Prostate Adenoma - Information Overview

Prostate adenoma is a process of proliferation of paraurethral glands, which begins in adulthood and leads to the appearance of urination disorders.

To designate the disease "prostate adenoma" at various stages of accumulation of knowledge about it, the following definitions were used: prostatic disease, benign prostatic hypertrophy, prostate tumor, dyshormonal adenomatous prostatopathy, adenoma of the paraurethral glands, benign enlargement of the prostate gland, nodular hyperplasia of the prostate gland, adenoma of the prostate gland.

Prostate adenoma is the most common urological disease in old and senile age - an increase in the size of the prostate gland - occurs in 30-40% of men over 50 years old. In the development of benign prostatic hyperplasia, the leading role is played by hormonal imbalance during aging: decreasing production of androgens by the testicles leads to increased production of gonadotropic hormone by the pituitary gland, which stimulates the proliferation of tissue of the paraurethral glands. In this case, the initial (prostatic) part of the urethra is lengthened, its diameter decreases due to the back part protruding into the lumen, which creates resistance to the flow of urine from the bladder. Chronic urinary retention progresses and, as a consequence, dilation of the ureters, pelvis, and calyces. 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 due to 3 reasons: uremia, sepsis and complications from surgical interventions. The only risk factors for the development of 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 affiliation, heart disease, diabetes and liver cirrhosis - has not yet been confirmed.

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Epidemiology

Prostate adenoma is the most common disease in older men and can manifest itself already at the age of 40-50 years. The social significance and relevance of the problem is emphasized by demographic studies of the WHO, indicating a significant increase in the population of the planet over 60 years old, including men, which significantly outpaces the growth of the population as a whole. This global pattern is also characteristic of our country. Statistical data on the frequency of the disease are based on clinical and pathomorphological studies.

An increase in prevalence is noted from 11.3% at 40-49 years to 81.4% at 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 in 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 relationship has been established between the frequency of pronounced symptoms and the age of patients. As a result of the study of signs, the use of UFM and TRUS, it has been established 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 have palpable enlargement of the prostate gland. Subsequently, only half of them have clinical manifestations that require treatment. In the course of studying the problem, much attention is paid to the risk factors for the development of prostate adenoma. The most significant include age and normal functional state of the testicles. In men castrated before reaching puberty, adenoma does not develop, only a few observations have noted the occurrence of the disease after castration in puberty. Pharmacological reduction of testosterone levels to post-castration values also leads to a decrease in the size of the prostate in adenoma.

Prostate adenoma (prostate gland) and the degree of sexual activity of men are not related. Currently, it is recognized that prostate adenoma is observed in blacks somewhat more often, which has been proven by studying the epidemiological situation in various regions of the world. On the other hand, the lower prevalence rate 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.

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Symptoms prostate adenomas

Prostate adenoma is divided into three stages (depending on the degree of urodynamic impairment). In the first stage (compensation), urination is difficult to start, which is accompanied by straining. There is often a feeling of incomplete emptying of the bladder, pollakiuria is observed both during the day and at night, the urine stream becomes sluggish, intermittent. In case of hypothermia, consumption of alcoholic beverages, spicy food, taking certain medications, blood stagnation in the pelvic organs (in 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, vertical stream of urine, prolongation of urination up to several minutes, a feeling of incomplete emptying of the bladder, involuntary leakage of urine at the end of urination. During this period of the disease, residual urine is detected in the bladder (50 ml or more).

There is a risk of developing pyelonephritis and often acute ischuria. In the third stage of the disease - complete decompensation - atony and overstretching of the bladder develop. With an overfilled bladder, urinary incontinence may occur (urine is released drop by drop involuntarily) - the so-called paradoxical ischuria. Pyelonephritis that occurs in the second stage of the disease progresses, leading to the development of chronic renal failure. Bleeding from the dilated veins of the prostatic part of the urethra and the neck of the bladder is often observed.

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Stages

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

• in stage I of the disease, patients experience urination disorders with complete emptying;
• in stage II, the function of the bladder 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. Urination disorders, depending on the severity of infravesical obstruction, in combination with accompanying signs and complications make up the clinical picture of the disease. In this case, prostate adenoma may not correspond to the degree of urination disorder 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 distinguished, but some features of the transition from one stage to another cannot be taken into account. Therefore, for reasons of continuity and clinical appropriateness, it is considered justified to retain the classical classification, consisting of three stages. The 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 changes in the detrusor, its hypertrophy and the absence of significant changes in the functional state of the kidneys and upper urinary tract.

At this stage, patients note a change in the dynamics 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 more frequent, but it does not occur immediately, but after a certain period of waiting, especially in the morning. Later, daytime urinations become more frequent against the background of a decrease in the volume of urine excreted at one time. The appearance of imperative urges is characteristic, in which the patient cannot delay the onset of urination up to urinary incontinence. Urine is excreted in a sluggish stream, sometimes it is directed almost vertically, and does not form, as is normal, a curve of a characteristic parabolic shape. At the same time, to facilitate emptying, patients often strain the muscles of the anterior abdominal wall at the beginning and end of urination.

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

The functional state of the kidneys and upper urinary tract does not suffer 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.

Depletion of compensation reserves means transition to the next stage - prostate adenoma stage 2. It is characterized by intermediate stages of dysfunction of the upper urinary tract and kidneys. The patient does not empty the urine completely when urinating, 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. To empty the bladder, 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 rest periods lasting several minutes. Due to increased pressure in the bladder, mechanical compression of the ureteral orifices by hyperplastic tissue and loop-shaped bundles of overstretched muscles, as well as loss of elasticity by the muscular structures of the detrusor, a violation of urine transport along the upper urinary tract and their expansion are observed. Against this background, renal function continues to decline (compensated or intermittent stage of renal failure). A progressive decline in renal function is manifested by thirst, dryness, bitterness in the mouth, polyuria, etc.

Failure of compensation mechanisms means the transition of the disease to the final stage III of the disease development, which is characterized by complete decompensation of the bladder function, upper urinary tract and intermittent or terminal stage of renal failure. The bladder loses the ability to contract, its emptying is ineffective even with the participation of extravesical forces. The wall of the bladder is stretched, it is overfilled 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 reaching the level of the navel or higher. The patient feels a constant desire to empty. In this case, urine is released very often and not in a stream, but in drops or small portions.

Long-term chronic retention 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 note periods of nighttime and then daytime constant involuntary release of urine in drops. Thus, a paradox of a combination of urinary retention and incontinence is observed, which is called paradoxical ischuria.

Prostate adenoma (prostate gland) stage III - patients note a pronounced expansion of the upper urinary tract and progressive impairment of partial functions of the renal parenchyma due to obstructive uropathy. Without medical care, the intermittent stage of chronic renal failure passes into the terminal stage, azotemia increases, water-electrolyte balance disorders, and the patient dies from uremia.

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Diagnostics prostate adenomas

Prostate adenoma is detected based on:

• subjective research data;
• digital rectal examination, which allows determining the size and consistency of the prostate gland;
• ultrasound examination, which provides information about the condition of not only the prostate, but also the kidneys and urinary tract;
• functional methods for determining 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;
• data from X-ray examinations: excretory urography with late cystography, cystography with oxygen, cystography with contrast agent and double contrast according to Kneise-Schober. This allows us to determine the presence or absence of a violation of the outflow of urine from the upper urinary tract, visualize BGP, diagnose stones and diverticula of the bladder, determine residual urine and conduct differential diagnostics with sclerosis of the neck of the bladder;
• results of an endoscopic examination conducted to identify 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 questionable situations, perineal or transrectal biopsy of the prostate gland, computed tomography and magnetic resonance imaging are performed.

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Treatment prostate adenomas

The only treatment method accepted worldwide that allows a patient to get rid of a disease such 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 in case of absolute contraindications to surgery. At the first signs of obstruction of urine outflow, 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 / day). Drugs in this group are effective in 70% of patients. Restrictions on 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, strokes, a tendency to hypotension). Prostate adenoma is treated using herbal preparations containing African plum bark extract (tadenan 50-100 mg/day), lipid-steroid extract of American dwarf palm (permixon 320 mg/day), etc. These agents, used in courses for 3-6 months, not only improve hemodynamics, but also lead to a decrease in the size of the prostate without reducing libido and potency (unlike finasteride, a 5-a reductase inhibitor).

To decide on surgical liver surgery, a combination of three components is necessary: prostatic hyperplasia, urinary dysfunction and intravesical obstruction.

Surgical treatment includes open prostatectomy, transurethral resection (TUR), laser destruction and ablation (removal of part of the tissue) of the prostate gland, as well as palliative surgical methods - cryodestruction of the prostate gland, trocar cystostomy, epicystostomy - for urine drainage in stage 3 of the disease. Patients who also have a disease such as prostate adenoma must be constantly monitored, and as the symptoms of obstruction increase, the amount of residual urine and mass increase, a decision must be made in favor of one or another type! Liver.

Postoperative care is of great importance in the rehabilitation of geriatric patients. It is necessary to carefully monitor, especially in the first hours after surgery, the color of the urine released from the bladder in order to detect early such a complication as bleeding (the appearance of intensely colored urine with clots against the background of a decrease in blood pressure and tachycardia). An idea of the admixture of blood in the urine can be obtained by applying a few drops of urine to gauze: the circles of urine (outside) and blood (in the center of the drop) that form after several minutes are compared. It should be taken into account that the release of dark brown, brown urine does not indicate ongoing bleeding, but rather the washing out of coloring substances from previously formed clots by urine.

In the first days after the operation, the patient may be bothered by painful false urges to urinate (due to the stitches placed on the bladder neck and irritation of the bladder wall by the drainage tube). The patient should be warned that straining and trying to urinate with these urges is prohibited.

If there are drainages, they are extended in the ward using polymer tubes and connected to transparent urine collectors, into which a small amount of antiseptic solution is poured beforehand. It is necessary to regularly change urine collectors and monitor the nature of the discharge, take into account the amount of urine excreted (separately - excreted independently and through drainages) and compare it with the volume of liquid drunk. 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 on it, which is removed together with the tumor; in this case, the absence of discharge through the catheter may not pose any danger. If the patient undergoes adenomectomy with a blind suture of the bladder, then ensuring good function of the permanent urethral catheter and its fixation is of paramount importance.

To prevent thromboembolic complications that are common in geriatric patients, the shins are bandaged with an elastic bandage the day before the operation and the patient is activated early (after most urological operations, patients begin to walk the next morning).

In case of postoperative urinary retention, emptying of the bladder should not be postponed for more than 12 hours, since its longer overstretching, in addition to the negative effect on the upper urinary tract, leads to an even greater decrease in the contractile ability of the detrusor and slows down the restoration of spontaneous urination. Prevention of this complication consists in allowing the patient to urinate standing up as early as possible, using medications that increase detrusor contractions: pilocarpine solution (1% - 1.0) or proserin (0.5% - 1.0). Only in extreme cases is catheterization of the bladder with a rubber catheter used.

From the second day after the operation, it is necessary to begin physical therapy: exercises for the limb, breathing exercises, sitting, standing up, etc.

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Prevention

Prevention of prostate hyperplasia (for middle-aged, elderly and old men) consists of an active motor regime. Avoid spicy foods, marinades and alcohol. Vegetables and fruits, replenishment of vitamin deficiency in the winter-spring period, and courses of diuretic phytotherapy are useful. Measures to prevent constipation are necessary. Patients should be advised to sleep on a hard bed and not to cover themselves too warmly.

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