Benign Prostatic Hyperplasia is a histological diagnosis, whose prevalence increases 25% in men in the fifth decade of life, to more than 80% in the eighth decade. It is the most common benign tumor of man.
Many men with BPH have no symptoms, but more than 50% of men older than 60 years and up to 90% older than 80 have low urinary tract syndrome (STUB). In some cases it is a family disorder of the autosomal dominant type: first-degree relatives of consanguinity of men with BPH have 4 times the risk of developing it.
In 1978, McNeal described 4 histologically distinct zones in the prostate gland: the central zone, the peripheral zone, the transitional zone and the periurethral glands. Subsequently, the anterior fibromuscular stroma (non-glandular) was added. BPH develops in the transition zone in 70% of cases. It is a hyperplastic process as a result of an increase in cell number. Under the microscope, a nodular growth pattern composed of variable amounts of epithelium and stroma is observed, which in turn is composed of collagen and smooth muscle. This is important to explain the response to treatment according to the predominant tissue in the formation of BPH. As the nodules grow, they compress the outer portion of the prostate, resulting in the formation of the surgical capsule (the prostate does not have a true anatomic capsule). That is the anatomical repair at the time of intervening a patient.
The symptoms associated with prostatic growth are explained by the obstructive component of the prostate or secondary to the response of the bladder to the resistance of the outgoing urinary tract. The obstructive component can be subdivided into mechanical or dynamic obstruction. There may be mechanical obstruction due to intrusion to the bladder neck or urethral lumen, leading to greater resistance in the outflow tract. The obstructive component can be subdivided into mechanical obstruction by intrusion to the bladder neck or urethral lumen, leading to greater resistance in the outflow tract. Dynamic obstruction explains the variability in the clinical response of patients to treatment. The stroma, composed of smooth muscle and collagen, is rich in adrenergic innervation. The level of autonomous stimulation determines the tone of the prostatic urethra. Irritative symptoms are output. The obstruction generates hyperplasia and hypertrophy of the detrusor and deposits of collagen, this being responsible for the low bladder adaptability. Pseudodiverticulos can appear only formed by herniated mucosa through the muscular fascicles and serosa.
What is the definition of LUST?
LUST or Lower Urinary Tract Syndrome in older men are common and often uncomfortable, resulting in significant resources in the health system. These symptoms may be secondary to benign prostatic obstruction or benign prostatic growth. However, it should be noted that these symptoms can occur in men without prostatic growth and in women. These can also appear due to hyperactivity of the detrusor muscle, urolithiasis, urethral stricture, non-urological conditions, medications or lifestyles. Management of obstruction of the outflow tract constitutes an important proportion of the daily practice in Urology and will increase as the adult population increases.
There are several terms within the syndrome that we will refer to below:
The term “prostatism” was used to mention clinical, pathological and low urinary symptoms, generating an erroneous concept with regard to its gender and organ specificity. For this reason, a series of definitions has been proposed in order to reflect the aforementioned components in a more accurate way:
- Benign prostatic growth: clinical findings of an enlarged prostate due to benign prostatic hyperplasia.
- Outflow urinary tract obstruction: Urodynamic diagnosis characterized by an increase in detrusor emptying pressure and reduction in urinary flow rate.
- Benign prostatic obstruction: obstruction of the urinary tract of secondary exit to benign prostatic growth in the absence of prostate cancer.
- Benign prostatic hyperplasia: histological diagnosis that involves cell proliferation in the prostate.
- Filling symptoms: frequency, nocturia, urgency, incontinence
- Emptying symptoms: hesitation, pushing, weak jet, burning dysuria, intermittency, dripping.
- Post-voiding symptoms: Tenesmus, post-void drip
How is a patient with low urinary syndrome evaluated?
LUST are divided into 3 types:
The predominance of certain symptoms can suggest the origin of them; however, it must be remembered that the bladder is not a reliable witness and that additional studies may often be required in search of an accurate diagnosis.
- Clinical history: It must determine the presence of hematuria, urinary tract infection (UTI), erectile dysfunction, diabetes, hypertension as well as any previous urological condition such as acute urinary retention and any subsequent intervention. You should also write down if you are receiving medical treatment (alpha blockers, anticholinergics).
- Physical exam: Should include the abdomen, external genitalia and right touch to estimate the prostate size and the presence of alterations, asymmetric growth, increase in consistency.
- Uroanalysis, voiding diary and uroflowmetry: Uroanalysis should be performed to exclude microhematuria and UTIs that will require additional studies. The voiding diary is a simple and complete tool in which you must write down for at least 3 days and provide information about filling symptoms, bladder capacity and may indicate other causes of symptoms, such as nocturnal polyuria or excessive ingestion of liquids. Uroflowmetry (UFM) measures voiding volume per second but is not specific; for example, it can not determine whether a low flow is secondary to an obstruction in the outflow tract or detrusor failure. Ideally, more than one UFM should be performed and can only be considered representative if the voiding volume is greater than 150cc.
- Postvoid residual (PVR) and Prostate-specific Antigen (PSA): PVR can be estimated by ultrasound or catheterization. Its measurement must be practiced several times, taking into account the variation of the result between these occasions. High postvoid residual may be associated with detrusor dysfunction or early obstruction of prostate cancer; The benefits and disadvantages of its use should be discussed with the patient with STUB. The most widely used is the International Prostate Symptoms Score (IPSS), also known as the “AUA score” (American Urological Association). It consists of 7 questions each one about a symptom: 3 filling and 4 emptying. The IPSS also evaluates the commitment of symptoms in the quality of life. The biggest problem is that this scale does not evaluate incontinence. Each question is given a score of 0 to 5 according to the severity of the symptom. The sum gives a total score is 35
- Urodynamics: Your information is very useful. Several normograms, such as the ICS or also called Abrams – Griffith, determine if a patient is obstructed, based on the information obtained in the flow-pressure study. This is calculated using the output tract obstruction index: Pdet to Qmax – 2Qmax. A value> 40 suggests obstruction, 20-40 is equivocal and <20 does not suggest obstruction. The contractility index is calculated as follows: Pdet a Qmax + 5Qmax, where a value> 150 is normal, 100-150 is equivocal and <100 suggests low contractility. Being an invasive procedure, it is usually reserved for patients in whom the management has failed and some intervention is planned.
What is the natural history of the disease?
The progression of BPH in untreated patients can only be inferred due to the nature of the disease and the lack of longitudinal studies. However, conclusions can be drawn from the placebo arms in long-term studies. It has been shown that an average increase in prostate volume of 1.6% / year and in the IPSS of 0.18 / year.
Are there risk factors for developing acute urinary retention (AUR)?
- Age:> 70 years are at risk 8 times more to have RUA than men between 40 and 49 years.
- Prostatic volume> 30 cc
- IPSS> 7
- Qmax <12 cc/s
- PVR> 50 cc
Annual incidence of AUR 0.7%
What is the treatment for LUTS?
- Change of lifestyle: Require patient education and periodic monitoring.
- Strategies include: Reduction in fluid intake, avoiding the use of bladder stimulants (coffee, tea, lemon, chili pepper, cigarette), double-micturition technique, urethral milking, bladder retraining in conjunction with the review of used medications . With adequate adherence, these changes can have a significant improvement in IPSS similar to alpha blockers
- Alpha-adrenergic blockers: The prostate and bladder contain alpha-adrenergic receptors that generate a contractile response to the stimulus.
- Inhibidores de 5α reductasa (I5AR): El efecto de la testosterona y dehidrotestosterona (DHT) en el desarrollo de la HPB es bien conocido. La 5α reductasas convierte la testosterona en DHT (más potente). Los I5AR bloquean dicha enzima. Su efecto se ve a los 2-6 meses reduciendo el volumen prostático 25-30%, limita su crecimiento, reduce la angiogéensis, mejora IPSS 5 o 5 Puntos, reduce los niveles de PSA hasta 50%, reduce necesidad de cirugía en 55% y RUA en 57%.
- Combined therapy: There is no difference in the short term. Long term: reduces risk of RUA or surgery 66% greater adverse effects.
- Anticolinergic drugs: they are not indicated in combination with αblockers in STUB management, unless there is associated detrusor hypereactivity.
- Inhibitors of 5-phosphodiesterase (I5PDE): 5-Phosphodiesterase (5PDE) is present in the transitional zone, detrusor and smooth muscle of the urinary tract. Antiproliferative effect in smooth muscle of prostate and bladder. Tadalafil 5mg QD start of action at 4 weeks, reduces IPSS by 2.8 points to 6 weeks and 3.8 to 12 weeks.
- Physiotherapy: there is no significant clinical evidence (Serenoa repens, vira vira)
Surgery: The patient must be sent to the urology service so that respective specialty, determine what is the surgical procedure to follow.