Prostate sclerosis

Prostate sclerosis is a disease in which the shrinking parenchyma of the gland compresses the prostatic part of the urethra, narrows the neck of the bladder and the vesical parts of the ureters, compresses the vas deferens, leads to a violation of the act of urination, stagnation of urine in the upper urinary tract, decreased kidney function and disruption of various phases of the copulatory cycle.

ICD-10 code

N42.8. Other specified diseases of prostate gland.

What causes prostate sclerosis?

Prostate sclerosis develops as a result of chronic prostatitis, although some researchers noted the etiological role of mechanical impact on the prostate gland, developmental anomalies, allergic, immunological factors, vascular atherosclerosis, hormonal effects. It was concluded that prostate sclerosis is an independent polyetiological disease.

In the etiology of bacterial prostatitis, the most common pathogens (65-80%) are gram-negative pathogens, primarily Escherichia coli or several microorganisms.

The etiology of chronic nonbacterial prostatitis has not been studied sufficiently. However, it is believed that urethroprostatic reflux plays a significant role in the origin of chronic bacterial and nonbacterial prostatitis, which, with sterile urine, promotes the development of chemical inflammation.

Pathogenesis of prostate sclerosis

It is known that in the pathogenesis of both forms of chronic prostatitis, microcirculation disorders in the prostate gland, revealed by rheographic and echo-Doppler studies, are of significant importance.

The development of prostate sclerosis occurs during the progression of chronic bacterial and non-bacterial inflammation, and it is considered the final stage of chronic prostatitis.

In the natural course of the disease, the sclerosing process may involve the neck of the bladder, the trigone of the bladder, the orifices of the ureters, and the seminal vesicles.

All this contributes to the progression of IBO, the development of chronic renal failure and sexual dysfunction.

Prostate sclerosis is not considered a common disease, although its true incidence has not been sufficiently studied.

Thus, according to the researchers, 5% of patients with chronic prostatitis were diagnosed with stage III of the disease (fibrosclerosis).

Prostate sclerosis was found in 13% of patients treated for acute and chronic urinary retention.

Symptoms of prostate sclerosis

The main clinical symptoms of prostate sclerosis are symptoms characteristic of IVO of any etiology:

• difficult, often painful urination, even to the point of strangury;
• feeling of incomplete emptying of the bladder;
• acute or chronic urinary retention.

Along with this, patients complain of:

• pain in the perineum, above the pubis, in the groin area, rectum;
• sexual dysfunction (decreased libido, worsening erection, painful intercourse and orgasm).

As the urinary outflow disorder progresses, ureterohydronephrosis and chronic pyelonephritis develop, thirst, dry mouth, and dry skin appear, i.e., symptoms characteristic of renal failure.

It is appropriate to note that the general condition of patients can be satisfactory for a long time, despite fairly pronounced changes in the kidneys and urinary tract.

The appearance of patients with the development of renal failure changes significantly and is characterized by pale skin with a yellowish tint, pastosity of the face, and emaciation.

The kidneys are usually not palpable; with a significant volume of residual urine in the lower abdomen, a spherical, painful bladder can be detected by palpation.

If there is a history of epididymitis, palpation reveals enlarged, moderately painful testicular appendages.

A digital rectal examination reveals a reduced-sized, dense, asymmetrical, smooth, nodule-free prostate gland.

Massage of the sclerotic prostate gland is not accompanied by secretion, which indicates the loss of its function.

Classification of prostate sclerosis

Morphological changes in the prostate gland are polymorphic. V. S. Karpenko et al. (1985) developed a histological classification of prostate sclerosis.

Pathogenetic factors:

• Sclerosis of the prostate with focal parenchymal hyperplasia.
• Sclerosis of the prostate with parenchyma atrophy.
• Sclerosis of the prostate in combination with nodular adenomatous hyperplasia.
• Sclerosis of the prostate with cystic transformation.
• Cirrhosis of the prostate gland:
  • combined with infectious follicular or parenchymal (interstitial) prostatitis;
  • combined with allergic prostatitis;
  • without prostatitis: atrophic changes, dystrophic changes, congenital developmental anomalies.

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Diagnosis of prostate sclerosis

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Laboratory diagnostics of prostate sclerosis

Blood and urine tests can identify inflammatory changes in the kidneys, urinary tract, and renal dysfunction caused by prostate sclerosis, as well as assess the degree of severity.

Leukocyturia, bacteriuria are common symptoms; creatininemia and anemia appear with the development and progression of renal failure. UFM is of great importance for determining the severity of IVO. The maximum urine flow rate decreases to 4-6 ml/s, and the duration of urination increases in most patients.

TRUS is of great value, determining the volume and echostructure of the prostate gland and helping to differentiate prostate sclerosis from adenoma and cancer. This method also makes it possible to determine the volume of residual urine, identify thickening of the bladder wall and the presence of its false diverticula.

Ultrasound scanning of the kidneys and upper urinary tract allows to establish ureterohydronephrosis. Conventional radiological examination methods are performed in the following order: survey and excretory urography (according to indications: infusion, in combination with the introduction of diuretics, delayed), descending cystourethrography. In the absence of information on the state of the prostatic section of the urethra, ascending urethrocystography is performed.

However, none of these radiological methods provide any information about the size and condition of the prostate gland.

Such data can be obtained using X-rays and MRI.

The listed methods of radiation diagnostics are minimally invasive, and if they provide information about the condition of the prostatic section of the urethra, ascending urethrocystography can be avoided. Ascending contrast urethrocystography, according to justified indications, helps diagnose narrowing of the prostatic section of the urethra, an increase in the size of the bladder, and vesicoureteral pelvic reflux.

However, this method is invasive, not entirely safe (the development of infectious and inflammatory complications is possible, including acute pyelonephritis and urosepsis) and does not provide any information about the condition of the prostate gland.

Vasovesiculography has no direct relation to the diagnosis of prostate sclerosis, but it allows one to assess the extent of the spread of the inflammatory process to the seminal vesicles and surrounding tissues, and its results can be taken into account when choosing the extent of the operation.

Indications for this study, according to some authors:

• erectile dysfunction;
• painful orgasm;
• pain deep in the pelvic cavity, perineum or rectum

It was found that pathological changes in the seminal vesicles occur in 35% of patients with prostate sclerosis.

Radionuclide studies can be used to more fully assess the functional state of the kidneys and upper urinary tract.

Urethrocystoscopy is performed at the final stage of the examination, as it can activate a urinary infection. This method is used to assess the patency of the prostatic urethra, determine signs of IVO (bladder wall trabeculation, false diverticula), and exclude or diagnose associated diseases (stones, bladder cancer).

Thus, the diagnosis of prostate sclerosis can be established on the basis of:

• patient complaints of difficult, often painful urination;
• history of chronic prostatitis, prostate surgery;
• reduction in the size of the gland, determined by digital rectal examination, TRUS (including slowing of blood circulation during echo-Dopplerography), computed X-ray or magnetic resonance imaging;
• diagnostics of retention changes in the upper urinary tract and lower urinary tract.

Differential diagnosis of prostate sclerosis

Differential diagnostics of prostate sclerosis is carried out with adenoma, cancer, and, less frequently, tuberculosis of this organ. For adenoma, as well as for prostate sclerosis, irritative and obstructive symptoms are characteristic. Similar manifestations are possible with cancer and tuberculosis of the prostate gland. However, digital rectal examination with prostate adenoma usually reveals its enlargement with a dense-elastic consistency, while with cancer, it reveals uneven density and tuberculosis of the organ. If tuberculosis is suspected, mycobacteria are searched for in the secretion of the prostate gland and ejaculate.

Modern laboratory and radiation research methods, and if indicated, prostate biopsy, allow us to successfully solve differential diagnostic problems.

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Treatment of prostate sclerosis

Conservative treatment of prostate sclerosis, including medication, has an auxiliary value and is usually used in the preoperative and postoperative periods.

Despite the opinion of some authors about the advisability of urethral bougienage, there is no alternative to surgical treatment of prostate sclerosis, since bougienage and catheterization of the urethra are not only ineffective, but also contribute to urinary tract infection, exacerbation of pyelonephritis and worsening of the course of the disease.

The purpose of the operation is to remove the sclerotic prostate gland and restore the outflow of urine in the vesicoureteral segment.

Indications for surgical treatment of prostate sclerosis:

• acute and chronic urinary retention complicated by increased volume, diverticula, bladder stones;
• disorders of urine outflow from the upper urinary tract, complicated by vesicoureteral reflux, ureterohydronephrosis, pyelonephritis, latent and compensated renal failure;
• urethrovesicular reflux complicated by empyema of the seminal vesicles.

Temporary contraindications are:

• acute pyelonephritis;
• intermittent stage of chronic renal failure;
• anemia.

Surgical treatment of prostate sclerosis is contraindicated in the following cases:

• terminal stage of chronic renal failure;
• decompensation of concomitant diseases;
• senile dementia;
• psychosis.

Currently, the following operations are used to treat prostate sclerosis:

• TUR of the sclerotic prostate gland;
• transvesical prostatectomy;
• prostatovesiculectomy - when the inflammatory process spreads to the seminal vesicles;
• adenomoprostatectomy - when adenomatous nodes are included in the scar tissue of the gland;
• vesiculectomy - performed for empyema of the seminal vesicles;
• prostatectomy with plastic surgery of post-traumatic urethral stricture - used in cases of recurrent urethral stricture, when the prostate gland is involved in the process due to urethroprostatic reflux.

TUR for prostate sclerosis is performed using classical technology.

With this aid, TUR of bladder cancer and removal of bladder stones can be performed simultaneously with resection of the sclerosed prostate gland. The advantages of the method include the possibility and effectiveness of repeated resection of scars formed in the infravesical segment.

The technique of prostatectomy is as follows. After digital and visual revision of the internal opening of the urethra, a decision is made on the scope of the operation. If the tip of the index finger barely passes through the narrowed neck of the bladder and the back of the urethra, and metal instruments of 19-22 calibers freely overcome the narrowed areas of the prostatic section of the urethra, this does not serve as a basis for refusing prostatectomy.

A clamp is placed on the posterior semicircle of the internal opening of the urethra. The neck of the urinary bladder is pulled upward. A scalpel is used to make an incision in the posterior wall of the urethra in the area where the prostate gland contacts the neck of the urinary bladder.

The mobilized prostate tissue is grasped with a clamp. The gland is cut off from the surrounding tissues on all sides with scissors, avoiding damage to the bladder neck. For hemostasis, 1-2 U-shaped removable sutures are applied to the bladder neck, which, together with two drainage tubes, are brought out through the urethra. The anterior wall of the bladder and the anterior abdominal wall are sutured, leaving drainage in the prevesical space. The bladder is constantly flushed through the urethral drains. Hemostatic sutures are removed after 18-24 hours, the irrigation system - after 7 days.

Intraoperative complications of prostatectomy include damage to the anterior wall of the rectum (rare). In this case, the damaged area is sutured and a temporary colostomy is applied, which is subsequently closed surgically. Bleeding from the surgical area in a volume of more than 500 ml requires replenishment of blood loss. In the postoperative period, exacerbation of pyelonephritis and worsening of renal failure are often observed, therefore antibacterial drugs are used in accordance with the type of bacterial agent and its sensitivity to antibacterial drugs, detoxification measures are carried out.

The mortality rate, according to some researchers, is 2.6%.

The most common causes of death in patients are acute pyelonephritis, urosepsis, bilateral pneumonia, and terminal renal failure. Given the traumatic nature of prostatectomy, the difficulty of controlling the volume of tissue excised, and the risk of damage to the rectum, it should be considered that in modern conditions the main method of surgical treatment of prostate sclerosis is TUR of sclerotic tissue.

The long-term results of surgical treatment of prostate sclerosis are satisfactory: the patency of the vesicourethral segment can be restored with the help of these operations, and kidney function is partially restored.

How to prevent prostate sclerosis?

It is possible to prevent prostate sclerosis if early diagnosis of chronic prostatitis is carried out in accordance with the modern classification and treatment is adequate to the form (bacterial, non-bacterial) of prostatitis.

The clinical classification of V.S. Karpenko provides for the identification of four stages of impaired urine passage in this disease.

• Stage I - functional disorders of urination.
• Stage II - functional disorders of urine passage through the upper and lower urinary tract.
• Stage III - persistent functional disorders of urodynamics and initial morphological changes in the urinary organs and seminal ducts.
• Stage IV: terminal changes in the parenchyma of the kidneys, ureters, bladder and seminal ducts.

Prognosis of prostate sclerosis

The prognosis for prostate sclerosis is quite satisfactory if the operation is performed before the onset of severe stages of chronic renal failure.