Benign prostatic hyperplasia, is treated
Benign prostate hyperplasia consists in an increase of the size of the prostate gland that causes difficulty urinating, and is common in men over 50 years old. You know your symptoms and how it is.
Two factors are involved in the pathophysiology of benign prostatic hyperplasia: on the one hand the increase in the size of the gland, which can cause an obstruction to urine flow by the light of the urethra and, on the other, the alteration of muscle tone in the neck of the urinary bladder and the smooth muscle of the prostate, which may cause irritation.
The prevalence of benign prostate hyperplasia increases with age, and mainly affects men over the age of 50 years (very rare, it occurs before age 40 is). At age 40, 14% of men have symptoms that make suspect its presence; 50-60 years this percentage increases to 40-50%; and up to 80% of those older than 80 years may be affected by benign prostate hyperplasia. Black males are more likely to develop this entity that males of Caucasians, while the men of Asian origin are less affected than the other two listed races.
The prognosis of benign prostate hyperplasia is highly variable. While in some men symptoms get progressively worse despite treatment, others remain unchanged or improve over time without treatment.
· Drain or obstructive symptoms: fine stream of urine, difficulty starting urination, incomplete intermittent, emptying jet of the bladder, dripping after urination.
· Filling or irritative symptoms: abdominal pain, incontinence, urinary frequency (increase in the number of urination during the day, which are usually of small quantity), nocturia (increased frequency of nighttime urination, in such a way that it becomes more common to go to the bathroom at night than in day) and urinary urgency (feeling of not being able to contain urine and the need to urinate as soon as possible).
Obstruction caused by benign prostatic hyperplasia of prostate can cause complications, and that the patient does not completely empty the bladder (leaving traces of urine after urination), that there is dilation of the upper urinary tract, kidney failure, frequent urinary tract infections or formation of stones in the bladder (bladder lithiasis). In the vast majority of patients the progression of symptoms is slow, with fluctuations, and serious complications are not common.
· History: suspected of benign prostate hyperplasia, it is necessary to ask the patient about the presence of symptoms to think that you have this disease (obstructive or irritative symptoms). These symptoms are not specific of benign prostate hypertrophy, so that they may also occur in males with normal prostate gland due to other diseases such as diabetes, infection of urine, or consumption of drugs. A careful history will allow us to perform a differential diagnosis.
· International level of prostatic symptoms (IPSS): to assess the intensity of the clinic of the benign prostatic hyperplasia have been used different questionnaires, being the most widely used international scale of prostatic symptoms (IPSS). It consists of seven questions about symptoms that suffers from the patient, with six possible answers scoring between 0 and 5 depending on the intensity of the clinic. In addition, there is a separate question which values the influence that have symptoms on quality of life of the patient.
· Physical examination anddigital rectal examination: at the slightest suspicion of a benign enlarged prostate a complete physical examination that includes a digital rectal examination should be performed. This allows information about the size, shape and consistency of the prostate as well as check the existence of nodules. In addition, it allows the differential diagnosis with other diseases, such as prostate cancer.
· Blood test: the realization of a blood test that allows to see the values of substances as creatinine is useful to check the existence of complications, such as kidney failure. The determination of a substance known as PSA (prostate specific antigen) levels in blood is quite widely in patients with lower urinary tract symptoms. However, it is not a good practice, as these patients have an increased risk of prostate cancer. PSA must only be requested if you suspect prostate cancer.
· Analysis of urine: may be normal or altered in patients with benign prostatic hyperplasia. Their usefulness lies in that allows you to identify complications or rule out diseases that present with similar symptoms.
· Suprapubic ultrasound: provides information about the size of the prostate, the presence of post-voiding residue (urine that remains in the retained bladder after urination), and the existence of associated complications. In the evaluation of benign prostate hyperplasia, ultrasound is performed first with a full bladder and subsequently is repeated with this empty, to assess the post-voiding residue as well.
· Urinary flow: a test is non-invasive, which allows to quantify the flow of urine. Allows you to assess, relatively reliably, the existence of obstruction. It consists of collecting a spontaneous urination on a precision scale attached to a timer that records the flow of urine. Before you submit any patient to surgery for benign prostatic hyperplasia it is essential to practice a flowmetry or urodynamic another test to assess the existence and the degree of obstruction.
If the symptoms are mild are recommended certain simple measures which can improve the quality of life of the patient, such as:
· Do not consume alcohol or caffeine, especially at night.
· Do not drink large amount of fluid at a time.
· Deliver fluids throughout the day and avoid its consumption two hours before bedtime.
· Try to empty the bladder the most during urination (despite having finished urinating, try to urinate a little more to help to completely empty the bladder).
· Exercise regularly and avoid sedentary lifestyle, because you can make the symptoms worse.
· Avoid the stress.
To treat benign prostatic hyperplasia prostate is available three drug groups:
· Alpha-adrenergic blockers (alfuzosin, tamsulosin, doxazosin, terazosin): reduce the tone of the muscles of the neck of the bladder and prostate, improving symptoms and urinary flow. They do not diminish the volume of prostate, therefore do not alter the natural history of the disease. They are used in cases of small but very obstructive hypertrophy. When these drugs are administered should monitor blood pressure, which can cause voltage drops.
· Extracts of plants (phytotherapy): various drugs with not very well known mechanisms of action are included in this group. The most commonly used are derivatives of the Pygeum africanum and the Serenoa repens.
· 5-alpha-reductase inhibitors (finasteride and dutasteride): block an enzyme that allows the passage of testosterone to dihydrotestosterone, which is the hormone that causes the growth of the prostate. They are indicated in cases of important hypertrophy, since they reduce the size of the prostate.
· Antimuscarinics and Phosphodiesterase-5 inhibitors: recently it has shown the usefulness of these drugs improve symptoms.
To summarize, the management of patients with benign prostatic hyperplasia would read as follows:
· Patients with moderate symptoms and little involvement of their quality of life: remains an expectant; treatment is not started.
· Patients with moderate-severe symptoms or significant involvement of their quality of life: starts medical treatment with an alfa-bloqueante. If the patient does not improve or not well tolerated these drugs you can use phytotherapy (Serenoa Repens) despite the lack of evidence. Finally, when the predominant symptoms are more of irritant type and there is no increase in the size of the prostate or signs of obstruction you can associate is an antimuscarinic drug
· Patient with significant risk for an acute retention of urine (RAO) without surgical criteria: If in these patients, symptomatic treatment is dismissed and seeks to prevent / delay a RAO or surgical intervention, there must be treatment with finasteride. If the patient has many symptoms is used combined therapy (inhibitor of 5-alpha-reductase and alfa-bloqueante).
· Patient with complications of benign prostate hyperplasia or no response to pharmacological treatment: we recommend surgical treatment, performing what is known as a Transurethral prostate resection (if it is not very large) or other more aggressive techniques such as Prostatectomy open (if the size is greater). Transurethral resection involves inserting a thin tube through the urethra to gradually cut fragments of an enlarged prostate. Open Prostatectomy is to remove the prostate through an incision in the lower abdomen. These surgeries are performed under anesthesia and require hospital admission. They are currently developing new therapies less invasive.
Benign prostatic hyperplasia prostate complications that might require the patient to be operated are: Frank urinary flow obstruction, acute or chronic retention of urine produced by the growth of the size of the prostate, urinary tract infections, or presence of blood in urine of repeatedly (without any other cause), the presence of bladder stones (lithiasis), or kidney failure caused by benign prostatic hyperplasia of prostate.
When the prostate grows it compresses the urethra and can hinder the expulsion of urine
Benign prostatic hyperplasia
Benign prostate hyperplasia He is characterized by an increase in non-malignant prostatic volume, or what is the same, a non-cancerous growth of the size of the prostate. The prostate is small (similar to a chestnut) which lies in front of the rectum and below the bladder, surrounding the urethra, which is the conduit by which urine is ejected outdoors. To grow, you can progressively compress the urethra and cause difficulty urinating.Two factors are involved in the pathophysiology of benign prostatic hyperplasia: on the one hand the increase in the size of the gland, which can cause an obstruction to urine flow by the light of the urethra and, on the other, the alteration of muscle tone in the neck of the urinary bladder and the smooth muscle of the prostate, which may cause irritation.
Causes of benign hyperplasia of prostate
The mechanisms by which this disorder occurs are not well known. In the past were considered to be the androgens (male hormones) and the advance of age the two factors involved in its development. Currently considered two distinct groups of factors as causes of benign prostate hyperplasia: the extrinsic (especially hormones, environmental factors or the hereditary predisposition) and the intrinsic, which act as regulators of growth of the prostate through autocrine and paracrine (which are types of cellular communication that uses chemical messengers).The prevalence of benign prostate hyperplasia increases with age, and mainly affects men over the age of 50 years (very rare, it occurs before age 40 is). At age 40, 14% of men have symptoms that make suspect its presence; 50-60 years this percentage increases to 40-50%; and up to 80% of those older than 80 years may be affected by benign prostate hyperplasia. Black males are more likely to develop this entity that males of Caucasians, while the men of Asian origin are less affected than the other two listed races.
The prognosis of benign prostate hyperplasia is highly variable. While in some men symptoms get progressively worse despite treatment, others remain unchanged or improve over time without treatment.
Symptoms of benign prostate hyperplasia
In benign prostate hyperplasia are two major types of symptoms:· Drain or obstructive symptoms: fine stream of urine, difficulty starting urination, incomplete intermittent, emptying jet of the bladder, dripping after urination.
· Filling or irritative symptoms: abdominal pain, incontinence, urinary frequency (increase in the number of urination during the day, which are usually of small quantity), nocturia (increased frequency of nighttime urination, in such a way that it becomes more common to go to the bathroom at night than in day) and urinary urgency (feeling of not being able to contain urine and the need to urinate as soon as possible).
Obstruction caused by benign prostatic hyperplasia of prostate can cause complications, and that the patient does not completely empty the bladder (leaving traces of urine after urination), that there is dilation of the upper urinary tract, kidney failure, frequent urinary tract infections or formation of stones in the bladder (bladder lithiasis). In the vast majority of patients the progression of symptoms is slow, with fluctuations, and serious complications are not common.
Diagnosis of benign hyperplasia of prostate
Diagnosis of benign prostate hyperplasia it must be verified the existence of an increase of the size of the prostate, the presence of symptoms consistent with the condition, and the existence of a blockage below the bladder.· History: suspected of benign prostate hyperplasia, it is necessary to ask the patient about the presence of symptoms to think that you have this disease (obstructive or irritative symptoms). These symptoms are not specific of benign prostate hypertrophy, so that they may also occur in males with normal prostate gland due to other diseases such as diabetes, infection of urine, or consumption of drugs. A careful history will allow us to perform a differential diagnosis.
· International level of prostatic symptoms (IPSS): to assess the intensity of the clinic of the benign prostatic hyperplasia have been used different questionnaires, being the most widely used international scale of prostatic symptoms (IPSS). It consists of seven questions about symptoms that suffers from the patient, with six possible answers scoring between 0 and 5 depending on the intensity of the clinic. In addition, there is a separate question which values the influence that have symptoms on quality of life of the patient.
· Physical examination anddigital rectal examination: at the slightest suspicion of a benign enlarged prostate a complete physical examination that includes a digital rectal examination should be performed. This allows information about the size, shape and consistency of the prostate as well as check the existence of nodules. In addition, it allows the differential diagnosis with other diseases, such as prostate cancer.
· Blood test: the realization of a blood test that allows to see the values of substances as creatinine is useful to check the existence of complications, such as kidney failure. The determination of a substance known as PSA (prostate specific antigen) levels in blood is quite widely in patients with lower urinary tract symptoms. However, it is not a good practice, as these patients have an increased risk of prostate cancer. PSA must only be requested if you suspect prostate cancer.
· Analysis of urine: may be normal or altered in patients with benign prostatic hyperplasia. Their usefulness lies in that allows you to identify complications or rule out diseases that present with similar symptoms.
· Suprapubic ultrasound: provides information about the size of the prostate, the presence of post-voiding residue (urine that remains in the retained bladder after urination), and the existence of associated complications. In the evaluation of benign prostate hyperplasia, ultrasound is performed first with a full bladder and subsequently is repeated with this empty, to assess the post-voiding residue as well.
· Urinary flow: a test is non-invasive, which allows to quantify the flow of urine. Allows you to assess, relatively reliably, the existence of obstruction. It consists of collecting a spontaneous urination on a precision scale attached to a timer that records the flow of urine. Before you submit any patient to surgery for benign prostatic hyperplasia it is essential to practice a flowmetry or urodynamic another test to assess the existence and the degree of obstruction.
Treatment of benign hyperplasia of prostate
Treatment in benign prostate hyperplasia depends on the intensity of the symptoms the patient, affects how their quality of life, of the risk of acute retention of urine (inability to carry out despite the desire urination and patient efforts to do so), and the presence of complications. Three types of actionscan be taken accordingly: expectant, symptomatic treatment, and treatment with intentionality curative (either pharmacological or surgical).If the symptoms are mild are recommended certain simple measures which can improve the quality of life of the patient, such as:
· Do not consume alcohol or caffeine, especially at night.
· Do not drink large amount of fluid at a time.
· Deliver fluids throughout the day and avoid its consumption two hours before bedtime.
· Try to empty the bladder the most during urination (despite having finished urinating, try to urinate a little more to help to completely empty the bladder).
· Exercise regularly and avoid sedentary lifestyle, because you can make the symptoms worse.
· Avoid the stress.
To treat benign prostatic hyperplasia prostate is available three drug groups:
· Alpha-adrenergic blockers (alfuzosin, tamsulosin, doxazosin, terazosin): reduce the tone of the muscles of the neck of the bladder and prostate, improving symptoms and urinary flow. They do not diminish the volume of prostate, therefore do not alter the natural history of the disease. They are used in cases of small but very obstructive hypertrophy. When these drugs are administered should monitor blood pressure, which can cause voltage drops.
· Extracts of plants (phytotherapy): various drugs with not very well known mechanisms of action are included in this group. The most commonly used are derivatives of the Pygeum africanum and the Serenoa repens.
· 5-alpha-reductase inhibitors (finasteride and dutasteride): block an enzyme that allows the passage of testosterone to dihydrotestosterone, which is the hormone that causes the growth of the prostate. They are indicated in cases of important hypertrophy, since they reduce the size of the prostate.
· Antimuscarinics and Phosphodiesterase-5 inhibitors: recently it has shown the usefulness of these drugs improve symptoms.
To summarize, the management of patients with benign prostatic hyperplasia would read as follows:
· Patients with moderate symptoms and little involvement of their quality of life: remains an expectant; treatment is not started.
· Patients with moderate-severe symptoms or significant involvement of their quality of life: starts medical treatment with an alfa-bloqueante. If the patient does not improve or not well tolerated these drugs you can use phytotherapy (Serenoa Repens) despite the lack of evidence. Finally, when the predominant symptoms are more of irritant type and there is no increase in the size of the prostate or signs of obstruction you can associate is an antimuscarinic drug
· Patient with significant risk for an acute retention of urine (RAO) without surgical criteria: If in these patients, symptomatic treatment is dismissed and seeks to prevent / delay a RAO or surgical intervention, there must be treatment with finasteride. If the patient has many symptoms is used combined therapy (inhibitor of 5-alpha-reductase and alfa-bloqueante).
· Patient with complications of benign prostate hyperplasia or no response to pharmacological treatment: we recommend surgical treatment, performing what is known as a Transurethral prostate resection (if it is not very large) or other more aggressive techniques such as Prostatectomy open (if the size is greater). Transurethral resection involves inserting a thin tube through the urethra to gradually cut fragments of an enlarged prostate. Open Prostatectomy is to remove the prostate through an incision in the lower abdomen. These surgeries are performed under anesthesia and require hospital admission. They are currently developing new therapies less invasive.
Benign prostatic hyperplasia prostate complications that might require the patient to be operated are: Frank urinary flow obstruction, acute or chronic retention of urine produced by the growth of the size of the prostate, urinary tract infections, or presence of blood in urine of repeatedly (without any other cause), the presence of bladder stones (lithiasis), or kidney failure caused by benign prostatic hyperplasia of prostate.
Article contributed for educational purposes