(Benign prostatic hypertrophy)
Benign prostatic hyperplasia (BPH) is a benign adenomatous overgrowth of the periurethral prostate gland The symptoms are similar to those of the bladder outlet. Weak urine stream, urinary retention, urinary frequency, urgency, nocturia, incomplete emptying, dribbling, overflow incontinence and complete urinary retention. The diagnosis is based primarily on digital rectal examination and symptoms; Cystoscopy, transrectal ultrasonography, urodynamics or other imaging techniques may also be required. Therapeutically come 5-alpha reductase inhibitors, alpha-blockers, tadalafil or a surgical procedure into consideration.
Referring to the criteria of a prostate volume> 30 ml and a moderate or high IPSS (International Prostate Symptom Score, equivalent to the American Urological Association symptom score, AUASS; see Table: American Urological Association symptom score for benign prostatic hyperplasia), so the prevalence BPH in men 55 to 74 years without prostate cancer 19%. But one takes as further criteria a maximum urinary flow rate <10 ml / s and a residual urine volume> 50 mL added, the prevalence is only 4%. In consideration of autopsy findings, the prevalence of BPH increases by 8% in men 31 to 40 years to 40-50% in men 51 to 60 years and> 80% in men> 80 years.
Benign prostatic hyperplasia (BPH) is a benign adenomatous overgrowth of the periurethral prostate gland The symptoms are similar to those of the bladder outlet. Weak urine stream, urinary retention, urinary frequency, urgency, nocturia, incomplete emptying, dribbling, overflow incontinence and complete urinary retention. The diagnosis is based primarily on digital rectal examination and symptoms; Cystoscopy, transrectal ultrasonography, urodynamics or other imaging techniques may also be required. Therapeutically come 5-alpha reductase inhibitors, alpha-blockers, tadalafil or a surgical procedure into consideration. Referring to the criteria of a prostate volume> 30 ml and a moderate or high IPSS (International Prostate Symptom Score, equivalent to the American Urological Association symptom score, AUASS; see Table: American Urological Association symptom score for benign prostatic hyperplasia), so the prevalence BPH in men 55 to 74 years without prostate cancer 19%. But one takes as further criteria a maximum urinary flow rate <10 ml / s and a residual urine volume> 50 mL added, the prevalence is only 4%. In consideration of autopsy findings, the prevalence of BPH increases by 8% in men 31 to 40 years to 40-50% in men 51 to 60 years and> 80% in men> 80 years. Clinical Calculator: prostatism symptom score American Urological Association symptom score for benign prostatic valuation During the last month Never <20% of the time <50% of the time over 50% of the time> 50% of the time Almost always How often have you had already the to have not completely emptied your bladder after urination feeling? 0 1 2 3 4 5 How often to <2 hours you had to re urinate? 0 1 2 3 4 5 How often have you stopped during urination and then started again? 0 1 2 3 4 5 How often found it difficult to postpone urination? 0 1 2 3 4 5 How often you had a weak Urnstrahl? 0 1 2 3 4 5 How often you had to push or strain to begin urination? 0 1 2 3 4 5 How often do you have stood up usually at night to urinate? Significantly the time between going to bed is to get up in the morning. none = 0 1 = 1 times 2 times 3 times = 2 = 3 = 4 ? 4 times 5 times 5 = American Urological Association symptom score = total ______. Adapted from Barry MJ, Fowler FJ, O'Leary MP, et al: The American Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology 148: 1549, 1992. The etiology is unknown, but probably hormonal changes play in connection with aging a role. Pathophysiology are developing in the periurethral region of the prostate many fibroadenomatöse nodes that are likely to be descended rather from the periurethral glands than from the actual fibromuscular prostate (surgical capsule) and are pushed to the periphery during the growth process of the nodes. To the extent in which the lumen of the prostatic urethra becomes narrower and longer, and the urine flow is increasingly obstructed. Increased micturition and Blasendistension can lead to trabecularization, dimples and diverticula to hypertrophy of Blasendetrusors. An incomplete emptying of the bladder can cause stasis and predisposes to stone formation and infection. A long-lasting Harntraktobstruktion, even if it is only incomplete, may lead to hydronephrosis and compromise renal function. Symptoms and discomfort symptoms of lower urinary tract symptoms of BPH are called symptoms of lower urinary tract: urination urgency nocturia hesitation intermittency Frequent urination, urinary urgency and nocturia are a result of incomplete evacuation and a rapid refilling of the bladder. A weak urine stream caused a delayed Miktionsbeginn and Harnstottern. Pain and dysuria are not usually available. The feeling of incomplete bladder emptying, terminal dribbling, overflow incontinence or even a complete urinary retention may follow. Pressing urination into the prostatic urethra and Blasentrigonum to congestion of the superficial veins, which can trigger a rupture and hematuria. Presses can also cause acute and long-term vasovagal dilatation of the hemorrhoidal veins or Leistenbrüche.Harnretention Some patients present themselves with sudden and complete urinary retention, with significant abdominal discomfort and a Blasendistension. A retention may be triggered by one of the following: Prolonged attempts urine restrain immobilization cold influence use of anesthetics, anticholinergics, sympathomimetic, opioids or alcohol symptom scores The symptoms can be based on reviews as the "seven-question American Urological Association Symptom Score "(see table: American Urological Association symptom score for benign prostatic hyperplasia) quantify. This scoring allows doctors and the progression of symptoms to monitor: Mild symptoms: Scores 1 to 7 Moderate symptoms: Scores 8 to 19 Serious symptoms: is results 20 to 35 digital rectal exam In the digital rectal examination, the prostate often enlarges and insensitive , a firm-elastic consistency and often the middle furrow lost. However, the size of the prostate as it is found in the digital rectal examination can be misleading. A seemingly small prostate can cause an obstruction. An overextended bladder may be palpable or by percussion detectable in the abdominal examination. Diagnostic digital rectal examination urinalysis and urine culture PSA levels Sometimes uroflowmetry and bladder sonography The lower urinary tract symptoms of BPH can also be caused by other disorders, such as infection and prostate cancer. Furthermore BPH and prostate cancer can coexist. Although a palpable prostate sensitivity indicating an infection, the findings of digital rectal examination in BPH and cancer can often overlap. Although cancer can cause a rock-hard, knotty irregular enlarged prostate, the prostate feels benign enlarged at in most patients with cancer, BPH or in both cases. Therefore testing should be considered with symptoms or palpable prostate abnormalities in patients. Typically, urine analysis and urine culture are carried out, and PSA levels measured. In men with moderate or severe obstructive symptoms may also Uroflowmetry (an objective test of urine volume and flow rate) are carried out with measurement of the residual urine volume by bladder sonography. A flow rate <15 ml / s indicates a obstruction and a residual urine volume of> 100 mL of a retention down. PSA levels The interpretation of PSA levels can be complex. The PSA level is elevated in 30-50% of patients with BPH, increases depending on the size of the prostate and the degree of obstruction and in 25-92% of patients with prostate cancer according to tumor volume. In patients without cancer, interpret PSA serum levels> 1.5 ng / mL, generally on a prostate volume ? 30 ml out. If PSA is elevated (mirror is> 4 ng / ml), further discussion / participatory decision-making in relation to other tests or biopsy is recommended. In men <(2.5 ng / ml 50 or in those with high risk for prostate cancer, a lower threshold PSA) can> be used. Other measures, including the rate of PSA increase, the ratio of free to bound PSA and other markers may be useful (a full discussion of prostate cancer screening and diagnosis is sihc elsewhere) .For testing procedures A transrectal biopsy normally carried out by means of ultrasound guidance. Transrectal sonography can also measure prostate volume. A clinical assessment is necessary to determine whether further tests should be used. Imaging techniques with contrast agents (eg., CT, IPPC) are rarely necessary because the patient had had a urinary tract infection with fever or long-term and severe obstructive symptoms. Among the abnormalities of the upper urinary tract, which are generally caused by bladder outlet obstruction, include a cranial displacement of the terminal ureter (fishhook), ureteral and hydronephrosis. If due to pain or elevated serum creatinine levels an image forming method for the upper wing is attached, a sonography can be advantageous, because radiation and i.v. be avoided contrast agents. Therapy avoidance of anticholinergics, sympathomimetics and opioids use of alpha blockers (eg. As terazosin, doxazosin, tamsulosin, alfuzosin), 5-alpha reductase inhibitors (finasteride, dutasteride) or if at the same time there is a erectile dysfunction, the phosphodiesterase type -5 inhibitor tadalafil transurethral resection of the prostate or a less invasive procedure. A urinary retention urinary retention requires immediate relief. First, a standard urinary catheter will lay attempted if this fails, may be a catheter with a tip Thiemann- effective. So can not be placed, the catheter is a flexible cystoscopy or introducing filiform probes (guidewire and dilators which successively the Harnpassage wide) necessary (typically this procedure is performed by a urologist). Suprapubic percutaneous decompression of the bladder can be used if transurethral approaches unsuccessfully bleiben.Medikamentöse Therapy With partial obstruction with annoying symptoms all anticholinergics, sympathomimetic and opioids should be discontinued and infection be treated with antibiotics. In patients with low or medium obstructive symptoms, therapy with alpha-adrenergic blockers (eg. As terazosin, doxazosin, tamsulosin, alfuzosin) can reduce the problems with urination. 5-alpha-reductase inhibitors (finasteride, dutasteride) can reduce the enlarged prostate volume and reduce the problems with urination for months, especially in patients with large (> 30 ml) glands. A combination of both classes of drugs is superior to a monotherapy. In men with concurrent erectile dysfunction, can help eingemommens tadalafil to improve both symptoms daily. Many complementary and alternative OTC agents are recommended for the treatment of BPH, but none – including thoroughly investigated saw palmetto – has more effective than a placebo erwiesen.Operative interventions An operation is performed when patients do not respond to drug therapy or complications such as develop recurrent urinary tract infections, urinary stones, severe bladder dysfunction or dilatation of the upper urinary tract. Standard therapy is transurethral resection of the prostate (TURP). Erectile function and continence are usually recovered, although about 5-10% of patients have postoperative problems, most retrograde ejaculation. The incidence of erectile dysfunction after TURP is between 1 and 35%, and the incidence of incontinence in about 1-3%. About 10% of men who undergo TURP, the engaging within 10 years to repeat, because the prostate continues to grow. Various laser ablation techniques are used as alternatives to TURP. A larger prostate (usually> 75 g) requires an open procedure through a suprapubic or retropubic access. All surgical methods require postoperative catheter treatment over 1-7 Tage.Andere method to the less invasive procedures include microwave thermotherapy, electrovaporization, “High-Intensity Focused Ultrasonography”, transurethral needle ablation, radiofrequency vaporization, injection therapy with heated pressurized water, elevation of the urethra and intraurethral stents. The conditions under which these methods can be used have not yet been firmly established. the methods are used more and more that can be done in the doctor’s office (microwave thermotherapy, and radio frequency) and no anesthesia require. Their long-term effect on the natural history of BPH is still under investigation. (N. D. Ed .: In Central Europe, this alternative method are controversial and do not require a high percentage of [30 to 50%] of a reoperation by TURP. In addition to the gold standard of transurethral electroresection of the prostate (TURP) are laser vaporization and laser enucleation in experienced hands now well-established process. most of the alternative therapies require regional or general anesthesia.) Conclusion BPH is very common with aging, but only sometimes causes symptoms. In cold and prolonged attempts to retain urine in immobilization or use of anesthetics, anticholinergics, sympathomimetics, opioids or alcohol is an acute urinary retention may develop. Patients should be digital rectal studied and performed a urinalysis, measurement of PSA value and urine culture in general. In men with BPH, the use of anticholinergics, sympathomimetic and opioids should be avoided. Troublesome obstructive symptoms can with alpha-adrenergic blockers (eg. As terazosin, doxazosin, tamsulosin, alfuzosin), 5?-reductase inhibitors (finasteride, dutasteride), or if a concomitant erectile dysfunction is to be treated with tadalafil. When a BPH complications caused (z. B. recurrent stones, bladder dysfunction, dilatation of the upper respiratory tract), or if troublesome symptoms to drugs are resistant, a TURP or ablation should be considered.