Symptoms of prostate adenoma

In the clinic of prostate adenoma (prostate gland), symptoms are distinguished that are associated with pathophysiological changes in the lower urinary tract, symptoms caused by secondary changes in the kidneys, upper urinary tract, as well as the presence of complications of prostate adenoma (prostate gland). Dysfunction of the bladder and urethra is the main factor determining the clinical symptoms of prostate adenoma (prostate gland).

The most characteristic symptoms of prostate adenoma (prostate gland) are urination disorders, which occur as a result of complex interaction between the prostate and the bladder. These symptoms are observed in 15% of men aged 40-49 years and in 50% of men aged 60-69 years.

Infravesical obstruction in prostate adenoma is caused by two components: static (as a result of mechanical compression of the urethra by hyperplastic tissue of the prostate gland - compression) and dynamic (due to hyperactivity of alpha-adrenergic receptors of the bladder neck, prostatic part of the urethra and prostate gland - structure). In this regard, the symptoms of prostate adenoma (prostate gland) can be divided into two groups: obstructive, associated with progressive obstruction of urine outflow as a result of prostate hyperplasia, and irritative (i.e. irritation symptoms), determined by the degree of functional disorders of the neuromuscular apparatus of the bladder.

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Obstructive symptoms of prostate adenoma (prostate gland)

• initial urinary retention,
• weak urine stream,
• a feeling of incomplete emptying of the bladder,
• the need to tense the abdominal muscles when urinating,
• intermittent urination and dribbling of urine at the end of urination

These symptoms of prostate adenoma are revealed during emptying of the bladder; they may be caused not only by infravesical obstruction, but also by a possible decrease in the contractile ability of the detrusor.

Irritative symptoms of prostate adenoma (prostate gland)

Irritative symptoms of prostate adenoma (prostate gland) are associated with instability of the bladder and appear at the stage of accumulation and presence of urine there:

• daytime and nighttime pollakiuria,
• imperative urges and urinary incontinence due to involuntary contractions of the detrusor during its secondary hyperactivity in response to obstruction.

The detrusor reflex occurs when a small part of the bladder volume (50-200 ml) is filled and is not inhibited by volitional effort. The first urge to urinate, coinciding with the contraction of the detrusor, is noted by patients already at a minimum volume of urine in the bladder. Following it, repeated imperative urges are immediately noted, caused by uncontrolled contractions of the detrusor, and a weak urine flow is observed.

Detrusor instability is observed in approximately 70% of men with prostate adenoma and obstructive symptoms, and a correlation has been noted between detrusor dysfunction and the severity of the obstruction to urine outflow. Preservation of normal detrusor function was observed in only 32% of patients with prostate adenoma and obstructive symptoms, while its instability was noted in 68%. In 83% of patients complaining of frequent urination, the functional capacity of the bladder was less than 200 ml.

One of the leading symptoms of prostate adenoma is nocturnal pollakiuria (nocturia), 3 times or more, which complicates the lives of patients. At the same time, an increase in the frequency of night urination and the volume of urine excretion (nocturia) can be due to the functional state of the kidneys. Age-related changes in the kidneys are characterized by a weakening of the function of the tubular apparatus, and the clearance of free water decreases significantly more than glomerular filtration. One of the causes of nocturia in elderly men is a weakening of the concentrating ability of the kidneys. Another cause of nocturia in the elderly and old age can be a violation of the biological rhythm of urine excretion during the day and at night.

In normal functioning of the bladder locking mechanism, contraction of the detrusor occurs with wide opening of the bladder neck. Changes in the urine stream occur with involuntary unstable contraction of the smooth muscles that open the internal opening of the urethra, as well as with dyssynergia of the detrusor and cervical sphincter apparatus.

The mechanism of detrusor instability in patients with prostate adenoma is apparently due to a change in its activity in relation to adrenergic influences against the background of weakening contractile properties as a result of hypertrophy. Overstretching of the bladder, especially in the area of the bladder triangle, and the growth of hyperplastic prostate tissue lead to a local increase in the sensitivity of alpha-adrenergic receptors, which belong to the sympathetic nervous system.

Hyperplastic nodes cause circulatory disorders in the bladder neck and posterior urethra, which, along with a decrease in the excitability threshold of the detrusor and bladder neck and non-simultaneous activation of mechanisms that ensure urination, leads to detrusor dysfunction, manifested by irritative symptoms of prostate adenoma. In addition, severe detrusor hypoxia against the background of its ultrastructural changes plays a significant role in the pathogenesis of urination disorders. The cause of detrusor instability in infravesical obstruction is attributed to typical examples of postsynaptic denervation hypersensitivity. A decrease in the number of cholinergic receptors in detrusor instability has been proven.

Detrusor instability is often observed in patients with prostate adenoma without signs of infravesical obstruction, both with and without neurological disorders. Detrusor hyperreflexia may be a consequence of some neurological diseases accompanied by a disorder of detrusor innervation at the supraspinal level ( multiple sclerosis, parkinsonism, cerebrovascular accident). The mechanism of detrusor hyperreflexia in organic diseases of the central nervous system is based on a decrease in the cortical and hypothalamic inhibitory effect on the spinal centers that regulate urination. Age-related hemodynamic changes in the cortex and subcortical structures of the brain may play a role in this process.

A pronounced degree of infravesical obstruction in patients with prostate adenoma against the background of detrusor decompensation, decreased sensitivity of the bladder wall and impaired transmission of neuromuscular impulses can lead to the development of detrusor hyporeflexia and areflexia. Detrusor hyporeflexia is characterized by a sharp inhibition or absence of signs of bladder contractions. It can be a consequence of impaired segmental innervation of the detrusor as a result of trauma, tumor or lesion of the spinal cord cone, diabetic myelopathy.

Timely determination of the nature of urodynamic disorders and, first of all, detrusor instability in patients with prostate adenoma is of great practical importance, since failure to take this factor into account significantly worsens the functional results of surgical treatment of prostate adenoma. About 25-30% of patients referred for surgical treatment, according to the results of a comprehensive examination, do not meet the urodynamic criteria of infravesical obstruction, and up to 30% of patients with reduced contractility of the detrusor without signs of obstruction do not require surgical treatment. Detrusor instability disappears in 60% of patients with prostate adenoma after surgical elimination of the obstruction to the outflow of urine.

At the same time, 15-20% of patients with prostate adenoma experience irritative symptoms after surgery: frequent urination, nocturia, imperative urge to urinate, and urinary incontinence. First of all, these are the cases when there is no correlation between the severity of irritation symptoms and infravesical obstruction. In this regard, a comprehensive study of the urodynamics of the lower urinary tract is indicated for all patients with clinical symptoms of detrusor instability to identify its cause and establish a relationship with obstruction in the vesicoureteral segment.

Thus, the diagnostic value of symptoms characteristic of prostate adenoma is relative, since symptoms of prostate adenoma do not always indicate the presence of an enlarged prostate or infravesical obstruction. Most of these symptoms are also present in elderly women.