Sclerosis of the prostate

Sclerosis of the prostate is a disease in which the wrinkled parenchyma of the gland squeezes the prostatic part of the urethra, narrows the neck of the bladder and the vesical parts of the ureters, squeezes the vas deferens, leads to a violation of the act of urination, stagnation of urine in the upper urinary tract, decreased renal function and impaired the various phases of the copulatory cycle.

ICD-10 code

N42.8. Other specified diseases of the prostate.

What causes sclerosis of the prostate?

Sclerosis of the prostate develops as a result of  chronic prostatitis, although some researchers noted the etiological role of the mechanical effect on the prostate gland, developmental anomalies, allergic, immunological factors, arteriosclerosis of vessels, hormonal effects. It was concluded that sclerosis of the prostate is an independent polyethological disease.

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

The etiology of chronic non-bacterial prostatitis has not been adequately studied. However, it is believed that in the origin of chronic bacterial and non-bacterial prostatitis, an important role is played by urethroprostatic reflux, with sterile urine contributing to the development of chemical inflammation.

Pathogenesis of sclerosis of the prostate

It is known that in the pathogenesis of both forms of chronic prostatitis, disturbances of microcirculation in the prostate gland, revealed by rheographic and echodopplerographic studies, are of great importance.

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

In the natural course of the disease, the neck of the bladder, the urinary bladder, the ureteral anus, the seminal vesicles may be involved in the sclerosing process.

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

Sclerosis of the prostate is not considered a common disease, although its true frequency has not been studied enough.

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

In 13% of patients treated for acute and chronic urinary retention, sclerosis of the prostate was detected.

Symptoms of sclerosis of the prostate

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

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

Along with this, patients complain of:

• pain in the perineum, above the pubis, in the groin areas, rectum;
• disorders of sexual function (decreased libido, deterioration of erection, painful sexual intercourse and orgasm).

When the outflow of urine outflow is progressing, ureterohydronephrosis develops, chronic pyelonephritis, thirst, dry mouth, dryness of the skin appear , ie. Symptoms, characteristic of renal failure.

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

Appearance of patients with the development of renal insufficiency largely changes and is characterized by pallor of the skin with icteric shade, facial pasty, emaciation.

The kidneys are usually not palpable, with a significant amount of residual urine in the lower abdomen, palpation is determined by a spherical painful bladder.

If there is a history of the transferred epididymitis by palpation, the moderately painful appendages of the testicles are enlarged in size.

In digital rectal examination, a diminished dense, asymmetric, smooth, without nodes, prostate gland is diagnosed.

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

Classification of sclerosis of the prostate

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

Pathogenetic factors:

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

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

Diagnosis of sclerosis of the prostate

[8], [9], [10]

Laboratory diagnosis of prostate sclerosis

Analyzes of blood and urine make it possible to establish changes in the inflammatory nature in the kidneys, urinary tract and impaired renal function due to the sclerosis of the prostate, as well as assess the degree of severity.

Leukocyturia, bacteriuria are frequent symptoms; Creininaemia and anemia occur with the development and growth of renal failure. To determine the severity of IVO, the UFM is of great importance. The maximum flow rate of urine decreases to 4-6 ml / s, and the duration of the act of urination in most patients increases.

Of great value is TRUS, which determines the volume and echostructure of the prostate and helps to differentiate sclerosis of the prostate from adenoma and cancer. This method also makes it possible to determine the volume of residual urine, to reveal the thickening of the wall of the bladder and the presence of its false diverticula.

Ultrasonic scanning of the kidneys and upper urinary tract allows us to establish ureterohydronephrosis. Conventional x-ray methods of research are performed in the following order: review and excretory urography (according to indications: infusion, combined with the introduction of diuretics, delayed), descending cystourethrography. In the absence of information on the state of the prostatic department of the urethra, ascending urethrocystography is performed.

However, none of these X-ray methods gives an idea of the size and condition of the prostate gland.

Such data can be obtained with the use of X-ray and MRI.

The above methods of radiation diagnosis are minimally invasive, and if they are used to obtain information on the state of the prostatic department of the urethra, then it is possible to abstain from the ascending urethrocystography. Ascending contrastive urethrocystography on justified indications helps to diagnose a narrowing of the prostatic section of the urethra, an increase in the size of the bladder, vesicoureteral and pelvic reflux.

However, this method is invasive, not completely safe (it is possible to develop complications of an infectious-inflammatory nature, including acute pyelonephritis and urosepsis) and does not give any idea of the state of the prostate gland.

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

Indications for this study, according to some authors:

• erectile dysfunction;
• painful orgasm;
• pain in the depth of the cavity of the pelvis, perineum or in the rectum

It was found that pathological changes in 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 study, since it can activate the urinary infection. This method assesses the degree of patency of the prostatic section of the urethra, determines the signs of IVO (trabecularity of the bladder wall, false diverticula), exclude or diagnose concomitant diseases (stones, bladder cancer).

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

• complaints of the patient to a difficult, often painful urination;
• presence in the history of chronic prostatitis, operations on the prostate gland;
• reduction of the gland in size, established by digital rectal, TRUS (including slowing of blood circulation in echodopplerography), computer X-ray or magnetic resonance imaging;
• diagnosis of retentional changes in the upper urinary tract and lower urinary tract.

Differential diagnosis of sclerosis of the prostate

Differential diagnosis of sclerosis of the prostate is carried out with adenoma, cancer, less often - tuberculosis of this organ. For adenoma, as for prostate sclerosis. Characterized by irritative and obstructive symptoms. Similar manifestations are possible with cancer and tuberculosis of the prostate. However, digital rectal examination with prostatic adenoma usually allows one to detect an increase in it with a densely-elastic consistency, with cancer - uneven density and tuberosity of the organ. When suspicion of tuberculosis, a search is made for mycobacteria in the secretion of the prostate gland and ejaculate.

Modern laboratory and radiation methods of investigation, and in the presence of indications and biopsy of the prostate gland, can successfully solve differential diagnostic problems.

[11], [12], [13], [14], [15]

Treatment of sclerosis of the prostate

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

Despite the opinion of individual authors about the expediency of boiling the urethra, there is no alternative to prompt treatment of sclerosis of the prostate, since bougie and catheterization of the urethra are not only ineffective, but also contribute to infection of the urinary tract, exacerbation of pyelonephritis, and worsening of the course of the disease.

The purpose of the operation is to remove the sclerosed prostate and restore the outflow of urine in the zone of the vesicourethral segment.

Indications for surgical treatment of prostate sclerosis:

• acute and chronic urinary retention, complicated by an increase in volume, diverticula, bladder stones;
• disturbances of urinary outflow from the upper urinary tract complicated by vesicoureteral reflux, ureterohydronephrosis, pyelonephritis, latent and compensated renal insufficiency;
• uretovesicular reflux, complicated by empyema seminal vesicles.

Temporary contraindications are:

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

Operative treatment of sclerosis of the prostate is contraindicated when:

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

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

• TUR of sclerotized prostate;
• prostatectomy for transhepatic technology;
• prostatevysikulektomiya - with the spread of the inflammatory process on the seminal vesicles;
• adenomoprostatectomy - when adenomatous nodes are included in the scar tissue of the gland;
• vesiculoectomy - performed with empyema of seminal vesicles;
• prostatectomy with plasty of posttraumatic stricture of the urethra - are used for recurrences of the stricture of the urethra, when in connection with urethroprostatic refluxes the prostatic gland is involved in the process.

TUR with prostate sclerosis is performed by classical technology.

With the help of this manual, simultaneously with resection of the sclerotic prostate, TUR of bladder cancer and removal of bladder stones can be performed. Among the merits of the method is the possibility and effectiveness of repeated resection of scars formed in the infravesical segment.

The technique of prostatectomy is as follows. After finger and visual revision of the internal opening of the urethra, a decision is made about the scope of the operation. If the end of the index finger barely passes through the narrowed neck of the bladder and the posterior part of the urethra, and the metal instruments of calibers 19-22 freely overcome the narrowed sections of the prostatic section of the urethra, this does not serve as a basis for rejecting prostatectomy.

A clamp is placed on the posterior semicircle of the internal opening of the urethra. The neck of the bladder is pulled upward. The incision is made by a scalpel in the posterior wall of the urethra in the area of contact between the prostate and the neck of the bladder.

Mobilized prostate tissue is clamped. Iron from all sides with scissors is cut off from surrounding tissues, avoiding damage to the neck of the bladder. On the neck of the bladder for the purpose of haemostasis, 1-2 P-shaped removable sutures are applied, which, together with two drainage tubes, are led out through the urethra. The anterior wall of the bladder and the anterior abdominal wall are sutured with the drainage left in the pre-bubble space. On the urethral drainage is constantly washed the bladder. Hemostatic sutures are removed after 18-24 hours washing system - after 7 days.

The intraoperative complications of prostatectomy include damage to the anterior wall of the rectum (rarely). At the same time, it is sewn to its damaged area and superimposed a temporary colostomy, which is subsequently closed operatively. Bleeding from the operation area in the volume of more than 500 ml requires replenishment of blood loss. In the postoperative period, exacerbation of pyelonephritis and worsening of the course 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, and carry out detoxification activities.

Lethality, according to some researchers, is 2.6%.

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

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

How to prevent sclerosis of the prostate?

Prevent sclerosis of the prostate can be done if an early diagnosis of chronic prostatitis in accordance with modern classification and treatment, adequate form (bacterial, non-bacterial) prostatitis.

The clinical classification of BC Karpenko provides for the identification of four stages of urinary passage disorders in this disease.

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

Prognosis of sclerosis of the prostate

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