which was the comparison of various alpha-blockers with each other, have not been conducted. Therefore, claims that any of them are better than the others are not substantiated. As a rule, treatment should be carried out throughout life. A less commonly reported side effect is abnormal or retrograde (reverse) ejaculation, which is experienced by 6% of patients taking tamsulosin.

5-alpha reductase inhibitors The enzyme 5-alpha reductase converts testosterone to its active form, dihydrotestosterone, in the prostate gland. Finasteride prevents this transformation from occurring. Taking this drug relieves the symptoms of BPH, increases the rate of urine flow, and reduces the size of the prostate. However, such improvements can be called no more than modest, and they are achieved in a period of up to six months. Recent studies have shown that finasteride may be more effective in men with large prostates, but less effective in patients with small gonads. The remedy in question does indeed reduce the incidence of urinary retention. Thanks to him, the need for prostate surgery is reduced by 50% in four years. Side effects include: breast enlargement (0.4%), impotence (3-4%), decreased ejaculate volume, and a 50% drop in PSA levels.

This is the most common urological procedure. Only in the United States of America, 200,000 operations are performed annually. BPH prostatectomy involves removing only the inside of the prostate. This surgery is different from radical prostatectomy for cancer, which removes all of the prostate tissue. Prostatectomy is the best and fastest way to improve the symptoms of benign prostatic hyperplasia. However, it may not alleviate all irritative bladder symptoms. Unfortunately, this is more true for older men over 80 years of age, where bladder instability is thought to be the cause of most of the symptoms.

Indications for prostatectomy:

• urinary retention;
• renal failure on the background of obstruction;
• recurrent urinary tract infections;
• bladder stones;
• large residual volume of urine (relative indication);
• unsuccessful drug therapy (turned out to be ineffective or accompanied by severe side effects);
• patients who are not enthusiastic about the prospect of undergoing drug therapy.

Transurethral resection of the prostate (TURP) This operation is still considered the "gold standard" in the treatment of BPH, which is equal to all other treatment options. TURP is performed using a resectoscope, which is inserted through the urethra into the bladder. A wire loop that conducts electric current is cut out of the prostate tissue. The catheter is left for one or two days. The hospital stay is usually three days. TURP is usually painless or causes little discomfort. On the third week after surgery, the patient fully recovers.

Significant improvement after this operation is observed in 93% of men with severe symptoms, and 80% with moderate disorders.

Complications associated with TURP can include:

• the mortality rate is less than 0.25%;
• bleeding requiring transfusion - 7%;
• stricture (narrowing) of the urethra or neck of the bladder - 5%;
• erectile dysfunction - 5%;
• incontinence - 2-4%;
• retrograde ejaculation (during ejaculation, seminal fluid enters the bladder) - 65%;
• the need for another transurethral resection - 10% within five years.

There are several types of TURP:

Transurethral incision of the prostate/prostatectomy/bladder neck incision. As with TURP, an instrument is inserted into the bladder. Instead of a loop, an electric knife is used to make one or more incisions in the prostate to relieve pressure on the urethra. Sex gland tissue is not removed, and if removed, then a very small piece. Results achieved with small prostate prototomy (

Transurethral vaporization of the prostate This type of resection is performed using a resectoscope inserted through the urethra. However, in this case, the tissue is not cut off, but exposed to powerful electrical energy. As a result, the tissue is evaporated with minimal blood loss. Potential benefits of electrovaporization include shorter catheter wear, shorter hospital stay, and lower cost compared to TURP or laser prostatectomy.

Open prostatectomy Larger prostates are less suitable for TURP because complications often occur due to the longer resection time. Open prostatectomy is the treatment of choice if the prostate is larger than 70-80g. A transverse incision is made in the lower abdomen to expose the bladder and prostate. The capsule of the gonad is dissected, and benign hyperplasia is husked. It is possible to open the bladder and exfoliate the prostate through it. To do this, one catheter is placed into the bladder through the urethra, and the second through the lower abdomen. The catheters are left in place for four to five days. This operation gives good results, but it is more severe than TURP. The hospital stay and rehabilitation period is longer and the complications are slightly worse. But at the same time, open prostatectomy is considered a very effective way to remove BPH tissue. And only a small number of patients subsequently have difficulty with the normal emptying of the bladder.

Despite the success of TURP, scientists are constantly looking for less invasive, safer and less expensive procedures that can be performed in one day under local

anesthesia

Without leaving the person overnight in the hospital. A variety of energy sources were tested for point heating of the prostate tissue and its destruction. Based on this principle

laser

Microwave Thermotherapy, High Intensity Focused Ultrasound Therapy, Radio Frequency Therapy and Transurethral Needle

prostate gland (TUIA). All these types of manipulations lead to fewer complications during therapy, but are characterized by less efficiency and greater postoperative troubles. The hospital stay is shorter than with TURP, but the catheter time is longer. As a result, many patients require retreatment, which is usually done with TURP. Various laser methods are also used to treat the prostate gland. The latest and most promising invention is holmium laser therapy, similar to TURP in that the prostate tissue is actually removed. According to studies, blood loss with this therapy is significantly less than with transurethral resection.

There are patients for whom any type of surgical intervention is contraindicated. To help such patients, intraurethral stents are placed in the prostatic part of the male urethra to keep it open. This allows the patient to pass urine normally. Stents can be inserted under local anesthesia. In the short term, this method gives good results. Due to displacement and other complications, these devices are removed in 14-33% of cases. Of course, it is better not to wear an indwelling catheter all the time. But they are the only salvation for people who are sick, debilitated or bedridden. As an alternative, they offer

intermittent (periodic) self-catheterization, which the patient, or the person caring for him, can do himself.

Unfortunately, it is impossible to prevent the development of benign prostatic hyperplasia. It is not known whether long-term treatment with finasteride, which began before the clinical manifestations of the disease, significantly affects the pathological process of BPH.

There were problems with the toilet. You run there every half an hour, but it feels like you didn’t go at all. The urologist diagnosed BPH and warned that a long, almost lifelong treatment was ahead.

What is this disease? How to diagnose a pathological process and how is it treated?

BPH stands for benign prostatic hyperplasia or adenoma. The tumor develops from the glandular epithelium or stromal component of the prostate.

Initially, a small seal, a nodule, forms in the tissues of the prostate gland. Gradually, it increases in size and begins to compress the surrounding tissues. The bladder and urethra are the first to be affected.

The tumor is benign. That is, it has a slow growth rate and does not metastasize either by the hemogenous or lymphogenous route. Indicators of the PSA tumor marker do not go beyond the normal range.

The main contingent of patients with BPH are men over 40 years of age. At an earlier age, this disease is extremely rare.

The reasons for the development of prostatic hyperplasia at the current moment in the development of medicine have not been identified. There are a number of factors contributing to the onset of the development of the pathological process:

• decrease in androgen levels;
• increased estrogen production.

Any links between the development of hyperplasia and sexual activity, sexual orientation, the presence or absence of bad habits have not been identified. The same applies to past STDs or other diseases of inflammatory origin in the reproductive sphere.

The main symptomatology of prostate adenoma depends on the stage of development of the pathological process.

1. At the first - compensated - stage, patients note the following signs:

• the onset of urinary problems;
• weak stream;
• frequent urges, worse at night.
• the bladder is emptied completely, there is no residual urine.

This stage lasts from 1 to 3 years. The organ is enlarged, but palpation is painless.

1. At the second - subcompensated - stage, the symptoms of urinary dysfunction progresses. Observed:

• urinary retention;
• frequent urge and small portion of urine;
• feeling of incomplete emptying of the bladder;
• urine is cloudy, with impurities of blood;
• sometimes urine begins to stand out spontaneously, incontinence develops;
• in severe cases, there is an acute urinary retention;
• developing chronic renal failure.

1. The third stage - decompensated - the urinary canal is almost completely blocked. Urine is excreted drop by drop. It is cloudy, with an admixture of blood. General symptoms are weakness, body odor, dry mouth, weight loss, development of iron deficiency, acute renal failure due to impaired urine outflow, impaired defecation.

In the initial stages of the disease, conservative treatment is possible. In the later stages, only surgical intervention.

Diagnosis of BPH is based on the totality of the patient's complaints and the results of his examination. The procedure for making a diagnosis is described in the WHO protocols and includes:

1. Examination and questioning of the patient, including rectal digital examination. This will give information about the size of the organ, the degree of its hyperplasia, the assessment of pain when pressed, the presence or absence of a groove between the lobes of the organ.
2. Laboratory research.

If prostate adenoma is suspected, a general urinalysis, blood biochemistry and a general blood test, an analysis for the PSA tumor marker are shown to exclude the malignant nature of the neoplasm.

1. Ultrasound of the urinary system and transrectal examination of the prostate. Diagnostic imaging allows you to identify stones in the urinary system and the body of the prostate, the size of the lobes of the prostate gland, the condition of the tissues of the organ, the volume of residual urine after urination.
2. Uroflowmetry is a non-invasive study of the rate of urine outflow.
3. X-ray studies with and without contrast agents. This allows you to evaluate the complications of prostatic hyperplasia, identify stones in the kidneys and prostate gland, expansion of the renal pelvis due to stagnation of urine, and the formation of diverticula.

The choice of treatment method depends on the degree of the disease and its severity at the time of contacting a medical institution.

There are 3 approaches:

• conservative therapy;
• surgical intervention;
• minimally invasive treatment methods.

This type of therapy is carried out at the initial stages of the disease. The goal is to stop inflammatory processes in the prostate and kidneys, facilitate the outflow of urine, improve the blood supply to the organ and outflow from the tissues of the gland, and slow down the development of the disease.

What will the urologist prescribe:

1. Antibiotics to suppress bacterial flora.
2. Preparations based on animal prostate extracts. They help to improve the blood supply to the tissues of the organ and reduce the size of hypertrophied tissue.
3. Adrenoblockers to improve the process of urination, relax smooth muscles.

Sedatives, vitamin complexes, physiotherapy procedures are prescribed as additional therapy drugs. The doctor indicates the need for dietary adjustments. Alcoholic beverages are completely banned. The patient is encouraged to lead an active lifestyle, move and undergo regular check-ups and preventive treatment.

In case of acute urinary retention - for example, after drinking alcoholic beverages - urgent hospitalization is indicated in the urological department of a hospital for catheterization.

Surgical treatment of prostate adenoma is carried out in severe cases. Either partial resection of the affected tissues or complete removal of the organ is performed.

Indications for surgical treatment:

• continued urinary retention after catheterization;
• blood in the urine, developing kidney failure;
• the appearance of stones, diverticula in the bladder;
• repeated inflammatory processes in the urinary system after massive drug treatment.

There are a number of conditions in which prostate surgery is not performed.

Contraindications for surgery:

• renal and heart failure;
• pyelonephritis, cystitis in the acute phase;
• aortic aneurysm;
• heart pathology;
• atherosclerosis of cerebral vessels.

Currently, doctors use sparing techniques for removing the organ. Open abdominal operations are extremely rare.

This type of intervention is performed using an endoscope. The procedure takes place either under general anesthesia or spinal anesthesia is used.

The instrument is inserted into the urethra and passed through the bladder to the prostate. Then, using a loop through which high-frequency currents are passed, parts of the organ are removed. At the same time, adjacent vessels are cauterized, which reduces the risk of bleeding.

This method allows you to remove not only hypertrophied tissues, but also the gland as a whole.

The duration of stay in the hospital is 2 days. The first day you will have to wear a catheter to drain urine.

An open intervention is performed when the weight of the prostate exceeds 80 g. In this case, only the affected organ is removed, the testicles remain in their place.

The incisions are made either in the lower abdomen or between the anus and the scrotum. An incision is made in the wall of the bladder, then prostate tissue is removed through the wound.

The term of stay in the hospital is 7 days. Be sure to wear a catheter after surgery.

The intervention is performed through a small incision in the patient's lower abdomen. An ultrasonic knife is used to remove tissue.

The whole procedure is reflected on the monitor screen. Duration of stay in a medical institution - 6 days. Be sure to wear a catheter after surgery.

As a scalpel, light waves of various lengths are used. In parallel, nearby vessels are cauterized. The operation is gentle, since the risk of bleeding is minimal. There are also no postoperative complications - retrograde ejaculation, enuresis, erectile dysfunction.

Instruments are inserted through the urethra. Radio waves of various frequencies act as a scalpel. During the procedure, a kind of cauterization of excess tissue of the organ occurs.

The procedure does not require hospitalization and is performed under local anesthesia. Does not require a catheter.

These are flexible devices that are inserted into the urethra to allow urine to drain. The procedure is performed under local anesthesia, does not require hospitalization and can be performed on an outpatient basis.

A drainage device must be worn for several hours after the intervention. During this time, the patient stays in the hospital.

Urology is a delicate part of the body. Diseases of this system should be treated under the guidance of an experienced doctor, on time and in full. After all, neglect of one's own health can lead to an operating table.

Benign prostatic hyperplasia is an increase in the size of an organ that does not correspond to the norms of physiology and anatomy. Most experts are inclined to believe that the gradual enlargement of the prostate is a completely natural mechanism for the aging of the gland. Half of the male population over 65 years of age has hypertrophy, expressed to one degree or another.

In men older than 40 years, this pathology is less common. An increase in the size of the gland indicates a clear imbalance in the male body.

The prostate is a small secretory organ located near the bladder and rectum. Partially, the prostate gland covers a fragment of the urethra. The glandular organ produces a secret that enters the seminal fluid.

Prostate hyperplasia in men after 40 years is a non-cancerous enlargement of the prostate that develops under the influence of male hormonal substances. A gradual increase in the body threatens even men with excellent health. Pathological enlargement of the prostate due to its anatomical features leads to deformation of the fragments of the urethra. The outflow of urine is disturbed. Patients begin to pursue irritative and obstructive symptoms.

The size of the organ itself does not affect the clinical picture. Sometimes even very large hyperplasia phenomena do not cause symptoms, and very slight deviations from the norm lead to unpleasant consequences. It all depends on how quickly the pathology develops, whether it affects the organ completely or partially.

In the vast majority of cases, men over 60 years of age who do not experience much discomfort do not need radical treatment. However, all patients aged 40-55 require adequate therapy.

The structure of the prostate is formed by glandular elements and stroma. With hyperplasia, it is the muscle fibers and the connective tissue that increase most of all.

Male sex hormones have a positive effect on the development of pathology. They are not the main cause of the development of the disease, however, without these biologically active substances, further growth of the gland is impossible.

In young and adulthood, high testosterone levels have a beneficial effect on the functioning of the prostate. However, after the age of 40, an excess amount of male hormones has a twofold effect. Old age and hormonal levels are a specific "foundation" for the development of hyperplasia.

Pathological growths compress the urethra, adversely affect the functional features of the bladder.

Progressive obstruction causes the following symptoms:

• the stream of urine is rather weak;
• the bladder never empties completely;
• the beginning of the process of urination is difficult.

In addition to obstructive phenomena, patients are worried about irritative symptoms:

• constant irritation of the tissues of the urethra provokes constant urge to go to the toilet with an unproductive act of urination;
• the urge to go to the toilet is almost impossible to suppress, and the bladder itself is rarely full;
• frequent calls at night.

If the prostate enlargement occurs rather quickly, and pathological changes negatively affect the general health of a man, the following clinical manifestations are observed:

• traces of blood in the urine;
• burning during urination;
• tendency to infections and constant inflammatory processes;
• urinary incontinence;
• the quality of the blood deteriorates;
• general fatigue, weakness;
• the appearance of bladder diverticula;
• hydronephrosis;
• kidney pathology.

There is very little information in medical documentary sources about which course of the disease is considered the most common and natural. It is not known for certain in which cases the growth of prostate tissue occurs in a forced and uncontrollable way, and in which situations the disease does not threaten with special complications.

Statistical data show that in 45% of patients, minor hyperplasia remains at the initial level for quite a long time and does not threaten with serious consequences. However, 10-25% of all cases require adequate therapy and surgery.

It has already been stated that hyperplasia occurs in men over 65 with high testosterone levels.

However, there are a number of factors that can provoke further tissue growth:

• genetic predisposition;
• unbalanced diet;
• pathological hypertension;
• diabetes;
• excess weight;
• bad ecology;
• hypertrophied androgen receptors;
• hormonal imbalance.

Any conditions associated with urinary incontinence or the inability to fully release urine for a long time should be amenable to therapy. It is worth contacting a specialist at the first appearance of blood in the urine. Also, you can’t do without medical help if the hypertrophied prostate gland has become inflamed and turned into a source of pathogenic microflora.

If urinary retention is accompanied by severe pain, most likely, obstructive renal failure develops in the body. This is an extremely serious pathological condition, which can only be removed by qualified specialists in a modern hospital.

Benign prostatic hyperplasia is relatively easy to diagnose. To do this, the doctor collects a complete history, conducts a full examination and prescribes a number of laboratory and, if necessary, instrumental tests.

It is important to carefully study the clinical picture in order to exclude other possible pathologies.

At the first stages of diagnosis, prostatic hyperplasia can be confused with such diseases:

• structural phenomena in the urethra;
• bladder cancer;
• infections;
• atypical prostatitis;
• disorders in the urinary system from neurological disorders that appear due to strokes, sclerotic processes or Parkinson's disease;
• diabetes mellitus with an atypical course.

After conducting a digital rectal examination, the doctor can already determine the approximate size of the prostate and the degree of hyperplasia. The patient needs to pass a complete urinalysis, undergo studies that will help calculate the rate of urine flow, as well as a series of activities to study renal function.

Depending on the data obtained during the initial examination, the diagnostician may prescribe a number of auxiliary diagnostic procedures:

• urodynamic study by flow/pressure type;
• identification of PSA in the blood;
• Ultrasound of the abdominal organs;
• ISI kidneys and bladder;
• transrectal ultrasound.

Prostatic hyperplasia requires constant monitoring by doctors. Medical therapy and surgery are welcome.

Often drugs are used to eliminate swelling and inflammation. Alpha blockers and 5 alpha reductase inhibitors are widely used. Prostatectomy and transurethral resection of the gland are acceptable if the patient suffers from pain, excretory dysfunction, and urethral obstruction.

Benign prostatic hyperplasia - this is the term recognized by most experts around the world, as it more fully expresses the essence of the disease and its histological structure.

Different age groups of the male half of humanity demonstrate different prevalence of BPH. The incidence in the group of patients aged 40-50 years is approximately 50%. Among men aged 50-60 years, about 60% suffer from this disease. Patients in the age category of 70 years and older are prone to illness in 85% of cases. Therefore, with increasing age, the likelihood of developing the disease increases.

At the same time, in the course of histological examination, signs of prostatic hyperplasia were also detected in 30-40-year-old men. Among the reasons that provoke the development of this disease, there are, first of all, hormonal changes occurring in the body. At the same time, no relationship of BPH with sexual activity, dietary habits, or race has been identified.

The prostate gland is an organ that surrounds the urethra at the very base of the bladder. The prostate synthesizes a secret that, during ejaculation, is released into the urethra, and then ejected with semen. The activity of the prostate gland is determined by the amount of "male" hormones - androgens.

Hyperplasia of the prostate is called the growth of prostate tissue, an increase in its volume. In the case when such a pathology is observed only with the tissues of this gland, and there are no metastases to other organs, we are talking about benign hyperplasia - it is usually called prostate adenoma.

Benign hyperplasia can be described in another way: there is no degeneration of gland cells, only their number increases. The gland increases in volume, which causes disturbances in the functioning of adjacent organs.

If the growth of the prostate occurs with the formation of metastases that spread to other organs, then we are talking about prostate cancer, and not about BPH. In this case, prostate cells degenerate into cancer cells, which spread through the bloodstream and lymph, and then penetrate into other organs.

As mentioned, the state of the prostate gland is greatly influenced by the hormonal background. As long as the "male" and "female" hormones are in a stable balance in the male body, nothing threatens the healthy state of the prostate. But very often, usually after 40 years, the hormonal background of the body fluctuates very often and strongly. If the body produces more "male" androgens than necessary, the process of growth of prostate tissue may begin.

The formation of prostate adenoma is accompanied by the appearance of "nodules" - growth zones. Over time, there are more "nodules", the size of the gland increases, and it squeezes the urethra more and more. At the initial stage of the disease, a man notices changes in the nature of urination: the urine stream no longer has the usual strong pressure, the urge to urinate more and more often (this happens more often at night).

When the gland grows further, it puts even more pressure on the bladder and squeezes the urethra even more. Because of this, the walls of the bladder and urethra stretch and lose their tone. The bladder can no longer excrete all the accumulated fluid, and the last portion of it, which is called residual urine, remains in it.

This condition provokes the development of infectious processes. There is a violation of the volition of urination, that is, there may be an involuntary exit of urine or it will be delayed. Urine may come out in very small portions, it may contain blood, it may be with a changed color and smell. The man is no longer able to complete the full process of emptying the bladder.

Due to disturbances in the functioning of the bladder, disturbances in the functioning of the kidneys begin, which leads to pathological changes in all metabolic processes of the body. A person begins to experience frequent dizziness, appetite disturbances, general weakness appears. The psyche suffers greatly: the man becomes oppressed and irritable. If you do not start timely treatment of adenoma, it will provoke the appearance of acute urinary retention, the development of severe renal failure, and then the most unfavorable prognosis.

All the described stages of prostatic hyperplasia do not replace each other too quickly, they can last for several years. It is very important to immediately consult a doctor when the first signs of prostate hyperplasia appear. After all, if the diagnosis is made at an early stage, and treatment is carried out immediately, then the fewer health problems will arise.

In order for the diagnosis to be made as accurately as possible, it is necessary to undergo a thorough examination. It all starts with an examination, in particular, with rectal palpation of the prostate. Then, to obtain more accurate results, you will need to undergo a transrectal ultrasound and transabdominal ultrasound, cystoscopy, uroflowmetry. Laboratory tests, in particular, PSA, a prostate-specific antigen, should help to adequately assess the patient's condition (they will also help to distinguish between benign and malignant hyperplasia). If complications are present, the doctor may prescribe x-ray methods.

Treatment of prostatic hyperplasia is aimed at minimizing the pressure exerted by the prostate tissue on the bladder and urethra. In some cases, it is quite enough to make lifestyle changes and prescribe medications to normalize the hormonal state of the body.

All men suffering from prostatic hyperplasia should lead an active lifestyle and not give up physical activity. It is also important to adhere to a healthy diet, that is, to minimize the consumption of smoked, fatty and fried foods. It is necessary to control the amount of fluid consumed, this is especially true for the second half of the day and the time before bedtime.

Prescribed medications can have a dual effect. The strength of some may be aimed at relaxing the muscles of the walls of the bladder and urethra, which contributes to an easier outflow of urine. One of these drugs is "Zokson". The action of other drugs will reduce the activity of androgens that stimulate prostate hyperplasia. These drugs include Penester.

The tissue of the prostate gland can also be influenced using hardware methods, such as ultrasound or cryotherapy. During the application of such methods, the structure of the prostate tissue is disrupted, as a result of which it stops its growth.

It is also possible to mechanically expand the urethra with the help of special stents, which normalizes the outflow of urine. If required, surgical treatment can be performed. At home, you can carry out herbal medicine, which is based on the use of plant extracts. It must be said that this method does not differ in powerful efficiency, although the dwarf palm extract relieves swelling of the prostate and has an anti-inflammatory effect.

Established 1 standard for the treatment of prostate hyperplasia

There are a large number of treatments for benign prostatic hyperplasia. They are versatile and highly effective. These methods can be divided into three groups:

1. Medical treatment
2. Operative methods of treatment
3. Non-operative methods

At the first symptoms of prostate adenoma, drug treatment is used.

Treatment is aimed at improving blood circulation in the pelvic organs, inhibiting the growth of hyperplastic prostate tissue, reducing concomitant inflammation of the prostate tissue and surrounding tissues (bladder), eliminating constipation, reducing or eliminating urinary stasis, facilitating urination and eliminating secondary infection of the urinary tract.

The patient is recommended a mobile lifestyle, a decrease in fluid intake before bedtime. Also, the patient is prohibited from drinking alcohol, smoking, eating spicy, spicy foods. Replacement therapy with male sex hormones is prescribed only if there are obvious laboratory and clinical signs of age-related androgen deficiency. In parallel, treatment of complications is prescribed - pyelonephritis, prostatitis and cystitis.

In acute urinary retention, the patient is urgently hospitalized for bladder catheterization.

Medical treatment

Basically, two types of drugs are used to treat prostate adenoma:

1. Alpha-1-blockers. These drugs relax the smooth muscles of the prostate and bladder neck, preventing urethral obstruction and making it easier for urine to pass. Their action can be short or prolonged.
2. 5-alpha reductase blockers. Drugs in this group prevent the formation of dihydrotestosterone (a biologically active form of testosterone), which helps to reduce the size of the prostate gland and counteracts urethral obstruction.

Operative methods of treatment

In severe cases, with the ineffectiveness of drug therapy, they resort to surgical intervention. It consists in excision of hyperplastic tissue - adenomectomy, or total resection of the prostate gland - prostatectomy. In this case, there are two types of operations: 1. Open (transvesical adenomectomy) - with access through the wall of the bladder. They are used in advanced cases, they are more traumatic, but provide a complete cure for the disease. 2. Minimally invasive operations (with a minimum amount of surgical intervention) - without an incision, through the urethra, using modern video endoscopic technology.

The modern "gold standard" for the treatment of benign prostatic hyperplasia is holmium laser enucleation of the prostate. With the help of a special high-power laser, endoscopic (without incisions, through the urethra) exfoliation of the hyperplastic prostate tissue into the bladder cavity is performed, after which the adenomatous nodes are removed. This technique has the same efficiency as open adenomectomy. At the same time, the number of complications is significantly less than with other methods of treatment.

Embolization of the arteries of the prostate gland is an endovascular operation, the essence of which is the blockage of the arteries of the prostate gland with particles of a special medical polymer. It is performed under local anesthesia, access through the femoral artery.

Non-surgical treatments include:

Balloon dilatation of the prostate gland (expansion of the narrowed area by inflating the balloon inserted into the urethra);

Installation of prostatic stents in the area of ​​narrowing;

The method of thermotherapy or microwave coagulation of the prostate;

High Intensity Focused Ultrasound;

Transurethral needle ablation;

Cryodestruction.

Main points

• benign hyperplasia prostate (BPH)- non-cancerous enlargement of the prostate.
• It is believed that this disease is part of the normal aging process.
• 50% of men over 60 have clinically significant BPH.
• Prostate cancer and this disease are not connected in any way.
• Symptoms are not necessarily progressive and may change.
• Medical treatment can be very effective.
• Transurethral resection of the prostate (TURP) remains the "gold standard" in the treatment of benign prostatic hyperplasia.

Description

The prostate is a walnut-shaped gland located just below the

bladder

and in front of the rectum. It covers the upper part from all sides

(urethra), which is a tube that starts from the bladder and opens outward.

The prostate produces a portion (±0.5 ml) of seminal fluid containing nutrients. The bladder neck and prostate form a genital sphincter that provides antegrade ejaculation and eruption of seminal fluid outward, rather than backward, into the bladder.

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate. Its development depends on male hormones: testosterone and dihydrotestosterone. Over time, the disease of varying severity affects all men, even those whose testicles and prostates function normally.

Enlargement of the prostate leads to deformation of the urethra, due to which the flow of urine from the bladder is disturbed, and obstructive or irritant (irritative) symptoms appear.

The size of the prostate does not directly affect the severity of symptoms. Sometimes very large prostate disease is asymptomatic, while small prostate disease is characterized by very severe symptoms.

Clinically significant BPH is present in 50% of men aged 60-69 years. Of this number, ±50% are in need of treatment. The risk that a man will have to resort to prostate surgery in his lifetime is 10%.

The prostate gland consists of glandular structures and stroma. The second element contains smooth muscle fibers and connective tissue. With BPH, all components of the prostate increase, but the stroma, nevertheless, is relatively larger than the rest.

For the growth of the gland, male hormones (testosterone and dihydrotestosterone) are needed. They are not the root cause of the appearance of benign hyperplasia, but without them its development is impossible.

Aging and male hormones are the only confirmed risk factors that can trigger the development of BPH. Every male with a healthy prostate and normally functioning testicles develops this disease if he lives long enough.

The testicles produce 95% of the testosterone in the body. In the prostate gland, this hormone is converted into dihydrotestosterone, to which it is more sensitive than to testosterone. An enzyme called 5-alpha reductase is an intermediate link in the chain of transformation of testosterone into its active form. It is contained exclusively in the secretion of the male gonad. 5-alpha-reductose can be controlled with medications (see "Treatment" section).

Over time, dihydrotestosterone stimulates the formation of growth factor in the prostate, which, in turn, leads to an imbalance between cell growth and their programmed death (apoptosis).

The result of all this is a slow, progressive, enlargement of the prostate gland. Such a clinically pronounced disease is present in the vast majority of older men, however, in itself it does not necessarily cause symptoms or lead to complications.

Symptoms may occur because BPH directly affects the prostate or bladder outlet, resulting in an obstruction (see "Symptoms" below).

BPH may be accompanied by the absence or presence of symptoms. They occur due to mechanical compression of the urethra by an enlarged prostate, secondary bladder changes due to obstruction, or complications of BPH.

Obstruction (blockage) of the bladder outlet can lead to various consequences, such as thickening and instability of the bladder muscles. The instability is thought to cause irritant (irritative) symptoms.

In addition, the narrowing of the lumen of the urethra can lead to insufficient contraction of the muscles of the bladder, or further aggravate their condition. The result of this disorder on the face is obstructive symptoms and insufficient emptying of the urinary bladder. Although the natural aging process is responsible for the appearance of these symptoms, it is the obstruction that will exacerbate both signs of the withering of the male body.

Obstructive symptoms:

• weak stream of urine;
• feeling of incomplete emptying of the bladder;
• intermittent stream of urine;
• Difficulty initiating urination (delay);
• tension during urination.

Irritant (irritative) symptoms:

• Frequency (frequent going to the toilet);
• Urgency (strong urge to urinate that is difficult to suppress);
• Nocturia (the need to wake up at night to empty the bladder).

Symptoms indicating the presence of complications:

• Blood in the urine (hematuria): BPH can cause blood in the urine. However, this disease cannot be considered the culprit of bleeding, unless other, more serious reasons for this have already been excluded.
• Urinary tract infection with symptoms such as burning during urination, pain in the bladder area, fever and frequent urination.
• Urinary retention (complete inability to go to the toilet).
• Urinary incontinence (urinary leakage due to an overfilled bladder that does not empty properly).
• Kidney failure (fatigue, weight loss, increase in total blood volume (hypervolemia), etc.).

Only ±50% of men with a histologically confirmed diagnosis of benign prostatic hyperplasia will develop symptoms. Enlargement of the male gonad does not always lead to obstruction or symptoms.

The clinical syndrome (symptoms and signs) associated with prostate enlargement is known by various names including BPH, LUTS (lower urinary tract symptoms), prostatism, and urinary tract obstruction.

50% of men aged 51-60 and 90% over 80 have histological BPH. However, only 25% of fifty-five-year-olds and 50% of seventy-five-year-old men will be bothered by symptoms reminiscent of an enlarged prostate.

The natural course of development of untreated BPH is variable and unpredictable. There is little reliable information in the medical literature on this subject. But what is clear is that prostatic hyperplasia is not necessarily a progressive disease.

Many studies have shown that in about 30% of patients, symptoms may improve or go away with time. In 40% of men, they remain the same, and in 30% they worsen. In 10% of patients who did not resort to medical care, urinary retention will appear in the future. And 10-30% of patients who reject medicine will eventually need surgery for an enlarged prostate.

Potentially possible risk factors:

• western food;
• high blood pressure;
• diabetes;
• overweight;
• industrialized environment;
• increased androgen receptors;
• imbalance of testosterone and estrogen levels.

Any healthy man who lives long enough will fall prey to prostate hyperplasia. Time and male hormones (dihydrotestosterone and testosterone) are the only risk factors whose influence on the development of BPH has been established.

Prostate cells are much more sensitive to dihydrotestosterone than to testosterone. An enzyme, 5-alpha-reductase, which is unique to the prostate, converts testosterone to dihydrotestosterone. Those representatives of the strong half of humanity who were castrated in their youth or suffer from a lack of 5-alpha reductase do not experience BPH.

Recent research suggests that there is a likely genetic link to BPH. The risk of surgery for a man increases four times if his next of kin was operated on for this disease. The genetic link is especially strong for men with large prostates before the age of 60.

Some medical research has found that the number of male hormone receptors (androgen receptors) can be increased in BPH cells. And the role of the environmental factor, as well as nutrition, overweight and the industrialized environment, is not fully understood.

The incidence among Eastern men (especially Japanese) is low. Their regional diet is rich in phytoestrogens and may have a protective effect.

In this scenario, the bladder never empties properly, which can lead to obstructive kidney failure and other complications such as infections or stones.

It is not worth associating the appearance of blood with an enlarged prostate until other, more serious causes (bladder cancer) can be ruled out.

Every man over the age of 50 should have an annual screening for prostate cancer. Blacks, who are at higher risk of developing this type of cancer, and men with a genetic predisposition to it, should start getting regular screenings at age 40. The goal of annual prostate exams is to diagnose prostate cancer at an early stage, when it can still be cured.

As a rule, at an early stage, prostate cancer is asymptomatic. If a man has ever had gonadal surgery for BPH (namely, transurethral resection or open prostatectomy), this does not mean that he is no longer at risk of developing prostate cancer.

Prostate cancer usually starts in the outer part of the prostate that is not removed during surgery for BPH.

You may be asked to complete a questionnaire that will help you assess the severity of your symptoms (using the Prostate Symptom Score). During the physical examination, a digital examination of the rectum will be done.

The healthcare provider will usually order a urinalysis and may ask you to urinate into a device to measure the flow rate. Shortly before a visit to the doctor, it is better not to empty the bladder.

Disease history

The symptoms of BPH are divided into obstructive and irritant (see "Symptoms" section). It is impossible to make a diagnosis based on symptoms alone, since many diseases mimic the symptoms of BPH. A thorough medical history can help identify other conditions than BPH that are causing the symptoms.

Diseases similar to BPH:

• urethral stricture (narrowing of the lumen of the urethra in the penis);
• bladder cancer;
• bladder infection;
• prostatitis (chronic infection of the prostate);
• neurogenic bladder (dysfunction of this organ due to neurological disorders such as stroke, Parkinson's disease or multiple sclerosis);
• diabetes.

Urethral stricture can occur as a result of previous injuries, the use of technical means in treatment (referring to the catheter), or infections (gonorrhea). Blood in the urine may indicate the presence of bladder cancer. Burning and pain when urinating may indicate an infection or stones.

Diabetes may be a possible cause of frequent urination and insufficient emptying, as it affects bladder muscles and nervous system function.

A scoring scale is used to assess the severity of prostate symptoms. It helps to determine whether further evaluation of the patient's condition is necessary or whether treatment should be initiated. The American Urological Association Symptom Index is the most commonly used assessment method.

Symptoms are classified according to the total score: 1-7 points - mild symptoms, 8-19 - moderate and 20-35 - severe. If the disorders are mild, then in most cases no treatment is needed. With moderate signs, treatment is required, and in the case of severe manifestations of the disease, surgical intervention is most often resorted to.

During this examination, the doctor assesses the general health of the patient and feels the abdominal cavity for the presence of a full bladder. A digital examination of the rectum is performed in order to determine the size, shape and consistency of the prostate gland. To do this, the doctor inserts the finger of a gloved hand into the rectum. The prostate lies adjacent to the anterior intestinal wall and can be easily palpated in this way. This procedure is slightly unpleasant, but does not cause pain. In BPH, the enlargement is smooth and uniform, while in prostate cancer it is nodular and irregular.

Unfortunately, prostate size alone is poorly correlated with symptoms or obstruction. It happens that men with large prostates show no symptoms and no obstruction occurs, and vice versa, small prostatic hyperplasia can be characterized by severe obstruction with symptoms and / or complications.

An enlarged prostate in itself is not an indication for treatment. The size of the prostate of patients who actually need therapy may influence the choice of treatment. A neurological examination is indicated if the medical history suggests that the cause of the symptoms may be neurological.

In order to eliminate all doubts about the correctness of the diagnosis, check for other causes of symptoms, confirm or refute obstruction and find complications associated with it, special studies are prescribed.

The minimum list of examinations required to diagnose BPH:

• medical history, including symptom severity index (see above);
• physical examination including digital rectal examination (see above);
• Analysis of urine;
• urine flow rate;
• evaluation of renal function (serum creatinine).

Additional tests:

• urodynamic study "pressure-flow";
• determination of the level of prostate-specific antigen (PSA) in blood serum
• ultrasound examination of the abdominal organs;
• ultrasound of the kidneys, ureter and bladder;
• transrectal ultrasound of the prostate.

A simple urine test can be done in the office using a test strip. If it indicates a possible infection, a urine culture is taken. If blood has been found in the urine, further testing should be done to rule out other causes of this symptom.

To determine the rate of urine flow, the patient is asked to urinate into a special machine that produces an indicator. Most devices measure urine volume, maximum flow rate, and the amount of time it takes for the bladder to empty. In order for the result to be accurate, at least 125-150 ml of urine is needed at a time.

The most useful parameter is the maximum urine flow rate (Qmax), measured in milliliters per second. Despite the fact that the mentioned parameter is an indirect sign of urinary tract obstruction, it appears that the presence of this disorder is confirmed in the majority of patients whose urine flow rate is less than 10 ml/sec. At the same time, those whose urine flow rate exceeds 15 ml/sec show no signs of obstruction.

Moreover, patients with low values ​​measured before undergoing surgery feel better after it, compared with those with higher urinary flow rates. It must be understood that a low value of this parameter does not indicate what exactly is the cause of a weak urine flow - obstruction or impaired function of the bladder muscle.

The level of creatinine is determined in the serum of the taken blood sample. The result obtained gives an idea of ​​how the kidneys function. Creatinine is one of the waste products excreted by the kidneys. If the level of this substance is elevated due to urinary tract obstruction, then it is better to drain the bladder with a catheter, which will allow the kidneys to recover before starting prostate surgery.

The pressure-flow urodynamic study is the most accurate method to determine the presence of urinary tract obstruction. Bladder pressure and urine flow pressure are measured simultaneously. Obstruction is characterized by high pressure and low flow. This is an invasive test, for which sensors are inserted into the bladder and rectum. Many scientists do not recommend this procedure for patients with severe prostate symptoms. At the same time, such a study is indispensable if there are doubts about the diagnosis.

Indications for urodynamic study:

• any neurological disorder, such as a seizure, Parkinson's disease, and multiple sclerosis;
• acute symptoms, but normal urinary velocity (>15 ml/sec);
• long-term diabetes;
• previous failed prostate surgery.

The level of prostate-specific antigen (PSA) in the blood serum increases in the presence of BPH. There are controversies associated with the use of this test to detect prostate cancer. The American Urological Association, like most urologists, recommends that serum PSA levels be checked every year in patients over 50 years of age, whose life expectancy is 10 years.

Representatives of the black race and men with a genetic predisposition to prostate cancer should undergo such a study, starting at the age of 40. PSA levels rise before prostate cancer becomes clinically apparent. Thanks to this, it is possible to establish an early diagnosis and start timely treatment.

Abdominal ultrasound may be helpful in detecting hydronephrosis (enlargement) of the kidneys and determining the volume of urine that remains in the bladder after the patient has defecated. This indicator does not directly explain the appearance of other symptoms and signs of prostatism, and on its basis it is impossible to predict the outcome of surgery.

It is also not known whether a large residual volume of urine indicates impending bladder or kidney problems. Most experts believe that it is necessary to more closely monitor patients with a high value of this indicator if they prefer non-surgical therapy.

Renal failure with obstruction results from progressive enlargement of the kidneys (hydronephrosis). Ultrasonography of patients with elevated serum creatinine levels can determine if the deficiency is due to obstruction or other factors.

Transrectal ultrasound of the prostate is not always done in patients with benign hyperplasia. But still, during this examination, you can very accurately measure the volume (size) of the prostate. The main function is to help do a biopsy of the gland in case of suspected cancer of this organ.

Follow-up, drug therapy and surgery are the main treatment options. Patients who are unsuitable for surgery and who have not received positive results from drug treatment are placed in permanent catheters, intermittent (periodic) self-catheterization, or an internal urethral stent (read below). Complications arising from BPH are usually an indication for surgery. Therefore, patients with complications are not treated by dynamic observation or medications.

To improve the symptoms of BPH, consider these recommendations. Drink alcohol and caffeinated drinks in moderation, especially in the late evening before going to bed. Tranquilizers and antidepressants weaken the muscles of the bladder and prevent complete emptying. Cold and flu medicines usually contain decongestants that increase the tone of the smooth muscles in the bladder neck and prostate, causing symptoms to worsen.

Phytotherapy is the use of plant extracts for medicinal purposes. Recently, this method of treating the symptoms of BPH has attracted the attention of the press. The most popular extract was the dwarf palm (also known as saw palmetto). The mechanism of action of herbal medicine is unknown, and its effectiveness has not been proven. It is believed that the extract of this plant has an anti-inflammatory effect that reduces swelling of the prostate, and inhibits hormones that control the growth of prostate cells. It is possible that the positive results obtained from the use of plants are only a consequence of the placebo effect.

There are two groups of drugs that have shown their effectiveness in the treatment of benign prostatic hyperplasia. These are alpha blockers and 5-alpha reductase inhibitors.

Alpha blockers The prostate gland and bladder neck contain a large number of smooth muscle cells. Their tone is under the control of the sympathetic (involuntary) nervous system. Alpha receptors are nerve ending receptors. Alpha blockers are drugs that block alpha receptors, thereby lowering the tone of the muscles of the prostate and bladder neck. As a result, the rate of urine flow increases and the symptoms of prostate disease improve. Alpha receptors are also found in other parts of the body, particularly in the blood vessels. Alpha blockers were originally developed to treat high blood pressure. Not surprisingly, the most common side effect of these medications is orthostatic hypotension (dizziness caused by a drop in blood pressure).

The list of commonly used alpha blockers includes:

• prazosin;
• doxazosin;
• terazosin;
• tamsulosin.

The last drug is a selective α1A-adrenoceptor blocker, designed specifically to inhibit the alpha receptor subtype, located mainly in the bladder and prostate.

Alpha-blockers are effective in treating patients with a residual urine volume of less than 300 ml, and who do not have an absolute (vital) indication for surgery. Most studies have shown that symptoms have been reduced by 30-60% with these drugs, and urine flow has moderately increased. All of the above alpha-blockers, taken in therapeutic dosages, have the proper effect. The maximum result is achieved within two weeks, and persists for a long time. 90% of patients tolerate the treatment well. The main reasons for stopping treatment are dizziness due to hypotension and lack of efficacy. Direct studies, the subject of which was the comparison of various alpha-blockers with each other, have not been conducted. Therefore, claims that any of them are better than the others are not substantiated. As a rule, treatment should be carried out throughout life. A less commonly reported side effect is abnormal or retrograde (reverse) ejaculation, which is experienced by 6% of patients taking tamsulosin.

5-alpha reductase inhibitors The enzyme 5-alpha reductase converts testosterone to its active form, dihydrotestosterone, in the prostate gland. Finasteride prevents this transformation from occurring. Taking this drug relieves the symptoms of BPH, increases the rate of urine flow, and reduces the size of the prostate. However, such improvements can be called no more than modest, and they are achieved in a period of up to six months. Recent studies have shown that finasteride may be more effective in men with large prostates, but less effective in patients with small gonads. The remedy in question does indeed reduce the incidence of urinary retention. Thanks to him, the need for prostate surgery is reduced by 50% in four years. Side effects include: breast enlargement (0.4%), impotence (3-4%), decreased ejaculate volume, and a 50% drop in PSA levels.

This is the most common urological procedure. Only in the United States of America, 200,000 operations are performed annually. BPH prostatectomy involves removing only the inside of the prostate. This surgery is different from radical prostatectomy for cancer, which removes all of the prostate tissue. Prostatectomy is the best and fastest way to improve the symptoms of benign prostatic hyperplasia. However, it may not alleviate all irritative bladder symptoms. Unfortunately, this is more true for older men over 80 years of age, where bladder instability is thought to be the cause of most of the symptoms.

Indications for prostatectomy:

• urinary retention;
• renal failure on the background of obstruction;
• recurrent urinary tract infections;
• bladder stones;
• large residual volume of urine (relative indication);
• unsuccessful drug therapy (turned out to be ineffective or accompanied by severe side effects);
• patients who are not enthusiastic about the prospect of undergoing drug therapy.

Transurethral resection of the prostate (TURP) This operation is still considered the "gold standard" in the treatment of BPH, which is equal to all other treatment options. TURP is performed using a resectoscope, which is inserted through the urethra into the bladder. A wire loop that conducts electric current is cut out of the prostate tissue. The catheter is left for one or two days. The hospital stay is usually three days. TURP is usually painless or causes little discomfort. On the third week after surgery, the patient fully recovers.

Significant improvement after this operation is observed in 93% of men with severe symptoms, and 80% with moderate disorders.

Complications associated with TURP can include:

• the mortality rate is less than 0.25%;
• bleeding requiring transfusion - 7%;
• stricture (narrowing) of the urethra or neck of the bladder - 5%;
• erectile dysfunction - 5%;
• incontinence - 2-4%;
• retrograde ejaculation (during ejaculation, seminal fluid enters the bladder) - 65%;
• the need for another transurethral resection - 10% within five years.

There are several types of TURP:

Transurethral incision of the prostate/prostatectomy/bladder neck incision. As with TURP, an instrument is inserted into the bladder. Instead of a loop, an electric knife is used to make one or more incisions in the prostate to relieve pressure on the urethra. Sex gland tissue is not removed, and if removed, then a very small piece. Results achieved with small prostate prototomy (

Transurethral vaporization of the prostate This type of resection is performed using a resectoscope inserted through the urethra. However, in this case, the tissue is not cut off, but exposed to powerful electrical energy. As a result, the tissue is evaporated with minimal blood loss. Potential benefits of electrovaporization include shorter catheter wear, shorter hospital stay, and lower cost compared to TURP or laser prostatectomy.

Open prostatectomy Larger prostates are less suitable for TURP because complications often occur due to the longer resection time. Open prostatectomy is the treatment of choice if the prostate is larger than 70-80g. A transverse incision is made in the lower abdomen to expose the bladder and prostate. The capsule of the gonad is dissected, and benign hyperplasia is husked. It is possible to open the bladder and exfoliate the prostate through it. To do this, one catheter is placed into the bladder through the urethra, and the second through the lower abdomen. The catheters are left in place for four to five days. This operation gives good results, but it is more severe than TURP. The hospital stay and rehabilitation period is longer and the complications are slightly worse. But at the same time, open prostatectomy is considered a very effective way to remove BPH tissue. And only a small number of patients subsequently have difficulty with the normal emptying of the bladder.

Despite the success of TURP, scientists are constantly looking for less invasive, safer and less expensive procedures that can be performed in one day under local

anesthesia

Without leaving the person overnight in the hospital. A variety of energy sources were tested for point heating of the prostate tissue and its destruction. Based on this principle

laser

Microwave Thermotherapy, High Intensity Focused Ultrasound Therapy, Radio Frequency Therapy and Transurethral Needle

prostate gland (TUIA). All these types of manipulations lead to fewer complications during therapy, but are characterized by less efficiency and greater postoperative troubles. The hospital stay is shorter than with TURP, but the catheter time is longer. As a result, many patients require retreatment, which is usually done with TURP. Various laser methods are also used to treat the prostate gland. The latest and most promising invention is holmium laser therapy, similar to TURP in that the prostate tissue is actually removed. According to studies, blood loss with this therapy is significantly less than with transurethral resection.

There are patients for whom any type of surgical intervention is contraindicated. To help such patients, intraurethral stents are placed in the prostatic part of the male urethra to keep it open. This allows the patient to pass urine normally. Stents can be inserted under local anesthesia. In the short term, this method gives good results. Due to displacement and other complications, these devices are removed in 14-33% of cases. Of course, it is better not to wear an indwelling catheter all the time. But they are the only salvation for people who are sick, debilitated or bedridden. As an alternative, they offer

intermittent (periodic) self-catheterization, which the patient, or the person caring for him, can do himself.

Unfortunately, it is impossible to prevent the development of benign prostatic hyperplasia. It is not known whether long-term treatment with finasteride, which began before the clinical manifestations of the disease, significantly affects the pathological process of BPH.

There were problems with the toilet. You run there every half an hour, but it feels like you didn’t go at all. The urologist diagnosed BPH and warned that a long, almost lifelong treatment was ahead.

What is this disease? How to diagnose a pathological process and how is it treated?

BPH stands for benign prostatic hyperplasia or adenoma. The tumor develops from the glandular epithelium or stromal component of the prostate.

Initially, a small seal, a nodule, forms in the tissues of the prostate gland. Gradually, it increases in size and begins to compress the surrounding tissues. The bladder and urethra are the first to be affected.

The tumor is benign. That is, it has a slow growth rate and does not metastasize either by the hemogenous or lymphogenous route. Indicators of the PSA tumor marker do not go beyond the normal range.

The main contingent of patients with BPH are men over 40 years of age. At an earlier age, this disease is extremely rare.

The reasons for the development of prostatic hyperplasia at the current moment in the development of medicine have not been identified. There are a number of factors contributing to the onset of the development of the pathological process:

• decrease in androgen levels;
• increased estrogen production.

Any links between the development of hyperplasia and sexual activity, sexual orientation, the presence or absence of bad habits have not been identified. The same applies to past STDs or other diseases of inflammatory origin in the reproductive sphere.

The main symptomatology of prostate adenoma depends on the stage of development of the pathological process.

1. At the first - compensated - stage, patients note the following signs:

• the onset of urinary problems;
• weak stream;
• frequent urges, worse at night.
• the bladder is emptied completely, there is no residual urine.

This stage lasts from 1 to 3 years. The organ is enlarged, but palpation is painless.

1. At the second - subcompensated - stage, the symptoms of urinary dysfunction progresses. Observed:

• urinary retention;
• frequent urge and small portion of urine;
• feeling of incomplete emptying of the bladder;
• urine is cloudy, with impurities of blood;
• sometimes urine begins to stand out spontaneously, incontinence develops;
• in severe cases, there is an acute urinary retention;
• developing chronic renal failure.

1. The third stage - decompensated - the urinary canal is almost completely blocked. Urine is excreted drop by drop. It is cloudy, with an admixture of blood. General symptoms are weakness, body odor, dry mouth, weight loss, development of iron deficiency, acute renal failure due to impaired urine outflow, impaired defecation.

In the initial stages of the disease, conservative treatment is possible. In the later stages, only surgical intervention.

Diagnosis of BPH is based on the totality of the patient's complaints and the results of his examination. The procedure for making a diagnosis is described in the WHO protocols and includes:

1. Examination and questioning of the patient, including rectal digital examination. This will give information about the size of the organ, the degree of its hyperplasia, the assessment of pain when pressed, the presence or absence of a groove between the lobes of the organ.
2. Laboratory research.

If prostate adenoma is suspected, a general urinalysis, blood biochemistry and a general blood test, an analysis for the PSA tumor marker are shown to exclude the malignant nature of the neoplasm.

1. Ultrasound of the urinary system and transrectal examination of the prostate. Diagnostic imaging allows you to identify stones in the urinary system and the body of the prostate, the size of the lobes of the prostate gland, the condition of the tissues of the organ, the volume of residual urine after urination.
2. Uroflowmetry is a non-invasive study of the rate of urine outflow.
3. X-ray studies with and without contrast agents. This allows you to evaluate the complications of prostatic hyperplasia, identify stones in the kidneys and prostate gland, expansion of the renal pelvis due to stagnation of urine, and the formation of diverticula.

The choice of treatment method depends on the degree of the disease and its severity at the time of contacting a medical institution.

There are 3 approaches:

• conservative therapy;
• surgical intervention;
• minimally invasive treatment methods.

This type of therapy is carried out at the initial stages of the disease. The goal is to stop inflammatory processes in the prostate and kidneys, facilitate the outflow of urine, improve the blood supply to the organ and outflow from the tissues of the gland, and slow down the development of the disease.

What will the urologist prescribe:

1. Antibiotics to suppress bacterial flora.
2. Preparations based on animal prostate extracts. They help to improve the blood supply to the tissues of the organ and reduce the size of hypertrophied tissue.
3. Adrenoblockers to improve the process of urination, relax smooth muscles.

Sedatives, vitamin complexes, physiotherapy procedures are prescribed as additional therapy drugs. The doctor indicates the need for dietary adjustments. Alcoholic beverages are completely banned. The patient is encouraged to lead an active lifestyle, move and undergo regular check-ups and preventive treatment.

In case of acute urinary retention - for example, after drinking alcoholic beverages - urgent hospitalization is indicated in the urological department of a hospital for catheterization.

Surgical treatment of prostate adenoma is carried out in severe cases. Either partial resection of the affected tissues or complete removal of the organ is performed.

Indications for surgical treatment:

• continued urinary retention after catheterization;
• blood in the urine, developing kidney failure;
• the appearance of stones, diverticula in the bladder;
• repeated inflammatory processes in the urinary system after massive drug treatment.

There are a number of conditions in which prostate surgery is not performed.

Contraindications for surgery:

• renal and heart failure;
• pyelonephritis, cystitis in the acute phase;
• aortic aneurysm;
• heart pathology;
• atherosclerosis of cerebral vessels.

Currently, doctors use sparing techniques for removing the organ. Open abdominal operations are extremely rare.

This type of intervention is performed using an endoscope. The procedure takes place either under general anesthesia or spinal anesthesia is used.

The instrument is inserted into the urethra and passed through the bladder to the prostate. Then, using a loop through which high-frequency currents are passed, parts of the organ are removed. At the same time, adjacent vessels are cauterized, which reduces the risk of bleeding.

This method allows you to remove not only hypertrophied tissues, but also the gland as a whole.

The duration of stay in the hospital is 2 days. The first day you will have to wear a catheter to drain urine.

An open intervention is performed when the weight of the prostate exceeds 80 g. In this case, only the affected organ is removed, the testicles remain in their place.

The incisions are made either in the lower abdomen or between the anus and the scrotum. An incision is made in the wall of the bladder, then prostate tissue is removed through the wound.

The term of stay in the hospital is 7 days. Be sure to wear a catheter after surgery.

The intervention is performed through a small incision in the patient's lower abdomen. An ultrasonic knife is used to remove tissue.

The whole procedure is reflected on the monitor screen. Duration of stay in a medical institution - 6 days. Be sure to wear a catheter after surgery.

As a scalpel, light waves of various lengths are used. In parallel, nearby vessels are cauterized. The operation is gentle, since the risk of bleeding is minimal. There are also no postoperative complications - retrograde ejaculation, enuresis, erectile dysfunction.

Instruments are inserted through the urethra. Radio waves of various frequencies act as a scalpel. During the procedure, a kind of cauterization of excess tissue of the organ occurs.

The procedure does not require hospitalization and is performed under local anesthesia. Does not require a catheter.

These are flexible devices that are inserted into the urethra to allow urine to drain. The procedure is performed under local anesthesia, does not require hospitalization and can be performed on an outpatient basis.

A drainage device must be worn for several hours after the intervention. During this time, the patient stays in the hospital.

Urology is a delicate part of the body. Diseases of this system should be treated under the guidance of an experienced doctor, on time and in full. After all, neglect of one's own health can lead to an operating table.

One of the most common diseases that occur in men, doctors consider prostate adenoma. Until now, it was this term that was commonly used everywhere, but recently another formulation has become more popular: benign prostatic hyperplasia (BPH).

Benign prostatic hyperplasia - this is the term recognized by most experts around the world, as it more fully expresses the essence of the disease and its histological structure.

Different age groups of the male half of humanity demonstrate different prevalence of BPH. The incidence in the group of patients aged 40-50 years is approximately 50%. Among men aged 50-60 years, about 60% suffer from this disease. Patients in the age category of 70 years and older are prone to illness in 85% of cases. Therefore, with increasing age, the likelihood of developing the disease increases.

At the same time, in the course of histological examination, signs of prostatic hyperplasia were also detected in 30-40-year-old men. Among the reasons that provoke the development of this disease, there are, first of all, hormonal changes occurring in the body. At the same time, no relationship of BPH with sexual activity, dietary habits, or race has been identified.

"Prostatic hyperplasia" - what does this wording mean?

The prostate gland is an organ that surrounds the urethra at the very base of the bladder. The prostate synthesizes a secret that, during ejaculation, is released into the urethra, and then ejected with semen. The activity of the prostate gland is determined by the amount of "male" hormones - androgens.

Hyperplasia of the prostate is called the growth of prostate tissue, an increase in its volume. In the case when such a pathology is observed only with the tissues of this gland, and there are no metastases to other organs, we are talking about benign hyperplasia - it is usually called prostate adenoma.

Benign hyperplasia can be described in another way: there is no degeneration of gland cells, only their number increases. The gland increases in volume, which causes disturbances in the functioning of adjacent organs.

If the growth of the prostate occurs with the formation of metastases that spread to other organs, then we are talking about prostate cancer, and not about BPH. In this case, prostate cells degenerate into cancer cells, which spread through the bloodstream and lymph, and then penetrate into other organs.

What causes prostate adenoma

As mentioned, the state of the prostate gland is greatly influenced by the hormonal background. As long as the "male" and "female" hormones are in a stable balance in the male body, nothing threatens the healthy state of the prostate. But very often, usually after 40 years, the hormonal background of the body fluctuates very often and strongly. If the body produces more "male" androgens than necessary, the process of growth of prostate tissue may begin.

Main symptoms of BPH

The formation of prostate adenoma is accompanied by the appearance of "nodules" - growth zones. Over time, there are more "nodules", the size of the gland increases, and it squeezes the urethra more and more. At the initial stage of the disease, a man notices changes in the nature of urination: the urine stream no longer has the usual strong pressure, the urge to urinate more and more often (this happens more often at night).

When the gland grows further, it puts even more pressure on the bladder and squeezes the urethra even more. Because of this, the walls of the bladder and urethra stretch and lose their tone. The bladder can no longer excrete all the accumulated fluid, and the last portion of it, which is called residual urine, remains in it.

This condition provokes the development of infectious processes. There is a violation of the volition of urination, that is, there may be an involuntary exit of urine or it will be delayed. Urine may come out in very small portions, it may contain blood, it may be with a changed color and smell. The man is no longer able to complete the full process of emptying the bladder.

Due to disturbances in the functioning of the bladder, disturbances in the functioning of the kidneys begin, which leads to pathological changes in all metabolic processes of the body. A person begins to experience frequent dizziness, appetite disturbances, general weakness appears. The psyche suffers greatly: the man becomes oppressed and irritable. If you do not start timely treatment of adenoma, it will provoke the appearance of acute urinary retention, the development of severe renal failure, and then the most unfavorable prognosis.

All the described stages of prostatic hyperplasia do not replace each other too quickly, they can last for several years. It is very important to immediately consult a doctor when the first signs of prostate hyperplasia appear. After all, if the diagnosis is made at an early stage, and treatment is carried out immediately, then the fewer health problems will arise.

Diagnosis of BPH

In order for the diagnosis to be made as accurately as possible, it is necessary to undergo a thorough examination. It all starts with an examination, in particular, with rectal palpation of the prostate. Then, to obtain more accurate results, you will need to undergo a transrectal ultrasound and transabdominal ultrasound, cystoscopy, uroflowmetry. Laboratory tests, in particular, PSA, a prostate-specific antigen, should help to adequately assess the patient's condition (they will also help to distinguish between benign and malignant hyperplasia). If complications are present, the doctor may prescribe x-ray methods.

How to treat prostate adenoma

Treatment of prostatic hyperplasia is aimed at minimizing the pressure exerted by the prostate tissue on the bladder and urethra. In some cases, it is quite enough to make lifestyle changes and prescribe medications to normalize the hormonal state of the body.

All men suffering from prostatic hyperplasia should lead an active lifestyle and not give up physical activity. It is also important to adhere to a healthy diet, that is, to minimize the consumption of smoked, fatty and fried foods. It is necessary to control the amount of fluid consumed, this is especially true for the second half of the day and the time before bedtime.

Prescribed medications can have a dual effect. The strength of some may be aimed at relaxing the muscles of the walls of the bladder and urethra, which contributes to an easier outflow of urine. One of these drugs is "Zokson". The action of other drugs will reduce the activity of androgens that stimulate prostate hyperplasia. These drugs include Penester.

The tissue of the prostate gland can also be influenced using hardware methods, such as ultrasound or cryotherapy. During the application of such methods, the structure of the prostate tissue is disrupted, as a result of which it stops its growth.

It is also possible to mechanically expand the urethra with the help of special stents, which normalizes the outflow of urine. If required, surgical treatment can be performed. At home, you can carry out herbal medicine, which is based on the use of plant extracts. It must be said that this method does not differ in powerful efficiency, although the dwarf palm extract relieves swelling of the prostate and has an anti-inflammatory effect.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Prostatic hyperplasia (N40)

Urology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 of December 12, 2013

benign prostatic hyperplasia(BPH) is a benign tumor that develops as a result of hyperplasia of predominantly glandular (epithelial) and less stromal cells of the prostate, against the background of a violation of the prostate receptor apparatus that interacts with testosterone metabolites, which leads to an increase in organ weight, as well as a deterioration in the passage of urine from the bladder ( infravesical obstruction), due to compression of the posterior urethra (the prostate surrounds the urethra). The process has a chronic course, resulting in decompensation of the contractile function of the bladder, an increase in residual urine, the formation of ureterohydronephrosis, the occurrence and progression of inflammatory diseases of the kidneys, bladder, and renal failure. (Lopatkin N.A. 1998)

I. INTRODUCTION

Full title: benign prostatic hyperplasia
Tooneprotocol:

ICD-10 code:
N40 - Prostatic hyperplasia

Abbreviations used in the protocol:
BAC-biochemical blood test
BPH - benign prostatic hyperplasia
IVO - infravesical obstruction.
OAM-general urinalysis
PSA prostate specific antigen
Ultrasound-ultrasound examination

Protocol development date: April, 2013
Patient category: men aged 45 years and over, with complaints of difficulty urinating, who, according to ultrasound, have BPH
Protocol Users: urologists, andrologists, surgeons

Classification

Clinical classification:
Stage 1 - the occurrence of urination disorders with complete emptying of the bladder,
Stage 2 - a significant violation of the function of the bladder, the appearance of residual urine,
Stage 3 - the development of complete decompensation of bladder function, the appearance of paradoxical ischuria. (Lopatkin N.A. 1998)

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Examinations required before planned hospitalization:

Name	Multiplicity (expiration date of the result)
UAC	1 (no more than 10 days)
OAM	1 (no more than 10 days)
BAK (total protein, urea, creatinine, glucose, total bilirubin, direct blirubin, ALT, AST)	1 (no more than 10 days)
ECG with conclusion	1 (no more than 10 days)
Urine culture tank	1 (no more than 10 days)
Coagulogram	1 (no more than 10 days)
microreaction	1(no more than 15 days)
Blood type and Rh factor	1(with seal and signature)
Fluorography	1 (no more than 10 days)
HIV test	1(no more than 6 months)
Hepatitis B and C markers	1(no more than 6 months)
Inspection of the therapist, ENT doctor, dentist	1 (no more than 10 days)
	1 (no more than 10 days)
Excretory urography with descending cystography	1 (no more than 2 months)

Examinations required in a planned hospital:

Name of service	Main	Additional
Complete blood count (6 parameters)	1(every 10 days)
General urine analysis	1 (every 10 days)
BAC (with determination of urea, glucose, total and direct bilirubin, creatinine, ALT, AST)		1(every 10 days)
Examination of the anesthesiologist	1
Histological examination of tissue	1
ECG		1
Ultrasound of the urinary system		1
Intravenous urography with descending cystography		1
Computed tomography of the urinary system		1
Determination of the PSA level of the general.	1
Uroflowmetry	1
Consultation of narrow specialists in the presence of severe concomitant diseases (cardiologist, endocrinologist, neurologist, etc.)		1

Diagnostic criteria

Complaints and anamnesis: complaints of difficulty urinating, frequent nocturnal urination, feeling of residual urine for a long time, or acute urinary retention, resulting in catheterization or cystostomy.

Physical data: rectally, the prostate is enlarged in size, adenomatously changed, densely elastic consistency, also in the presence of a large volume of residual urine, when the bladder is palpated in the suprapubic region, an overflowing bladder is palpated.

Laboratory research:
- in OAM, leukocyturia, bacteriuria, hematuria are possible;
- with prolonged IVO in the LHC, an increase in blood urea and creatinine is possible.

Instrument data:
- according to the ultrasound examination: residual urine, echographic signs of BPH;
- according to uroflowmetry: violation of the urodynamics of the lower urinary tract;
- on roentgencystography: a filling defect along the lower contour of the bladder.

Pproviding expert advice: taking into account the severity of concomitant diseases:
- in coronary pathology - a cardiologist;
- in case of diabetes mellitus - endocrinologist;
- in chronic renal failure - nephrologist;
- elevated PSA and hematuria-oncologist, etc.

Differential Diagnosis

Differential Diagnosis

signs	prostate cancer	BPH
Features of the anamnesis	Dysuria, terminal macrohematuria. weight loss, general malaise due to the paraneoplastic process. More often unilateral lymphedema due to lymphostasis.	Dysuria, nocturia, residual urine, weakness, malaise due to concomitant infectious process of the genitourinary system, symmetrical edema due to exacerbations of chronic pyelonephritis is possible.
rectal prostate	Slightly increased in size or the usual size of a woody consistency (especially along the periphery), the contour is uneven, bumpy.	The prostate has a densely elastic consistency, adenomatously changed, enlarged, the contour is even
X-ray signs	Unilateral ureterohydronephrosis, due to germination of the mouth of the ureter, uneven contour of the filling defect on the cystogram	Possible 2-sided ureterohydronephrosis due to compression of the mouths of the ureters, the symptom of "fish hooks", an even filling defect along the lower contour on the cystogram
Computed tomography ultrasound	Signs of tumor growth outside the organ	The tumor is smooth adenomatous structure does not extend beyond the capsule
Prostate specific antigen level	Raised, sharply elevated	Normal, slight increase due to adenomitis or after rectal examination
prostate biopsy	prostate cancer cells	BPH cells

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

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Treatment

Targetandtreatment:
Elimination of BPH as a cause of infravesical obstruction, drainage to unload the lower urinary tract. During the hospitalization of the patient, the volume of the necessary additional examination is determined in order to determine the volume of BPH and comorbidities, which determines the volume and type of surgical intervention, as well as measures of preoperative preparation and features of postoperative management of patients.

Treatment tactics

Non-drug treatment: stationary mode, semi-bed, table No. 15.

Medical treatment during planned hospitalization:
1. Antibacterial therapy (3rd generation cephalosporins 1 g x 2 r/d i/m, amikacin 0.5 g x 2 r/d i/m, metronidazole 100 ml x 1-2 r/d/i/v, ciprofloxacin 100 ml x 1-2 r/d i.v., levofloxacin 500 mg x 1 r/d i.v.)
2. Hemostatic therapy (dicynone 2.0 x 2 r/d i/m, etamsylate 2.0 x 2 r/d i/m, tramin 10% 5 ml x 1-2 r/d i/v)
3. Restorative therapy (glucose 5% 250 ml x 1 r/d i.v., vit. C 10.0 x 1 r/d i.v., vit. B1 1.0 x 1 r/d i.v., vit. B6 1.0 x 1 r/d i/v)
4. Metabolic drugs with immunomodulating effect: Vitaprost suppositories 1 time per day. 10 days
5. Pain relief therapy (ketoprofen 2.0 x 2 r/d i/m, promedol 2% 1.0 x 1 r/d i/m)
6. Antispasmodic therapy (drotaverine 2.0 x 2 r/d i/m)
7. Drugs that improve intestinal motility (metoclopramide 2.0 x 2 r/d i/m)

Other types of treatment: No

Surgery: Trocar cystostomy, transvesical adenomectomy, transurethral photoselective laser vaporization of BPH, transurethral plasma vaporization of BPH, transurethral microwave thermotherapy of BPH, mono- and bi-polar transurethral resection of BPH, high section of the bladder epicystostomy (Gold standard - Transurethral resection of BPH-, with prostate adenoma up to 80 grams)

Preventive actions:
- drugs inhibitors of alpha 5 reductase: dutasteride 500mcg x 1 r/d-3-6 months, finasteride 500mcg x 1 r/d-3-6 months, prostamol-uno 320mg x 1 r/d-3 months
- alpha adreno-blockers: doxazosin 1 tab x 1 r / d and its forms, tamsulosin 0.4 mg 1 capsule x 1 time per day and its forms;
- metabolic therapy: vitaprost tablets 100 mg x 2 times a day for 30 days;
- Observation by a urologist, control of the KLA, OAM, ultrasound of the kidneys, bladder, prostate, the volume of residual urine - after 1 month, if necessary, anti-inflammatory therapy, in order to sanitize chronic foci of urinary system infection.

Further management:
- within 1 month after the operation: do not take anticoagulants, antiaggregants
- restriction of physical activity
- control of blood pressure (not higher than 140/90 mm Hg)
- do not take hot water treatments
- to prevent intestinal obstipation (during defecation, do not strain).

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
- decrease or absence of residual urine volume, free urination, light urine
- with adenomectomy - wound healing by primary intention, consistency of sutures, dry and clean postoperative wound
- in laboratory tests, the absence of high leukocytosis, leukocyturia is allowed, a moderate decrease in hemoglobin and erythrocyte levels.

Drugs (active substances) used in the treatment

Amikacin (Amikacin)

Ascorbic acid

Dextrose (Dextrose)

Doxazosin (Doxazosin)

Drotaverine (Drotaverinum)

Dutasteride (Dutasteride)

Ketoprofen (Ketoprofen)

Levofloxacin (Levofloxacin)

Metoclopramide (Metoclopramide)

Creeping palm fruit extract (Serenoa repens fructuum extract)

Pyridoxine (Pyridoxine)

Prostate extract (Prostate extract)

Tamsulosin (Tamsulosin)

Thiamine (Thiamin)

Tranexamic acid (Tranexamic acid)

Trimeperidine (Trimeperidine)

Finasteride (Finasteride)

Ciprofloxacin (Ciprofloxacin)

Etamzilat (Etamsylate)

Groups of drugs according to ATC used in the treatment

Hospitalization

Indications for hospitalization (planned):
- difficult, frequent urination,
- nocturnal pollakiuria,
- residual urine,
- chronic urinary retention,
- the impossibility of independent urination, with the presence of a cystostomy or urethral catheter.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. "2010 Update: Guidelines for the management of benign prostatic hyperplasia", Canadian Board of Prostate Health and Canadian Urological Association Guidelines Committee‡; Can Urol Assoc J 2010;4(5):310-316 2. Lopatkin N.A. Benign prostatic hyperplasia. - M., 1998. 3. Gorilovsky L.M. Prostate diseases in the elderly. - M., 1999. 4. Trapeznikova M.F. Classification of methods for the treatment of benign prostatic hyperplasia - M., 1997.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers:
Alchinbaev M.K. - Doctor of Medical Sciences, Director of the Scientific Center of Urology. Academician B.U. Dzharbusynova

Reviewers:
MD, Professor Hairley G.Z.

Indication of no conflict of interest: missing.

Indication of the conditions for revising the protocol: Revise the protocol 5 years after its entry into force and / or when new methods of diagnosis / treatment appear with a higher level of evidence.

Attached files

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Passport part.

Name: Kravchenkov Alexey Evgenievich

Age: 70 years

Place of residence: st. Popova 54-74

Place of work: pensioner

Clinical diagnosis:

Complication of the underlying disease: chronic urinary retention

Operation 16.03.05 - one-stage adenomectomy with closure of the bed according to Lopatkin.

Curation start date: 17.03.05

Curation end date: 03/22/05

Inquiry (Interrogatio)

Complaints

The patient complains of frequent urination, incl. at night up to 5 times, which is difficult, especially in the morning. Urination in small portions, painful. Urination time is increased. The patient also complains of a feeling of heaviness in the lower abdomen, the absence of a feeling of emptying the bladder.

Anamnesis morbi.

He considers himself ill for about 3 years. The disease developed gradually, the symptoms increased. He was treated on an outpatient basis, but without a significant result. Hospitalized for examination and decision on surgical treatment.

Anamnesisvitae

1) Family history. He was born full-term, the last of 2 children in a family of workers. The parents were healthy. The mother's pregnancy proceeded uneventfully. In development, he did not lag behind his peers. I went to school at the age of 7, graduated from 10 classes, a vocational school as a mechanic, at the Iskra plant. Within 5 years of retirement. Heredity is burdened by coronary artery disease, hypertension.

2) Dietary history. Was breastfed. Nutrition throughout life recognizes satisfactory, sufficient. He does not notice any particular tastes in food. I do not smoke. Does not abuse alcoholic beverages

3) Past illnesses, trauma surgeries. Children's infections are difficult to name. Periodically (1-2 times a year) ARVI is sick. No injury noted. In 1982 he was operated on for gastric cancer T 2 N 0 M 0 , gastric resection was performed. For 15 years he has been suffering from hypertension. ST, BT, BB, tbc, venereal disease denies.

4) allergic history. History of allergic reactions to novocaine, iodine.

5) Sanitary and epidemiological anamnesis. Lives in an area relatively favorable in ecological, radiation and epidemiological respects. Lives in a well-appointed apartment. Follows the rules of personal hygiene. In the last 0.5 years, he did not travel outside the region, was not in contact with infectious patients, and did not undergo parenteral interventions.

7) Insurance history. Pensioner

Status praesens

1. General inspection(ectoscopia)

The condition is satisfactory. Consciousness is clear. The position is active. The posture is correct, the gait is not changed. The constitutional body type is normosthenic. The head is mesocephalic, normal size. Facial expression is calm.

Eyeballs, conjunctiva, pupils, eyelids, periorbital tissue without visible changes.

The skin is flesh-colored, clean, moderately moist, elastic, turgor is preserved. Derivatives of the skin without changes.

Subcutaneous adipose tissue is developed enough, evenly distributed. The thickness of the subcutaneous fat layer at the level of the umbilicus is about 2 cm. Peripheral lymph nodes accessible for palpation are not determined. There are no visible edema.

Muscles are moderately developed, painless, muscle strength is sufficient, muscle tone is preserved. The skeletal system without visible deformations. Joints of normal configuration, active and passive movements are preserved in full. Soft tissues in the area of ​​the joints are not changed.

Examined for pediculosis - neg.

Anthropometric study. Height 168 cm, weight 70 kg. Temperature 36.7 ° C.

1. Research by Systems

Respiratory system

a) private inspection (inspectio).

Nose of normal shape. The nasal septum is not curved. Nasal breathing is not difficult. There is no pain on palpation in the paranasal sinuses. The voice is loud. There are no pronounced deformities of the larynx.

The chest is normosthenic. Both halves are symmetrical (clavicles and shoulder blades are located at the same level, supraclavicular and subclavian fossae are equally pronounced on both sides). Both halves of the chest are equally involved in the act of breathing. Mixed tap breathing, rhythmic, normal depth. The frequency is 16 per minute. Auxiliary muscles do not take part in the act of breathing. Chest circumference 94 cm, respiratory excursion - 6 cm.

b) palpation (palpatio)

The chest is painless, rigid.

c) percussion (percussio)

With comparative percussion over symmetrical areas of the chest, a pulmonary sound is detected.

Topographic percussion. The height of the apices in front is 6 cm above the middle of the clavicle, in the back - 3 cm lateral to the spinous process C VII. The width of the Krenig fields on the right and left is 5 cm.

Inferior borders of the lungs:

	Right	Left
Lin. parasternalis	lower edge of the 5th rib	demarcation
Lin. mediaclavicularis	lower edge of the 6th rib	not carried out
Lin. axilaris anterior	lower edge of the 7th rib	lower edge of the 7th rib
Lin. axilaris media	lower edge of the 8th rib	lower edge of the 8th rib
Lin. axilaris posterior	lower edge of the 9th rib	lower edge of the 9th rib
Lin. scapularis	lower edge of the 10th rib	lower edge of the 10th rib
Lin. paravertebralis		at the level of the spinous process Th XI

d) auscultation (auscultatio)

Vesicular breathing is heard over the entire surface of the lungs. There are no wheezes.

The cardiovascular system

a) private inspection (inspectio)

There are no visible deformities of the chest wall in the region of the heart. The apical impulse is not visually determined. Pathological pulsations during examination of the vessels of the neck, in the region of the heart, epigastric region were not detected.

b) palpation (palpatio)

The apex beat is not palpable. Cardiac impulse, systolic and diastolic trembling is not determined by palpation.

The pulse is the same on both radial arteries, the frequency is 68 beats per minute, uniform, normal filling and tension, the speed is not changed, the vascular wall is sealed.

c) percussion (percussio)

Limits of relative dullness of the heart:

The width of the vascular bundle is 5 cm. The outline is of normal configuration. Right diameter - 3.5 cm, left - 9 cm, diameter - 12.5 cm; md/ms - 1/2.5

d) auscultation (auscultatio)

Heart sounds of normal frequency, clear, rhythmic. There are no noises and accents of the 2nd tone. BP - 150/90, pulse 60.

Digestive system

a) private inspection (inspectio)

The mucous membrane of the oral cavity, palatine arches, posterior pharyngeal wall, soft and hard palate is pink. The tongue is moist, not furred. The gums don't bleed. There are no carious teeth. The tonsils protrude from behind the palatine arches. Swallowing is not disturbed. The passage of liquid and thick food through the esophagus is not difficult.

The abdomen is oval, symmetrical, the anterior abdominal wall is involved in breathing. There is a scar after the upper median laparotomy.

b) palpation (palpatio)

With superficial approximate palpation, the tone of the muscles of the anterior abdominal wall is reduced, there is no pain. Divergences of the rectus abdominis muscles and hernial protrusions along the white line of the abdomen were not found. Soreness in the points and zones of the gallbladder and pancreas was not noted. With deep palpation, the abdominal organs of normal localization and characteristics, large curvature is not determined by palpation, pathological formations are not palpable.

c) percussion (percussio)

With comparative percussion over the symmetrical parts of the abdomen, a tympanic sound of different heights is revealed. The dimensions of the liver according to Kurlov: 10(0)x9x8 cm, the dimensions of the spleen: 6(0)*4 cm.

d) auscultation (auscultatio)

Peristaltic noises of moderate strength are heard. Noise of friction of the peritoneum and vascular noises are not determined.

urinary system

The lumbar region is not changed. Her skin and soft tissues are normal. The kidneys are not palpable. The ureteral points are painless. Pasternatsky's syndrome is not detected.

Endocrine system

The development is proportional, harmonious. The thyroid gland is not enlarged, there are no signs of hyper- and hypothyroidism. Secondary sexual characteristics are developed according to sex and age.

Psychoneurological status.

Oriented in space, time and self. The mood is stable, sociable. Consciousness is clear. There were no pronounced disorders of attention, memory, cognitive sphere, psychoproductive symptoms.

Pupils D=S, reaction to light is alive. Full range of eyeball movements. Sensitivity in the face is not broken. Mimic in full. Tongue in the midline. Swallowing is not disturbed. The voice is sonorous.

There are no pronounced sensory disturbances. Muscle strength is sufficient, tone is preserved. Reflexes D=S, live. Pathological reflexes are not detected.

Statuslocalis.

Per rectum. The prostate gland is densely elastic, enlarged 2-2.5 times, painless. The contours are uneven. The mucosa is displaced.

Preliminary diagnosis: benign hyperplasia

prostate, HZM

Related: hypertonic disease

Data from additional examination methods:

1) UAC dated 15.03.2005

Indicators	26.01	Norm
Erythrocytes (*10 12 /l)	4,3	4-5,1
Hemoglobin (g/l)	140	130-160
Color indicator	0,97	0,86-1,05
Leukocytes (*10 9 /l)	5,6	4,0-8,8
ESR (mm/h)	5	1-10
Leukocyte formula (in%)
Eosinophils	1	0-5
Basophils	—	0-1
stab	1	1-6
Segmented	62	45-70
Lymphocytes	29	18-40
Monocytes	7	2-9

Conclusion: within the normal range

Indicators	15.03	Norm
Color	s/f	s/f
Transparency	transparent	transparent
Specific gravity (g/l)	1017	1008-1026
Protein (g/l)	0,033	<=0,033
pH	neutral	4,5-8,0
bile pigments	—	—
Urobilin	—	—
epithelial cells	0-1	0-1
Leukocytes	2-3	0-3
red blood cells	units in p. / sp.	0-1
salt	—

Conclusion: within normal limits

• HD blood

Conclusion: within normal limits

4) RW 03/15/05 - neg.

5) ECG 14.03.05. Sinus tachycardia 100 per minute, horizontal EOS due to the high position of the diaphragm. Frequent ventricular extrasystole. Left ventricular hypertrophy. Hypoxia of the myocardium of the anterior region of the left ventricle.

6) Ultrasound of the kidneys from 15.03.05.

Right: the position is normal, the contours are even, clear, the dimensions are medium (10.2x5.0), the thickness of the parenchyma is 1.85 mm, the PCS is not expanded

Left: the position is normal, the contours are even, clear, the dimensions are medium (10.4x5.6), the thickness of the parenchyma is 1.85 mm, the PCS is not expanded

Bulk formations were not identified. The bladder is poorly filled. The prostate gland is enlarged to 6.7x5.0x5.6 cm. V=98.1 cm 3 . The contours are fuzzy, irregular in shape. 1.5 cm protrudes into the lumen of the bladder. The parenchyma is heterogeneous, areas of dysplasia up to 0.9 cm in diameter.

7) Uroflometry from 15.03.05

Urination time - 44.3 sec., Urine volume - 101 ml, max speed - 3.4 ml/sec. The average speed is 2.3 ml / sec.

Conclusion: infravesical obstruction.

Clinical diagnosis:

Main disease: benign prostatic hyperplasia (N 40), subcompensation

Complication of concomitant disease: chronic urinary retention

Concomitant disease: hypertension, stage II.

Substantiation of the diagnosis

The diagnosis of the disease was made on the basis of:

• complaints of frequent, especially at night, difficulty urinating in small portions, as well as a feeling of heaviness in the lower abdomen, no feeling of emptying the bladder
• History data - gradual development of the disease, age 70 years, no history of diseases and injuries of the urethra or perineum
• Data of an objective study - palpation definition of hyperplastic prostate per rectum.
• These additional methods of examination - prostatic hyperplasia according to ultrasound without signs of kidney damage; detection of infravesical obstruction according to uroflometry.

Treatment

Patients with asymptomatic or asymptomatic disease should be observed. Men who develop urinary retention, recurrent infections, bladder stones, or kidney failure should have surgery. There are two approaches to the treatment of benign prostatic hyperplasia. Blockers of a-adrenergic receptors relax the smooth muscles of the gland and partially alleviate the active part of the obstruction. Drugs alleviate the condition and improve the conditions for the outflow of urine in most patients. Finazieride, an inhibitor of 5-a-reductase activity, reduces the level of intraprostatic dihydrotestosterone without reducing the content of the hormone in plasma. Although the drug significantly reduces the size of the prostate, however, only 30% of patients have a positive effect.

In case of ineffectiveness, progression of the disease, surgery is indicated. There are several options:

1) Transurethral resection of the prostate. It is an electroresection of the prostate through the urethra. Pieces of tissue are removed under direct visual control, often in combination with endoscopic lithotripsy (crushing and removal of bladder stones). The same technique is acceptable for prostate carcinoma that does not respond to treatment or temporary relief. Relapses occur in up to 10-15% of cases.

2) Open prostatectomy from different accesses(transvesical, retropubic, perineal). Indications for it are an adenoma of considerable size and a combination of a tumor and bladder stones. The most radical kind of operation.

3) Epicystostomy. It is used as a palliative operation in debilitated patients with severe concomitant pathology. Sometimes used as the first stage of 2 -

momentary prostatectomy for decompensated BPH.

In this patient, the indications for surgery are:

1) the presence of BPH in the stage of subcompensation with the development of CMM.

2) ineffectiveness of conservative treatment

Curation diary

15.03.05	Preoperative epicrisis Patient Kravchenkov A.E. Born in 1937, hospitalized in the Regional Clinical Hospital with complaints of difficult, frequent urination, lack of sensation of bladder emptying. History of gastric resection for cancer (T 2 N 0 M 0), hypertension. Objectively - an increase in the prostate by the type of benign hyperplasia. With ultrasound V=98.1 cm 3 , with uroflometry - signs of infravesical obstruction. The diagnosis was made: BPH, subcompensation, CMM, concomitant - hypertension stage II. An operation is indicated - a one-stage adenomectomy under the MCA with a transvesical access. The patient is prepared for surgery, consent is obtained
16.03.05	Operation: one-stage adenomectomy with closure of the bed according to Lopatkin. Under the MCA, after processing the surgical field, a lower-median incision of the ventral wall was made. The anterior wall of the bladder was isolated, taken on 4 "holders". Between them the bladder is opened. The revision revealed a large adenoma. Bimanually exfoliated with one conglomerate of adeno tissue. The bed is large, not reduced - sutured with catgut according to Lopatkin (3 sutures). A Foley catheter No. 20 was placed in the urethra. Petu's catheter was placed in the bladder. The wound is sutured in layers. An aseptic bandage was applied. Appointments: 2% solution of Omnopon i / m, 2 ml at 14, 18, 22 hours on 16.03, 6 hours on 17.03. Etamzilat 2.0 2 times a day FFP 300 ml IV cap.
	Inspection b/w 2 hours Complaints of pain in the area of ​​p / o wounds. The bandage is dry. Hemodynamics is stable. Urine in sufficient quantity, colored in the color of meat slops, no clots.
17.03.05	Complaints of pain in the area of ​​p / o wounds. The condition is satisfactory. The skin is clean. Vesicular breathing in the lungs, no wheezing. Heart sounds are clear, rhythmic, there are no noises, accents of 2 tones. The abdomen is soft, painful in the area of ​​the p / o wound. Pasternatsky's symptom is negative on both sides. The bandage was soaked with hemorrhagic discharge. Bandaged. Wound with no signs of inflammation. Urine in sufficient quantity, colored in the color of meat slops, no clots. Appointments: Cefotaxime 1.0 IM 3 times a day Etamzilat 2.0 2 times a day
19.03.05	No active complaints. The condition is satisfactory. The skin is clean. Vesicular breathing in the lungs, no wheezing. Heart sounds are clear, rhythmic, there are no noises, accents of 2 tones. The abdomen is soft, painful in the area of ​​the p / o wound. Pasternatsky's symptom is negative on both sides. The bandage is dry. Bandaged. Wound with no signs of inflammation. Urine in sufficient quantity. Appointments:
21.03.05	No active complaints. The condition is satisfactory. The skin is clean. Vesicular breathing in the lungs, no wheezing. Heart sounds are clear, rhythmic, there are no noises, accents of 2 tones. The abdomen is soft and painless. Pasternatsky's symptom is negative on both sides. The bandage is dry. Bandaged. Wound with no signs of inflammation. Urine in sufficient quantity. Appointments:
	Stage epicrisis. Patient Kravchenkov A.E. Born in 1937, hospitalized in the Regional Clinical Hospital with complaints of difficult, frequent urination, lack of sensation of bladder emptying. History of gastric resection for cancer (T 2 N 0 M 0), hypertension. Objectively - an increase in the prostate by the type of benign hyperplasia. With ultrasound V=98.1 cm 3 , with uroflometry - signs of infravesical obstruction. The diagnosis was made: BPH, subcompensation, CMM, concomitant - hypertension stage II. 03/16/05 operation - one-stage adenomectomy with closure of the bed according to Lopatkin. The postoperative period proceeds without features. For life - the disease at this stage does not pose an immediate threat For health - a radical operation, the prognosis is favorable.

References:

• Department lectures
• Handbook of Surgery, ed. S. Schwartz, J. Shiers, F. Spencer (electronic version)
• Textbook on urology, ed. N.A. Lopatkina, M., Med. 1982