Prostate adenoma: an overview of information

Prostate adenoma is a process of proliferation of paraurethral glands, beginning in adulthood and leading to the appearance of urinary disorders.

The following definitions were used to indicate the disease prostate adenoma at various stages of accumulation of knowledge about it: prostatic disease, benign prostatic hypertrophy, prostate, dishormonal adenomatous prostatopathy, paraurethral adenoma, benign enlargement of the prostate, prostate adenoma, prostate adenoma.

Prostate adenoma - the most common urological disease in the elderly and senile age - an increase in the size of the prostate gland - occurs in 30-40% of men older than 50 years. In the development of benign prostatic hyperplasia, hormone imbalance during aging plays a leading role: decreasing production of androgens by the testes leads to increased production of the pituitary gonadotropic hormone, which stimulates the proliferation of paraurethral gland tissue. At the same time, the initial (prostatic) part of the urethra is extended, its diameter decreases due to the protruding rear part of the lumen, which creates resistance to urine flow from the bladder. Chronic urinary retention and, as a result, the expansion of the ureters, pelvis, cups. The resulting violation of urodynamics is further complicated by the development of chronic pyelonephritis and renal failure. Mortality from a disease such as prostate adenoma occurs mainly from 3 causes: uremia, sepsis, and complications from surgical interventions. The only risk factors for a disease such as prostate adenoma are aging and the level of androgens in the blood. The role of other factors in the development of BPH - such as sexual activity, social and marital status, tobacco and alcohol use, blood group, heart disease, diabetes and liver cirrhosis - has not yet been confirmed.

[1], [2], [3], [4]

Epidemiology

Prostate adenoma is the most common disease in older men and can manifest itself at the age of 40-50 years. The social significance and relevance of the problem emphasize the WHO demographic studies indicating a significant increase in the world's population over 60 years old, including male, which is significantly ahead of the growth of the population as a whole. This global pattern is characteristic for our country. Statistics on the incidence of the disease are based on clinical and pathological studies.

The increase in prevalence is noted from 11.3% in 40-49 years old to 81.4% in 80 years. After 80 years, prostate adenoma occurs in 95.5% of men. During preventive examinations of men over 50, prostate adenoma is detected in 10-15% of patients. Ultrasound scanning - in 30-40% of patients of the same age group. The presence of morphological signs, as well as its increase, determined by palpation or ultrasound, does not always correlate with the degree of clinical manifestations of the disease and infravesical obstruction.

Based on clinical observations, a direct correlation was established between the frequency of the symptoms expressed and the age of the patients. As a result of the study of signs, the use of UFM and TRUS, it was found that clinical symptoms are observed in 33% of men aged 40–49 years, reaching 43% by 60–69 years.

Thus, only 50% of men with morphological signs determine a palpable enlargement of the prostate gland. In the future, only half of them observe the clinical manifestations requiring treatment. In the course of studying the problem, great attention is paid to the risk factors for developing prostate adenoma. The most significant include age and normal functional state of the testicles. In men subjected to castration before puberty, adenoma does not develop, only a few observations indicate the occurrence of the disease after castration in the mature age. A pharmacological decrease in testosterone to post-extraction values also leads to a decrease in prostate size in adenoma.

Prostate adenoma (prostate gland) and the degree of sexual activity in men are not interrelated. Currently, it is recognized that prostate adenoma is observed in blacks more often, as has been proven when studying the epidemiological situation in various regions of the world. On the other hand, the lower prevalence observed in residents of Eastern countries, primarily Japan and China, is associated with the peculiarities of the local diet, containing a large number of phytosterols, which have a preventive effect.

[5], [6], [7], [8], [9], [10], [11], [12]

Symptoms of the prostate adenoma

Prostate adenoma is divided into three stages (depending on the degree of violation of urodynamics). In the first stage (compensation), the beginning of urination is difficult, which is accompanied by straining. Often there is a feeling of incomplete emptying of the bladder, pollakiuria is noted both day and night, the stream of urine becomes sluggish, intermittent. When hypothermia, drinking alcohol, spicy foods, taking certain medications, blood stasis in the pelvic organs (in the case of prolonged sitting, for example) patients may experience acute urinary retention. The second stage (decompensation) is manifested by a significant delay in the onset of urination, a sluggish, sheer stream of urine, lengthening of urination to several minutes, a feeling of incomplete emptying of the bladder, and involuntary outflow of urine after urination. During this period of the disease, residual urine in the bladder is detected (50 ml or more).

There is a threat of pyelonephritis and often acute ischuria. Atony and overdistension of the bladder develops in the third stage of the disease - complete decompensation. With an overflowing bladder, urinary incontinence may occur (urine is expelled drop by drop involuntarily) - so-called paradoxical ishuria. Pyelonephritis, which has arisen in the second stage of the disease, progresses, leading to the development of chronic renal failure. Often marked bleeding from the dilated veins of the prostatic urethra and bladder neck.

[13], [14], [15], [16]

Stages

Prostate adenoma has a clinical course in which there are three stages (compensation, subcompensation and decompensation):

• in stage I of the disease, patients have urinary disorders with full emptying;
• in stage II, bladder function is significantly impaired and residual urine appears;
• in stage III, complete decompensation of bladder function and paradoxical ischuria develop.

The disadvantage of this classification is the lack of indications of anatomical and functional changes in the upper urinary tract and kidneys. Violations of urination, depending on the severity of bladder obstruction, in combination with the accompanying signs and complications constitute the clinical picture of the disease. In this case, prostate adenoma may not correspond to the degree of violation of urination and severity of clinical symptoms. It is important to note that the clinical course in patients is so diverse that more stages can be distinguished, but it is impossible to take into account some features of the transition from one stage to another. Therefore, for reasons of continuity and clinical expediency, it is considered reasonable to preserve the classical classification consisting of three stages. Modern clinical classification is based on the characteristics of the functional state of the upper urinary tract and kidneys.

Prostate adenoma in stage 1 is characterized by complete emptying as a result of compensatory detrusor changes, its hypertrophy and the absence of significant changes in the functional state of the kidneys and the upper urinary tract.

In this stage, patients note a change in the dynamics of the act of urination, which becomes less free, less intense and more frequent. Nocturia appears up to 2 times or more. During the day urination may not be speeded up, but it does not occur immediately, but after a certain waiting period, especially in the morning. In the future, there is an increase in daily urination against the background of a decrease in the volume of urine excreted once. Characteristic appearance of imperative urges, in which the patient can not delay the onset of urination until the urine incontinence. Urine is excreted by a sluggish stream, sometimes it is directed almost vertically, and does not form, as normal, a characteristic parabolic curve. At the same time, to facilitate emptying, patients often at the beginning and at the end of urination strain the muscles of the anterior abdominal wall.

Prostate adenoma (prostate gland) stage I - the main feature of this stage - effective emptying due to compensatory hypertrophy of his muscles. There is no residual urine or its amount is insignificant.

The functional state of the kidneys and upper urinary tract does not undergo significant damage, it remains compensated (latent or compensatory stage of chronic renal failure). At this stage, the patient's condition can be stable without progression over many years due to the reserve capacity of the bladder, upper urinary tract and kidneys.

The depletion of compensation reserves means the transition to the next - prostate adenoma stage 2. It is characterized by intermediate stages of dysfunction of the upper urinary tract and kidneys. When urinating, the patient does not empty completely, 100-200 ml of residual urine appears, the volume of which increases.

Dystrophic changes develop in the detrusor, as a result of which it loses the ability to actively expel urine during contraction and dilates. For emptying, patients are forced to strain their abdominal muscles throughout the entire urination act, and this is an additional factor for increasing intravesical pressure. Urination is intermittent, multi-phase, with rest periods reaching several minutes. Due to an increase in pressure in the bladder, mechanical compression of the ureteral orifices with hyperplastic tissue and loop-like bundles of overstretched muscles, as well as loss of elasticity in the detrusor muscle structures, a violation of urine transport along the upper urinary tract and their expansion are observed. Against this background, kidney function continues to decline (compensated or intermittent stage of renal failure). The increasing decline in kidney function is manifested by thirst, dryness, bitterness in the mouth, polyuria, etc.

Disruption of compensation mechanisms means the transition of the disease to the final stage III of the development of the disease, which is characterized by complete decompensation of bladder function, upper urinary tract and intermittent or terminal stage of renal failure. The bladder loses its ability to contract, its emptying is ineffective even with the participation of extravesical forces. The bladder wall is stretched, it is filled with urine and can be determined visually or by palpation in the lower abdomen. Spherical in shape, its upper edge gives the impression of a tumor that reaches the level of the navel or higher. The patient feels a continuous desire to empty. In this case, urine is excreted very often and not in a stream, but in drops or in small portions.

Prolonged chronic delay of large volumes of urine causes a gradual weakening of the urge to urinate and pain due to the development of atony of the bladder. As a result of its overflow, patients mark periods of nocturnal, and then daily, constant involuntary urine excretion dropwise. Thus, the paradox of a combination of urinary retention and incontinence is observed, which is called paradoxical ishuria.

Prostate adenoma (prostate gland) stage III - patients report a marked expansion of the upper urinary tract and a progressive violation of the partial functions of the renal parenchyma due to obstructive uropathy. Without the provision of medical care, the intermittent stage of chronic renal failure go over the terminal one, azotemia and water-electrolyte imbalance increase, and the patient dies from uremia.

[17], [18], [19], [20]

Forms

Classification

The adenoma of the prostate has a clinical course in which three stages are distinguished (compensation, subcompensation and decompensation):

• in the I stage of the disease, patients develop urinary disorders when emptied completely;
• in the II stage, the function of the bladder is significantly impaired and residual urine appears;
• in the III stage there is a complete decompensation of the bladder function and a paradoxical ishuria.

The disadvantage of this classification is no indication of anatomical and functional changes in the upper urinary tract and kidneys. Violations of urination, depending on the degree of severity of infravesical obstruction, in combination with concomitant signs and complications constitute a clinical picture of the disease. In this case, prostate adenoma may not correspond to the degree of violation of the act of urination and the severity of clinical symptoms. It is important to note that the clinical course in patients is so diverse that more stages can be identified, but one can not take into account some features of the transition of one stage to another. Therefore, for reasons of continuity and clinical expediency, the preservation of a classical classification consisting of three stages is considered justified. Modern clinical classification is based on the characteristics of the functional state of the upper urinary tract and kidneys.

The prostate adenoma in stage 1 is characterized by complete evacuation as a result of compensatory changes in the detrusor, its hypertrophy and absence of significant changes in the functional state of the kidneys and upper urinary tract.

In this stage, patients notice a change in the dynamics of the act of urination, which becomes less free, less intense and more frequent. Appears nocturia up to 2 times or more. During the day, urination may not be rapid, but it does not come immediately, but after a certain waiting period, especially in the morning. In the future, there is an increase in daily urination on the background of a decrease in the volume of urinary excretion once. Characteristic is the emergence of imperative urges, in which the patient can not delay the onset of urination until urinary retention. Urine is excreted by a lethargic stream, sometimes it is directed almost vertically, and does not form, as in the norm, the curve of a characteristic parabolic shape. In order to facilitate emptying, patients often at the beginning and at the end of urination strain the muscles of the anterior abdominal wall.

Adenoma of the prostate (prostate gland) stage I - the main sign of this stage - effective emptying due to compensatory hypertrophy of his muscles. There is no residual urine or its amount is insignificant.

The functional state of the kidneys and upper urinary tract does not undergo significant damage, it remains compensated (latent or compensatory stage of chronic renal failure). At this stage, the patient's condition can be stable without progression for many years due to the reserve capacity of the bladder, upper urinary tract and kidneys.

The depletion of the reserves of compensation means the transition to the next stage - prostate adenoma of the 2nd stage. It is characterized by intermediate stages of disruption of the function of the upper urinary tract and kidneys. The patient during urination empties not completely, appears 100-200 ml of residual urine, the volume of which increases.

Dystrophic changes in detrusor develop, as a result of which it loses the ability to actively expel urine during contraction and dilates. For emptying patients are forced to strain the abdominal muscles throughout the act of urination, and this is an additional factor in increasing intravesical pressure. Urination is intermittent, multiphase, with periods of rest, reaching several minutes. Due to increased pressure in the bladder, mechanical compression of the ureteral by hyperplastic tissue and loop-shaped bunches of overstretched muscles, as well as loss of elasticity, detrusor muscular structures observe a violation of urine transport along the upper urinary tract and their expansion. Against this background, the kidney function continues to decrease (compensated or intermittent stage of renal failure). The growing decline in kidney function is manifested by thirst, dryness, bitterness in the mouth, polyuria, etc.

Disruption of the mechanisms of compensation means the transition of the disease to the final stage of the development of the disease, which is characterized by complete decompensation of the function of the bladder, upper urinary tract and intermittent or terminal stage of renal failure. The bladder loses its ability to contract, its emptying is ineffective even with the participation of extravesical forces. The wall of the bladder is stretched, it is full of urine and can be determined visually or by palpation in the lower abdomen. Spherical in shape, its upper edge produces the impression of a tumor that reaches the level of the navel or higher. The patient feels a continuous desire to emptying. In this case, urine is released very often and not by a stream, but by drops or small portions.

Prolonged chronic retention of large volumes of urine causes a gradual weakening of urination and painful sensations due to the development of atony of the bladder. As a result of its overcrowding, patients note periods of nocturnal and then daily permanent involuntary discharge of urine dropwise. Thus, the paradox of the combination of urinary retention and its incontinence is observed, which is called paradoxical ishuria.

Prostate adenoma (prostate gland) of the third stage - the patients note a pronounced widening of the upper urinary tract and a progressive violation of the partial functions of the renal parenchyma due to obstructive uropathy. Without providing medical assistance, the intermittent stage of chronic renal failure passes terminal, increases azotemia, disturbs water-electrolyte balance, and the patient dies from uremia.

Diagnostics of the prostate adenoma

Prostate adenoma is detected based on:

• subjective research data;
• digital rectal examination, which allows to determine the size and consistency of the prostate gland;
• ultrasound, giving information about the status of not only the prostate, but also the kidneys and urinary tract;
• functional methods for the determination of urodynamics (urine flow rate, urination time, etc.) - conducting urofluorometry;
• laboratory tests - detection of prostate-specific antigen (PSA), which normally should not exceed 3-4 ng / ml;
• X-ray data: excretory urography with late cystography, oxygen cystography, contrast cystography and Kneise-Schobert double contrast. This allows you to determine the presence or absence of violations of the outflow of urine from the upper urinary tract, visualize BPH, diagnose bladder stones and diverticula, determine residual urine and make a differential diagnosis with bladder neck sclerosis;
• the results of endoscopic examination carried out in order to detect a hyperplastic prostate gland, establish sources of bleeding from the bladder, identify diverticula and bladder stones, diagnose an enlarged middle lobe, and develop treatment tactics.

In doubtful situations, a perineal or transrectal biopsy of the prostate gland is performed, as well as computed and magnetic resonance imaging.

[21], [22], [23], [24], [25], [26]

Treatment of the prostate adenoma

The only method of treatment accepted all over the world, allowing to save the patient from such a disease as prostate adenoma, is surgery. However, in recent years, conservative therapy has been increasingly used, which is carried out in the initial stages of the disease or with absolute contraindications to surgery. At the first signs of an obstacle to the outflow of urine, adrenergic blockers are used to prevent spasm of the smooth muscles of the bladder neck - prazorin (1 mg / day), alfuzosin (5 mg / day), omnic (0.4 mg / day), cardura (2 mg per day.). Drugs in this group are effective in 70% of patients. Restrictions in the use of these drugs are due to the resumption of urodynamic disorders 1-2 months after discontinuation of the drug (repeated courses of treatment are necessary) and side effects in the form of lowering blood pressure (not recommended for severe atherosclerosis, stroke, and the tendency to hypotension). Prostate adenoma is treated with the use of herbal remedies containing extract of African plum bark (tadenan 50-100 mg / day), lipid-steroid extract of the American dwarf palm (permixon 320 mg / day), etc. These products are used by courses for 3b months, not only improve hemodynamics, but also lead to a decrease in prostate size, without reducing libido and potency (unlike finasteride, an inhibitor of 5-a reductase).

To address the issue of operative liver, a combination of three components is necessary: prostatic hyperplasia, urinary disorders and intravesical obstruction.

Surgical treatment includes open prostatectomy, transurethral resection (TUR), laser destruction and ablation (removal of tissue) of the prostate gland, as well as palliative operative methods - cryodestruction of the prostate gland, trocar cystostomy, epicystostomy for urinary diversion in 3 stages of the disease. Patients who also have a disease, like prostate adenoma, must be constantly monitored, and as the symptoms of obstruction increase, the amount of residual urine and mass increase, decide in favor of one or another species! Cookies.

Postoperative care is of great importance in the rehabilitation of geriatric patients. It is necessary to closely monitor, especially in the first hours after surgery, the color of urine released from the bladder in order to early detect such complications as bleeding (the appearance of intensely colored urine with clots against the background of lowering blood pressure and tachycardia). An idea of blood impurity in the urine can be obtained by inflicting a few drops of urine on gauze: the circles of urine (outside) and blood (in the center of the drop) formed after a few j minutes are compared. It should be borne in mind that the release of dark brown, brown urine does not indicate a continuing bleeding, but a washout of dye from urine from previously formed clots.

In the first days after surgery, the patient may be disturbed by painful false urge to urinate (due to the stitches placed on the bladder neck and irritation of the drainage tube of the vesical wall). The patient must be warned that it is impossible to push and try to urinate during these urges.

In the presence of drainage, they are extended in the ward with the help of polymer tubes and connected with transparent urinals, into which a small amount of antiseptic solution is poured. It is necessary to regularly change urinals and monitor the nature of the discharge, take into account the amount of urine released (separately - allocated independently and by drainage) and compare it with the volume of fluid consumed. The bladder is washed daily.

If an epicystostomy is left after the operation, then a permanent urethral catheter is needed not for drainage of the bladder, but for better formation of the prostatic part of the urethra, which is removed along with the tumor; in this case, the absence of discharge through the catheter may not pose any danger. If the patient is subjected to adenomactomy with a deaf suture of the bladder, then ensuring a good function of the permanent urethral catheter and its fixation is of paramount importance.

For the prevention of frequent thromboembolic complications in geriatric patients, the legs are bandaged with an elastic bandage on the eve of the operation and the early activation of the operated patient (after most urological surgeries, patients begin to walk in the morning of the next day).

When postoperative urinary retention should not be delayed emptying the bladder for more than 12 hours, since its longer overdistension, in addition to the negative effects on the upper urinary tract, leads to an even greater decrease in detrusor contractility and slows down the recovery of independent urination. The prevention of this complication is to maximally allow the patient to urinate while standing, using medications that increase detrusor contractions: pilocarpine solution (1% - 1.0) or prozerin (0.5% - 1.0). Only as a last resort resort to catheterization of the bladder with a rubber catheter.

From the second day after the operation, exercise therapy should be started: exercises for the limb, breathing exercises, sitting, standing up, etc.

[27], [28]

Prevention

Prevention of prostatic hyperplasia (for men of middle, old and old age) consists in active motor mode. It excludes the use of spicy dishes, marinades and alcohol. Useful vegetables and fruits, the replenishment of vitamin deficiencies in the winter-spring period, courses of diuretic herbal medicine. Necessary measures to prevent constipation. Patients should be advised to sleep in a hard bed and not be covered too warmly.

[29], [30], [31], [32], [33], [34]