- Prevalence of the disease
- Excursion to anatomy and features of prostate function
- The causes of prostate adenoma
- The stages of the disease depending on the symptoms
- Complications of prostatic adenoma
- Diagnosis of prostate adenoma
- Treatment of prostate adenoma
Adenoma of the prostate is a benign tumor that develops from the stroma or glandular epithelium of the prostate. Adenoma itself does not give metastasis, but it can eventually degenerate into adenocarcinoma (prostatic cancer).
Many specialists, speaking about prostate adenoma, prefer to use the term "benign prostatic hyperplasia" (DHBW), emphasizing in this way its polycentric growth against the background of pronounced dyshormonal character of the changes occurring in the prostate gland.
Prevalence of the disease
Adenoma of the prostate is one of the most common urological diseases in men. Previously, it was rarely found until the age of 54, and usually occurred in 57-60-year-old men.
At present, the disease is significantly "younger". For example, the initial signs of prostatic hyperplasia are increasingly appearing at the age of 25 years. According to the data obtained from the autopsy of the dead from various diseases, at present, prostate adenoma occurs up to 30 years in 8%, up to 50 years - in 50%, and after 80 years adenoma affects more than 80% of men.
It is believed that in China, Japan, prostate adenoma is very rare, and most often in North America, Europe, Egypt and India.
Excursion to anatomy and features of prostate function
Under normal conditions, the shape of the prostate gland is like a chestnut, the size of which varies slightly with age. At 30 she is 3x4 cm and weighs about 16 grams. The prostate is located in such a way that its tissues from all sides surround the urethra (for this reason, in the adenoma, normal urination first of all starts to suffer). Its nearest "neighbors" in the small pelvis are the rectum and bladder, therefore diseases of the prostate gland can affect the general condition and functioning of these organs.
In a newborn baby, the prostate weighs less than 1 gram, and by the age of 30 it increases almost 20 times. After 45-50 years prostatic glands gradually atrophy and replaced with a connective tissue, from which almost all of this gland is composed, since the age of 65 years.
Features of functioning
Prostate refers to hormone-dependent organs. Her activity is controlled by the so-called hypothalamic-pituitary-gonadal system, and for her normal growth and functioning, the male hormone testosterone predominantly "answers".
The most intensive hormonal restructuring of the male body begins after 40-45 years, when a decrease in testosterone and an increase in estradiol occur in the plasma. These changes are increasingly progressing towards old age. During this restructuring, periods of destabilization of hormone levels are possible, which can serve as an impetus to the development of adenoma.
The causes of prostate adenoma
The exact answer to the question why the prostate adenoma is developing, to date, not one of the specialists involved in the study of this disease. The fact is that the gland hyperplasia occurs in men, with both violent and low sexual activity, in smokers and non-smokers, who abuse alcohol and do not drink.
Nevertheless, it is noted that the age and level of male hormones greatly affect the incidence of adenoma. Also, the development of hyperplasia is promoted by a hereditary factor and a sedentary lifestyle (noted in 60% of adenoma cases). It was also found that adenoma does not develop in castrated men, so castration was offered at one time as one of the ways to treat BPH.
Many experts believe that the immediate cause of the development of prostate adenoma should be sought in the complex interaction of prostate cells among themselves, changing their sensitivity to hormones, etc.
The stages of the disease depending on the symptoms
Modern medicine distinguishes 4 stages of development of prostatic adenoma.
The first stage: the compensated form
Experiencing a constant resistance to the usual outflow of urine, the muscles of the bladder gradually hypertrophy, increase in volume in order to literally "squeeze out" the urine outward.
The most characteristic changes in the urination of this stage are:
- more frequent,
- less free,
- not as intense as before (the urine stream no longer looks like a characteristic parabola, but falls almost vertically).
Gradually disturbed by night sleep, as patients are forced to get up to urinate 2-3 times a night. However, this fact is usually not alarming, and is easily explained by other causes, for example, insomnia, fluid intake, etc.
During the day, the frequency of urination may remain the same, but in most cases, urine begins to stand out only after a while waiting (especially in the morning after waking).
With the further growth of the prostate and the intensification of the compression of the urethra, the following symptoms appear:
- increased urge to urinate during the day,
- decrease in the release volume of urine,
- the increase in cases of irresistible urge to urinate (the so-called imperative urges),
- participation of auxiliary muscles: the patient for a better emptying from time to time straining the abdomen at the beginning or at the end of urination.
Despite the presence of these symptoms, the kidneys and ureters do not change, and the general condition of the affected adenoma can remain stable for many years without any significant signs of disease progression.
However, even at this stage, acute urinary retention may occur periodically.
The second stage: subcompensation or periodic violations
At this stage, the bladder is not fully emptied, and the amount of urine remaining in it after urination reaches 1-2 glasses.
The characteristic symptoms of this stage are:
- an increase in the volume of the bladder,
- the need to strain during the entire urination,
- The jet of urine is excreted intermittently, wavy,
- due to the presence of rest periods, when urine is not excreted, the entire act of urination is stretched for several minutes.
Due to the constant increase in the volume of urine remaining in the urinary bladder, changes in the upper parts of the urinary system are gradually beginning to occur:
- expand ureters,
- there are signs of kidney failure.
Other possible symptoms at this stage:
- dry skin,
- kidney - a violation of the nitrogen excretory function and the development of the initial stage of renal failure.
The third stage: decompensation
Gradually, the body loses its ability to resist the huge amount of urine that is constantly left because of the increased prostate adenoma. The bladder will overgrow, therefore practically does not shrink and does not help to expel urine outside, even straining during the act of urination practically does not help.
At this stage, the bladder is similar to a liquid-filled ball that reaches the level of the navel or even higher.
Symptoms typical for this stage:
- a feeling of a constant desire to empty the bladder,
- the appearance of severe pain in the lower abdomen,
- frequent discharge of urine drop by drop or very small portions.
Gradually, the body adapts to this state, and the pain passes. Urine constantly "drips", which creates the impression of incontinence. However, this situation is not due to the fact that the urinary bladder does not retain urine, but because it can not get out of the large adenoma in large quantities. This phenomenon is known as the "paradoxical retention of urine."
In the upper parts of the urethra there are also changes:
- the functions of the kidneys are significantly impaired, which leads to the development of decompensated renal failure,
- maximally expand the ureters.
Due to the loss of the purifying function by the kidneys, slags gradually accumulate in the body, which is accompanied by:
- loss of appetite,
- vomiting, nausea,
- general weakness,
- characteristic body odor.
Because of the restriction of the fluid intake in this period, patients are constantly thirsty, they have dry mouth and hoarseness. From the side of the psyche, there is apathy, depression, anxiety.
Fourth stage: terminal
As the pathological process progresses, phenomena of renal insufficiency arise that are not compatible with life: a sharp disturbance of the water-electrolyte balance occurs, an increase in the nitrogen content in the blood, and a person dies from uremia.
Complications of prostatic adenoma
Even at the initial stages, when the prostatic hyperplasia is still relatively small and the violation of urination is insignificant, periodically there may be an acute delay in urination or blood in the urine (hematuria) can be detected. In the future, prostate adenoma can be complicated by the formation of stones or by the attachment of infection of the urino-genital organs. Let's consider some types of complications in more detail.
Acute retention of urine
Acute urinary retention is a condition when it is absolutely impossible to urinate with a full bladder. The most common in the second and third stages of the disease.
The causes of the development of acute delay in prostate adenoma:
- abuse of food containing spices,
- reception of diuretics,
- prolonged retention of urination,
- long stay in a lying or sitting position,
- reception of alcohol.
All these conditions contribute to the onset of swelling of the tissues of an already enlarged prostate, etc.
- absence of urine during the act of urination,
- pain in the lower abdomen (above the pubis),
- in the suprapubic region the appearance of a "vesicle ball" - the swelling of an overflowing bladder,
- anxiety, anxiety on the part of the patient.
Very rarely acute urinary retention with adenoma passes by itself, so the bladder is emptied by catheterization or surgery.
The appearance of blood in the urine with prostate adenoma occurs spontaneously if there is bleeding from the enlarged veins in the neck of the bladder or the urethra is damaged during any manipulation (for example, catheterization).
Hematuria can be small, detectable only under a microscope, or very significant, with the formation of a lot of blood clots and the subsequent tamponade by them of the bladder. In this case, the patient with an adenoma needs to urgently operate.
Stones of the bladder
Formed at those stages of development of adenoma, when in the bladder enough to keep a large enough volume of urine. Another way is the migration of the stone from the kidney to the ureters and the impossibility of its exit through the narrowed lumen of the urethra.
Symptoms of having a stone in the bladder:
- frequent urination,
- pain in the head of the penis, increasing with movement, walking and disappearing in a horizontal position,
- the periodic appearance of the symptom of "pouring a stream of urine."
- cystitis ,
- epididymoorkhit and the like.
Often, the development of infection contributes to stagnation in the bladder, as well as catheterization.
Development of renal failure
It is typical for the third and terminal stage of adenoma development and is associated with a decrease in urine production by the kidneys.
1. Stage of latent manifestations : periodic dry mouth, weakness, with the delivery of tests - at times a slight violation of blood electrolytes.
2. Compensation stage : increased frequency of urination, changes in blood tests (increase in urea, creatinine).
3. The stage of decompensation :
- dry mouth,
- decreased appetite,
- fast fatiguability,
- general weakness,
- a decrease in immunity, manifested in a more severe course of common colds,
- tremor of fingers,
- twitching of muscles,
- pain in the bones and joints,
- dry skin,
- bad breath,
- in the blood - increased urea, creatinine.
Stress, eating disorders, excessive physical exacerbation exacerbate the manifestations of kidney failure.
4. Terminal stage :
- disturbance of night sleep,
- inadequacy of behavior,
- emotional lability,
- the smell of urine from the patient,
- the stomach is swollen,
- decrease in temperature (hypothermia),
- gray-yellow color of the skin and face,
- stinking stool,
- changes in almost all internal organs and the nervous system due to the phenomena of uremic intoxication.
Diagnosis of prostate adenoma
Complex diagnostics of adenoma is carried out on the basis of the data of the patient's questionnaire, urological examination and a number of additional laboratory-instrumental methods of examination.
During the conversation, the doctor is informed of the complaints, and also conducts a survey according to the standardized international IPSS questionnaire developed by WHO and its QOL appraisal, which assesses the overall quality of life. It contains questions about the frequency and nature of urination, whether it was necessary to strain while trying to urinate, etc.
In addition to an external examination of the genitals, a compulsory examination of the prostate through the rectum is included. It is carried out as follows:
- Before arriving at the urologist, the patient must first empty the rectum.
- At the reception the doctor will put on a sterile medical glove, lubricate the finger with Vaseline and gently insert it into the rectum.
- Further, by gentle movements, he will perform palpation (palpation) of the posterior wall of the prostate.
With adenoma, the prostate gland is enlarged, elastic, painless.
According to the general analysis, urine is judged on possible bleeding, accession of urinary tract infection, signs of kidney failure.
Kidney tests are also important for detecting insufficient kidney function. Particular attention is paid to the level of creatinine and residual nitrogen, which as the progression of renal insufficiency increases.
The level of prostate-specific antigen is determined in order to exclude prostate cancer, which can be observed together with the adenoma. With cancer, the level of this antigen is increased.
Histological examination is performed by prostate biopsy to exclude the possibility of cancer.
Most commonly, the following methods are used to diagnose prostate adenoma:
1. Ultrasound . Gives an idea of the degree of enlargement of the prostate, its structure, to reveal nodular formations in the gland, and also to get an idea of the presence of stones in the bladder and the volume of residual urine. Performed in the usual way, in which the sensor is placed on the front surface of the abdomen or placed in the rectum (the so-called transrectal examination - TRUZI).
2. X-ray methods . These include a review radiograph and excretory urography. The latter is done using contrast and allows you to determine the expansion of the ureters, the kidneys, the change in their shape, the presence of protrusions (diverticula) in the wall of the bladder.
3. Uroflowmetry . This study is carried out using a special device, which is a funnel that connects to a computer or a recorder. An hour before the procedure, you need to drink 1 liter of pure still water, and then urinate in the funnel of the device. On paper or on the screen of the monitor, a curve is drawn, according to the nature of which the doctor will get an idea of the functioning of the urethra and the sphincter of the bladder.
Other urodynamic studies are also carried out according to the testimony, for example:
- multichannel urodynamics,
- urethral profilometry,
- video dynamics,
4. Urethrocystoscopy . Allows you to visually assess the nature of the narrowing of the urethra and identify possible changes in the bladder.
The results obtained help to determine the tactics of treatment, choosing the most effective method for each specific case. It is believed that in the case of prostate adenoma should be alarmed the following results of laboratory-instrumental research:
- prostate specific antigen above 1.4 ng / ml,
- prostate volume of more than 40 cm 3 ,
- by IPSS questionnaire more than 7,
- the maximum flow rate of urine is less than 10 ml / s.
Treatment of prostate adenoma
Currently, there is no single method for treating prostatic hyperplasia, because in each case, many factors must be considered, for example:
- general condition and age of the patient,
- his consent to the operation,
- stage of adenoma,
- accompanying illnesses,
- degree of violation urodynamics,
- whether there are signs of prostate cancer,
- the possibility of a medical institution.
In general, prostate adenoma can be treated both conservatively and operatively. The use of this or that method of treatment depends on the stage of development of the adenoma:
- The first stage . Usually at this stage, hyperplasia of the prostate is treated conservatively: medication is prescribed, recommendations on the regimen and lifestyle are given-to lead a physically active lifestyle, avoiding the use of spices and other irritating foods, smoked foods, and alcohol and coffee. If there is difficulty urinating, transurethral electroresection may be recommended.
- The second stage . The gold standard of care at this stage is the removal of adenoma by surgery, using a variety of minimally invasive and classical techniques.
- The third stage . Here the main tasks are to ensure a good outflow of urine in order to relieve azotemic toxicity. In this case, use percutaneous puncture nephrostomy, cystostomy, etc. Further, the condition of the liver, kidneys, and cardiovascular system is normalized, and then the question of possible further surgical treatment is resolved.
The drugs used to treat adenoma do not lead to its complete disappearance. They must be used for a long time, regularly, otherwise the adenoma will begin to progress. Usually the following groups of drugs are prescribed:
1. Medicines, relaxing the tone of smooth muscles in the neck of the bladder and prostate, which leads to a decrease in pressure on the urethra and to facilitate the outflow of urine out. These are α-adrenoblockers of long (prolonged) and short-acting:
- tamsulosin and others.
2. Drugs that block the conversion of testosterone into an active form and thereby reduce the volume of the prostate (5-α-reductase inhibitors):
3. Phytomedication. Currently, herbal preparations in view of the low efficiency and lack of proven clinical effect in many developed European countries and the United States for the treatment of adenoma are not used. Nevertheless, in a number of countries plant remedies are made, including lipidosterol extracts, for example, Serenoa repens, Pygeum africanum, etc. It is believed that they have anti-inflammatory action, reduce swelling, block the conversion of testosterone into an active form and stop the growth of adenoma.
4. Combined funds. Currently, the "gold standard" is the joint intake of the drugs of the first two groups for 3-4 years. This allows you to almost immediately improve urination and after a few years to a quarter to reduce the volume of the prostate gland.
In parallel, the treatment of concomitant diseases - cystitis, prostatitis, pyelonephritis, urethritis.
Operative methods of treatment
They are radical methods of treating prostate adenoma and are widely used in urology. These include:
1. Open adenomectomy . It can be performed in various ways, the most well-known of which is transvezikuryannaya adenomectomy. Through a conventional surgical incision, access to the prostate gland is provided and its removal is performed. Usually, it is used in case of inability to use less traumatic techniques.
2. Endoscopic operations . All of them are performed with the help of special surgical instruments, introduced directly into the urethra under the control of video equipment. These include:
- transurethral resection of the prostate (TUR), which is the "gold standard" of surgical treatment of adenoma - during its passage through the urethra a special tool cuts and excises prostate tissue;
- transurethral electrovaporization - all also access to the prostate is provided through the urethra, and then the tissues are heated up to a high temperature and evaporate, and the small blood vessels coagulate;
- transurethral incision - in the area of the prostatic urethra make a cut, so that the lumen of the urethra expands, this operation is effective in the case of small adenomas.
3. Embolization of the arteries of the prostate . This operation is performed by vascular surgeons and is reduced to the fact that the arteries of the prostate are clogged with a special polymer, providing them access through the femoral artery.
4. Cystotomy . Used as an intermediate stage of treatment in order to relieve the organs of the urinary system from the excessive amount of accumulated urine in an emergency and to remove intoxication.
Although surgical treatment is the best and often the only method of successful treatment, there are a number of complications, including:
- urinary incontinence,
- the formation of adhesions in the ureter or its fusion,
- frequent urination,
- Preservation of a significant amount of residual volume of urine,
- throwing semen into the bladder,
- impotence, etc.
The most famous among them:
- Balloon dilatation of the prostate (narrowed area is expanded with a balloon).
- Stenting of the urethra (a sufficiently elastic element is inserted into the constriction area, which prevents the narrowing of the lumen of the urethra).
- Evaporation of prostate tissue by microwaves - microwave coagulation.
- Cryodestruction (freezing of prostate tissue and their subsequent necrosis).
- Evaporation of the tissues of hyperplastic gland by ultrasound of high frequency.
- Transurethral needle ablation - small needles are placed in the prostate, and then, acting by radio waves, heat and destroy the tissues of the prostate gland.
- Removal of prostate tissue with a laser.
All those suffering prostate adenoma, it is recommended to regularly perform special exercises that improve the circulation of the pelvic organs and prevent the stagnation of blood, for example, "walk on the buttocks" for several minutes.
You also need to normalize your weight, and in the daily diet to introduce foods rich in zinc and selenium - sardines, salmon, herring, pumpkin seeds, buckwheat and oatmeal, olive oil, celery and parsnip.