Benign Prostatic Hypertrophy (BPH)
The prostate is a gland that is part of the male reproductive system, shaped like a walnut. It consists of two components: glandular (alveolar tubule) and a connective tissue stroma divided into three zones. A centrality of 25%; a transition which has a 5% and a peripheral which occupies 70%. Benign prostatic hypertrophy (BPH) occurs in the transition zone. It is located in front of the rectum and just below the bladder surrounding the proximal urethra.
GROWTH: between 10 and 20 years produces the highest growth, reaching a normal weight 20gr. Then remains the same for 25 years and then begin again to increase in size.
• 25% of patients treated 80 years. para HPB. for BPH.
• At 60 years 50% have histological changes compatible.
• At 80 years, 95% have changes compatible.
• 10% of patients present with acute urinary retention.
In the USA is the second major surgery performed after the falls: 300,000 per year.
Physiology: not known with certainty the origin of BPH. It has been known for years that the age and androgens play a key role in its development. Hence orchiectomy patients in puberty do not develop BPH.
Pituitary : LH and FSH stimulate release of testosterone in the testis, which becomes the peripheral level to dihydrotestosterone by 5 alpha reductase. The latter binds to the receptor in the prostate and stimulates its growth.
Symptoms: Symptoms of BPH can be divided into 2 categories. These symptoms are related to two components: the first dynamic since the stimulation of alpha adrenergic receptors and the second a static component given by the proliferation of glands and stroma and changes in the level of the detrusor muscle.
- Irritating: they occur first. The most common are urinary frequency, dysuria, nocturia and incomplete emptying sensation.
- Obstructive: occur in stages when growth occurs due to a certain degree of obstruction, e.g thin stream, and difficulty starting urination, broken and full retention of urine.
Importantly, the size of the prostate does not correlate with the intensity of symptoms, and patients with small prostate can be highly symptomatic and otherwise.
Not infrequently, patients present with acute obstruction: basically those with little symptomatic BPH who drink coffee, alcohol or drugs with alpha-agonist action, such as nasal decongestants.
Complications: occur in less than 10% of patients.
- Urinary tract infections: 30% of surgery patients will have asymptomatic bacteria
- Renal failure secondary to obstructive uropathy.
- Gross hematuria.
- Acute urinary retention.
Diagnosis: The initial assessment of a patient with BPH, consisting of:
- Interrogation: general history and also will ask the following.
- Frequent urination.
- Presence or absence of nocturia.
- Decreased force of the jet.
- Feeling of incomplete emptying.
- Postvoid dribbling.
- General physical examination.
DRE: size, texture, shape and texture.
Index of the American Urologic Association.
Dosage of creatinine and urinary sediment.
Dosage of PSA (OPTIONAL).
Importantly, the two ultrasound is better because it allows us to see if there uronefrosis or not.
Urinary flow studies (uroflowmetry) is the best noninvasive urodynamic test to detect obstruction. It measures the average and maximum flow. The bladder must be full and performed in the office.
Normal: according to patient age
- <40 years> or = 22ml/seg.
- 40 to 60 years> or = 18ml/seg.
- > 60 years> or = 13ml/seg.
Not routinely performed. It must apply to patients with atypical symptoms or young, e.g significant irritative symptoms and very little obstruction.