PROSTATIC HYPERPLASIA (ENLARGED PROSTATE)
In many patients older than 50 years, the
prostate gland enlarges, extending upward into the bladder and obstructing the
outflow of urine by encroaching on the vesical orifice. This condition is known
as benign prostatic hyperplasia (BPH), the enlargement, or hypertrophy, of the
prostate. BPH is one of the most common pathologic conditions in older men
Examination reveals a prostate gland that is
large, rubbery, and nontender. The cause is uncertain, but evidence suggests
that hormones initiate hyperplasia of the supporting stromal tissue and the
glandular elements in the prostate (McConnell, 1998). The hypertrophied lobes
may obstruct the vesical neck or pros-tatic urethra, causing incomplete
emptying of the bladder and urinary retention. As a result, a gradual dilation
of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary
tract infections may result from urinary stasis, because some urine remains in
the urinary tract and serves as a medium for infective organisms.
The obstructive and irritative symptom
complex (referred to as prostatism)
includes increased frequency of urination, nocturia,urgency, hesitancy in
starting urination, abdominal straining with urination, a decrease in the
volume and force of the urinary stream, interruption of the urinary stream,
dribbling (urine drib-bles out after urination), a sensation that the bladder
has not been completely emptied, acute urinary retention (when more than 60 mL
of urine remains in the bladder after urination), and re-current urinary tract
infections. Ultimately, azotemia (accumula-tion of nitrogenous waste products)
and renal failure can occur with chronic urinary retention and large residual
volumes. Gen-eralized symptoms may also be noted, including fatigue, anorexia,
nausea, vomiting, and epigastric discomfort. Other disorders pro-ducing similar
symptoms include urethral stricture, prostate can-cer, neurogenic bladder, and
urinary bladder stones.
physical examination with DRE and diagnostic studies may be performed to
determine the degree to which the prostate is en-larged, the presence of any
changes in the bladder wall, and the efficiency of renal function. These tests
may include urinalysis and urodynamic studies to assess urine flow. Renal
function tests, including serum creatinine levels, may be performed to
determine if there is renal impairment from prostatic back-pressure and to
evaluate renal reserve. Complete blood studies are performed. Be-cause
hemorrhage is a major complication of prostate surgery, all clotting defects
must be corrected. A high percentage of patients with BPH have cardiac or
respiratory complications, or both, because of their age; therefore, cardiac
and respiratory function is also assessed.
The treatment plan depends on the cause of
BPH, the severity of the obstruction, and the patient’s condition. If the
patient is admitted on an emergency basis because he cannot void, he is
immediately catheterized. The ordinary catheter may be too soft and pliable to
advance through the urethra into the bladder. In such cases, a thin wire called
a stylet is introduced (by a urologist) into the catheter to prevent the
catheter from collapsing when it encounters resistance. In severe cases, metal
catheters with a pro-nounced prostatic curve may be used. Sometimes an incision
is made into the bladder (a suprapubic cystostomy) to provide drainage.
Although prostatectomy to re-move the hyperplastic
prostatic tissue is frequently performed, other treatment options are
available. These include “watchful waiting,” transurethral incision of the
prostate (TUIP), balloon di-lation, alpha-blockers, 5-alpha-reductase
inhibitors, transurethral laser resection, transurethral needle ablation, and
microwave ther-motherapy (Lepor, 1998; Mebust, 1998; McCullough, 1998).
Watchful waiting is the appropriate treatment for many patients because the
likelihood of progression of the disease or the devel-opment of complications
is unknown. Patients are monitored pe-riodically for severity of symptoms,
physical findings, laboratory tests, and diagnostic urologic tests.
receptor blockers (eg, terazosin [Hytrin]) relax the smooth muscle of the bladder
neck and prostate. These agents help to reduce obstructive symptoms in many
the hormonal component of BPH has been identi-fied, one method of treatment
involves hormonal manipulation with antiandrogen agents, such as finasteride
(Proscar). In clini-cal studies, 5-alpha-reductase inhibitors such as
finasteride have been effective in preventing the conversion of testosterone to
di-hydrotestosterone (DHT). With decreased levels of DHT, sup-pression of
glandular cell activity and decreases in prostate size have been demonstrated.
Side effects of these medications in-clude gynecomastia (breast enlargement),
erectile dysfunction, and flushing.
ultrasound guidance, resection of the prostate can be ac-complished with
lasers. The treated tissue either vaporizes or be-comes necrotic and sloughs.
This treatment is delivered in the outpatient setting and generally results in
less postoperative bleeding than a traditional surgical prostatectomy.
Transurethral needle ablation uses low-level
radiofrequencies to produce localized heat to destroy prostate tissue while
sparing the urethra, nerves, muscles, and membranes. The radiofrequen-cies are
delivered by thin needles placed into the prostate gland from a catheter. The
body then resorbs the dead tissue.
In microwave thermotherapy, heat is applied
to the hypertro-phied prostatic tissue. A transurethral probe is inserted into
the urethra, and microwaves are carefully directed to the prostate tis-sue. A
water-cooling system helps to minimize damage to the ure-thra and decreases the
discomfort from the procedure. The tissue becomes necrotic and sloughs.
Saw palmetto is a botanical remedy used for
symptoms of mild to moderate BPH such as urinary frequency and decreased force
of urine stream (Gerber, 2000; Marks, Partin, Epstein et al., 2000; Wilt,
Ishani, Stark et al., 1998). It is theorized that saw palmetto works by
interfering with the conversion of testosterone to DHT. In addition, saw
palmetto may directly block the ability of DHT to stimulate prostate cell
growth. It should not be used with finasteride or medications containing