Diagnosis of prostate adenoma

Diagnosis of prostate adenoma has the following objectives:

• the detection of the disease, the definition of its stage and associated complications;
• differential diagnosis of prostatic adenoma with other prostate diseases and disorders of urination;
• choice of the optimal method of treatment. 

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

The first group includes an anamnesis, a quantitative examination of the patient's complaints using the system of summary evaluation of symptoms in points for prostate gland diseases and QOL, filling of the diary of urination (recording frequency and volume of urination), physical examination, digital rectal examination of the prostate and seminal vesicles, general urine analysis, evaluation of the functional state of the kidneys (determination of serum creatinine level), and serum analysis for PSA.

Recommended methods include UVM and ultrasound determination of the amount of residual urine. Optional methods involve an in-depth examination of the patient using a pressure-flow study and visualization methods: transabdominal and TRUS, excretory urography, urethrocystoscopy. At the initial examination do not recommend the implementation of retrograde urethrography, profilometry of the urethra. Mikrotsionnoy cystourethrography and EMG of the urethral sphincter.

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

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

The separation of symptoms into obstructive and irritative symptoms is considered to be clinically important. This allows at the first stage to presumably assess the degree of involvement of the mechanical and dynamic components of obstruction and to plan a further program for examining the patient, including for the purpose of differential diagnosis of prostate adenoma with other diseases accompanied by similar disorders of urination.

For the collection of an adequate history, special attention should be paid to the duration of the disease, the state of the urinary tract, the pre-operative treatment and manipulations on them, to find out what treatment was and is currently being carried out for prostate adenoma. Clarify the nature of concomitant diseases. In this case, special attention is paid to diseases. Which can lead to a violation of urination (multiple sclerosis, Parkinsonism, stroke, spinal cord diseases, spine diseases and injuries, diabetes mellitus, alcoholism, etc.). In addition, assess the overall health of the patient and the degree of preparedness for possible surgical intervention.

Symptoms of prostate adenoma should be quantified using an international system of summary assessment of symptoms in prostate gland diseases 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, at 8-19 as moderate, and 20-35 as expressed. With a general examination of the patient with prostate adenoma, special attention should be paid to the examination and palpation of the suprapubic region to avoid overflow of the bladder, to assess the tonus 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 the signs of concomitant neurogenic disorders.

Despite the significant role of technical means of diagnosis, palpation of the prostate is of great importance, since in assessing its results, personal experience of the doctor is concluded. Finger rectal examination allows you to determine the size, consistency and configuration of the prostate, its soreness (in the presence of chronic prostatitis), changes in seminal vesicles and promptly reveal palpatory signs of prostate cancer.

[1], [2], [3], [4], [5], [6], [7]

Laboratory diagnosis of prostate adenoma

Laboratory diagnosis of prostate adenoma is reduced to the detection of inflammatory complications, signs of renal and hepatic insufficiency, as well as 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, it is possible to reduce the hemoglobin and the number of erythrocytes. Leukocyturia testifies to the attachment of inflammatory complications, and hematuria may be the result of varicose veins of the region of the neck of the bladder, bladder stones, chronic cystitis. To clarify all cases of microhematuria, it is necessary to conduct appropriate diagnostic measures. Before the operation in all cases it is necessary to carry out a bacteriological study of urine with the determination of the sensitivity of the microflora to antibiotics and chemotherapeutic drugs.

The violation of the kidney function is indicated by an increase in serum creatinine and urea levels. An earlier indication is a decrease in the concentration ability of the kidneys, as indicated by a decrease in the specific gravity of urine.

Dysfunction of the liver may accompany chronic renal failure or be a consequence of concomitant diseases, which can be detected by the determination of total, direct and indirect bilirubin, aminotransferase activity, cholinesterase prothrombin, protein content and protein fractions of blood. Disproteinemia is an important diagnostic sign of slow 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 decrease the total protein of the blood, while in the phase of active inflammation there was hyperproteinemia . Increasing with the development of chronic renal failure.

The study of blood coagulability before the operation is important. Disturbances in kidney function in patients with prostatic adenoma in the development of chronic pyelonephritis are accompanied by shifts in the hemocoagulation system, which manifests itself in the form of a decrease in the coagulation ability of the blood, and signs of hypercoagulation and underlies possible thromboembolic and hemorrhagic complications.

The determination of PSA levels in combination with prostate palpation and transrectal echography is currently the best way to detect cancer, concomitant prostatic adenoma, and the selection of a group of patients for biopsy. The extensive use of long-term drug therapy and alternative thermal treatments for prostate adenoma make this study more relevant.

The magnitude of PSA values can be influenced by factors such as ejaculation on the eve of the study, chronic prostatitis, instrumental manipulations in the prostatic urethra, ischemia or prostate infarction. The question of the effect of digital rectal examination is being studied.

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

Instrumental diagnosis of prostate adenoma

The main indications for biopsy in prostate adenoma are clinical data indicating the possibility of combining this disease with prostate cancer. The presence of palpable signs suspicious of prostate cancer, or an increase in the PSA level above 10 ug / ml (with a PSA value> 0.15) makes a prostate biopsy necessary. The list of indications for biopsy in patients with prostate adenoma can be expanded. The growing interest in drug therapy and the increasing role of conservative therapies dictate the need for more active interventions aimed at detecting hidden cancer, especially since 20-40% of malignant neoplasms of the prostate at an early stage are not accompanied by an increase in the level of PSA. 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 classified as facultative methods. Urethrocystoscopy is indicated in the presence of hematuria, even anamnestic, or suspected bladder neoplasm according to radiographic examination or ultrasound of the prostate. In some cases, pronounced changes in the detrusor as a result of its hypertrophy, trabecularity, diverticulosis, or the formation of concrements do not allow the exclusion of a tumor of the bladder. This is the indication for endoscopic examination. In addition, the result of some alternative treatments for prostate adenoma, such as thermal therapy, focused ultrasound thermal ablation, radio-frequency transurethral thermodestruction, interstitial laser coagulation, transurethral needle ablation, balloon dilatation, stenting, depends on the anatomical configuration of the prostate that justifies the use of urethrocystoscopy in preparation for these procedures. The need for endoscopy is determined in each case, based on the clinical situation.

An important place in the assessment of the functional state of the kidneys and the upper urinary tract is occupied by dynamic radioisotope techniques. Dynamic nephroscintigraphy and radioisotope renography allow assessing the filtration and secretory functions of the kidneys, urine transport along the upper urinary tract, perform radioisotope UVM, and determine the amount of residual urine.

X-ray methods of research not so long ago were leading in the diagnosis and definition of treatment tactics for patients with prostate adenoma. However, recently the view on the role of these methods has changed, which was reflected in the recommendations of the International Conciliation Committee on prostate adenoma, according to which excretory urography is classified as optional methods, and it must be performed by individual patients according to the following indications:

• urinary tract infection at present or in the anamnesis;
• hematuria;
• urolithiasis at present or in the anamnesis:
• previous operations on the genitourinary tract in the anamnesis.

X-ray examination usually begins with an overview of the organs of the urinary system, on which it is possible to reveal concrements in the projection of the kidneys, ureters or the bladder. Excretory urography allows us to clarify the state of the upper urinary tract, the degree of expansion of the calyx and pelvic system and ureters, and to identify associated urological diseases. However, excretory urography in renal failure is impractical due to low information content.

Cystography is a valuable method of diagnosing prostate adenoma. On the descending cystogram, an image of a bladder with a filling defect in the region of its neck in the form of a hill caused by an enlarged prostate is determined. Diverticula, stones and neoplasms of the bladder can also be seen. In the case of compression of the intramural sections of the ureters with hyperplastic tissue and the deformation of their juxtavezic segments with sub- or retrogrigonal growth, a characteristic x-ray symptom of "fish hooks" can be observed. Sometimes, in order to obtain more clear images of the bladder, ascending cysto- and pneumocystography or combined Kneis-Shober cystography is carried out with simultaneous administration of 10-15 ml of RVB and 150-200 ml of oxygen. However, the scope of these studies is currently limited to the diagnosis of concomitant neoplasms of the bladder, since the configuration, growth direction and size of the prostate can be more effectively recorded by ultrasound.

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

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

Recently published data on the use of MRI in diseases of the prostate. One of the advantages of the method is a more precise definition of the anatomical structure, configuration and size of the organ due to the image in three spatial dimensions. Another advantage is associated with the ability to evaluate tissue characteristics and identify zonal anatomy of the prostate. MRI allows you to clearly identify the central, peripheral and transitional zones of the prostate, measure and compare their sizes. And also to determine the volume of hyperplastic tissue. The accuracy of the study is increased by the use of special transrectal coils-emitters. The results of MRI in typical cases 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 approaches density in relation to fatty tissue, and with a predominance of the stromal component, a higher density is characteristic. This is important in determining the tactics of treatment, primarily conservative.

The overwhelming number of elderly and senile men (80-84%) complaining of frequent urination and difficulty urinating, a sluggish urine stream and mandatory urges to urinate, when detecting an increase in the prostate by a digital rectal examination and ultrasound, the diagnosis of prostatic adenoma is beyond doubt. However, in 16-20% of patients, symptoms of impairment of the function of the lower urinary tract are not associated with prostate adenoma. In this case, differential diagnosis is performed with obstructive and non-obstructive processes of another etiology, for which a similar clinical symptomatology is characteristic.

Ultrasound can provide extremely important information about the condition, the size of the kidneys and the thickness of the parenchyma, the presence and extent of retention changes in the bowel-and-pelvic system, concomitant urological diseases, as well as the state of the bladder and prostate.

With prostate adenoma on ultrasound scans, an increase in the prostate of various degrees is determined, which in the form of a rounded formation with smooth contours partially covers 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 calculi and calcifications are evaluated. During the study, it is necessary to determine the volume of the bladder when urge to urinate, pay attention to the evenness of its contours, ultrasound signs of detrusor hypertrophy and trabecularity. The method allows the exclusion of diverticula, stones and neoplasm of the bladder with high reliability. 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 us 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 diagnosis of prostate adenoma (prostate gland). It allows you to evaluate in detail the structure of the prostate, make accurate measurements of its size and volume, separately calculate the volume of nodes of hyperplasia, identify ultrasound signs of prostate cancer, chronic prostatitis, sclerosis of the prostate. The use of modern transrectal multi- or biplane sensors with variable scanning frequency (5-7 MHz) allows to obtain a detailed image of the organ both in the longitudinal and in the 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 anteroposterior to the height. In most cases, nodes of hyperplasia along the calcification chain at the border with the peripheral parts of the prostate are differentiated. Echogenicity of 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 globular or ovoid form. At the same time, an increase in the volume of the central zone is noted compared with the peripheral one, which is squeezed and forced outward by hyperplastic prostate tissue with a significant volume of which the peripheral zone can be visualized as a thin hypoechogenic band on the periphery of the organ, in the region adjacent to the rectum.

In some cases, the prostate acquires a pear-shaped form due to an isolated increase in the mean proportion in the absence of pronounced hyperplastic changes in the lateral lobes. Often such an option for the development of prostate adenoma is observed in patients with a prolonged course of chronic prostatitis in the anamnesis. The presence of sclerotic changes and calcification centers in the central part of the prostate, which can be noted during echography. The detection of cases of prostate adenoma, accompanied by an increase in the mean proportion, is of fundamental importance, since the rapid progression of infravesical obstruction in such patients makes the application of conservative methods unpromising.

Often, ultrasound in the prostate of the patients is determined by concrements, calcification centers and small cysts. Calcinates are observed in 70% of patients, mainly in two areas:

• paraurethral and in the central zone, which is most often observed in patients with prostatic adenoma with an increase in the mean proportion and chronic history of prostatitis;
• on the boundary between the central and peripheral zones in the area of the surgical capsule, which is sometimes practically completely calcified. This option is usually observed with a significant amount of hyperplastic tissue, which leads to compression of the peripheral zone of the prostate.

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

Thus, transrectal echography is currently one of the leading methods of diagnosing prostate adenoma, which makes it possible to assess the volume, configuration and echostructure of the prostate. In this case, the direction of growth of the nodes of hyperplasia, the degree of increase in the mean proportion and the characteristics of the internal structure of the organ have a more weighty clinical significance than a simple statement of an increase in the volume of the prostate. Therefore, transrectal echography should be performed for each patient with prostate adenoma.

Prospects for diagnosis are provided by the introduction of new ultrasound technologies: transrectal Doppler duplex sonography with color mapping of the prostate vessels, devices that allow visualizing the third projection and build a three-dimensional image of the organ, as well as computerized ultrasound imaging (AUDEX) systems for the early diagnosis of prostate cancer .

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

The most often used to measure the uroflowmetry curve are indicators of the maximum flow rate (Qmax) and the allocated volume of urine (V). The results are documented as Qmax (in ml / s). Uroflowmetry parameters strongly depend on the volume of urination, the age of the patient and the conditions of the study. In this regard, to obtain more reliable data, the UFM is recommended to be conducted at least 2 times. In conditions of functional filling of the bladder (150-350 ml), when there is a natural urge to urinate. Additional factors affecting the rate of urination are abdominal tension and its physiological delay due to patient's anxiety and inconvenience caused by the need to urinate in the presence of medical personnel. The arbitrary tension of the abdominal press to facilitate urination provokes the appearance of abnormally high Qmax bursts against the background of a characteristic intermittent urodi on the curve. A plateau graph is observed with urethral stricture, and a curve with a rapid rise to Qmax in less than 1 second from the onset of urination is typical of an unstable detrusor.

Despite the fact that the UFM is a screening test, it gives extremely important information about the nature of urination disorders, allowing in some cases to carry out differential diagnosis of prostate adenoma with other diseases or to isolate a group of patients for further urodynamic studies. Values of Qmax greater than 15 ml / s are considered normal. To increase the informative value of the method, the evaluation of the UVM should be performed taking into account the whole set of indicators, including, in addition to Qmax and V, information on the total time of urination (Tobsch), the time of its delay until the appearance of the first drops of urine (T). The time to reach the maximum rate of urination (Tmax) and the average urinary flow rate (Qsr). The limits of objectivity of the method are determined. So, the normal indicator of Tobacco is 10 s for a volume of 100 ml and 23 s for 400 ml. With a volume of urine in the urinary bladder of less than 100 ml and more than 400 ml, the UFM is of little informative.

Reliable comparison of the results of several studies performed by one patient in the dynamics or comparison of the data obtained from different groups of patients is possible only on the basis of the calculation of special indices representing the share or percentage ratio of the real value of this or that uroflowmetric index to its normal value established for of this volume of urination.

As a result of large-scale studies, the dependence of the change in urinary output on age is established. Normally, a decrease in Qmax with an age of about 2 ml / s is noted for every 10 years of life. If the normal Qmax for men without signs of impairment of the function of the lower urinary tract in 50 years is an average of 15 ml. From. Then at 83 years 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, for a comparative evaluation of uroflowgrams and calculation of uroflowmetry indices, nowadays the nomograms are adapted, adapted for each age group. In modern models of uroflowmeter these calculations are performed automatically.

Determination of the amount of residual urine is of fundamental importance for determining the stage of the disease and indications for conservative or operative treatment. It is recommended to perform the ultrasound method immediately after urination. It is advisable to combine this research with the UFM. The recently developed technique of radioisotope UFM presents 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 h after renography or nephroscintigraphy with hippuran. The method is based on graphical 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 the same patient may vary depending on the degree of filling of the bladder. If it overflows, residual urine may appear even in those patients who did not have it earlier, so if a significant amount of residual urine is detected at the first determination, the study is recommended to be repeated.

Additional possibilities for detecting latent decompensation of detrusor provide pharmacouroflometry with the determination of the amount of residual urine after administration of furosemide. If, with a moderate infravesical obstruction against the background of detrusor hypertrophy in the polyuric phase, the growth of Qmax is observed in the absence of residual urine, then with a significant decrease in the reserve capacity of the lower urinary tract there is a persistent decrease in Qmax due to a marked 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 control and evaluation of the effectiveness of treatment. The presence and direction of clinical manifestations of prostate adenoma depends on the relationship of the three main components: enlargement of the prostate due to hyperplasia. Severity of symptoms and the degree of infravesical obstruction.

Sector C - patients with an enlarged prostate, symptoms of impairment of the functions of the lower urinary tract and IVO.

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

Sector P - patients with symptoms of impairment of the function of the lower urinary tract and obstructive manifestations with no signs of prostate adenoma. This group may include patients with sclerosis of the neck of the bladder, urethral stricture, prostate cancer or chronic prostatitis.

Sector B - patients with symptoms of prostatic adenoma in the absence or insignificant manifestation of obstructive manifestations. Two groups of patients can be classified here: with the primary reduced detrusor contractility and cases of prostate adenoma in combination with bladder hyperreflexia. This is the most complex category of patients requiring targeted differential diagnosis.

The main tasks of advanced UDI of patients with symptoms of impairment of the function of the lower urinary tract:

• the correlation between the existing dysfunction of the lower urinary tract, prostate enlargement and obstruction:
• confirmation of obstruction of the lower urinary tract, its degree and localization;
• Evaluation of detrusor contractile ability;
• revealing subclinical neuropathic vesicourethral dysfunction, its contribution to the development of obstruction of the prostatic section of the urethra;
• prediction of the results of the chosen method of treatment.

When examining patients with symptoms characteristic of prostate adenoma, it is possible to identify the following types of urodynamic disorders from the lower urinary tract:

• mechanical IVO, caused by the growth of prostate adenoma;
• dynamic (sympathetic) obstruction due to spasm of smooth muscle cells of the neck of the bladder, prostate and prostatic section of the urethra;
• reduction detrusor detrusor capacity;
• instability detrusora (obstructive or idiopathic);
• neurogenic detrusor hyperreflexia:
• hypersensitivity of the prostate or bladder.

A special role is played by urodynamic methods when examining patients who have a history of clinical or subclinical manifestations of central nervous system diseases: diabetic polyneuropathy, stroke, Parkinson's disease, changes in intervertebral discs, etc. In combination with prostate enlargement. Detailed Urodynamic study in such patients allows to determine the contribution of existing neurogenic disorders to the symptomatology of prostate adenoma.

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

During the filling phase, cystomanometry measures the reservoir function of the detrusor of the bladder, and the relationship between pressure and volume of the bladder characterizes its elastic properties. The cystomanometric curve reflects the phase of the initial rise in the intravesical pressure due to the ability to contract, and the subsequent relatively stable accommodation phase (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 of 7-10 cm of water. A pronounced urge - when filling up to 250-350 ml and intravesical pressure 20-35 cm of water. . This type of reaction of the bladder is called normoreflectory. A significant increase in intravesical pressure and the emergence of a pronounced urge to urinate with a small amount of urine (100-150 ml) corresponds to the detrusor hyperreflexia. A significant increase in intravesical pressure (up to 10-15 cm of water) with the filling of the bladder to 600-800 ml speaks of detrusor hyporeflexia.

The performance of cystomanometry during urination makes it possible to judge the permeability of the vesicourethral segment and detrusor contractility. Normally, the maximum intravesical pressure during urination in men is 45-50 cm of water. An increase in intravesical pressure during urination testifies to the presence of an obstruction to the emptying of the bladder.

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

The "pressure-flow" study is the only way to separate patients with low Qmax due to impaired detrusor function from patients with true infravesical obstruction. At the same time, low indices of the volume rate of urination against the background of high intravesical pressure testify to the presence of an infravesical obstruction. On the other hand, the combination of a low intravesical pressure with a relatively high Qmax indicates a non-obstructive urinary tract disorder.

Significant clinical interest is represented by patients with violations that are borderline. They need dynamic observation and repeated studies to identify the true nature of the prevailing urodynamic disorders. If a patient with symptoms of urination disorder does not have signs of IVO, then it is unlikely that traditional methods of surgical treatment will be effective.

The state of the bladder closure is judged by the results of the intraurethral pressure profile. Measure and record the resistance exerted by the outgoing fluid (or gas) internal and external sphincters and prostate. However, in the primary diagnosis of prostate adenoma, this method has not been widely used and it is used mainly in examining patients in cases of postoperative urinary incontinence.

Diseases with which differential diagnosis of prostatic adenoma is necessary

Diseases with obstructive symptoms:

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

Diseases with irritative symptoms:

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

As shown above, mandatory urges for urination and urinary incontinence can also occur in non-obstructive diseases and are associated with instability of detrusor cuts. Violations of urination in men elderly and senile, associated with instability reduction Detrusor, observed in cerebral atherosclerosis, Parkinsonism, discogenic diseases of the spine, pernicious anemia and especially often with diabetes. These patients usually have a weakening of the urine stream, which is released in small portions, a feeling of incomplete emptying of the bladder, the presence of residual urine. These symptoms are often interpreted as manifestations of prostatic obstruction, and patients undergo surgical treatment. The operation performed erroneously, in the case when the non-assault detrusor is not the result of an 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 efferent impulses to the bladder are violated from segments of SII-IV of the spinal cord, as well as when the afferent pathways from the bladder to the corresponding segments of the spinal cord are damaged or the supraspinal pathways are damaged. Detrusor areflexia can be a consequence of ischemic or traumatic myelopathy, multiple sclerosis, changes in intervertebral discs, diabetic polyneuropathy. The diagnosis of a neurologic disease that caused detrusor reflexology can be established on the basis of anamnesis, neurological and urodynamic studies. The defeat of the sacral segments of the spinal cord is diagnosed on the basis of a decrease in the surface sensitivity in the perineal region 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 arbitrary anal sphincter of the anal opening and a reduction in the bulbous cavernous muscle, determined visually. The absence of bulbocavernous reflex indicates damage to the reflex arc at the level of the sacral segments of the spinal cord. Diagnosis detruzornoy arefleksii confirm UDI: "pressure-flow" or cystomanometry in combination with EMG of the external sphincter.

Methodically correctly organized examination of patients allows to reveal in time most of the indicated conditions.

[8], [9], [10], [11], [12], [13], [14], [15]