Diagnosis of prostate adenoma

The diagnostics of prostate adenoma has the following goals:

• identification of the disease, determination of its stage and associated complications;
• differential diagnosis of prostate adenoma with other prostate diseases and urination disorders;
• selection of the optimal treatment method.

One of the urgent tasks at the stage of diagnostics of prostate adenoma is standardization of applied research methods and development of the optimal diagnostic algorithm. According to the recommendations of the 4th meeting of the International Conciliation Committee on Prostate Hyperplasia (Paris, 1997), mandatory research methods for the initial assessment of the patient's condition, recommended and optional research methods are defined. Diagnostic methods not recommended for the initial examination are separately highlighted.

The first includes collecting anamnesis, quantitative study of patient complaints using the IPSS prostate disease symptom score system and quality of life (QOL) scale, filling out a urination diary (recording frequency and volume of urination), physical examination, digital rectal examination of the prostate and seminal vesicles, general urine analysis, assessment of renal function (determination of serum creatinine level) and serum PSA analysis.

Recommended methods include UFM and ultrasound determination of residual urine. Optional methods include in-depth examination of the patient using pressure-flow testing and visualization methods: transabdominal and TRUS, excretory urography, urethrocystoscopy. Retrograde urethrography, urethral profilometry, micturition cystourethrography and urethral sphincter EMG are not recommended for the initial examination.

During the second visit, after evaluating laboratory parameters, a digital rectal examination of the prostate, transabdominal echography of the kidneys, bladder, prostate and TRUS of the prostate and seminal vesicles are performed. After performing UFM, the amount of residual urine is determined using the ultrasound method. An analysis of the prostate secretion is also performed to identify and assess the severity of concomitant chronic prostatitis.

To clarify the diagnosis of "prostate adenoma" and the nature of urodynamic disorders, the following are performed according to indications: complex UDI (cystomanometry, "pressure-flow", EMG, urethral pressure profile), excretory urography, urethrocystography, renography or dynamic nephroscintigraphy, prostate biopsy, etc.

The division of symptoms into obstructive and irritative is considered to be of fundamental importance in clinical terms. This allows, at the first stage, to presumably assess the degree of participation of the mechanical and dynamic components of obstruction and to plan a further program of examination of the patient, including for the purpose of differential diagnosis of prostate adenoma with other diseases accompanied by similar urination disorders.

To collect an adequate anamnesis, special attention should be paid to the duration of the disease, the condition of the urinary tract, previous surgical treatment and manipulations on them, find out what treatment was carried out and is currently being carried out for prostate adenoma. The nature of concomitant diseases is clarified. In this case, special attention is paid to diseases that can lead to urination disorders (multiple sclerosis, Parkinsonism, stroke, spinal cord diseases, diseases and injuries of the spine, diabetes, alcoholism, etc.). In addition, the general health of the patient and the degree of preparedness for possible surgical intervention are assessed.

Symptoms of prostate adenoma should be quantitatively assessed using the international system of total assessment of symptoms in prostate diseases IPSS and quality of life QOL. The total score is documented as follows: S - 0-35; QOL - 6. In this case, the severity of symptoms with IPSS 0-7 is assessed as insignificant, with 8-19 as moderate, and 20-35 as severe. During a general examination of a patient with prostate adenoma, special attention should be paid to the examination and palpation of the suprapubic area to exclude bladder overflow, to assess the tone of the sphincter of the rectum, the bulbocavernous reflex, to assess the motor function and sensitivity of the skin of the lower extremities in order to identify signs of concomitant neurogenic disorders.

Despite the significant role of technical diagnostic tools, palpation of the prostate is of great importance, since the evaluation of its results includes the personal experience of the doctor. Digital rectal examination allows determining the size, consistency and configuration of the prostate, its soreness (in the presence of chronic prostatitis), changes in the seminal vesicles and promptly identifying palpation signs of prostate cancer.

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Laboratory diagnostics of prostate adenoma

Laboratory diagnostics of prostate adenoma is reduced to identifying inflammatory complications, signs of renal and hepatic insufficiency, and changes in blood clotting. Clinical blood and urine tests for uncomplicated prostate adenoma should be normal. In the presence of inflammatory complications, there may be a leukocyte reaction and an increase in ESR.

In chronic renal failure, hemoglobin levels and red blood cell counts may decrease. Leukocyturia indicates the addition of inflammatory complications, and hematuria may be a consequence of varicose veins in the bladder neck, bladder stones, and chronic cystitis. To clarify all cases of microhematuria, appropriate diagnostic measures must be taken. Before surgery, in all cases, a bacteriological study of urine should be performed to determine the sensitivity of microflora to antibiotics and chemotherapy drugs.

Impaired renal function is indicated by increased levels of creatinine and urea in the blood serum. An earlier sign is a decrease in the concentrating ability of the kidneys, as indicated by a decrease in the specific gravity of urine.

Liver dysfunction may be accompanied by chronic renal failure or be a consequence of concomitant diseases, which can be revealed by determining total, direct and indirect bilirubin, aminotransferase activity, prothrombin cholinesterase, protein content and protein fractions of the blood. Dysproteinemia is an important diagnostic sign of sluggish chronic pyelonephritis in patients with prostate adenoma, which indicates a violation of protein synthesis by the liver. Studies show that in the latent phase of pyelonephritis in patients with prostate adenoma there is a tendency to a decrease in total blood protein, while in the phase of active inflammation hyperproteinemia was observed. increasing as chronic renal failure develops.

The study of blood coagulation before surgery is of great importance. Renal dysfunction in patients with prostate adenoma during the development of chronic pyelonephritis is accompanied by shifts in the hemocoagulation system, which manifests itself both as a decrease in the coagulation capacity of the blood and signs of hypercoagulation and underlies possible thromboembolic and hemorrhagic complications.

Determination of the PSA level in combination with prostate palpation and transrectal echography is currently the best way to detect cancer accompanying prostate adenoma and to select a group of patients for biopsy. The widespread use of long-term drug therapy and alternative thermal methods of treating prostate adenoma make this study more relevant.

The PSA values may be affected by factors such as ejaculation the day before the test, chronic prostatitis, instrumental manipulations in the area of the prostatic urethra, ischemia or prostate infarction. The effect of digital rectal examination is currently being studied.

The diagnostic value of the method increases significantly when determining the concentration of the free PSA fraction and its ratio to the total PSA in the blood serum. It is known that prostate-specific antigen can be represented by free (PSA 10-40%) and forms associated with a1-antichymotrypsin (PSA-ACT -60-90%), a2-macroglobulin (<0.1%), protease inhibitor (<1.0%) and inter-a-trypsin inhibitor (<0.1%). It has been established that in prostate cancer, the PSA content is lower than in prostate adenoma. The ratio (PSA/PSA less than 15% indicates the possible presence of latent prostate cancer. Patients with this indicator require a biopsy.

Instrumental diagnostics of prostate adenoma

The main indications for biopsy in prostate adenoma are clinical data indicating the possibility of a combination of this disease with prostate cancer. The presence of palpation signs suspicious of prostate cancer or an increase in the PSA level above 10 ig/ml (with a PSA value of >0.15) makes prostate biopsy necessary. The list of indications for biopsy in patients with prostate adenoma can be expanded. Growing interest in drug therapy and an increasing role of conservative treatment methods dictate the need for more active measures aimed at identifying latent cancer, especially since 20-40% of malignant neoplasms of the prostate at an early stage are not accompanied by an increase in the PSA level. In addition, in some cases, prostate biopsy can help predict the results of conservative treatment.

Endoscopic examination of the lower urinary tract in patients with prostate adenoma is considered an optional method. Urethrocystoscopy is indicated in the presence of hematuria, even anamnestic, or suspicion of a bladder tumor based on X-ray examination or prostate ultrasound. In some cases, significant changes in the detrusor due to its hypertrophy, trabecularity, diverticulosis or stone formation do not allow excluding the presence of a bladder tumor. This is an indication for endoscopic examination. In addition, the result of some alternative treatments for prostate adenoma, such as thermotherapy, focused ultrasound thermal ablation, radiofrequency transurethral thermal destruction, interstitial laser coagulation, transurethral needle ablation, balloon dilation, stenting, depends on the anatomical configuration of the prostate, which justifies the use of urethrocystoscopy in preparation for these procedures. The need for endoscopic examination is determined in each specific case, based on the clinical situation.

Dynamic radioisotope methods play an important role in assessing the functional state of the kidneys and upper urinary tract. Dynamic nephroscintigraphy and radioisotope renography allow assessing the filtration and secretory functions of the kidneys, urine transport through the upper urinary tract, performing radioisotope UFM and determining the amount of residual urine.

X-ray examination methods were recently the leading ones in diagnostics and determination of treatment tactics for patients with prostate adenoma. However, recently the view on the role of these methods has undergone changes, which is reflected in the recommendations of the International Consensus Committee on Prostate Adenoma, according to which excretory urography is classified as an optional method, and it should be performed on individual patients according to the following indications:

• current or history of urinary tract infections;
• hematuria;
• Current or history of urolithiasis:
• history of previous operations on the genitourinary tract.

An X-ray examination usually begins with a survey image of the urinary system, which can reveal stones in the projection of the kidneys, ureters, or bladder. Excretory urography allows you to clarify the condition of the upper urinary tract, the degree of expansion of the renal pelvis and ureters, and identify concomitant urological diseases. However, performing excretory urography in renal failure is inappropriate due to its low information content.

Cystography is a valuable diagnostic method for prostate adenoma. A descending cystogram shows a bladder with a filling defect in the neck area in the form of a hill caused by an enlarged prostate. Diverticula, stones, and bladder neoplasms may also be visible. In the case of compression of the intramural ureters by hyperplastic tissue and deformation of their juxtavesical segments with sub- or retrotrigonal growth, a characteristic radiographic symptom of "fish hooks" may be observed. Sometimes, to obtain clearer images of the bladder, ascending cysto- and pneumocystography or combined Kneise-Schober cystography with simultaneous administration of 10-15 ml of RVC and 150-200 ml of oxygen are performed. However, the scope of application of these studies is currently limited to the diagnosis of concomitant neoplasms of the bladder, since the configuration, direction of growth and size of the prostate can be more effectively recorded by ultrasound.

Retrograde urethrocystograms in prostate adenoma show elongation, deformation and narrowing of the prostatic urethra. The most common indication for this method is the need for differential diagnostics of prostate adenoma with other diseases that manifest symptoms of infravesical obstruction: urethral stricture and bladder neck sclerosis. In addition, urethrocystography can be used to measure the length of the prostatic urethra from the bladder neck to the seminal tubercle, which is sometimes necessary when planning treatment with thermal methods, balloon dilation or prostatic stenting.

CT supplements the diagnostic data on the prostate obtained by echography and provides extensive information on its topographic-anatomical relationship with neighboring organs. This is of great importance in differentiating prostate adenoma from cancer, and allows obtaining accurate information on the spread of the malignant process beyond the capsule and the involvement of regional lymph nodes. The picture of prostate adenoma on CT is presented by homogeneous masses with clear, even contours. The most important signs of organ changes during cancer development are blurred contours of the gland, asymmetric enlargement, heterogeneity of the structure with areas of increased density and rarefaction, and enlargement of regional lymph nodes. But the method does not allow differentiating cancer with prostate adenoma and chronic prostatitis at an early stage.

Recently, data on the use of MRI in prostate diseases have been published. One of the advantages of the method is a more accurate determination of the anatomical structure, configuration and size of the organ due to obtaining an image in three spatial dimensions. Another advantage is the ability to assess tissue characteristics and identify the zonal anatomy of the prostate. MRI allows you to clearly identify the central, peripheral and transitory zones of the prostate, measure and compare their sizes, and determine the volume of hyperplastic tissue. The accuracy of the study is increased by using special transrectal emitter coils. In typical cases, MRI results make it possible to presumably judge the morphological structure of the prostate and the stromal-epithelial ratio. In the case of glandular hyperplasia, the image is close in density to fatty tissue, and with a predominance of the stromal component, a higher density is characteristic. This is important in determining treatment tactics, primarily conservative.

In the overwhelming majority of elderly and senile men (80-84%) complaining of frequent and difficult urination, weak urine stream and imperative urge to urinate, when prostate enlargement is detected by digital rectal examination and ultrasound, the diagnosis of prostate adenoma is beyond doubt. However, in 16-20% of patients, symptoms of lower urinary tract dysfunction are not associated with prostate adenoma. In this case, differential diagnostics are carried out with obstructive and non-obstructive processes of other etiologies, which are characterized by similar clinical symptoms.

Ultrasound allows us to obtain extremely important information about the condition, size of the kidneys and thickness of the parenchyma, the presence and degree of retention changes in the renal pelvis, concomitant urological diseases, as well as the condition of the bladder and prostate.

In prostate adenoma, ultrasound scans reveal prostate enlargement of varying degrees, which in the form of a rounded formation with smooth contours partially closes the lumen of the bladder. In this case, the size and configuration of the prostate, the direction of node growth, changes in the echostructure, the presence of stones and calcifications are assessed. During the study, it is necessary to determine the volume of the bladder when the urge to urinate occurs, pay attention to the smoothness of its contours, ultrasound signs of detrusor hypertrophy and trabecularity. The method allows to exclude with high reliability the presence of diverticula, stones and neoplasms of the bladder. But the diagnostic capabilities of transabdominal ultrasound are limited to obtaining only a general idea of the prostate. In most cases, the method does not allow to identify specific signs of prostate cancer, especially in the early stages. An error in measuring the volume of the prostate and hyperplastic tissue is possible.

TRUS is an important stage in the diagnostics of prostate adenoma (prostate gland). It allows for a detailed assessment of the prostate structure, accurate measurements of its size and volume, separate calculation of the volume of hyperplasia nodes, detection of ultrasound signs of prostate cancer, chronic prostatitis, prostate sclerosis. The use of modern transrectal multi- or biplane sensors with a variable scanning frequency (5-7 MHz) allows for obtaining a detailed image of the organ both in longitudinal and cross-section, which significantly increases the diagnostic capabilities of the method and the accuracy of measurements.

The earliest echographic sign of prostate adenoma is an increase in the size of the prostate, mainly the anteroposterior size in relation to the height. In most cases, hyperplastic nodes are differentiated by a chain of calcifications on the border with the peripheral parts of the prostate. The echogenicity of the nodes depends on the predominance of stromal or glandular elements. The development of the disease leads to a further change in the configuration of the prostate, which acquires a spherical or ovoid shape. At the same time, an increase in the volume of the central zone is noted compared to the peripheral one, which is compressed and pushed outward by hyperplastic prostate tissue, with a significant volume of which the peripheral zone can be visualized as a thin hypoechoic strip on the periphery of the organ, in the area adjacent to the rectum.

In some cases, the prostate acquires a pear-shaped form due to an isolated increase in the middle lobe in the absence of pronounced hyperplastic changes in the lateral lobes. Often, this variant of prostate adenoma development is observed in patients with a long history of chronic prostatitis. the presence of sclerotic changes and calcification foci in the central part of the prostate, which can be noted during echography. Identification of cases of prostate adenoma accompanied by an increase in the middle lobe is of fundamental importance, since the rapid progression of infravesical obstruction in such patients makes the use of conservative methods unpromising.

Often, ultrasound examinations of the prostate reveal stones, calcification foci, and small cysts. Calcifications are observed in 70% of patients, primarily in two areas:

• paraurethral and in the central zone, which is most often observed in patients with prostate adenoma with an increase in the middle lobe and a history of chronic prostatitis;
• at the border between the central and peripheral zones in the area of the surgical capsule, which is sometimes almost completely calcified. This variant is usually observed with a significant volume of hyperplastic tissue, which leads to compression of the peripheral zone of the prostate.

The appearance of multiple small cystic formations in the projection of the enlarged central zone of the prostate indicates the final stage of the hyperplasia process, which morphologically corresponds to the 5th type of structure of the proliferative centers of the prostate. This sign has an important prognostic value, especially when planning drug therapy.

Thus, transrectal echography is currently one of the leading methods for diagnosing prostate adenoma, making it possible to assess the volume, configuration and echostructure of the prostate. At the same time, the direction of growth of hyperplasia nodes, the degree of increase in the middle lobe and the characteristics of the internal structure of the organ have a more significant clinical significance than a simple statement of an increase in the volume of the prostate. Therefore, transrectal echography should be performed on every patient with prostate adenoma.

The introduction of new ultrasound technologies offers prospects in diagnostics: transrectal Doppler duplex sonography with color mapping of prostate vessels, devices that allow visualization of the 3rd projection and construction of a three-dimensional image of the organ, as well as computerized ultrasound image processing systems (AUDEX) for the purpose of early diagnosis of prostate cancer.

UFM is the simplest screening test that can identify patients with infravesical obstruction and select a group of patients with borderline urination disorders for in-depth urodynamic examination. In infravesical obstruction caused by prostate adenoma, the maximum and average volumetric speed of urine flow decreases, the duration of urination increases. The uroflowmetric curve becomes flatter and more extended, and with a significant violation of the act of urination, it barely breaks away from the basal level. Uroflowmetry

The most frequently used parameters for evaluation of the uroflowmetric curve are the maximum flow rate (Qmax) and the volume of urine excreted (V). The results are documented as Qmax (in ml/s). Uroflowmetric parameters strongly depend on the volume of urination, the patient's age and the conditions of the study. In this regard, in order to obtain more reliable data, it is recommended to conduct UFM at least 2 times under conditions of functional filling of the bladder (150-350 ml), when a natural urge to urinate occurs. Additional factors affecting the rate of urination are abdominal tension and its physiological delay due to the patient's anxiety and a feeling of discomfort caused by the need to urinate in the presence of medical personnel. Arbitrary tension of the abdominal press to facilitate urination provokes the appearance of abnormally high bursts of Qmax against the background of a characteristic intermittent urination on the mic curve. A plateau-like graph is observed with urethral stricture, and a curve with a rapid rise to Qmax in less than 1 s from the onset of urination is typical for an unstable detrusor.

Despite the fact that UFM is a screening test, it provides extremely important information on the nature of urination disorders, allowing in some cases to conduct differential diagnostics of prostate adenoma with other diseases or to select a group of patients for further urodynamic studies. Qmax values exceeding 15 ml/s are considered normal. To increase the informativeness of the method, UFM should be assessed taking into account the entire set of indicators, including, in addition to Qmax and V, information on the total urination time (Ttotal), the time of its retention before the first drops of urine appear (T), the time to reach the maximum flow rate (Tmax) and the average urine flow rate (Qcp). The limits of objectivity of the method are determined. Thus, the normal Ttotal indicator is 10 s for a volume of 100 ml and 23 s for 400 ml. With a urine volume in the bladder of less than 100 ml and more than 400 ml, UFM is uninformative.

A reliable comparison of the results of several studies performed on one patient over time, or a comparison of data obtained from different groups of patients, is possible only on the basis of calculating special indices, which represent a proportional or percentage ratio of the actual value of a particular uroflowmetric indicator to its normal value established for a given volume of urination.

Large-scale studies have established a dependence of changes in urination parameters on age. Normally, Qmax decreases with age by approximately 2 ml/s for every 10 years of life. If the normal Qmax indicator for men without signs of lower urinary tract dysfunction at 50 years of age is on average 15 ml/s, then at 83 years of age it is already 6.3 ml/s. Such dynamics of urodynamic parameters in men without clinical signs of prostate adenoma is the result of aging of the bladder wall.

In this regard, modified nomograms adapted for each age group are currently proposed for comparative evaluation of uroflowgrams and calculation of uroflowmetric indices. In modern models of uroflowmeters, these calculations are performed automatically.

Determining the amount of residual urine is of fundamental importance for determining the stage of the disease and indications for conservative or surgical treatment. It is recommended to perform it using the ultrasound method immediately after urination. It is advisable to combine this study with UFM. The recently developed technique of radioisotope UFM provides the possibility of simultaneous non-invasive determination of the initial volume of the bladder, the flow rate and the volume of residual urine. Radionuclide UFM is usually performed 1-2 hours after renography or nephroscintigraphy with hippuran. The method is based on graphic recording of the amount of radioactive compound as it accumulates in the bladder after intravenous administration and the rate of evacuation during urination. Based on the measurement of activity above the bladder after urination, the amount of residual urine is judged.

The amount of residual urine in one and the same patient may vary depending on the degree of filling of the bladder. When it is overfilled, residual urine may appear even in those patients who did not have it before, therefore, if a significant volume of residual urine is detected during the first determination, the study is recommended to be repeated.

Additional opportunities for detecting hidden detrusor decompensation are provided by pharmacouroflowmetry with determination of the amount of residual urine after the administration of furosemide. If, with moderately expressed infravesical obstruction against the background of detrusor hypertrophy in the polyuric phase, an increase in Qmax is observed in the absence of residual urine, then with a significant decrease in the reserve capacity of the lower urinary tract, a persistent decrease in Qmax occurs against the background of a noticeable increase in the time of urination and an increase in the volume of residual urine.

Standardized study of patient complaints using the IPSS scale, digital prostate examination. UFM in combination with transabdominal and TRUS and echographic determination of residual urine are the main methods of objective dispensary monitoring and evaluation of treatment effectiveness. The presence and direction of clinical manifestations of prostate adenoma depend on the relationship of three main components: prostate enlargement due to hyperplasia, severity of symptoms and degree of infravesical obstruction.

Sector C - patients with prostate enlargement, symptoms of lower urinary tract dysfunction and IVO.

Sector S - patients with asymptomatic or minimally symptomatic course of the disease in the presence of prostate hyperplasia and IVO.

Sector P - patients with symptoms of lower urinary tract dysfunction and obstructive manifestations without signs of prostate adenoma. This group may include patients with bladder neck sclerosis, urethral stricture, prostate cancer or chronic prostatitis.

Sector B - patients with symptoms of prostate adenoma in the absence or insignificant expression of obstructive manifestations. This includes two groups of patients: with primary decreased contractility of the detrusor and cases of prostate adenoma in combination with hyperreflexia of the bladder. This is the most complex category of patients, requiring targeted differential diagnostics.

The main objectives of the extended UDI of patients with symptoms of lower urinary tract dysfunction are:

• identifying the correspondence between existing lower urinary tract dysfunction, prostate enlargement and obstruction:
• confirmation of lower urinary tract obstruction, determination of its degree and location;
• assessment of detrusor contractility;
• identification of subclinical neuropathic vesicourethral dysfunction and its contribution to the development of prostatic urethral obstruction;
• predicting the results of the chosen treatment method.

When examining patients with symptoms characteristic of prostate adenoma, the following types of urodynamic disorders of the lower urinary tract may be identified:

• mechanical IVO caused by the growth of prostate adenoma;
• dynamic (sympathetic) obstruction caused by spasm of the smooth muscle elements of the bladder neck, prostate and prostatic urethra;
• decreased contractility of the detrusor;
• detrusor instability (obstructive or idiopathic);
• neurogenic detrusor hyperreflexia:
• hypersensitivity of the prostate or bladder.

Urodynamic methods play a special role in examining patients with a history of clinical or subclinical manifestations of CNS diseases: diabetic polyneuropathy, stroke, Parkinson's disease, changes in intervertebral discs, etc. in combination with prostate enlargement. A detailed urodynamic study in such patients allows us to determine the contribution of existing neurogenic disorders to the symptoms of prostate adenoma.

Cystomanometry - determination of intravesical pressure at different stages of bladder filling and during urination. Simultaneous measurement of intra-abdominal pressure allows to avoid distortion of the study results due to abdominal muscle tension, patient movement and other factors. In combination with sphincter EMG, the method is very useful in patients with suspected neurogenic urination disorders. Important parameters of the method are cystometric capacity, first sensation of urge to urinate, bladder compliance and ability to suppress detrusor activity during filling.

During the filling phase, cystomanometry data allow us to evaluate the reservoir function of the bladder detrusor, and the relationship between the pressure and volume of the bladder characterizes its elastic properties. The cystomanometry curve reflects the phase of the initial increase in intravesical pressure, caused by the ability to contract, and the subsequent relatively stable phase of accommodation (adaptation) to the increasing volume of the bladder.

In a healthy person, the first urge to urinate occurs when the bladder is filled to 100-150 ml and the intravesical pressure is 7-10 cm H2O. A sharp urge occurs when the bladder is filled to 250-350 ml and the intravesical pressure is 20-35 cm H2O. This type of bladder reaction is called normoreflexive. A significant increase in intravesical pressure and the occurrence of a sharp urge to urinate with a small volume of urine (100-150 ml) corresponds to detrusor hyperreflexia. A significant increase in intravesical pressure (up to 10-15 cm H2O) when the bladder is filled to 600-800 ml indicates detrusor hyporeflexia.

Cystomanometry during urination allows us to judge the patency of the vesicoureteral segment and the contractile ability of the detrusor. Normally, the maximum intravesical pressure during urination in men is 45-50 cm H2O. An increase in intravesical pressure during urination indicates the presence of an obstruction to emptying the bladder.

A decrease in Qmax in most cases indicates an increase in intraurethral resistance, but may be associated with a decrease in the contractile ability of the detrusor. If the analysis of mandatory and recommended tests does not provide sufficient grounds for diagnosing bladder obstruction, then the patient, especially when deciding on the choice of invasive methods for treating prostate adenoma, needs to undergo a pressure-flow study. The method is the recording of intravesical pressure during urination with simultaneous measurement of the volumetric flow rate of urine during UFM.

The pressure-flow study is the only way to differentiate patients with low Qmax due to detrusor dysfunction from patients with true bladder outlet obstruction. Low urinary flow rates with high intravesical pressure indicate bladder outlet obstruction. On the other hand, the combination of low intravesical pressure with relatively high Qmax values indicates non-obstructive urinary obstruction.

Patients with borderline disorders are of significant clinical interest. They require dynamic observation and repeated studies to identify the true nature of the predominant urodynamic disorders. If a patient with symptoms of urinary dysfunction does not have signs of IVO, then traditional surgical treatment methods are unlikely to be effective.

The state of the bladder closure apparatus is assessed based on the results of determining the intraurethral pressure profile. The resistance exerted by the outgoing fluid (or gas) by the internal and external sphincters and the prostate is measured and recorded. However, this method has not found wide application in the primary diagnosis of prostate adenoma and is used mainly in examining patients with postoperative urinary incontinence.

Diseases that require differential diagnosis of prostate adenoma

Diseases with obstructive symptoms:

• urethral stricture;
• sclerosis of the bladder neck;
• prostate sclerosis;
• impaired contractility of the bladder (neurogenic or other causes);
• prostate cancer.

Diseases with irritative symptoms:

• urinary infection;
• prostatitis;
• detrusor instability;
• bladder cancer (in situ);
• foreign body (stone) of the bladder:
• stones in the lower third of the ureter.

As shown above, imperative urges to urinate and urinary incontinence may also occur in non-obstructive diseases and are associated with instability of detrusor contractions. Urination disorders in elderly and senile men associated with instability of detrusor contractions are observed in cerebral atherosclerosis, parkinsonism, discogenic diseases of the spine, pernicious anemia and especially often in diabetes mellitus. These patients usually experience a weakening of the urine stream, which is excreted in small portions, a feeling of incomplete emptying of the bladder, and the presence of residual urine. These symptoms are often interpreted as manifestations of prostatic obstruction, and patients undergo surgical treatment. An operation performed incorrectly, in cases where detrusor instabilities are not a consequence of infravesical obstruction, significantly worsens the patient's condition.

Neurogenic detrusor hyporeflexia (areflexia) is characterized by difficulty urinating, which can lead to an erroneous diagnosis of prostate adenoma. It occurs when the conduction of efferent impulses to the bladder from segments SII-IV of the spinal cord is impaired, as well as when the afferent pathways from the bladder to the corresponding segments of the spinal cord are impaired or the supraspinal conduction pathways are damaged. Detrusor areflexia can be a consequence of ischemic or traumatic myelopathy, multiple sclerosis, changes in the intervertebral discs, diabetic polyneuropathy. The diagnosis of a neurological disease that caused detrusor areflexia can be established based on the anamnesis, neurological and urodynamic studies. Damage to the sacral segments of the spinal cord is diagnosed based on a decrease in superficial sensitivity in the perineum and the disappearance of the bulbocavernous reflex, which is caused by short-term compression of the glans penis. In response, there is a rapid contraction of the voluntary sphincter of the anus and a contraction of the bulbocavernous muscle, determined visually. The absence of the bulbocavernous reflex indicates damage to the reflex arc at the level of the sacral segments of the spinal cord. The diagnosis of detrusor areflexia is confirmed by UDI: "pressure-flow" or cystomanometry in combination with EMG of the external sphincter.

A methodically correctly organized examination of patients allows for the timely detection of most of the above conditions.

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