benign prostatic hyperplasia

Disease name

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synonym Hyperplasia of prostate (Prostatic hyperplasia) Generally refers to benign prostatic hyperplasia

This entry is made by Compilation and application of scientific encyclopedia entries of "Science Popularization China" authentication.

Benign prostatic hyperplasia (BPH) is one of the common diseases of middle-aged and elderly men, which is increasing with the aging of the global population. The incidence of benign prostatic hyperplasia increases with age, but there may not be clinical symptoms when there are hyperplasia lesions. The incidence rate in towns is higher than that in villages, and Ethnic differences It also affects the degree of hyperplasia.

Chinese name

benign prostatic hyperplasia

Age of onset

Middle aged and elderly men

Expert interpretation

Treat benign prostatic hyperplasia and maintain high-quality life

It advocates the combination of traditional Chinese medicine and western medicine, and western medicine mostly uses α 1 receptor blockers and 5 α - reductase inhibitors.

atlas

Science popularization in China

Committed to authoritative science communication

The certification expert of this term is

Feng Ninghan | Chief physician

Wuxi Second People's Hospital Urology Department to examine

Zhang Xiaopeng | Deputy chief physician

Department of Urology, Peking University People's Hospital to examine

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essential information

Chinese name: benign prostatic hyperplasia

Age of onset: Middle aged and elderly men

pathogeny

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About benign prostate Hyperplastic Pathogenesis There have been many studies, but the etiology has not yet been clarified. Probably due to epithelium and Interstitial cell Proliferation and Apoptosis The balance of androgen And its relationship with estrogen The interaction between prostate stroma and Glandular epithelium Cell interactions growth factor 、 Inflammatory cell 、 Neurotransmitter And genetic factors. At present, it is known that benign prostatic hyperplasia must have two conditions: functional testis and aging. In recent years, smoking, obesity and Alcoholism 、 family history , race and geographical environment Relationship to BPH.

clinical manifestation

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In the early stage of BPH, due to compensation, the symptoms are not typical. With the aggravation of lower urinary tract obstruction, the symptoms gradually become obvious. The clinical symptoms include symptoms in the urine storage period, symptoms in the urination period, and symptoms after urination. Due to the slow progress of the disease, it is difficult to determine the onset time.

1. Urinary storage symptoms

The main symptoms of this stage include frequent urination Urgency of urination , urinary incontinence and Nocturnal urination Increase, etc.

(1) The frequency of urination and increased nocturia are early symptoms. The frequency of nocturia increases, but each time Urine output Not much. Detrusor muscle of bladder After loss of compensation Chronic urinary retention The effective capacity of the bladder is thus reduced, and the interval between urination is even shorter. If accompanied bladder stone Or infection, the frequency of urination is more obvious, and accompanied by pain in urination.

(2) Urgent urination, incontinence Urinary obstruction 50%~80% of patients have urgent urination or Urgent urinary incontinence 。

2. Urinary symptoms

Symptoms at this stage include urinary hesitancy 、 dysuria And intermittent urination.

With the enlargement of the gland, the mechanical obstruction and dysuria become more serious. The degree of lower urinary tract obstruction is not proportional to the size of the gland. Due to the increased resistance of the urethra, the onset of urination of the patient is delayed, the urination time is prolonged, the range is not far, and the urine line is thin and weak. Bifurcation of urine , row Incontinence Feeling. If the obstruction is further aggravated, the number of patients must be increased Abdominal pressure To help urinate. Breathing increases or decreases abdominal pressure Interruption of urine flow And dripping.

3. Symptoms after urination

Symptoms at this stage include continuous urination, Post-micturition dribble Etc.

Urinary exhaustion Residual urine Increase: residual urine is the result of decompensation of bladder detrusor. When Residual urine volume Very big, bladder Overexpansion And the pressure is very high, higher than the resistance of the urethra, and the urine and stool will overflow from the urethra automatically Overflow urinary incontinence 。 Some patients do not have much residual urine at ordinary times, but are suffering from cold, drinking, suffocating urine, taking drugs or other reasons Sympathetic excitation Acute urinary retention may occur suddenly. The symptoms of urinary retention may be good or bad. Some patients can be Acute urinary retention It is the first symptom.

4. Other symptoms

(1) Hematuria On prostatic mucosa blood capillary Hyperemia and small Vasodilation And it is pulled by the enlarged gland or rubbed with the bladder, which can cause microscopic or Gross hematuria It is one of the common causes of hematuria in elderly men. Cystoscopy , Metal catheter Catheterization Acute urinary retention Sudden decompression of bladder during catheterization is easy to cause severe hematuria.

(2) Urinary infection Urinary retention often causes Urinary infection , may have symptoms such as urgency of urination, frequency of urination, dysuria, and pain in urination. When secondary Upper urinary tract infection The fever , lumbago and systemic poisoning symptoms. Although there is no patient at ordinary times urinary tract infection Symptoms, but there may be more in the urine white blood cell , or Urine culture There is bacterial growth, which should be treated before surgery.

(3) Bladder stone lower Urinary obstruction , especially when there is residual urine, the urine is in the bladder residence time Prolongation can gradually form stones. When accompanied with bladder stones, there may be urinary line interruption, pain at the end of urination, and urination after changing the position.

（4） renal function Damage is mostly caused by ureter Reflow ， Hydronephrosis Resulting in renal function damage Chief complaint Often Anorexia 、 anemia , increased blood pressure, or Lethargy And dull consciousness. Therefore, for male elderly people with unknown reasons Renal insufficiency Symptoms, should first rule out benign prostatic hyperplasia.

(5) Long term obstruction of lower urinary tract Probable cause Diverticulum of bladder Lower caused by filling Abdominal mass Or upper abdominal mass caused by hydronephrosis. Long term dependence on increasing abdominal pressure to help urinate can cause hernia, hemorrhoids and Prolapse of anus 。

inspect

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one external genital exam

except External orifice of urethra Stenosis or other diseases that may affect urination (such as: Phimosis ， Penile tumor Etc.).

two Digital rectal examination （digitalrectalexamination，DRE）

Digital rectal examination is simple and important diagnostic method , which needs to be carried out after the bladder is emptied. Attention should be paid to the boundary, size and texture of the prostate. In benign prostatic hyperplasia, the gland may increase in length or width, or both. Different methods were used to describe the extent of prostate enlargement.

There are some errors in the estimation of prostate size by digital rectal examination. If the middle lobe protrudes toward the bladder, the prostate gland enlargement is not obvious during digital rectal examination. At the same time, if the digital rectal examination finds suspicious nodules on the prostate, Should be Puncture biopsy , to exclude prostatic cancer The possibility of. The proportion of patients with abnormal DRE finally diagnosed as prostate cancer is 26%~34%, and the positive rate is Upward trend 。 At the same time, attention should be paid to Anal sphincter Shrink function to exclude Neurogenic bladder dysfunction 。

3. Local nervous system Check (including movement and feeling)

Perianal and perineum Peripheral nervous system To indicate whether there is Neurogenic bladder Dysfunction.

four Urine routine

To determine Lower urinary tract symptoms (Lowerinarytractsymptoms, LUTS) hematuria 、 proteinuria 、 Pyuria and Urine sugar Etc.

five B-ultrasonic inspection

Observe the size, shape and structure of the prostate, whether there is abnormal echo, and the degree of penetration into the bladder, and Residual urine volume (Postvoidresidualvolume)。 The commonly used methods are transrectal and transabdominal Ultrasonic examination 。 The former is more accurate but requires high equipment, while the latter is simple and popular.

It can also be measured by transrectal ultrasound Prostate volume , from micturition Audiogram , judge the deformation and displacement of the urethra, and understand Urinary obstruction The dynamic change of can also understand the state after treatment. Transabdominal ultrasonography is widely used in China, and the observation of the internal structure of glands is not as good as that of transrectal ultrasonography.

6. Residual urine determination

because Detrusor muscle of bladder The increased urethral resistance can be overcome by means of compensation, and the urine in the bladder can be emptied. Therefore, the presence of no residual urine in the early stage of BPH cannot exclude the presence of lower urinary tract obstruction. It is generally believed that residual urine volume of 50~60ml indicates that the bladder detrusor is in an early decompensation state.

It is more accurate to determine residual urine by catheterization after urination. Use transabdominal B-mode ultrasonography The method of measuring residual urine is more simple, painless and repeatable. However, when the residual urine volume is small, the measurement is not accurate enough. Intravenous pyelography In the bladder Filling period And the method of taking one film each after urination to observe residual urine is of little practical value because it cannot be quantified. isotope Concentration measurement, that is, concentration quantification, can be determined according to the method of solution capacity of different concentrations. It is the most accurate method, but it is expensive and difficult to popularize.

7. Others

Magnetic resonance imaging It has no special value in the diagnosis of benign prostatic hyperplasia, but it can help to differentiate the early stage prostatic cancer 。 If necessary, urodynamic examination Urinary system Angiography, etc.

The clinical diagnosis of this disease mainly depends on the medical history Digital rectal examination And B ultrasonic inspection. Cystoscopy It can be implemented when necessary, and it is necessary to further understand whether there is upper urinary tract dilatation and renal function damage, and whether there is Neurogenic bladder dysfunction 、 diabetes Caused by Peripheral neuritis and Cardiovascular disease Finally, estimate the general condition and decide the treatment plan.

diagnosis

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Patients with benign prostatic hyperplasia Elderly patients Often combined with others chronic disease 。 Pay attention to the patient's general condition and make detailed diagnosis Inquire Physical examination and laboratory test, pay attention to heart, lung, liver and kidney functions. dysuria Symptoms combined with various examinations can make a definite diagnosis.

1. IPSS score

1995 International Society of Urology (SIU) launched IPSS scoring system, trying to Symptomatology Quantification is easy to compare and assist in diagnosis, and can also be used after treatment evaluation criterion 。 The system determines the score by answering 6 questions, up to 35 points. At present, it is considered that below 7 points is mild, 7-18 points is moderate, and above 18 points is severe, requiring surgical treatment. IPSS is currently internationally recognized as the best way to judge the severity of symptoms of BPH patients, but it is mainly the subjective reflection of the severity of lower urinary tract symptoms of BPH patients, and Maximum urinary flow rate , residual urine volume and Prostate volume No obvious relevance This scoring system can be used to assist diagnosis and treatment in clinical work.

2. Ask for medical history

(1) The characteristics, duration and accompanying symptoms of lower urinary tract symptoms;

（2） History of operation Trauma history, especially pelvic surgery or trauma history;

(3) Understanding Past history , including Sexually transmitted diseases , diabetes Nervous system diseases , possible and enuresis Related heart disease medical history;

(4) Medication history, to know whether the patient is currently or recently taking drugs that affect the bladder outlet function or cause LUTS;

(5) General condition of the patient.

differential diagnosis

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one Contracture of bladder neck

The patient has Urinary obstruction symptom, Digital rectal examination Not found prostate Obvious enlargement, in addition to possibly enlarging the glandular lobe to the bladder, it should also be considered Bladder neck The possibility of contracture. It is generally believed that bladder neck contracture is secondary to inflammatory lesions. Bladder neck smooth muscle by connective tissue Instead, it may be accompanied by inflammation. Patients with bladder neck contracture have longer Lower urinary tract obstruction medical history. Cystoscopy When the bladder neck is raised, Posterior urethra And Trigone vesicae The area shrinks and becomes shorter. Cystoscope There is no extrusion deformation of the prostate urethra, Internal orifice of urethra Zoom out. When the simple benign prostatic hyperplasia glandular lobe protrudes to the bladder neck, it is covered by soft mucosa, the bladder triangle is depressed, and the posterior urethra is extended.

Contracture of bladder neck It can be accompanied by benign prostatic hyperplasia Surgery The boundary between the capsules is not clear, Extirpation Often difficult, and glands are Digital rectal examination or B-mode ultrasonography The predictor is obviously small. If the contracture of bladder neck is not handled at the same time after gland removal Urinary obstruction Difficult to remove.

Treatment available α- Receptor blocker 。 If the symptom is serious, it will recur urinary tract infection , or Urodynamics In case of abnormality, transurethral resection may be considered, Pubic bone Upper transvesical wedge resection or bladder neck Y-V plasty 。

two prostatic cancer

Prostate cancer, especially Ductal carcinoma The types may be as follows Urinary obstruction It is the first symptom. Some patients are accompanied by benign prostatic hyperplasia and prostate cancer, Serum PSA （ Prostate specific antigen ）Increased, more than 10.0ng/ml. Digital rectal examination The surface of the prostate is not smooth, with a rocky feeling. Transrectal biopsy , better guidance of B-ultrasound Pathological examination The diagnosis can be made clearly.

three Neurogenic bladder 、 detrusor physiological sphincter Synergetic maladjustment

Often shown as Lower urinary tract Abnormal urination ， urinary incontinence Etc. Need to ask in detail if there is any History of trauma To check whether there is anal lifting reflex, it should be excluded by urodynamic examination, such as Filling bladder manometry , urethra Pressure diagram , pressure/flow rate Synchronous detection 。

4. Weak bladder (aging of bladder wall)

As Uroschesis . Abnormal urination in the lower urinary tract and a large amount of residual urine should be distinguished from benign prostatic hyperplasia, and injury, inflammation diabetes And other factors, mainly through urodynamic examination. In particular, urethral manogram, pressure/flow rate synchronous detection were used for identification. Bladder pressure The figure shows that the bladder pressure is low, No shrinkage Pressure waveform Etc.

treatment

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Benign prostatic hyperplasia harmfulness Is caused by Urinary obstruction Pathological and physiological changes after. The individual difference of pathology is great, and not all of them are progressive. Some lesions will not develop to a certain extent, so surgery is not required even if mild obstructive symptoms occur.

1. Observe and wait

For mild symptoms, IPSS score below 7 points can be observed without treatment.

two medication

（1） 5 α - reductase Inhibitors are suitable for treatment Prostate volume Increase with moderate and severe degree Lower urinary tract symptoms Of BPH patients. It is found that 5 α - reductase is testosterone towards Dihydrotestosterone An important enzyme for transformation. Dihydrotestosterone has a certain role in benign prostatic hyperplasia, so 5α-reductase inhibitor It can inhibit the proliferation to some extent.

（2）α1- Receptor blocker It is applicable to BPH patients with moderate and severe lower urinary tract symptoms. It is currently believed that such drugs can improve urinary tract Power Obstruction, reducing resistance to improve symptoms, commonly used drugs are Gottlin Etc. Common side effects of these drugs include dizzy 、 headache , fatigue, drowsiness Orthostatic hypotension Abnormal ejaculation, etc.

(3) Others include M receptor Antagonist , botanical preparations, traditional Chinese medicine, etc. M receptor antagonist alleviates by blocking M receptor in bladder detrusor Excessive contraction, lower bladder susceptibility So as to improve the symptoms of BPH patients in the urine storage period. Plant preparations such as Prostat It is applicable to the treatment of BPH and related lower urinary tract symptoms.

To sum up, before drug treatment, the patient's condition should be comprehensively estimated side effect And the possibility of long-term medication should also be fully considered. Observe the effect of drug therapy and follow up regularly Urodynamics So as not to delay the operation opportunity.

three surgical treatment

Operation is still an important treatment method for benign prostatic hyperplasia, which is suitable for moderate and severe cases LUTS And has obviously affected Quality of life Of BPH patients. classical surgical operation The methods are Transurethral resection of prostate (Transurethralresection of the prostate,TURP)、 Transurethral prostatotomy (Transirethrincision of the prostate, TUIP) and Openness prostate Extirpation 。 At present, TURP is still treated by BPH“ gold standard ”。

operation Indications Are: ① Yes Urinary obstruction Symptoms, urodynamic examination has significantly changed, or Residual urine More than 60ml; ② Severe symptoms of unstable bladder; ③ Has caused Upper urinary tract obstruction and renal function Damage; ④ Multiple seizures Acute urinary retention 、 urinary tract infection 、 Gross hematuria ；⑤ Complicated with bladder stones. ⑥ merge inguinal hernia , serious hemorrhoids or Prolapse of anus ， Clinical judgment It is difficult to achieve therapeutic effect without relieving the obstruction of lower urinary tract. Patients with long-term urinary tract obstruction, obvious impairment of renal function, severe urinary tract infection or acute urinary retention should be retained first catheter The operation can be performed after the obstruction is relieved and the infection is controlled and the renal function is recovered. If it is difficult to insert the catheter or the intubation time is long urethritis You can change the line when Pubic bone Upper bladder puncture Fistulation 。 The indications of emergency prostatectomy should be strictly mastered.

four Minimally invasive treatment

(1) Transurethral electrovaporization of prostate (TUVP) is applicable to Coagulation function Poor sum Prostate volume Smaller BPH patients are another option for TUIP or TURP. It is mainly the innovation of electrode metal material science, which makes its biology heat effect It is different from the former. Due to fast thermal conversion, 400 ℃ high temperature can be generated, which can quickly cause Tissue vaporization , or generate Coagulative necrosis Its hemostatic characteristics are extremely significant, so clinical application shows: ① increased indications: glands above 60g can be used. ② Operative field Clear: due to the remarkable hemostatic effect, the flushing solution is clear and convenient for surgery. ③ Reduction of operation time: because the hemostasis steps are reduced, the surgical resection is accelerated and the operation time is shortened. ④ complication Decrease: not easy to produce Water poisoning (Solidification Layer thickness ）Clear operation field reduces accidental injury and is not easy to produce physiological sphincter And capsule damage. ⑤ Rapid recovery after operation: flushing time is shortened.

(2) Transurethral prostate plasma bipolar Electrotomy (TUPKP) and transurethral plasma enucleation of the prostate (TUKEP) use a plasma bipolar electrosurgical system, and With Unipolar TURP is similar to transurethral prostatectomy. The main advantages of TUPKP include less bleeding during and after operation, lower blood transfusion rate, and shorter catheterization and hospital stay after operation; TUKEP resects the prostate in the capsule, which is more in line with the anatomical structure of the prostate, with more complete resected prostatic hyperplasia tissue Recurrence rate Low, less intraoperative bleeding..

（3） Microwave therapy It is applicable to patients who are not effective in drug treatment (or unwilling to take drugs for a long time) but are unwilling to undergo surgery, as well as those who have repeated Uroschesis High risk patients who cannot accept surgery. The system uses microwave to treat biological organization The principle of thermal coagulation is used to achieve the purpose of treatment. The microwave emitter can be positioned by rectal ultrasound, or Urethroscope Locate under direct vision. The latter can avoid the external urethral sphincter accurately and reduce urinary incontinence Complications.

（4） laser therapy Laser surgery The common feature of is that the intraoperative bleeding is relatively small, especially suitable for patients with high-risk factors, such as the elderly anemia The function of important organs declines. utilize laser Thermal coagulation vaporization or prostatectomy is similar to transurethral operation. With surface irradiation and insertion Hyperthermia Some also use laser beam to remove glands. The curative effect is positive: use laser to enucleate the gland and crush the tissue from the bladder Aspirate ， Long term effect And price performance ratio remain to be seen.

5. Others

（1） Transurethral acupuncture ablation TUNA is a simple and safe treatment method. It is applicable to high-risk patients whose prostate volume is less than 75ml and cannot accept surgery. It is not recommended as a first-line treatment method for general patients.

（2） Prostate stent (Stents) is placed in the Prostate A metal (or polyurethane) device for the urethra. In order to alleviate the symptoms of lower urinary tract caused by BPH. It is only applicable to high-risk patients with repeated urine retention who cannot accept surgery, as a kind of catheterization Alternative treatment method. Common complications include stent displacement, calcification, stent occlusion, infection Chronic pain Etc.

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