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Benign Prostatic Hyperplasia(BPH)

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Benign prostatic hyperplasia is a nonmalignant enlargement of the prostate. It is also known as benign prostatic hypertrophy and abbreviated as BPH. This condition is a universal problem affecting most men over the age of 50. The prostate weighs few grams at birth, but it undergoes a growth spurt during puberty (under the influence of androgen hormone) and reaches the adult size of about 20gram by the age of 20. It then remains relatively stable inssize until the fifth decade of life when the second growth spurt commences. This explains why the condition affects men above 45 years and the frequency increases with age, thereafter, such that by the eight decade of life, about 90 percent of all men have some degree of benign prostate enlargement. because, the prostate surrounds the urethra and the lower part of the bladder neck, benign prostatic hyperplasia is the commonest cause of obstruction to outflow of urine in men.  than whites and it is yet unclear whether BPH is a precursor for prostate carcinoma.
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Even though it occurs in all population, it does so less frequently in the Orient. The condition occurs earlier in blacks.The hyperplasia begins in the transitional zone as a localized proliferation and gradually expand and pushes on the remaining part of the prostate gland. This growth can compress the urethra ( causing obstruction to urine flow) or the rectum ( causing constipation). Prostate hyperplasia has been observed to be enhanced by testosterone. It is characterized by proliferation of the stroma and epthelial cells of the prostate resulting in formation of large, fairly discrete nodules, palpable on rectal examination.

Symptoms Of Benign Prostatic Hyperplasia

The symptoms of benign prostatic hyperplasia are classified as obstructive or irritative. Obstructive symptoms are due to the compression of the bladder neck, prostatic urethra, recturm and other adjoining structures. The two groups of symptoms may occur independently or coexist together. Sometimes, an individual may have enlarged prostate without any symptoms.

Obstructive symptoms include: weak stream, hesitancy ( waiting for the urine to flow), intermittent urinary stream, terminal dribbling, feeling of incomplete bladder emptying and urinary retention.

Irritative symptoms which is due to contraction of the bladder detrusor muscle ( caused by irritation from the enlarging prostate) include: nocturia ( waking up to urinate at night), increased daytime urine frequency, urgency ( the desire to urinate that brooks no delay), urge incontinence ( leakage of urine caused by intense and sudden desire to urinate that warrants no delay), and dysuria ( painful urination).

Early symptoms may be minimal, because the bladder can undergo compensatory hypertrophy to overcome the resistance to urinary flow caused by the enlarging prostate.

Management Of Benign Prostatic Hyperplasia

Diagnosis
After a careful illness history is taken by the attending health practitioner, a digital rectal examination is performed ( as part of a comprehensive physical examination), to evaluate the size of the gland, shape, consistence and presence of nodularity or indurations ( which may suggest possible malignancy). The bladder is also palpated for fullness, which may suggest obstruction ( secondary to enlarged prostate). The symptoms of the disease is quantified using the American Urologic Association symptom questionnaire. Measurement of PSA (prostate specific antigen) level measurement is used to exclude the diagnosis of advanced cancer of the prostate. Other tests that may be carried out include i) uroflowmetry ( to objectively assess rate of urine flow), ii) measurement of the postvoid residual urine volume, iii) pressure-flow studies, and iv) urethrocystoscopy ( to assess visual obstruction, diverticuli formation, bladder calculi or trabeculation).

Treatment
Patients who have benign prostate enlargement, but do not have any symptoms, generally are not placed on any treatment. Patients who have developed complications of BPH ( such as urinary retention and renal failure) are often considered as candidates for surgery by health practitioners. All other patients are carefully evaluated and treatment modalities are based on severity of the symptoms and patient's expectations weighed against the possible side effects of the management strategies. The health practitioner will discuss these with the affected individual. The main treatment modalities are described below:

  1. Watchful Waiting:
    A lot of patients benefit from this approach, because the disease progresses slowly. These patients are monitored closely with regular ( at least annually) reevaluation of the complaints and clinical presentation.

  2. Medical Treatment:
    Medical Treatment is generally used as the first line of action to relieve symptoms in men with mild to moderate disease. Several forms of medical treatment may be employed by the health practitioner and these include: i) hormone manipulation ( which involves the use of luteinizing hormone-releasing hormone agonist, which reduces prostate growth by inhibiting testosterone. This form of treatment may be complicated by hot flashes, reduced libido, impotence and gynecomastia. ii) 5 alpha-reductase enzyme inhibitors block the conversion of testosterone to DHT, thereby reducing prostate size and improving symptoms, with fewer side effects. Men who respond to these treatments may chose to continue on the therapies indefinitely, but are closely monitored by their physicians.

  3. Surgery:
    Prostate surgery offers the best chance of symptoms improvement, but also carries heavy risk of complications. There are numerous approaches to removing the prostate but the commonest approach employed by most health practitioners is transurethral resection, which can be performed in ambulatory settings. Open prostatectomy are often reserved for patients with massive enlargement of the prostate. Other procedures include: Balloon dilation, laser therapy, intraprostatic stents and thermal therapy.

Absolute Indications For Interventions
There are situations when some form of treatment must be carried out by the health practitioner. Complications such as urine retention, heavy or recurrent blood in the urine, development of bladder stones, recurrent urinary tract infections due to obstruction ( and stasis) and renal insufficiency secondary to obstruction to the bladder outlet by the prostate. The aim of the management is to improve the symptoms, improve bladder emptying, resolve hematuria ( blood in the urine) and preserve the the urinary tract and kidney functions.


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