Benign prostatic hyperplasia (prostate enlargement)
What is it?
Benign prostatic hypertrophy (BPH) is a very common condition in the male population. It is defined as a non-cancerous (benign) enlargement of the prostate gland that can make it difficult to urinate. The enlargement is due to an increase in the cellularity of the prostate tissue in the periurethral area (prostate adenoma) which can create problems with urination over time. In fact, the volume of the prostate undergoes a physiological growth with advancing age, because of hormonal imbalances (mainly of testosterone and dihydrotestosterone) and the action of several growth factors. Approximately 60% of men over the age of 60 experience urination disorders that may be secondary to prostatic hypertrophy. It is estimated that about 30% of men over the age of 65, suffer from severe urinary symptoms related to prostatic hypertrophy.
Which are the symptoms?
BPH is manifested by urinary disorders that can assume characteristics of severity significantly affectimg the quality of life of the patient. This symptomatology is linked to both an "obstructive" and an "irritative" component. The patient typically reports reduced urinary flow, often intermittent, and an increase in the number of daily urinations, especially at night. Patients with BPH are at increased risk of urinary tract infection and developing bladder stones. Urinary obstruction with retention of urine in the bladder can also cause impaired kidney function, urinary incontinence, and hematuria (blood in the urine). Finally, BPH can lead to episodes of acute urinary retention (i.e., the loss of the ability to urinate), requiring the installation of a bladder catheter.
- Reduced urinary flow
- Feeling of incomplete bladder emptying
- Lengthening of the time needed for urination
- Pollakiuria (increased number of urinations per day)
- Nocturia (need to urinate during the night)
- Bladder emptying in several times
- Urinary hesitation (urination starting difficulty)
- Urgent urination (inability to delay urination)
How is it diagnosed?
A thorough clinical evaluation, including assessment of symptoms and urination habits, and rectal examination, is important to exclude any other pathologies that may cause overlapping symptoms. Examinations useful for the diagnosis include uroflowmetry and urodynamic pressure-flow study helping to evaluate the flow of urine (measuring the strength of the jet, the rate of emptying and the residual urine) and the effects on bladder function caused by urinary obstruction. In addition, PSA (Prostate Specific Antigen) value in the blood is usually evaluated, which can be elevated due to increased prostate size, and requires correct interpretation to exclude the possible coexistence of a malignant prostate disease. Similarly, multiparametric MRI of the prostate may be required to rule out concomitant neoplastic pathology. Ultrasonography of the urinary tract is another useful diagnostic test to evaluate the presence of BPH repercussions on the kidneys and bladder. Other investigations usually include a urine test with urinoculture to exclude possible infection of the urinary tract, which can simulate symptoms of BPH. Finally, transrectal prostate ultrasound is a useful tool for evaluating the correct volume of the prostate, especially important for a possible surgical intervention.
How is it treated?
In treatment of BPH various therapeutic tools are used to improve the symptoms of the patient, his quality of life and avoid long-term complications, inclusing urinary retention, bladder stones and chronic renal failure. In addition to possible changes in the patient's lifestyle that can lead to an improvement in symptoms, the first therapeutic approach is usually pharmacological. In fact, there are different types of drugs effective at prostate level: α-lithics, 5α-reductase inhibitors and phytotherapy (Serenoa Repens). Pharmacological therapy is a long-term therapy that, depending on the case, may be sufficient on its own to treat the patient's symptoms. In case pharmacological therapy proves ineffective, the patient should be referred for surgical treatment. There are several surgical options for BPH, all aimed at resolving the obstruction to the outflow of urine by removing the prostate adenoma responsible for the obstruction itself. There are multiple surgical techniques for the treatment of BPH. Some are endoscopic, such as TURP (Trans-Urethral Endoscopic Resection of the Prostate), HoLEP (Holmium Laser Enucleation of the Prostate), Rezum (water vapor treatment), and some others are open, such as TVA (Trans-Vesical Prostate Adenomectomy), the latter necessary in case of large prostates. The therapeutic strategy to be implemented will therefore be based on the size of the prostate gland, the degree of severity of the patient's symptoms and the consequent impact on his daily life, including discussion of possible risks and benefits of the various therapeutic options.
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