2020年12月23日星期三

hemorrhoids zinc oxide,Diagnosis and treatment of benign prostatic hyperplasia

    Prostatic hyperplasia is a common disease in elderly men. Its cause is that the gradual enlargement of the prostate exerts pressure on the urethra and bladder outlet. It is clinically manifested as frequent urination, urgency, increased frequency of urination at night, and laborious urination, and can cause urinary system infection. Complications such as bladder stones and hematuria have a serious impact on the quality of life of elderly men, so active treatment is needed, and some patients even need surgery.

    Cause of disease

    The prostate is a sex gland organ unique to men. The prostate is like a chestnut, with the bottom facing up, touching the bladder, tip down, touching the urogenital diaphragm, pasting the pubic symphysis on the front, and next to the rectum at the back, so the back of the prostate can be palpated through the digital rectal examination.

    The human prostate develops and grows slowly from birth to before puberty; after puberty, the growth rate accelerates, reaching the peak at about 24 years old, and its volume is relatively stable between 30 and 45 years old, and some people may tend to Hyperplasia, the size of the glands gradually increases. If the urethra of the prostate is significantly compressed, it can cause obstruction of the bladder outlet and the related symptoms of dysuria, that is, prostate hyperplasia. Because this type of hyperplasia is a benign pathology, it is called Benign Prostatic Hyperplasia (BPH for short), formerly known as Prostatic Hyperplasia. Prostatic hyperplasia is a common disease in elderly men. Generally, pathological changes of hyperplasia begin after the age of 40, and related symptoms appear after the age of 50.

    At present, the cause of benign prostatic hyperplasia is still not well understood, but there are four theories that deserve attention:

    1. The role of sex hormones: the presence of functional testes is a necessary condition for the occurrence of prostate hyperplasia, and its incidence increases with age. Testosterone is a sex hormone in the male body. In the prostate, testosterone is transformed into dihydrotestosterone with a stronger effect through the action of 5α-reductase. Dihydrotestosterone can promote the increase of prostate cells and make the prostate volume gradually increase. Inhibiting the action of 5α-reductase in the body reduces the production of dihydrotestosterone and reduces the number of prostate cells, thereby reducing the size of the prostate. It is also believed that there is a synergistic effect of estrogen and androgen in the development and changes of benign prostatic hyperplasia, and the balance change of estrogen and androgen is the cause of prostatic hyperplasia.

    2. Prostate cells are reawakened by embryos: Some studies have found that the initial pathological changes of prostate hyperplasia, the formation of hyperplastic nodules, only occur in the area that accounts for 5% to 10% of the prostate gland, which is close to the transition zone and located in the prostate sphincter. In the area around the urethra inside the sphincter, the initial change of the prostatic hyperplasia nodule is the hyperplasia of glandular tissue, that is, the original glandular duct forms a new branch, which grows into the nearby interstitium, and forms a new framework structure after complex branching (I.e. nodules). According to the basic feature of embryonic development that is the formation of new structures, McNeal proposed the embryonic re-awakening theory of prostatic hyperplasia. It is believed that the formation of prostatic hyperplasia nodules is the spontaneous transformation of a certain prostatic stromal cell during growth. The result of embryonic developmental state.

    3. Polypeptide growth factors: Polypeptide growth factors are a type of polypeptide substances that regulate cell differentiation and growth. Studies have shown that polypeptide growth factors can directly regulate the growth of prostate cells, while sex hormones only play an indirect role. At present, the peptide growth factors found to play an important role in the occurrence of prostate hyperplasia mainly include: epidermal growth factor (EGF), transforming growth factors α and β, fibroblast growth factor (FGF) and insulin-like growth factor-I, etc. Among them, basic fibroblast growth factor (bFGF) has been proven to promote the mitosis of almost all cells in human prostate homogenate, and its role in the pathogenesis of prostate hyperplasia is receiving increasing attention.

    4. Lifestyle: Obesity is positively correlated with prostate volume, that is, the more fat, the larger the prostate volume. Although the conclusions are not consistent, some existing studies have shown that nutrients can affect the risks of BPH and LUTS. The increase in total energy and total protein intake, as well as the increase in fat, milk and dairy products, red meat, grains, poultry, and starch intake, can potentially increase the risk of prostate hyperplasia and prostate surgery. Vegetables, fruits, and more Saturated fatty acids, linoleic acid and vitamin D have the potential to reduce the risk of prostate hyperplasia.

    Pathophysiology

    The urethra passes through the middle of the prostate gland. It can be said that the prostate guards the urethra. Therefore, if the prostate is diseased, urination is affected first. The hyperplastic prostate gradually increases the volume of the prostate, compresses the urethra and bladder neck, and prevents the bladder from emptying urine. In order to overcome the resistance of the neck, the bladder strengthens its contraction so that the muscles of the bladder wall have compensatory hypertrophy, showing a trabecular protrusion. As the pressure in the bladder cavity increases, the bladder mucosa can bulge outward from the weak spots between the muscle bundles to form diverticula.The obstruction of the bladder neck continues to worsen. Every time you urinate, the bladder cannot completely empty the urine. After urination, there is still a part of urine in the bladder. The existence of residual urine is the basis for the occurrence of urinary system infection and secondary stones. If not actively treated, prostate hyperplasia will develop further, the pressure on the urethra will gradually increase, the bladder's ability to urinate will further decrease, the residual urine in the bladder will gradually increase, and the pressure in the bladder will increase, causing the urine in the bladder to flow back to the ureter and renal pelvis. , Causing hydrops on both sides of the upper urinary tract, increased pressure in the renal pelvis, ischemic atrophy of renal parenchyma, and decreased renal function.

    Clinical manifestations

    The symptoms of benign prostatic hyperplasia are mainly manifested in two groups of symptoms: one is bladder irritation; the other is obstructive symptoms caused by hyperplasia of the prostate and obstruction of the urinary tract.

    Bladder irritation

    Frequent urination, urgency, increased nocturia, and urge incontinence. Frequent urination is an early signal of prostate hyperplasia, especially the increase in nocturia is more clinically meaningful. Old people who can't afford to urinate at night have 1-2 times of urination at night, which often reflects the advent of early obstruction, and the development from 2 times a night to 4 to 5 times a night or more indicates the development and aggravation of the disease.

    Weak urination, thinning of urine lines, and dripping of urine

    Due to the obstruction of the hyperplastic prostate, the patient has to use greater force to overcome the resistance and urinary effort; the hyperplastic prostate will deflate the urethra and cause the urine line to become thin; as the disease progresses, urination may be interrupted, and the dripping after urination may not be exhausted. And other symptoms. When you feel the urge to urinate, you have to stand in the toilet and wait for a while before you urinate. The urine flow becomes thinner, the discharge is weak, and the range is not far, sometimes dripping from the urethral opening.

    hematuria

    An enlarged prostate indicates that there are many blood vessels. These blood vessels rupture when the pressure increases, making blood in the urine called hematuria, also known as hematuria. Under normal circumstances, there are no red blood cells in the urine. Medically, after centrifuging the patient’s urine, it is examined with a microscope. If there are more than 5 red blood cells in each high-power field, it is called hematuria.

    Urinary retention

    In patients with advanced prostate hyperplasia, acute urinary retention may occur due to cold, drinking, holding urine for a long time or infection, etc. when the obstruction is severe.

    complication

    Hydronephrosis

    This is because the proliferative prostate oppresses the urethra, and the bladder needs to contract forcefully to overcome resistance and expel urine from the body. Over time, the bladder muscles will become hypertrophy. If the pressure on the bladder cannot be relieved for a long time, the residual urine in the bladder will gradually increase, the bladder muscle will become ischemic and hypoxic, become no tension, and the bladder cavity will expand. Finally, the urine in the bladder will be poured back into the ureter and renal pelvis, causing hydronephrosis, and uremia may occur in severe cases.

    infection

    As the saying goes: "flowing water does not rot", but patients with benign prostatic hyperplasia often have different degrees of urinary retention. The residual urine in the bladder is like a pool of stagnant water, and bacterial growth may cause infection.

    Urinary retention and incontinence

    Urinary retention can occur at any stage of the disease, mostly due to sudden congestion and edema of the prostate caused by climate change, drinking, and fatigue. Excessive residual urine can make the bladder lose its ability to contract, and the urine retained in the bladder gradually increases. When the bladder is over-inflated, urine will overflow from the urethra unconsciously. This phenomenon of urinary incontinence is called filling urinary incontinence. Such patients must receive emergency treatment.

    Bladder stones

    Elderly bladder stones are also related to prostate hyperplasia. In the case of unobstructed urinary tract, stones generally do not grow in the bladder. Even if a stone falls from the ureter into the bladder, it can be excreted in the urine. It's different for elderly people suffering from prostate hyperplasia.

    hernia

    Prostatic hyperplasia may induce hernia (intestinal gas) and other diseases in the elderly. Some patients with prostatic hyperplasia will have symptoms of dysuria, requiring exertion and holding their breath to urinate. Due to constant exertion, the intestines will protrude from the weak part of the abdomen, forming a hernia (small intestinal gas), and sometimes patients will have hemorrhoids and varicose veins in the lower extremities.

    hemorrhoid

    Increased intra-abdominal pressure. It can easily cause hemorrhoids. Hemorrhoids are classified into internal hemorrhoids, external hemorrhoids and mixed hemorrhoids. They are masses caused by varicose veins of the upper and lower rectal plexus on both sides of the dentate line. Increased intra-abdominal pressure, blocked venous return, and blood stasis in the upper and lower rectal venous plexus are important causes of hemorrhoids. The patient may experience bleeding during defecation, prolapse of hemorrhoids, and pain. Therefore, hemorrhoids can often be relieved or even healed after the dysuria is relieved in patients with prostate hyperplasia.

    Check item

    Urinalysis

    Routine urine examinations of patients with benign prostatic hyperplasia can sometimes be normal. When urinary tract infection appears, white blood cell urine can be seen, and hematuria can also be judged.

    Determination of serum prostate specific antigen (PSA)

    PSA is a specific indicator of the prostate organ. Its elevation can be seen in prostate cancer, benign prostatic hyperplasia, acute urinary retention, prostate inflammation, massage of the prostate, operation of urethral instruments, and ejaculation before PSA. A significant increase in PSA is mainly seen in prostate cancer. In patients with benign prostatic hyperplasia, PSA can also increase, but the increase is relatively small.

    Urine flow rate check

    This test can calculate the speed of the patient's urine output. The change of urine flow rate can know the overall changes of the patient's urination function, the reasons for these changes include the pathological changes of the prostate, urethra and bladder. In patients with benign prostatic hyperplasia, the enlarged prostate compresses the urethra, which hinders the discharge of urine from the bladder, which is manifested as a decrease in the speed of urine discharge, that is, a decrease in urine flow rate. Urine flow rate examination is very important for patients with benign prostatic hyperplasia. It is not painful and can reflect the severity of dysuria in patients. Therefore, urine flow rate can be measured during initial diagnosis, treatment, and after treatment to determine the effect. Based on the non-invasiveness and clinical value of the test, where conditions permit, it should be determined before, during and after treatment.

    Ultrasonography

    You can know whether there is hydrops in the kidneys, whether the bladder is formed with diverticula, the size and shape of the prostate, and determine the residual urine volume. Patients with benign prostatic hyperplasia may have an increase in the amount of residual urine. Measuring the amount of residual urine helps to determine the degree of benign prostatic hyperplasia. Ultrasound examination is currently the main method for determining residual urine. After holding the urine and performing routine ultrasound examination of the bladder and prostate, the patient gets up to urinate. After fully urinating, the bladder is again observed with ultrasound to measure the residual urine volume in the bladder after urination.

    Digital rectal examination

    It can be found that the prostate is enlarged, the middle groove disappears or bulges, and attention should be paid to whether there are hard nodules and whether there is prostate cancer.

    Intravenous urography and urethral angiography

    If patients with benign prostatic hyperplasia are accompanied by repeated urinary tract infections, microscopic or gross hematuria, suspected hydronephrosis or ureteral dilatation, reflux, and urinary calculi, intravenous pyelography should be performed. It should be noted that intravenous urography is prohibited when the patient is allergic to contrast agents or has renal insufficiency. Urethral angiography is recommended when urethral stricture is suspected.

    Diagnosis points

    It is more common in elderly men over 50. It is manifested as frequent urination, urgency, increased nocturia, waiting to urinate, weakness and thinning of urine flow, dripping of urine, and intermittent urination.

    Digital rectal examination: The prostate is enlarged, the texture is tough, the surface is smooth, and the central groove disappears.

    Ultrasound examination: It can show a hyperplastic prostate and increased residual urine.

    Urine flow rate check: urine flow rate is reduced.

    Differential diagnosis

    This disease should be differentiated from urethral stricture, prostate cancer, and neurogenic bladder dysfunction.

    Disease treatment

    At present, the treatment methods for prostate hyperplasia include waiting for observation, drug treatment, surgical treatment and minimally invasive treatment. Each treatment option has advantages and risks. It is necessary to select a reasonable treatment plan according to the specific situation of the patient, so as to benefit the patient while avoiding complications and risks as much as possible.

    Wait and see

    If prostate hyperplasia has little impact on the patient's quality of life and no obvious distress, the patient can choose to wait for observation. Waiting for observation is not to passively observe the condition, but to assess the risk of the patient's BPH progression, to be alert to the occurrence of complications, to provide health education to the patient, and to improve the symptoms by adjusting the lifestyle. Lifestyle adjustments include proper water intake and avoid excessive consumption of caffeine and alcoholic beverages; it is necessary to know whether the patient is taking diuretics and other drugs that may affect urination symptoms at the same time, and make appropriate adjustments. When the patient progresses, he needs to actively intervene.

    medical treatement

    At present, standard drug treatments for LUTS/BPH include: α1 receptor blockers, 5α reductase inhibitors, and the combination of the two.

    Alpha1 receptor blockers can reduce the tension of the smooth muscles of the prostate and urethra, thereby alleviating the obstruction of the bladder outlet. It is currently the first-line medication for the treatment of benign prostatic hyperplasia. Alpha 1 blockers can improve symptoms and increase urinary flow rate, but it does not affect the volume of the prostate, nor can it significantly control disease progression. After using alpha 1 blockers for 2-3 days, 70% of patients can feel their symptoms improve. The adverse reactions of α1 blockers mainly include: orthostatic hypotension, dizziness, weakness, drowsiness, headache and ejaculation disorders. However, the overall incidence of adverse reactions is low, and most patients can tolerate them well.

    The 5α reductase inhibitor reduces the content of dihydrotestosterone in the prostate by inhibiting the activity of 5α reductase, so as to reduce the volume of the prostate. However, after taking a 5α reductase inhibitor, the size of the prostate decreases slowly, and it takes at least 3-6 months to relieve symptoms. Large-scale clinical studies have confirmed that 5α reductase inhibitors can control the clinical progress of benign prostatic hyperplasia and reduce the occurrence of acute urinary retention. Common side effects of 5α reductase inhibitors include erectile dysfunction, loss of libido, ejaculation disorders, and breast pain. The 5α reductase inhibitors currently on the market include finasteride and dutasteride. Finasteride only inhibits type II 5α reductase, while dutasteride can inhibit type I and type II 5α reductase. In a 12-month study, no significant difference in the efficacy of finasteride and dutasteride was found. Before using a 5α reductase inhibitor, the patient needs to be informed that the symptoms can be significantly improved after 6 months of treatment; after 12 months of treatment, the prostate specific antigen level will drop by 50%.

    Combination therapy of α1 receptor blocker and 5α reductase inhibitor: The combined treatment of α1 receptor blocker and 5α reductase inhibitor can effectively relieve symptoms, and can more effectively control the progression of BPH disease and reduce acute urine Retention and related surgical risks are mainly used in patients with a higher risk of progression of prostate hyperplasia. On the other hand, combination therapy also brings higher costs and more side effects.

    operation treatment

    Advances in drug treatment have significantly reduced the number of patients requiring surgical intervention. However, some patients still need surgical treatment. At present, clinically, patients who have poor drug treatment effect or who refuse to receive drug treatment are recommended to use when prostate hyperplasia causes repeated urinary retention, repeated hematuria, repeated urinary tract infections, bladder stones, and secondary hydronephrosis Surgical treatment.

    Surgical treatment methods include open surgery, intracavitary surgery and laser surgery. Among them, transurethral resection of the prostate (TURP) is still the "gold standard" for surgical treatment of BPH. After TURP, most patients' LUTS symptoms can be significantly improved. Laser surgery has the advantages of less bleeding and fewer complications. It is suitable for patients who cannot tolerate TURP surgery or whose prostate is small, and can achieve better results. With the advancement of technology, laser surgery may gradually replace most TURP surgeries. Minimally invasive treatment is a treatment method that can be considered for patients who cannot tolerate TURP with high surgical risk and have poor efficacy of drug therapy. At present, the commonly used clinically minimally invasive treatment methods include transurethral acupuncture, transurethral microwave hyperthermia, high-energy focused ultrasound, transurethral ethanol ablation of interstitial laser coagulation of the prostate, and prostate stents. However, these treatments still lack well-designed studies to confirm their efficacy.

    Follow up

    Various treatments for prostate hyperplasia should be followed up. The purpose of follow-up is to evaluate the efficacy and find side effects or complications related to treatment.

    The first follow-up of patients undergoing watchful waiting and drug treatment can be 6 months after the start of treatment, and once a year thereafter. If the above symptoms worsen or indications for surgery appear, the treatment plan needs to be changed in time. Follow-up content includes: symptom score, ultrasound (including residual urine measurement), urine flow rate, digital rectal examination, and measurement of prostate specific antigen.

    After receiving various surgical treatments, the patient should be arranged for the first follow-up one month after the operation. The content of the first follow-up is mainly to understand the patient's overall postoperative recovery status and related symptoms that may appear early after the operation. The effect of treatment can be basically evaluated at 3 months after surgery. The postoperative follow-up period is recommended to be 1 year. The follow-up content also includes symptom score, ultrasound (including residual urine measurement), urine flow rate, digital rectal examination, and measurement of prostate specific antigen.

    Self-care

    Prevent cold

    From the end of autumn to the beginning of spring, the weather is volatile, and cold tends to aggravate the condition. Therefore, patients must pay attention to cold protection, prevent colds and upper respiratory tract infections.

    Absolutely avoid alcohol, eat less spicy food

    Drinking can cause congestion and edema of the prostate and bladder neck and induce urinary retention. Spicy and irritating foods can not only cause congestion of the sexual organs, but also aggravate the symptoms of hemorrhoids and constipation, compress the prostate, and aggravate dysuria.

    Moderate drinking

    Drinking too little water will not only cause dehydration, but also adversely affect the flushing effect of urination on the urinary tract, and it is also easy to cause the urine to concentrate and form insoluble stones. Therefore, in addition to appropriately reducing drinking water at night to avoid overfilling the bladder after sleep, drink more water during the day.

    Use drugs with caution

    Some drugs can aggravate dysuria, and can cause acute urinary retention in large doses, including atropine, belladonna and ephedrine tablets, isoproterenol and so on.

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