The first basic knowledge
Benign prostatic hyperplasia (BPH) is the most common cause of urination disorders in middle-aged and elderly men. Mainly manifested as the histological prostatic interstitial and glandular hyperplasia, anatomical prostate enlargement (benign prostatic enlargement, BPE), lower urinary tract symptoms (lower urinary tract symptoms, LUTS)-based clinical symptoms and Urodynamic bladder outlet obstruction (bladder outlet obstruction, BOO).
Histologically, the incidence of BPH increases with age. It usually occurs after the age of 40, and is greater than 50% at the age of 60, and as high as 83% at the age of 80. Approximately 50% of men with a histological diagnosis of BPH have moderate to severe lower urinary tract symptoms.
The occurrence of BPH must have two important conditions for aging and a functional testis.
However, the specific mechanism of BPH is not yet clear. It may be caused by the balance of epithelial and mesenchymal cell proliferation and apoptosis.
Related factors include: androgen and its interaction with estrogen, the interaction of prostate mesenchyme-glandular epithelial cells, growth factors, inflammatory cells, neurotransmitters and genetic factors.
McNeal divides the prostate into peripheral zone, central zone, transition zone, and periurethral gland area.
All BPH nodules occur in the transitional zone and glands around the urethra.
After prostatic hyperplasia, the hyperplastic nodule compresses the rest of the gland to form a "surgical envelope", and there is a clear boundary between the two. After the hyperplasia is removed by surgery, the compressed glands are left behind, so the prostate glands can still be explored in the postoperative digital rectal examination and imaging examination.
6. Clinical manifestations, diagnosis and treatment
The main clinical manifestations of BPH include bladder irritation, obstruction and related complications.
The treatment of BPH mainly includes four categories: watchful waiting, drug treatment, minimally invasive treatment and surgical treatment.
The purpose of treatment is to improve the quality of life of patients while protecting kidney function.
Chapter 3 Clinical Progression of BPH
A number of studies have confirmed that BPH is a slowly progressing benign disease of the prostate, and its symptoms gradually aggravate with the age of the patient, and corresponding complications appear.
1. The definition of clinical progression of BPH
At present, the more recognized contents showing the clinical progress of BPH include: worsening lower urinary tract symptoms leading to a decrease in the quality of life of patients, a progressive decrease in maximum urine flow rate, acute urinary retention, recurrent hematuria, recurrent urinary tract infections, and renal impairment, etc. , BPH patients receiving surgical treatment is the final manifestation of disease progression.
2. Evaluation index of clinical progress
1. The exacerbation of LUTS symptoms is mainly evaluated by the IPSS score method
Studies have shown that the I-PSS scores of BPH patients increase year by year, with an average annual increase ranging from 0.29 to 2 points.
2. Progressive decrease in maximum urine flow rate
3. The occurrence of BPH-related complications
Acute urinary retention, recurrent hematuria, recurrent urinary tract infections, stone production, and renal impairment are the manifestations of the progression of BPH, among which acute urinary retention and renal impairment are the main indicators.
The experimental results of MTOPS suggest that among the serious complications caused by BPH, including renal insufficiency, repeated urinary tract infections, urinary stones and urinary incontinence, the incidence of acute urinary retention is the highest. The occurrence of acute urinary retention is the main manifestation of bladder decompensation and an important event in the progression of BPH.
There is a certain relationship between the clinical progress of BPH and chronic renal insufficiency.
4. Increased chances of BPH surgery
The increased risk of surgical treatment and the increased probability of surgery are signs of the clinical progress of BPH.
PLESS related research results showed that in the placebo group followed up for 4 years, 7% of patients had acute urinary retention, and 10% of patients needed surgical treatment. Acute urinary retention is the primary reason for surgical treatment.
3. Analysis of risk factors for clinical progress of BPH
At present, the most powerful studies supporting the clinical progress of BPH are the Olmsted County, PLESS and MTOPS studies. Numerous research data indicate that age, serum PSA, prostate volume (prostate volume), maximum flow rate (Qmax), postvoid residual urine (postvoid residual urine) and I-PSS score are related to the clinical progress of BPH. .
1. Age: Age is a high risk factor for the clinical progression of BPH.
2. Serum PSA: Serum PSA is one of the risk predictors of clinical progression of BPH.
3. Prostate volume: Prostate volume is another risk predictor of clinical progression of BPH.
4. Maximum urine flow rate: The maximum urine flow rate can predict the risk of acute urinary retention and the possibility of clinical progression in patients with BPH.
5. Residual urine volume: Residual urine volume can predict the clinical progress of BPH.
6. Symptom score: The symptom score also has a certain value in predicting the clinical progress of BPHI.
Although studies have shown that there are many factors that can predict the clinical progress of BPH, currently supported by most studies, the indicators for predicting the clinical progress of BPH are age, PSA, and prostate volume.
Chapter 4 Diagnosis of BPH
1. Initial assessment
l. Medical history inquiry (recommended)
The International Prostate Symptom Score (LPSS) is currently internationally recognized as the best method for judging the severity of symptoms in BPH patients.
Quality of Life Score (QOL)
2. Physical examination (recommended)
(1) Digital rectal examination (DRE)
Can know if there is prostate cancer:
You can understand the size, shape, texture, presence or absence of nodules and tenderness of the prostate, whether the central groove becomes shallow or disappear, and the tension of the anal sphincter.
(2) Local nervous system examination (including movement and sensation).
3. Urine routine (recommended)
4. Serum PSA (recommended)
Prostate cancer, BPH, and prostatitis may all increase serum PSA. Therefore, serum PSA is not unique to prostate cancer. In addition, urinary tract infection, prostate puncture, acute urinary retention, indwelling catheterization, digital rectal examination and prostate massage can also affect the serum PSA value.
5. Ultrasound examination (recommended)
Ultrasound examination can understand the shape and size of the prostate, whether there is abnormal echo, the degree of penetration into the bladder, and the amount of residual urine. Transrectal ultrasonography (TRUS) can also accurately measure prostate volume. In addition, transabdominal ultrasonography can understand whether the urinary system (kidney, ureter) has hydrops, dilatation, stones or space-occupying lesions .
6. Urine flow rate check (recommended)
Urine flow rate has two main indicators (parameters): maximum urine flow rate (Qmax) and average flow rate (average flow rate, Qave), of which the maximum urine flow rate is more important.
2. According to the results of the initial evaluation, some patients need further examination
1. Urination diary (optional)
2. Serum creatinine (optional)
3. Intravenous urography (IVU) examination (optional)
4. Urethrography (optional)
5. Urodynamics (optional)
This check is to analyze the detrusor function and determine whether there is bladder outlet obstruction through the pressure-flow rate function curve graph and A-G graph.
6. Urethrocystoscopy examination (optional)
Through urethral cystoscopy, the following conditions can be understood:
(1) Features of urethral or bladder neck obstruction caused by enlarged prostate;
(2) Obstruction caused by the elevation of the back lip of the bladder neck;
(3) The formation of bladder trabeculae and diverticula;
(4) Bladder stones;
(5) Determination of residual urine volume;
(6) Bladder tumors;
(7) The location and degree of urethral stricture.
3. Inspection items are not recommended
Computed tomography (CT) and magnetic resonance imaging (MRI) are generally not recommended due to the high cost of the examination.
Chapter 5 Treatment of BPH
1. Watchful waiting
After a long follow-up, only a few patients with BPH have complications such as urinary retention, renal insufficiency, and bladder stones.
Patients with mild lower urinary tract symptoms (I-PSS score ≤ 7) and patients with moderate or above symptoms (I-PSS score ≥ 8) and whose quality of life has not been significantly affected can use watchful waiting.
two. medical treatement
The short-term goal of drug therapy for patients with BPH is to alleviate the patients' lower urinary tract symptoms, and the long-term goal is to delay the clinical progression of the disease and prevent the occurrence of complications.
①The mechanism of action of α-receptor blockers and urinary tract selectivity
Alpha-receptor blockers block the adrenergic receptors distributed on the surface of the smooth muscle of the prostate and bladder neck, relax the smooth muscle, and achieve the effect of alleviating the dynamic obstruction of the bladder outlet.According to the selectivity of the urinary tract, α-receptor blockers can be divided into non-selective receptor blockers (phenoxybenzamine, Phenoxybenzamine) and selective α1 receptor blockers (Doxazosin, Alfurazole) Alfuzosin, Terazosin) and highly selective α1 receptor blockers (Tamsulosin-α1 A>α1D, Naftopidil-α1D>α1A).
Tamsulosin, doxazosin, alfurazosin and terazosin are recommended for the drug treatment of BPH. You can choose naftopidil for the treatment of BPH. Prazosin (Prazosin) and the non-selective receptor blocker phenoxybenzamine are not recommended for the treatment of BPH.
A clinical study on tamsulosin for the treatment of BPH for up to 6 years showed that long-term use of alpha-blockers can maintain a stable efficacy. At the same time, the MTOPS study has also confirmed the long-term efficacy of alpha-blockers alone.
The baseline prostate volume and serum PSA level of BPH patients do not affect the efficacy of α-blockers, and α-blockers do not affect prostate volume and serum PSA levels.
The clinical effects of various α-receptor blockers are similar, and the side effects are somewhat different. For example, tamsulosin has a low incidence of cardiovascular system side effects, but a high incidence of retrograde ejaculation .
⑤ Side effects
Common side effects include dizziness, headache, weakness, drowsiness, orthostatic hypotension, retrograde ejaculation, etc. Orthostatic hypotension is more likely to occur in elderly and hypertensive patients.
2. 5-α reductase inhibitor
① Mechanism of action
The 5-α reductase inhibitor inhibits the conversion of testosterone to dihydrotestosterone in the body, thereby reducing the content of dihydrotestosterone in the prostate, achieving the therapeutic purpose of reducing the volume of the prostate and improving dysuria. The 5-alpha reductase inhibitors currently used in China include Finasteride and Epristeride.
Finasteride is suitable for the treatment of BPH patients with enlarged prostate and lower urinary tract symptoms. For patients with high risk of clinical progression of BPHI, finasteride can be used to prevent the clinical progression of BPH, such as urinary retention or surgical treatment.
Multiple studies have shown that finasteride can reduce the incidence of hematuria in patients with BPH. The data of the study showed that the application of finasteride (5 mg/day, more than 4 weeks) before transurethral resection of the prostate can reduce the amount of bleeding in patients with BPH with larger prostate volume.
The most common side effects of finasteride include erectile dysfunction, abnormal ejaculation, low libido, and other such as feminization of male breasts and breast pain.
⑤Finasteride affects the serum PSA level: Finasteride can reduce the serum PSA level.
Epristeride (epristeride) is a non-competitive 5-α reductase inhibitor.
4. Chinese medicine and plant preparations
Botanical preparations, such as Pushitai, have achieved certain clinical effects in relieving BPH-related lower urinary tract symptoms, and have achieved a wide range of clinical applications at home and abroad.
two. Surgical treatment of BPH
1. Indications for surgical treatment
When BPH causes the following complications, surgical treatment is recommended:
1. Repeated urinary retention (cannot urinate after at least one extubation or two urinary retention)
2. Repeated hematuria, 5α reductase inhibitor treatment is ineffective
3. Repeated urinary tract infections
4. Bladder stones
5. Secondary upper urinary tract hydrops (with or without renal impairment)
BPH patients with large diverticulum of the bladder, inguinal hernia, severe hemorrhoids or prolapse of the anus, if clinical judgment does not relieve the lower urinary tract obstruction, surgical treatment should be considered.
The measurement of residual urine volume has a certain reference value for the degree of lower urinary tract obstruction caused by BPH, but it is currently believed that the upper limit of residual urine volume that can be used as a surgical indicator cannot be determined. However, if the residual urine increases significantly so that BPH patients with overflow incontinence should consider surgical treatment.
2. Surgical treatment
(1) Routine surgery The classic surgical methods are:
Transurethral Resection of the Prostate (TURP), currently TURP is still the "gold standard" for BPH treatment.
Transurethral Incision of the Prostate (TUIP) and
Transurethral Electrovaporization of the Prostate (TUVP)
Transurethral bipolar electrocautery (PKRP) is also currently used in surgical treatment.
①TURP is mainly suitable for the treatment of BPH patients whose prostate volume is below 80ml. Skilled surgeons can appropriately relax the restriction on prostate volume.
The incidence of blood volume expansion and dilutional hyponatremia (transurethral resection syndrome, TUR-Syndrome, TURS) caused by excessive absorption of washing fluid is about 2%. Risk factors include excessive intraoperative bleeding, long operation time and The prostate is large and so on.
The incidence of various postoperative complications: urinary incontinence is about 1-2.2%, retrograde ejaculation is about 65-70%, and bladder neck contracture is about 4%. Urethral stricture is about 3.8%.
②TUIP is suitable for patients with prostate volume less than 30g and no middle lobe hyperplasia.
③Open prostate enucleation is mainly suitable for patients with prostate volume greater than 80ml, especially those with bladder stones or bladder diverticula that require simultaneous surgery.
④TUVP is suitable for BPH patients with poor coagulation function and small prostate volume. It is another choice of TUIP or TURP. Compared with TURP, the hemostatic effect is better. Long-term complications are similar to TURP.
⑤PKRP uses a bipolar resection system and performs transurethral resection of the prostate in a similar way to unipolar TURP. Use normal saline as the intraoperative irrigation fluid. Intraoperative bleeding and TURS were reduced.
(2) Laser treatment
The methods with definite curative effect include transurethral holmium laser enucleation of the prostate, transurethral laser vaporization of the prostate, and transurethral laser coagulation of the prostate.
① Transurethral Holmium Laser Resection/Enucleation (HOLRP):
② Transurethral Laser Vaporization
③ Transurethral Laser coagulation
(3) Minimally invasive treatment
① Transurethral Microwave Therapy (TUMT)
② Transurethral Needle Ablation (TUNA)
③ Prostate stents (Stents)
At present, there is no clear evidence to support high-energy focused ultrasound and chemical ablation of prostate alcohol injection as an effective option for BPH treatment. Transurethral balloon dilation of the prostate is an obsolete treatment.