RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Prostatic hyperplasia (N40)

Urology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated December 12, 2013

Benign prostatic hyperplasia(BPH) is a benign tumor that develops as a result of hyperplasia of predominantly glandular (epithelial) and less stromal cells of the prostate, against the background of disruption of the prostate receptor apparatus, interacting with testosterone metabolites, which leads to an increase in the mass of the organ, as well as a deterioration in the passage of urine from the bladder ( bladder outlet obstruction), due to compression of the posterior urethra (the prostate surrounds the urethra). The process has a chronic course, resulting in decompensation of the contractile function of the bladder, an increase in residual urine, the formation of ureterohydronephrosis, the emergence and progression of inflammatory diseases of the kidneys, bladder, and renal failure. (Lopatkin N.A. 1998)

I. INTRODUCTORY PART

Full title: Benign prostatic hyperplasia
TOodprotocol:

ICD-10 code:
N40 - Prostatic hyperplasia

Abbreviations used in the protocol:
BAC-biochemical blood test
BPH - Benign prostatic hyperplasia
IVO - bladder outlet obstruction.
OAM-general urine analysis
PSA-prostate-specific antigen
Ultrasound examination

Date of development of the protocol: April, 2013
Patient category: men aged 45 years or more, with complaints of difficulty urinating, who have BPH according to ultrasound data
Protocol users: urologists, andrologists, surgeons

Classification

Clinical classification:
Stage 1 - the occurrence of urination disorder with complete emptying of the bladder,
Stage 2 - significant dysfunction of the bladder, the appearance of residual urine,
Stage 3 - development of complete decompensation of bladder function, the appearance of paradoxical ischuria. (Lopatkin N.A. 1998)

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Examinations necessary before planned hospitalization:

Name	Multiplicity (shelf life of the result)
UAC	1 (no more than 10 days)
OAM	1 (no more than 10 days)
BAC (total protein, urea, creatinine, glucose, total bilirubin, direct bilirubin, ALT, AST)	1 (no more than 10 days)
ECG with conclusion	1 (no more than 10 days)
Urine culture tank	1 (no more than 10 days)
Coagulogram	1 (no more than 10 days)
Microreaction	1(no more than 15 days)
Blood type and Rh factor	1(with stamp and signature)
Fluorography	1 (no more than 10 days)
HIV test	1(no more than 6 months)
Markers of hepatitis B and C	1(no more than 6 months)
Examination by a therapist, ENT doctor, dentist	1 (no more than 10 days)
	1 (no more than 10 days)
Excretory urography with descending cystography	1 (no more than 2 months)

Examinations required in a planned hospital:

Name of service	Basic	Additional
General blood test (6 parameters)	1(every 10 days)
General urine analysis	1 (every 10 days)
BAC (with determination of urea, glucose, total and direct bilirubin, creatinine, ALT, AST)		1(every 10 days)
Examination by an anesthesiologist	1
Histological examination of tissue	1
ECG		1
Ultrasound of the urinary system		1
Intravenous urography with descending cystography		1
Computed tomography of the urinary system		1
Determination of total PSA level.	1
Uroflowmetry	1
Consultation with specialists in the presence of significant concomitant diseases (cardiologist, endocrinologist, neurologist, etc.)		1

Diagnostic criteria

Complaints and anamnesis: complaints of difficulty urinating, frequent urination at night, feeling of residual urine for a long time, or acute urinary retention resulting in catheterization or cystostomy.

Physical data: rectally, the prostate is enlarged in size, adenomatically changed, of dense elastic consistency, also in the presence of a large volume of residual urine; when palpating the bladder in the suprapubic region, a full bladder is palpated.

Laboratory research:
- in OAM, leukocyturia, bacteriuria, hematuria are possible;
- with prolonged IVO in the LHC, an increase in blood urea and creatinine is possible.

Instrumental data:
- according to ultrasound examination: residual urine, echographic signs of BPH;
- according to uroflowmetry: disturbance of the urodynamics of the lower urinary tract;
- on x-ray cystography: a filling defect along the lower contour of the bladder.

Pproviding specialist consultations: taking into account the severity of concomitant diseases:
- for coronary pathology - cardiologist;
- for diabetes - endocrinologist;
- for chronic renal failure - nephrologist;
- elevated PSA and hematuria - oncologist, etc.

Differential diagnosis

Differential diagnosis

Signs	Prostate cancer	BPH
Features of the anamnesis	Dysuria, terminal macrohematuria. weight loss, general malaise due to the paraneoplastic process. More often, unilateral lymphedema due to lymphostasis.	Dysuria, nocturia, residual urine, weakness, malaise due to a concomitant infectious process of the genitourinary system, possible symmetrical swelling due to exacerbations of chronic pyelonephritis.
Rectal prostate	Slightly increased in size or normal size, woody consistency (especially along the periphery), the outline is uneven and lumpy.	The prostate has a dense elastic consistency, adenomatous changes, increased in size, smooth contour
X-ray signs	Unilateral ureterohydronephrosis, due to germination of the ureteric orifice, uneven contour of the filling defect on the cystogram	Possible 2-sided ureterohydronephrosis due to compression of the ureteric orifices; “fish hooks” symptom; smooth filling defect along the lower contour on the cystogram
Computed tomography ultrasound	Signs of tumor growth outside the organ	The tumor is a smooth adenomatous structure and does not extend beyond the capsule
Prostate-specific antigen level	Elevated, sharply increased	Normal, slight increase due to adenomitis or after rectal examination
Prostate biopsy	Prostate cancer cells	BPH cells

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Treatment

CelAndtreatment:
Elimination of BPH as the cause of bladder outlet obstruction, drainage to unload the lower urinary tract. During the patient's hospitalization, the volume of necessary additional examination is determined in order to determine the extent of BPH and concomitant pathology, which determines the volume and type of surgical intervention, as well as measures of preoperative preparation and features of postoperative management of patients.

Treatment tactics

Non-drug treatment: stationary mode, semi-bed mode, table No. 15.

Drug treatment for planned hospitalization:
1. Antibacterial therapy (3rd generation cephalosporins 1 g x 2 times a day IM, amikacin 0.5 g x 2 times a day IM, metronidazole 100 ml x 1-2 times a day / IV, ciprofloxacin 100 ml x 1-2 times a day IV, levofloxacin 500 mg x 1 time a day IV)
2. Hemostatic therapy (dicinone 2.0 x 2 times/d IM, etamsylate 2.0 x 2 times/D IM, tramine 10% 5 ml x 1-2 times/D IM)
3. General restorative therapy (glucose 5% 250 ml x 1 time per day i.v., Vit. C 10.0 x 1 time per day i.v., Vit. B1 1.0 x 1 time per day i.m., Vit. B6 1.0 x 1 r/d i.v.)
4. Metabolic drugs with an immunomodulatory effect: vitaprost suppositories once a day. 10 days
5. Analgesic therapy (ketoprofen 2.0 x 2 times a day IM, promedol 2% 1.0 x 1 time a day IM)
6. Antispasmodic therapy (drotaverine 2.0 x 2 times / day / m)
7. Drugs that improve intestinal motility (metoclopramide 2.0 x 2 times a day IM)

Other types of treatment: No

Surgery: Trocar cystostomy, transvesical adenomectomy, transurethral photoselective laser vaporization of BPH, transurethral plasma vaporization of BPH, transurethral microwave thermotherapy of BPH, mono- and bi-polar transurethral resection of BPH, high section of the bladder epicystostomy (Gold standard - Transurethral resection of BPH-, for prostate adenoma up to 80 grams)

Preventive actions:
- drugs inhibitors of alpha 5 reductase: dutasteride 500 µg x 1 daily - 3-6 months, finasteride 500 µg x 1 daily - 3-6 months, prostamol-uno 320 mg x 1 daily - 3 months
- alpha adrenergic blockers: doxazosin 1 tablet x 1 time per day and its forms, tamsulosin 0.4 mg 1 capsule x 1 time per day and its forms;
- metabolic therapy: vitaprost tablets 100 mg x 2 times/day for 30 days;
- observation by a urologist, monitoring of the UBC, OAM, ultrasound of the kidneys, bladder, prostate, volume of residual urine - after 1 month, if necessary, anti-inflammatory therapy, in order to sanitize chronic foci of infection of the urinary system.

Further management:
- within 1 month after surgery: do not take anticoagulants, antiplatelet agents
- limitation of physical activity
- blood pressure control (not higher than 140/90 mm Hg)
- do not take hot water procedures
- prevent intestinal obstipation (do not strain during bowel movements).

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- decrease or absence of residual urine volume, free urination, light-colored urine
- with adenomectomy - wound healing by primary intention, consistency of sutures, dry and clean postoperative wound
- in laboratory tests there is no high leukocytosis, leukocyturia, moderate decrease in hemoglobin and erythrocyte levels are allowed.

Drugs (active ingredients) used in treatment

Amikacin

Ascorbic acid

Dextrose

Doxazosin

Drotaverine (Drotaverinum)

Dutasteride

Ketoprofen

Levofloxacin

Metoclopramide

Creeping palm fruit extract (Serenoa repens fructuum extract)

Pyridoxine

Prostate extract

Tamsulosin

Thiamin

Tranexamic acid

Trimeperidine

Finasteride

Ciprofloxacin

Etamsylate

Groups of drugs according to ATC used in treatment

Hospitalization

Indications for hospitalization (planned):
- difficulty, frequent urination,
- nocturnal pollakiuria,
- residual urine,
- chronic urinary retention,
- inability to urinate independently, with the presence of a cystostomy or urethral catheter.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. “2010 Update: Guidelines for the management of benign prostatic hyperplasia,” Canadian Council on Prostate Health and the Canadian Urological Association Guidelines Committee‡; Can Urol Assoc J 2010;4(5):310-316 2. Lopatkin N.A. Benign prostatic hyperplasia. – M., 1998. 3. Gorilovsky L.M. Prostate diseases in old age. – M., 1999. 4. Trapeznikova M.F. Classification of methods for treating benign prostatic hyperplasia - M., 1997.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers:
Alchinbaev M.K. - Doctor of Medical Sciences, Director of the Scientific Center of Urology named after. Academician B.U. Dzharbusynova

Reviewers:
Doctor of Medical Sciences, Professor Khairli G.Z.

Disclosure of no conflict of interest: absent.

Indication of the conditions for reviewing the protocol: Review of the protocol 5 years after its entry into force and/or when new diagnostic/treatment methods with a higher level of evidence become available.

Attached files

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Prostatic hyperplasia is observed mainly in older men. According to statistics, in people over 65 years of age, pathology is detected in 85% of cases and is expressed in the formation of a benign tumor, which increases in size over time. As a result, representatives of the stronger sex have difficulty urinating due to compression of the urethra. In the absence of timely medical care, the disease causes serious complications.

What is this pathology?

Benign prostatic hyperplasia is changes in the tissues and cells of the prostate and further enlargement of this organ. The neoplasm is formed from glandular epithelium, which at the initial stage of development has the appearance of small nodules. But over time, the nodules increase in size, leading to the growth of a benign tumor. The development of a tumor does not lead to the growth of metastases, but with advanced pathology and lack of timely treatment, prostate hyperplasia can develop into a malignant formation (carcinoma). In medical terminology, there is another common name for this disease - prostate adenoma or prostatitis.

BPH of the prostate gland - causes

One of the most common factors in the development of adenoma is heredity. If there are close relatives in the family who suffer from prostatitis, then the likelihood of the disease increases significantly. This category of men is recommended to undergo an annual examination from the age of thirty for timely detection of pathology. In addition to the genetic factor, sources of risk also include:

• hormonal imbalances (changes in the balance between female and male hormones);
• inflammatory processes of the pelvic organs and urogenital area;
• old age;
• sedentary lifestyle, lack of physical activity;
• frequent hypothermia;
• bad habits (tobacco, alcohol);
• unhealthy diet (predominance of fatty meat foods and lack of plant fiber);
• previous venereal diseases;
• unfavorable environmental conditions and other environmental factors.

Prostatic hyperplasia - diagnosis

Timely diagnosis, especially in the early stages, is very important for quick and successful treatment. As a rule, it involves a comprehensive examination and includes an examination of the patient, as well as a number of instrumental studies and laboratory tests. During a medical examination, a palpation method is used, which makes it possible to determine the condition of the prostate gland, pain, compacted areas, etc.

Diagnostic methods are selected individually for each patient, depending on the complaints and the expressed clinical picture:

• examination by palpation;
• urine analysis for red blood cells, white blood cells, protein, glucose;
• blood analysis;
• uroflowmetry (volume and speed of stream during urination);
• contrast urography (X-ray) is prescribed if the presence of stones in the bladder is suspected;
• cystomanometry allows you to determine the pressure on the walls of the bladder;
• Urethrocystoscopy makes it possible to see the structure and condition of the urethra and bladder.

Prostatic hyperplasia - symptoms

The main feature of prostate adenoma is that it is practically asymptomatic for a long time. This is where the danger lies, since the man does not even suspect the presence of a benign formation in the body. Sensations and discomfort become pronounced only when pathological changes in the organ have occurred and the tumor has grown.

The following are the main signs of BPH, which can manifest themselves at any stage of the disease:

• frequent urination, sudden onset of urge;
• emptying in small drops, weak jet pressure;
• the stream during urination is intermittent;
• the pelvic muscles tense when emptying;
• feeling of urine residue in the bladder;
• pain when visiting the toilet;
• involuntary bowel movement;
• chronic urine retention resulting from a narrowing of the canal;
• blood in urine.

If a patient notices at least one symptom, he should take it seriously and immediately consult a doctor. You should not take this lightly and self-medicate.

Stages of development of prostatitis

In the clinical picture of the development of pathology, 3 stages are distinguished.

Prostatic hyperplasia of the 1st degree (compression) is characterized by problems with urination, mainly in the evening and at night. At the same time, the urge to go to the toilet is frequent, and the stream is very sluggish. The duration of the stage can last up to 3 years, while the main symptoms are practically not expressed. At this stage, the tumor responds very well to drug therapy.

The second stage of hyperplasia (subcompensatory) begins with serious disturbances in the functioning of the bladder, when its release poses serious difficulties. The patient feels a constant urge to urinate and spontaneous release of cloudy urine, often mixed with blood. At this stage of the disease, chronic renal failure may develop.

ORDER

The third stage (decompensation) is the most severe and dangerous, since there is a complete impossibility of emptying the bladder independently. And this is fraught with rupture of its walls. Urine is characterized by turbidity mixed with blood. During this period, a man feels constant fatigue and loss of strength. He suffers from constipation, his skin becomes pale, and he loses weight. People suffering from grades 2 and 3 prostatitis have a persistent smell of ammonia from their mouth.

Forms of the disease

Depending on the direction of tumor growth, hyperplasia has several forms:

• subvesical (tumor grows near the rectum). With this form, the patient often experiences discomfort not during urination, but during the act of defecation;
• intravesical (the formation grows in the direction of the bladder). Ingrowth of the prostate into the bottom of the bladder leads to deformation of the neck of the upper urethra;
• prevesical - expansion of the lateral parts of the prostate adjacent to the bladder.

Types of adenoma by growth form

Based on the form of tumor tissue growth, prostate adenoma is classified into 2 types.

Diffuse prostatic hyperplasia is characterized by a uniform increase in the organ during the development of the disease without pronounced foci. Adenomatous prostatic hyperplasia is characterized by the formation of nodules inside the prostate. There can be from one to several depending on the stage and course of the disease.

Prostate hyperplasia - treatment

The treatment regimen is selected by the doctor strictly individually after diagnosis and medical history. Currently, there are 3 methods of treating prostatitis.

1. Drug (conservative) therapy. As a rule, medications are used for mild cases of the disease, as well as for contraindications to surgical interventions.

Specialists have several groups of drugs at their disposal:

• alpha1 - adrenergic blockers help relax smooth muscles and improve the outflow of urine;
• 5-alpha reductase blockers stop the growth of prostate cells, which subsequently leads to normalization of the gland;
• phosphodiesterase blockers - 5 relax the muscles in the urogenital area, which significantly facilitates the outflow of urine;
• herbal preparations contain natural extracts and extracts of medicinal plants (African plum bark, rye, nettle, pumpkin seeds, etc.).

1. Surgical methods of treating prostatitis are indicated in cases where drug therapy does not bring the desired result. The following types of surgical intervention are used:

• Transurethral resection of the prostate is the most commonly used and standard method. A tube with a metal loop and a camera is inserted into the urethra. Under the influence of an electric current, the loop removes the overgrown formation layer by layer;
• Transurethral incision of the prostate is used when the gland is not overgrown. Overgrown tissue is removed between the prostate and the bladder neck;
• Holmium laser enucleation is the most progressive method of treating pathology. A laser is introduced into the urethra, which, under the influence of high power, gradually exfoliates the tissue of a benign tumor;
• open surgery is performed in advanced stages of the disease or in the presence of stones in the bladder. It is carried out through an incision in the bladder and is traumatic, but at the same time guarantees a complete cure.

1. Benign prostatic hyperplasia - treatment with non-operative methods:

• introduction of prostatic stents (coils) into the urethra for long or short periods. Over time, stents must be removed, as untimely removal will worsen symptoms;
• microwave coagulation of the prostate – microwaves heat the prostate tissue to 70 degrees, resulting in its destruction;
• prostate lifting with an implant - this method expands the diameter of the urethra and improves the quality of life for many patients;
• cryodestruction, needle ablation, focused ultrasound, etc. are also performed.

Forecast

If you seek medical help in a timely manner and follow all the recommendations of the attending physician, the prognosis for recovery is very favorable. Many men put off visiting a doctor for a long time because they are afraid that due to surgical intervention they will have to forget about the pleasures of their sexual life forever. But this is a common misconception - on average, sexual function is completely restored after a month.

Prevention

In order to stop the disease in the early stages, it is advisable for men to undergo an annual medical examination by a urologist, starting at the age of 40. Since it is impossible to indicate the exact reason why an adenoma develops, all preventive measures are exclusively of a general strengthening nature.

They consist, first of all, of maintaining a proper and balanced diet - less fatty and flour products, and more fiber and protein. It is also necessary to drink a large amount of clean water, and its intake must be limited in the evening.

An active lifestyle and sports help normalize blood circulation in the pelvic organs, which helps prevent stagnation. At the same time, you should be careful about lifting heavy objects and other increased loads.

To create a normal and comfortable psychological environment, stress and other conflict situations should be avoided. But it is better to avoid taking sedatives.

High-quality regular sex will help ensure good sexual function and prostate health. But excesses in bed and promiscuity can negatively affect a man’s health.

If there are problems with the prostate gland, doctors recommend massaging it. It not only has a beneficial effect on sexual activity and the duration of sexual intercourse, but also removes harmful substances and pathogens.

Prostate adenoma (benign hyperplasia, BPH) is diagnosed in middle-aged and older men. After 50 years, this neoplasm is found in every sixth person. Due to the enlarged gland, the process of urination becomes difficult, and inflammatory diseases of the genitourinary system develop. Overgrowth can be controlled to a certain extent, but ultimately most men are forced to resort to surgery.

Prostate adenoma is a pathological increase in the number of its cells. As a result, the gland loses functional tissue and increases in size.

Adenoma itself is a single (monocentric) tumor that occurs in the glandular epithelium. Hyperplasia is, as a rule, multiple nodular formations of various sizes. Most ordinary people and specialists identify these concepts.

The prostate consists of 70% glandular tissue (parenchyma). The rest is the urethral part and fibromuscular stroma (a kind of organ frame), represented by loose connective and smooth muscle tissue. It forms layers inside the body of the prostate. Depending on the area in which the process of hyperplasia began and which cells are involved in it, adenomatous (glandular), fibrous (from connective tissue), myomatous (from smooth muscle tissue) and stromal-glandular forms are distinguished. Pure stromal prostatic hyperplasia is rare.

Zonal anatomy of the prostate in cross sections at three levels

Hyperplastic processes occur predominantly in glandular tissue and go through several stages in their development. The origin of an adenoma is two or three glands tightly adjacent to each other, in which the process of pathological cell division begins (a proliferative center is formed). The neoplasm is surrounded by stromal tissues, which become more fibrous and dense over time.

At the second stage, active cell proliferation already occurs, resulting in the formation of nodules. The connective tissue around them becomes even more dense, creating the appearance of a capsule.

At the third stage, other foci of cell proliferation (daughter centers) are formed.

Due to the constant proliferation of cells, compression of the gland ducts begins, and the outflow of secretions is disrupted. As a result, the walls of the ducts expand and cysts form - this is the 4th stage of adenoma development.

At the fifth terminal stage of adenoma development, cysts grow, and the surrounding glandular cells atrophy.

According to the above scenario, 90% of prostate hyperplasias develop, the rest are called atypical. Of the latter, the most common form is basal cell.

Determining the structure of a benign prostate formation is very important for choosing treatment tactics. A true adenoma develops from a single focus (focal form), does not cause diffuse damage to the gland (many lesions) and does not recur after removal. Hyperplasia, on the contrary, is characterized by a pronounced ability to resume growth and is highly dependent on hormonal levels.

Another important point: after removing the hyperplasia, prostate function will not be restored, but after removing the adenoma, this is possible. It grows from the paraurethral glands located next to the urethra, expands and gradually presses the prostate parenchyma to the outer membrane. As a result, a so-called surgical capsule is formed. The compressed parenchyma after tumor removal is able to “unfold” and recover in 6-7 months. True adenoma (adenomatous hyperplasia) is uncommon. Usually the mixed form is removed - adenofibromyoma (includes glandular, connective and muscle tissue).

There are three types of tumors based on size:

• Small – up to 30 g;
• Medium – up to 70 g;
• Large – up to 250 g.

An adenoma larger than 250 g is already considered gigantic.

Differences from cancer

With hyperplasia or true adenoma, malignant degeneration of cells does not occur, which is why neoplasms of this class are called benign. The tissue grows, but does not surround itself with an additional vascular network for nutrition, and does not have a toxic effect on the body with the products of its metabolism.

Other differences between adenoma and cancer:

• Grows within the prostate capsule, stretches it;
• Does not grow into surrounding organs, but can compress them;
• Does not metastasize;
• Favorable prognosis for treatment.

However, neither the doctor nor the patient should relax, since against the background of hyperplasia, foci of precancer may well appear, prone to subsequent oncological degeneration.

Causes

The exact reason for the development of adenoma has not yet been identified. Doctors believe that the main provoking factor is an age-related decrease in testosterone levels. It has been proven that the paraurethral glands of the prostate respond to female estrogens by proliferation. With age, the level of male hormones decreases, female hormones begin to predominate, which becomes one of the causes of adenoma. The active form of testosterone, dihydrotestosterone, can also provoke the growth of glands.

According to statistics, adenoma is least common in rural residents, as well as among the Chinese and Africans. From which we can conclude that the development of pathology is provoked not only by age-related changes in hormonal levels, but also sedentary lifestyle, heavy consumption of fatty and refined foods, atherosclerosis. Active men who eat mainly plant foods rarely suffer from adenoma.

Risk factors for developing prostate adenoma

Favorable ground for the development of hyperplasia is also the wear and tear of prostate tissue due to other diseases, the consequences of which appear with age.

Stages of the disease

From the point of view of the clinical picture, the following stages of adenoma are distinguished:

1. Compensated. The name is due to the fact that problems with urination are still compensated by tension in the muscle that pushes urine out (detrusor) and hypertrophy of the muscles of the bladder walls. The adenoma increases in volume to 30-50 ml, begins to put pressure on the urethra, but the bladder can still be completely emptied. The urge becomes frequent, the pressure of the stream decreases. After a night's sleep, urination begins with a delay. There is no residual urine yet, the kidneys are working normally.
2. Subcompensated. The adenoma further grows to 60 cm 3, and therefore difficulty urinating is only partially compensated. Residual urine appears, the volume of which can reach 400 ml, the walls of the bladder are stretched, and their ability to contract normally is reduced. Urination becomes intermittent and requires abdominal tension. There is an expansion of the ureters leading to the kidneys, which contributes to their infection due to urine reflux.
3. Decompensated. The volume of the adenoma can reach 100-120 cm3. Urination is so impaired that the bladder is constantly full (up to 1 liter of urine), bloated, abdominal pain and drip of urine are characteristic. As the nerve receptors are depleted, the pain weakens, the urge to urinate also, and urine continues to leak (paradoxical ischuria).

In the absence of medical care, chronic renal failure, acute urinary retention, and possible inflammation of the testicles and appendages will develop against the background of adenoma.

The process of development of benign prostatic hyperplasia:

Symptoms of prostate adenoma

The time of onset of symptoms and their severity depends on the direction of growth of the adenoma. Several options are possible:

• Subvesical. The adenoma grows towards the rectum without affecting the urethra. There may be no symptoms even if the tumor reaches a significant volume.
• Intravesical. The adenoma gradually begins to prop up the neck of the bladder, changing its shape. There is constant discomfort in the lower abdomen.
• Retrotrigonal. The tumor puts pressure on the prostatic part of the urethra, difficulty urinating even with small volumes of growth.

Urologist-andrologist Alexey Viktorovich Zhivov talks about the symptoms of prostate adenoma.

Most often, an adenoma grows in several directions at once. The first symptoms: increased frequency of urination (especially at night), weakening of the pressure of the urine stream.

Further, as the walls of the bladder stretch, abdominal pain is added. Adenoma is often accompanied by inflammation of the prostate tissue, which can spread to the testicles, causing pain in the scrotum. Cystitis and urethritis often develop. Urination becomes painful.

With the development of renal failure, the temperature rises, lower back pain occurs, and the patient has a fever.

Diagnostics

If suspicious symptoms appear, you should consult a urologist. Before visiting your doctor, you can fill out a questionnaire that will help assess the severity of symptoms of urinary disorders.

Making a diagnosis of adenoma is not enough. The doctor needs to find out the stage of its development, the direction of growth, and identify complications.

Basic methods for diagnosing adenoma:

1. Rectal palpation of the prostate. Used in the absence of acute inflammation.
2. Blood and urine tests to identify complications of the urinary system and determine the patient’s immune status.
3. Ultrasound, TRUS.

PSA levels based on age and reasons for increased total PSA

1. Cystoscopy is an internal examination of the bladder. The indication is the appearance of blood in the urine, an unclear picture on ultrasound.
2. Radionuclide uroflowmetry to assess the nature of the urine stream.
3. X-ray of the urinary tract and kidneys.
4. CT, MRI of the pelvis.

To exclude prostate cancer and assess the structure of the tumor, if necessary, perform. After the procedure, the prostate cannot be operated on; you must wait 1-2 months. If the condition is acute, then there is no time.

How to treat prostate adenoma

As mentioned above, to choose treatment tactics for adenoma, it is important to determine the nature of the structure of the neoplasm. To do this, a morphological examination of a tissue sample (biopsy) is performed. If proliferative centers of levels 2 and 3 occur, then 5-alpha reductase blockers will be effective as conservative therapy. Transurethral resection in this case is not a radical method of getting rid of hyperplasia, which is especially important for young men (repeated operations will be required). When atypical lesions are detected, laser and electrosurgical methods of removal are excluded, since we are already talking about an optional precancer.

Urologist Kamaletdinov Rinaz Enesovich talks about the diagnosis and treatment of prostate adenoma

If proliferative centers of levels 4 and 5 are found in tissue samples, then conservative therapy is already meaningless. Atrophic processes are strongly expressed, so there is reason to hope for a relapse-free outcome of the operation. Electroresection will help reduce the size of the prostate by excision of ducts stretched by cysts.

The difficulty of treating adenoma also lies in the fact that in 96% of cases it is accompanied by inflammation, and in an acute form.

Medicines

It is impossible to cure adenoma using conservative methods. It is advisable to use medications and physical therapy in the absence of residual urine or in the presence of contraindications to surgery. As part of drug therapy for adenoma, drugs are used to reduce the volume of the gland, painkillers (Nurofen, Ibuprofen), antibiotics to relieve inflammation (levorin, mepartricin, ipertrofan), and immunomodulatory agents.

Hormone therapy

Since prostate tissue receptors respond to hormones, the following groups of drugs are used to treat adenoma:

• Containing a combination of androgens and estrogens (testobromestrol).
• Affecting the metabolism of androgens in the testicles and prostate (hydroxyprogesterone capronate, pregnin, depostat).
• Inhibiting the activity of the enzyme 5-alpha reductase to subsequently reduce the activity of dihydrotestosterone (finasteride). The effect can be expected no earlier than six months after the start of use.

A significant disadvantage of hormonal treatment of adenoma is the formation of fibrous changes in the surgical capsule, and this significantly complicates subsequent surgical intervention. Some patients even have foci of necrosis. In addition, there is a danger of endocrine imbalance in the body due to excess female hormones.

Natural 5-alpha reductase inhibitors

In addition to chemical 5-alpha reductase inhibitors, there are also natural ones, the most popular of which is Permixon based on saw palmetto extract. The drug has a pronounced anti-edematous effect and increases detrusor tone. An alternative to it is Prostaseren.

The drug permixon is a herbal antiandrogenic agent that is used to treat benign prostatic hyperplasia (BPH) and chronic prostatitis. Price from 748 rub.

Natural remedies also include “Tadenan” based on African plum extract. The drug inhibits the growth of fibroplastic cells in the stroma, relieves inflammation and swelling. The volume of residual urine is reduced by 35%. The course of treatment is at least 6 weeks.

Alpha-1 blockers

Another direction of action for adenoma is alpha-adrenergic receptors, which are located in the posterior urethra, stroma and capsule of the prostate. They tone smooth muscles, spasm them, which makes urination difficult. The severity of adenoma symptoms is largely determined by the functionality of these receptors. If they are blocked, spasms of the bladder and irritation of its neck and walls are eliminated.

Drugs from the group of alpha-1 adrenergic blockers help solve the problem. Unlike 5-alpha reductase inhibitors, they begin to act quickly. The prostate decreases in volume by 2-2.5 times due to the relief of spasm and swelling.

Tamsulosin (Omnic) is the safest in terms of side effects. It compares favorably with other alpha-blockers (alfuzosin, terazosin, prazosin) in that it does not cause a significant decrease in blood pressure. In the first days of use, the urine flow rate increases by 16%. The maximum effect can be felt within a month. Libido and erection remain intact, in some patients it occurs. An alternative drug is doxazosin (Cardura).

Omnic - α1-adrenergic receptor blocker; a drug for the symptomatic treatment of benign prostatic hyperplasia. Price from 330 rub.

To improve blood circulation and relieve spasms in adenoma, tadalafil (PDE-5 inhibitor) 5 mg daily is also prescribed. A 2012 study published in the journal European Urology found that Cialis is more effective in relieving the symptoms of adenoma than tamsulosin.

Drugs to improve the functional state of the prostate

At the initial stage of adenoma, drugs based on peptides extracted from bovine prostate extract are effective: “Prostatilen”, “Robaveron”, “Prostacor”. They improve blood microcirculation in the prostate and improve venous outflow.

Longidase suppositories, Indigal preparations (based on sabal palm extract) and Indigal Plus also have anti-edematous and immunomodulatory properties. However, many doctors consider them useless in the treatment of adenoma, since there is no reliable evidence of their effectiveness.

"Indigal Plus" is a biologically active food supplement (BAA), an additional source of epigallocatechin-3-gallate, fatty acids and indole-3-carbinol. Price from 2255 rub.

As an immunostimulating agent, you can try the dietary supplement "Todikamp" (walnut extract and petroleum products). According to reviews, it helps to reduce the volume of the prostate when used in the form of compresses on the perineum and lower back, as well as in the form of microenemas mixed with linseed oil.

At home

The success of conservative therapy for adenoma largely depends on the responsibility of the patient himself. Following a diet will help to avoid worsening the situation: avoiding alcohol, spicy, salty foods, and excess caffeine.

With adenoma, regular physical activity is important: squats, abdominal exercises, pumping the pelvic muscles. Sexual excesses are prohibited, since too frequent contractions of the prostate can cause inflammation and swelling.

Correct technique for performing squats

Folk remedies do not treat adenoma, but can act as an auxiliary therapy to relieve swelling and inflammation. Popular means:

• Propolis, dead bees, honey;
• Aspen bark, fireweed, onion peel;
• Pumpkin seeds;
• Castoreum;
• Cinnamon, turmeric.

There is a lot of information on the Internet about alkalizing the body using the Neumyvakin method. According to it, regular intake of soda has an antitumor effect, including for adenoma. The technique is dubious and not scientifically recognized.

Physiotherapy

Physiotherapeutic methods for adenoma are aimed at relieving swelling by improving blood flow and stimulating protective cellular mechanisms. For this purpose, magnetic, laser and inductotherapy are used. At home, you can use portable devices “Almag”, “Vitafon”, and Kuznetsov’s applicator. Although most men say that they have no effect compared to procedures in a physiotherapy room.

Video review of the Vitafon vibroacoustic device

There are also specific methods of physiotherapy aimed at partial destruction of adenoma tissue. These include:

1. Cryotherapy.
2. Transurethral needle ablation.
3. Transurethral microwave therapy.
4. Thermoablation.

Their use causes damage and subsequent degradation of adenoma tissue. They shrink, the volume of the gland decreases.

Surgical removal

Surgical methods for treating adenoma:

1. Electroresection. It is performed through the urethra using an endoscope with an electric loop at the end.
2. Open adenomectomy. Abdominal surgery to remove prostate adenoma (retropubic and transvesical) involves mechanical removal of the tumor through an incision above the pubis or behind the testicles. Used for large volumes of tumors.

1. Laser techniques. This involves transurethral removal of adenoma with a laser beam. There are 2 fundamentally different directions: vaporization (laser ablation, evaporation of tissue) and enucleation (excision of adenomatous nodes in blocks).
2. Plasma methods (bipolar ablation). The adenoma is removed using a plasma arc formed between the electrodes.
3. Transurethral resection (TUR) – excision of adenoma tissue using transurethral access.

The head of the surgical department of the Garvis clinic, Robert Molchanov, will talk about how the prostate TURP surgery is performed.

The choice of method depends on the volume of the adenoma and associated pathologies.

Clinics and prices:

• Vaporization at the Central Clinical Hospital of the Russian Academy of Sciences (Moscow) - 33 thousand rubles, at the Alexandrovskaya Hospital (St. Petersburg) - 75 thousand rubles;
• TOUR at the Urology Clinic named after. Fronshteina (Moscow) – 36 thousand rubles, laser enucleation – 55 thousand rubles. without consumables;
• Robot-assisted prostatectomy at the Clinic of Urology and Robotic Surgery (St. Petersburg) – 168 thousand rubles.

You can remove an adenoma free of charge under the compulsory medical insurance policy.

Why adenoma is dangerous for men: complications and consequences

The adenoma prevents complete emptying of the bladder, resulting in urine that constantly stagnates in it. Pathogens multiply in it, and the pressure created provokes expansion of the ureters. As a result, pathogenic microorganisms rise into the kidneys and descend into the testicles, which leads to complications:

1. Cystitis.
2. Urethritis.
3. Bladder atrophy.
4. Inflammation of the testicles and appendages.
5. Kidney failure.

Penetration of bacteria into the bloodstream can cause death.

Frequently asked questions about prostate adenoma

1. Is it possible to cure prostate adenoma without surgery? - It is forbidden. At the first stage, you can restrain its growth with medication, relieve symptoms and reduce its volume by relieving swelling and spasm of smooth muscles.
2. Can an adenoma resolve? - No. The formed nodes themselves will not disappear from the prostate capsule, the cells will not dissolve. The only thing that can happen is their compaction and transformation into foci of fibrosis.
3. How long do people live with prostate adenoma? − With adequate treatment, the adenoma does not affect life expectancy, but if it reaches, for example, kidney failure, death is possible. The growth of adenoma towards the rectum may be completely asymptomatic throughout life.
4. How does prostate adenoma affect potency? – It all depends on the stage and severity of the symptoms.
5. Is it possible to ride a bicycle or exercise on an exercise bike? – It’s possible, but these should be walks, not multi-hour marathons, and preferably a special saddle with a cutout for the crotch.

1. Is it possible to have sex with prostate adenoma? – Sex with an adenoma is not forbidden and is even encouraged, since stagnant processes in the pelvic area aggravate the symptoms.
2. Is it possible to massage the prostate with adenoma? – Direct massage of the prostate with adenoma is dangerous, since mechanical irritation can cause the movement of stones (if any) and provoke tissue proliferation. It is better to massage the sacrum.
3. Is it possible to go to the bathhouse? – With a small, controlled tumor, it is possible, but not often, and not to abuse overheating, otherwise the prostate tissue will swell.
4. Can I drink alcohol? – In case of adenoma, it is better to completely exclude it. Even 20-30 g of alcohol provokes a rush of blood into the pelvic area, in particular, into the submucosal part of the urethra, which can lead to acute urinary retention.

Prevention

There is no specific prevention of adenoma. You can only minimize the impact of the factors that provoke its development. Basic measures:

• Regular physical activity, sex;
• Balanced diet;
• Stop smoking, minimize alcohol;
• Maintaining normal weight;
• Regular testing for sexually transmitted infections.

Researcher at the Research Institute of Urology Dmitry Alekseevich Voitko will give 10 tips that will help maintain and strengthen the health of the prostate gland

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Treatment goals for benign prostatic hyperplasia:

Improving the quality of life of patients suffering from urinary disorders caused by benign prostatic hyperplasia (BPH); preventing the progression of BPH;

Extending or saving the lives of patients - at the present stage of development of medicine, such a goal is rarely pursued, only in complicated forms of the disease.

The role of the patient in choosing a treatment method

If there are subjective manifestations of the disease, the patient should be aware that the indications for therapy are dictated primarily by the degree of concern caused to him by the symptoms of BPH.

If only risk factors for the progression of BPH are identified, we can talk about preventive treatment.

At this stage, the key position is to inform the patient in detail and provide him with all available reliable, scientifically proven information regarding the disease and the risks associated with it, the advantages and disadvantages of various treatment options, and the characteristics of treatment for this patient. In a number of countries, special booklets and educational computer programs have been developed for the purpose of medical education of the patient, which makes it easier for the doctor to inform the patient.

The feasibility of this approach is due to the fact that when we touch on the issue of influence on the quality of life, no one is better than the patient in determining what is most significant for him both in the disease itself and in the methods of its treatment. As a result, the optimal type of treatment is determined not only based on the individual characteristics of the disease, but also taking into account/based on the personal preferences of the patient. We emphasize that such an approach is justified only in the absence of complications of BPH, which are absolute indications for surgical treatment, as well as when the patient’s ability to perceive information and make independent decisions is intact.

If a particular complication of prostate hyperplasia is identified, which is an absolute indication for surgical treatment, the nature of the intervention is determined by the doctor, based on the availability of the treatment method, the somatic status of the patient, the potential effectiveness and safety of the method for a particular patient, as well as taking into account the patient’s preferences.

Dynamic observation

The recommended interval between visits to the urologist and repeated examinations is 6 months after the first consultation, then 12 months.

Dynamic observation is considered preferable for mild (IPSS up to 7 points) and acceptable for moderate (TPSS up to 19 points) urinary disorders that do not cause significant concern to the patient, provided there are no absolute indications for surgical treatment.

As part of dynamic monitoring, it is important to change the lifestyle of patients and increase their educational level in matters relating to BPH and other prostate diseases.

As part of lifestyle changes, the following may be recommended:

Limiting fluid intake in the evening/before bed or in situations where increased urination is undesirable;
limiting the consumption of alcohol, coffee and other drugs and substances with diuretic activity;
eliminating constipation;
correction of concomitant therapy;
regular physical and sexual activity, breathing exercises and gymnastics aimed at strengthening the muscles of the genitourinary diaphragm.

Drug treatment

Given the progressive nature of this disease, drug therapy for its symptoms should be carried out for a long time (sometimes throughout the patient’s life).

The most commonly used drugs for the medical treatment of BPH are 5-α-reductase inhibitors, α1-blockers and herbal extracts. In recent years, muscarinic receptor antagonists (m-anticholinergic blockers), desmopressin analogues, as well as various combinations of drugs have become increasingly used in patients with BPH.

5-a-reductase inhibitors

Currently, two drugs of this pharmacological group are available: finasteride (an inhibitor of type II 5-a-reductase) and dutasteride (an inhibitor of both type I and type II 5-a-reductase). Since dutasteride is an inhibitor of 5-a-reductase types I and II, it causes a more pronounced decrease in the content 5-a-dihydrotestosterone (DHT) in the prostate gland than finasteride, which inhibits only type II enzyme. Both drugs, by affecting the amount of DHT, activate the processes of natural apoptosis in the prostate and cause a decrease in its volume.

The maximum clinical effect from the use of drugs of this group in patients with BPH develops 6-12 months after the start of treatment.

The main clinical effects of 5-a-reductase inhibitors:

Reduction in prostate volume by an average of 18-28%;
reduction in total IPSS score by approximately 15-30%;
increase in maximum urination rate by approximately 1.5-2.0 ml/s;
decrease in concentration prostate specific antigen (PSA) blood serum by 50%.

Considering the latter fact, to determine the true PSA level when screening patients for prostate cancer, the values ​​obtained after 6 months or more of continuous therapy with 5-a-reductase inhibitors must be doubled. In this case, 5-a-reductase inhibitors do not reduce the diagnostic value of PSA as a marker of prostate cancer.

Clinical features of the use of 5-a-reductase inhibitors:

Retain their effectiveness with long-term (7-10 years) administration;
drugs of this group are more effective when the prostate gland volume is more than 40 cm3;
unlike o-blockers, they reduce the risk of progression of BPH (by 64%), the occurrence of acute urinary retention (57-59%) and surgical intervention (by 36-55%);
reduce the likelihood of developing prostate cancer by 25%;
effective in the treatment of gross hematuria caused by prostatic hyperplasia;
have a good safety profile.

The most common side effects when taking finasteride are:

Decreased libido (6%);
impotence (8%);
reduction in ejaculate volume (4%); engorgement/enlargement of the mammary glands (less than 1%).

Finaeteride - 5 mg 1 time/day;
dutasteride - 0.5 mg 1 time / day.

A follow-up examination (filling out the IPSS questionnaire, uroflowmetry, determining the volume of residual urine) is recommended to be carried out after 3 and 6 months, and subsequently annually.

a1-Adrenergic blockers

Drugs in this group include terazosin, alfuzosin, and doxazosin. Tamsulosin is an α1-adrenergic receptor antagonist.

The mechanism of action of drugs in this group is to block stromal adrenoreceptors of the prostate gland, which helps relax the smooth muscles of the organ and reduce the dynamic component of bladder outlet obstruction. They have the ability to suppress irritative symptoms (filling symptoms).

The prescription of α1-blockers is the most common option for drug therapy in patients with mild, moderate and severe lower urinary tract symptoms (LUTS). This treatment is appropriate in the absence of risk factors for the progression of BPH in monotherapy.

Patients may notice symptomatic improvement within 48 hours of starting to take α1-blockers. The effectiveness of therapy is best assessed after 1 month from the start of treatment. The drugs in this group do not differ significantly from each other in the severity of their clinical effects.

The main clinical effects of α1-blockers:

Increase the maximum rate of urination by an average of 20-30%;
improve the quality of life of patients by reducing the severity of LUTS by 20-50%;
effective in eliminating acute urinary retention that has already occurred;
reduce the risk of developing postoperative acute urinary retention;
reduce the severity and duration of dysuria after transurethral resection (TUR) prostate gland;
do not reduce the volume of the prostate;
do not affect the concentration of PSA in the blood serum;
do not prevent the progression of BPH.

If, within 2 months, taking α1-blockers has not led to a decrease in the severity of LUTS, treatment should not be continued. Drugs in this group are ineffective in approximately a third of patients.

The main side effects when taking α1-blockers:

Dizziness;
headache;
orthostatic arterial hypotension;
asthenia, drowsiness;
nasal congestion;
retrograde ejaculation,

Modified-release dosage forms of tamsulosin, alfuzosin and doxazosin generally have slightly lower rates of adverse events than other α1-adrenergic receptor antagonists.

Doxazosin. Start taking 1 mg at night, gradually increasing the dose to 2-8 mg/day; the maximum recommended dose is 16 mg/day.
Doxazosin modified release. Reception begins with 4 mg/day; the maximum recommended dose is 8 mg/day.
Terazosin. The initial dose is 1 mg at night, it is gradually increased to 5-10 mg/day; the maximum recommended dose is 20 mg/day.

Alfuzosin modified release. Prescribe 5 mg in the morning and evening, starting with the evening dose.
Tamsulosin. Prescribe 0.4 mg/day in the morning, after breakfast.
Tamsulosin modified release. Prescribed at 0.4 mg/day. A follow-up examination (filling out the IPSS questionnaire, uroflowmetry, determining the volume of residual urine) is recommended to be carried out after 1.5 and 6 months, and subsequently annually.

Plant extracts

Herbal medicine for LUTS/BPH has been popular in Europe for many years and has spread to America in recent years. Several short-term randomized trials and meta-analyses have shown clinical efficacy without significant side effects of herbal components such as Serenoa repens and Pygeum africanum.

In some studies, herbal extracts of Serenoa repens and Pygeum africanum have demonstrated efficacy similar to finasteride and α1-blockers. An important feature of this group of drugs is the combination of a pathogenetic effect on BPH and a high safety profile with long-term use.

The mechanism of action of herbal medicines is difficult to assess, since they consist of various plant components, so it is difficult to determine which of them has the greatest biological activity.

Pharmacological effects of Serenoa repens extract:

Aptyapdrohepic;
antiproliferative;
decongestant;
anti-inflammatory.

Pharmacological effects of Pygeum africanum extract:

Regulation of the contractile activity of the bladder (reducing hyperactivity, reducing metabolic disorders in the wall and increasing its elasticity);
decongestant;
anti-inflammatory;
antiproliferative.

It is advisable to evaluate the effect of herbal medicine therapy after 2-3 months from the start of treatment.

Serenoa repens preparations are prescribed 160 mg 2 times a day or 320 mg 1 time/day after meals. Pygeum africanum preparations are prescribed 50 mg 2 times a day before taking the niche.

It is advisable to carry out a follow-up examination (filling out a TPSS questionnaire, uroflowmetry, determining the volume of residual urine) after 3 and 6 months, and then annually.

It should be noted that currently the clinical recommendations of the European Association of Urology state the insufficiency of the evidence base, the diversity of plant materials and the difficulty of taking into account the dosage of the active substance in existing herbal preparations. In this regard, the place of drugs containing herbal extracts in the treatment of BPH should be clarified in the course of large randomized placebo-controlled trials.

Muscarinic receptor antagonists

The prescription of m-anticholinergic drugs to men with bladder outlet obstruction is currently not officially permitted. In men with LUTS without signs of obstruction, only two drugs from this group were used as monotherapy - tolterodine and fesoterodine. The duration of studies using these drugs was usually 12 weeks and did not exceed 25 weeks. When using m-anticholinergic drugs, the severity of urgency, as well as night and daytime pollakiuria, decreased, and there was a slight decrease in the total IPSS score.

Tolterodine is prescribed 2 mg 2 times a day, fesoterodine - 4-8 mg 1 time a day, m-anticholinergic blockers are not considered the standard of drug therapy for patients with BPH. When prescribing them to patients with LUTS in the older age group, careful monitoring of the volume of residual urine is necessary through ultrasound examination (Ultrasound).

Vasopressin analogues

Desmopressin is an antidiuretic hormone analogue that significantly increases tubular reabsorption and reduces urine output. The administration of this drug is an effective method of combating nocturia if its cause is polyuria. Desmopressin has no effect on all other components of LUTS. It should be used with caution, monitoring the sodium content in the blood serum 3 days, a week and a month after the start of use, and then every 3-6 months with continuous use.

Desmopressin is prescribed sublingually at 10-40 mcg at bedtime. Before prescribing and while taking vasopressin analogues, consultation with a physician/cardiologist is indicated, since fluid retention in the body is associated with the risk of decompensation of a number of cardiovascular diseases, in particular heart failure.

Combination therapy

5-a-reductase inhibitors + a1-blockers

Large studies have convincingly demonstrated that combination treatment with a 5-α-reductase inhibitor plus an α-1 blocker reduces LUTS to a greater extent than either drug alone. At the same time, it has been proven that combination therapy minimizes the risk of BPH progression.

Thus, in the MTOPS study, when using a combination of finasteride with doxazosin, the risk of BPH progression was 64% lower than in the placebo group, and the likelihood of surgical intervention was 67% lower. In a 4-year study using the dual 5-α-reductase inhibitor dutasteride and the superselective α-blocker tamsulosin (the CombAT study), the overall risk of progression to BPH was reduced by 41%, the risk of acute urinary retention was reduced by 68%, and the risk of surgical intervention was reduced. by 71%. It is important that the CombAT study included only patients at high risk of BPH progression.

Thus, the combination of 5-a-reductase inhibitors with α-blockers is optimal for patients over 50 years of age with moderate or severe symptoms of BPH (IPSS >12), prostate volume >30 cm3, a decrease in maximum urine flow rate of 1.5 (but within normal values).

a-Adrenergic blockers + m-anticholinergic blockers

If there are signs of bladder overactivity (severe pollakiuria, urgency) in patients with prostate hyperplasia, it may be advisable to prescribe combination therapy with an α1-blocker and an m-anticholinergic blocker. Such combination therapy is effective in 73% of patients who previously did not notice improvement with monotherapy with α1-adrenergic receptor antagonists.

The few studies on the combined use of these drugs have provided experience with the use of doxazosin, tamsulosin or terazosin with oxybutynin, solifenapine or tolterodine.

If the patient is suspected of bladder outlet obstruction, treatment should be prescribed with caution, under ultrasound control of the volume of residual urine.

Surgery

Currently, the “gold standard” of surgical treatment for BPH is considered transurethral resection (TOUR) prostate gland. Transurethral incision of the prostate or open adenomectomy can also be performed.

The main goal of surgery for BPH is to relieve the patient of iphravesical obstruction and improve urination.

Absolute indications for surgical treatment:

Chronic urinary tract infection;
acute urinary retention after catheter removal;
resistant to therapy with a 5-a-reductase inhibitor, gross hematuria;
bilateral ureterohydronephrosis and renal failure:
bladder stones;
a large bladder diverticulum or a large (> 200 ml) volume of residual urine caused by prostatic hyperplasia.

Relative indications for surgical treatment:

Ineffectiveness or intolerance of drug therapy;
the presence of a middle lobe of hyperplasia;
unacceptability or unavailability of conservative treatment methods for the patient (for psychological, economic or other reasons);
relatively young age of the patient with LUTS.

Selection of surgical treatment method

Transurethral incision of the prostate is the method of choice in patients with a prostate volume of 20-30 cm3 in the absence of the middle lobe.
TUR of the prostate and SS modifications (transurethral vaporization of the prostate, bipolar TUR of the prostate, rotoresection) are the optimal surgical intervention in 95% of patients. It is most effective and safe when the prostate gland volume is from 30 to 80 cm3.
Open adenomectomy (retropubic, transvesical or perineal) for BPH is advisable when the prostate volume is more than 80-100 cm3 and in combination with large stones or diverticula of the bladder.

It is important to note that methods of surgical treatment of patients with BPH are constantly being improved. Thus, in a recent randomized study, it was found that in patients with a prostate gland with a volume of more than 100 cm3, transurethral enucleation of adenoma with a holmium laser has an effectiveness that is not inferior to open adenomectomy, with a significantly lower degree of severity and frequency of complications. Currently, there are all the prerequisites for this technique to become the new “gold standard” for surgical treatment of patients with BPH.

The results of TUR of the prostate, transurethral incision of the prostate or open adenomectomy are comparable. When using each method, the total 1PSS score is reduced on average by 71%. The maximum urinary flow rate after TUR of the prostate increases by approximately 115% (from 80 to 150%), or by 9.7 ml/s; after open adenomectomy - by 175%, or by 8.2-22.6 ml/s. The volume of residual urine is reduced by more than 50% (by 65% ​​after open adenomectomy, by 60% after TUR of the prostate and by 55% after transurethral incision of the prostate).

Long-term intra- and perioperative complications

Mortality after surgical interventions for BPH in modern clinics does not exceed 0.25%. The risk of TUR syndrome (hemodilution combined with a decrease in blood plasma Na+ concentration less than 130 nmol/l) does not exceed 2%.

Risk factors for developing TUR syndrome:

Severe bleeding with damage to the venous sinuses;
long-term surgical intervention;
large prostate size;
history of smoking.

The need for blood transfusion after TURP of the prostate occurs on average in 2-5% of patients; after open surgery, the frequency is usually higher. With transurethral incision of the prostate gland, there is almost never a need for blood transfusion.

Long-term complications:

Stress urinary incontinence. The average probability of its occurrence is 1.8% after transurethral incision of the prostate, 2.2% after TUR of the prostate and up to 10% after open surgery.
Urethral strictures. The risk of their development after open adenomectomy is 2.6%, after TUR of the prostate gland - 3.4%, after transurethral incision of the prostate gland - 1.1%.
Contracture of the bladder neck occurs in 1.8% of patients after open adenomectomy, in 4% after TUR of the prostate gland and in 0.4% of patients after transurethral incision of the prostate gland,
Retrograde ejaculation occurs in 80% of patients after open adenomectomy, in 65-70% of patients after TUR of the prostate and in 40% of patients after transurethral incision of the prostate.
Erectile disfunction (ED) after TUR of the prostate gland occurs on average in 6.5% of patients, which is comparable to the frequency of ED in patients with BPH of the same age during dynamic observation.

The timing of follow-up examinations after the above-mentioned surgical interventions is every 3 months. It is imperative to examine the histological material obtained during the operation.

Recommended methods of postoperative patient management include questionnaires using the 1PSS scale, uroflowmetry, and determination of residual urine volume. At the discretion of the doctor, a bacteriological examination of urine can be performed.

BPH is a current condition affecting a significant proportion of middle-aged and elderly men. BPH develops from the transition zone of the prostate gland and leads to disruption of the act of urination due to an increase in the size of the prostate, changes in the tone of the smooth muscles of the gland, bladder neck, posterior urethra and detrusor.

Numerous methods for diagnosing BPH are aimed primarily at assessing the severity of obstructive and irritative symptoms of urinary dysfunction, measuring the size of the prostate gland and urine flow rate, as well as the risk of disease progression in the future. Currently, there is no standard treatment for BPH that is suitable for any patient.

Depending on a number of symptoms, dynamic observation, drug treatment in mono- and combination therapy, surgical treatment, as well as various minimally invasive interventions are used. When choosing a treatment method, each patient should be approached individually, taking into account all associated factors (medical and social) and with the active participation of the patient himself.

P.V. Glybochko, Yu.G. Alyaev

Proliferation of glandular tissue and stroma of the transition zone of the prostate, leading to enlargement of the organ. Prostate adenoma can cause urinary disorders: a weak stream of urine, a feeling of incomplete emptying of the bladder, frequent or nighttime urges, paradoxical ischuria. Diagnosis is based on PSA levels, TRUS, uroflowmetry and the IPSS Symptom Assessment Questionnaire. Treatment correlates with the volume of the gland, age, concomitant pathology and severity of symptoms: waiting tactics, drug therapy, surgical interventions, including minimally invasive techniques are used.

General information

prostate adenoma, BPH, BPH) is a common worldwide problem faced by one third of men over 50 years of age and 90% of patients who live to 85 years of age. According to statistics, about 30 million men have genitourinary dysfunction associated with BPH, and this figure is increasing every year. The pathology is more common in African Americans with initially higher testosterone levels, 5-alpha reductase activity, growth factors, and androgen receptor expression (population-specific). In residents of eastern countries, prostate adenoma is registered less frequently, which is apparently associated with eating a large amount of foods containing phytosterols (rice, soybeans and its derivatives).

Causes of BPH

It is obvious that prostate adenoma is a multifactorial disease. The main factor is changes in hormonal levels associated with natural aging with normal functioning of the testicles. There are many hypotheses that explain the mechanisms of development of pathology (the theory of stromal-epithelial relationships, stem cells, inflammation, etc.), but most researchers consider the hormonal theory as fundamental. It is assumed that the age-related predominance of dihydrotestosterone and estradiol stimulate specific receptors in the gland, which trigger cell hyperplasia. Additional background risk factors include:

• Overweight/obesity. The accumulation of fatty tissue, especially in the abdominal area, is one of the indirect causes of prostate enlargement. This is associated with decreased testosterone levels in obese men. In addition, with hypoandrogenism, the amount of estrogen increases, which increases the activity of dihydrotestosterone, which promotes hyperplasia.
• Diabetes. High glucose levels and insulin resistance accelerate the progression of BPH. Glucose levels in diabetes are higher not only in the blood, but also in all prostate cells, which stimulates their growth. In addition, diabetes leads to damage to blood vessels, including the prostate gland, which can result in an enlarged prostate. A number of studies show that among men with diabetes and elevated levels of low-density lipoprotein, BPH is detected 4 times more often.
• Nutritional features. Eating a high-fat diet increases the likelihood of prostate hyperplasia by 31%, and daily inclusion of red meat in the diet increases the likelihood of prostate hyperplasia by 38%. The exact role of fatty foods in causing hyperplastic processes is unknown, but it is believed to contribute to the hormonal imbalance associated with BPH.
• Heredity. Genetic predisposition is of some importance: if first-degree male relatives were diagnosed early with prostate adenoma with severe symptoms, the risk of its development in the next generation of men increases.

Pathogenesis

Testosterone in a man's body is contained in different concentrations: its level is higher in the blood, and lower in the prostate. In older men, testosterone levels decrease, but dihydrotestosterone levels remain high. A significant role belongs to the prostate-specific enzyme 5-alpha reductase, thanks to which testosterone is converted into 5-alpha-dihydrotestosterone. Androgen receptors and DNA of prostate cell nuclei are most sensitive to its action, which stimulate the synthesis of growth factors and inhibit apoptosis (disruption of programmed processes of natural death). As a result, old cells live longer, and new ones actively divide, causing tissue proliferation and adenoma growth.

An enlarged prostate makes it difficult to urinate due to a narrowing of the prostatic part of the urethra (especially if the growth of the adenoma is directed inside the bladder) and an increase in the tone of the smooth muscle fibers of the stroma. At the initial stage of the pathology, the condition is compensated by the increased work of the detrusor, which, by straining, allows the urine to be completely evacuated.

As it progresses, morphological changes in the bladder wall appear: some muscle fibers are replaced by connective tissue. The capacity of the organ gradually increases, and the walls become thinner. The mucous membrane also undergoes changes: hyperemia, trabecular hypertrophy and diverticula, erosive ulcerations and necrosis are typical. When a secondary infection occurs, cystitis develops. Benign prostatic hyperplasia and stagnation of urine lead to reverse flow of urine, cystolithiasis, hydronephrotic transformation of the kidneys and chronic renal failure.

Classification

Diagnostics

There is a special questionnaire designed to assess the severity of symptoms of lower urinary tract obstruction. The questionnaire consists of 7 questions related to common symptoms of benign prostatic hyperplasia. The frequency of each symptom is assessed on a scale from 1 to 5. When summed, an overall score is obtained, which affects further treatment tactics (dynamic observation, conservative therapy or surgery): from 0-7 - mild symptoms, 8-19 - moderate, 20- 35 – serious problem with urination. Instrumental and laboratory diagnostics for BPH include:

• Ultrasound. TRUS and transabdominal ultrasound of the prostate and bladder are complementary imaging modalities. Ultrasound examination is performed twice - with a full bladder and after urination, which allows you to determine the amount of residual urine. Asymmetry, density, heterogeneity of structure, increased blood supply to the prostate indicate an adenoma.
• Radiography. With X-ray diagnostics (excretory urography, cystography), it is possible not only to determine the size of the prostate, but also to evaluate kidney function, developmental abnormalities, and diagnose pathologies of the bladder and urethra. The study involves intravenous administration of a contrast agent.
• Urodynamic studies. Uroflowmetry is a simple test to assess urine flow, graphically showing the rate of bladder emptying and the degree of obstruction. The study is performed to determine indications for surgical treatment and monitor dynamics during conservative therapy.
• PSA study. Prostate-specific antigen is produced by the cells of the organ capsule and periurethral glands. In patients with benign prostatic hyperplasia and prostatitis, PSA levels are elevated. The result is influenced by many factors, so a diagnosis cannot be made using one analysis.
• Urine tests. In men with prostate adenoma, concomitant inflammation of the bladder and kidneys is often diagnosed, so the OAM pays attention to signs of inflammation - leukocyturia, proteinuria, bacteriuria. Blood in the urine may indicate varicose changes in the vessels of the bladder neck, their rupture when straining. When changes occur, urine is cultured on nutrient media to clarify the composition of the microbial flora and sensitivity to antibiotics.

Differential diagnosis is carried out with a tumor process of the bladder or prostate, cystolithiasis, trauma, interstitial and post-radiation cystitis, neurogenic bladder, urethral stricture, prostate sclerosis, meatostenosis, urethral valves, phimosis, prostatitis.

Treatment of BPH

Therapy for prostate adenoma correlates with the severity of obstructive symptoms and complications; the choice of treatment tactics is influenced by the patient’s age and concomitant pathology. All existing treatment methods are aimed at restoring adequate urine diversion. Treatment options include:

• Watchful waiting. This strategy is used in men with mild symptoms ≤7 on the IPSS scale and in patients with an IPSS score ≤8 whose symptoms are not considered to impair quality of life in the absence of complications. Once a year, such patients undergo TRUS, PSA test, and digital examination. Drug therapy is not indicated, as it does not lead to improvement in well-being and has large risks that can significantly affect the quality of life (for example, erectile dysfunction during treatment with alpha-blockers).
• Drug therapy. With the advent of alpha-blockers, many patients with prostatic hyperplasia have the opportunity to avoid surgery. The drugs relax the muscles in the prostate, urethra and bladder neck, which increases the strength of the urine stream. Drug therapy is carried out in patients with severe, moderate and severe urinary disorders of 8 points and above. 5-alphareductase inhibitors are prescribed to prevent progression of symptoms of urinary obstruction. According to indications, combination therapy is possible. The inclusion of 5-phosphodiesterase inhibitors in the regimen improves urine output and has a positive effect on erectile function.
• Surgical treatment. There are several options for surgical interventions: adenomectomy, which is a radical operation (can be performed either open or laparoscopic) and transurethral resection of the prostate gland. Each operation has its own indications, advantages and disadvantages. In case of severe concomitant pathology, when the likelihood of an unfavorable outcome is high, epicystostomy is performed as a palliative measure. After normalization of the condition, it is possible to resolve the issue of removing the drainage and restoring independent urination.
• Minimally invasive therapy. There are a number of techniques available to avoid the adverse effects associated with TURP and adenomectomy. These include laser destruction (vaporization, coagulation) by contact or non-contact method, needle ablation, electroincision, transurethral microwave therapy (microwave energy), radiofrequency water thermotherapy, etc. A large volume of the prostate gland is a contraindication to minimally invasive treatment methods.

Prognosis and prevention

The prognosis for life is favorable; for most patients, long-term (lifelong) use of modern medications is sufficient to normalize urinary function. The need for surgery occurs only in 15-20% of men. After adenomectomy, the recurrence of the disease does not exceed 5%; minimally invasive techniques do not provide a 100% guarantee of healing and can be performed repeatedly. The improvement of the prognosis in the last decade has been facilitated by the introduction of minimally invasive treatment methods, which allows minimizing complications that threaten the lives of patients. To normalize erectile function, a consultation with an andrologist-sexologist is necessary.

Evidence from prostate cancer prevention studies suggests that a diet low in animal fat and red meat and high in protein and vegetables may reduce the risk of symptomatic BPH. Physical activity of at least 1 hour per week reduces the likelihood of nocturia by 34%.