Benign prostate hyperplasia (BPH) is a benign enlargement of the prostate gland, caused by enlargement of components in tissue include the prostate gland / fibromuscular tissue that causes blockage of urethra .
According to Mutaqqin in his book, Prostate Hyperplasia or BPH (Benign Prostate Hyperplasia) is a progressive enlargement of the prostate gland, benign hyperplasia is caused by the components that lead to blockage of urethra.
Suryanto and Madjid said that benign prostate hyperplasia (BPH) is an enlargement of the prostate gland and tissue associated with endocrine changes related to the aging process.
BPH (benign prostate hyperplasia) is a progressive enlargement of the prostate gland that can cause the obstruction and ristriction on the urine (the urethra).
Black & Hawks stated that the prostate is the organ most frequently affected genital neoplasms, benign enlargement of the prostate gland is a very common disease that occurs in almost all men with normal testicular functions. Benign prostate enlargement is defined as the growth of the prostate that block urethra, by disrupting the function of the lower urinary tract. However, the term of benign prostate hyperplasia (BPH), which is defined as the growth of the prostate gland.
Based on the writers above the definition of Benign Prostate Hyperplasia is an enlargement in prostate gland or men’s gland. This gland is only in men, no prostate gland in women, so this disease is like men disease. The enlargement of this gland will block the urethra where urine flow through it.
Etiology
BPH began in 45 years old men and it still will be growing in older age, over 80 years old men approximately 80% suffer from this disease. Now considered as the etiology of endocrine imbalance, testosterone is thought to affect the edge of the prostate, whereas estrogen (made by the adrenal gland) affects the central part of prostate.
The exact cause of the occurrence of BPH is still unknown. But certainly the prostate gland depends on androgen hormone. Another factor which is closely related to BPH are aging. According to Padilla, there are several possible causes of BPH:
Dihydrotestosteron
Increased 5 alpha reductase and androgen receptor causes epithelial and stromal hyperplasia of the prostate gland experience.
Changes in Estrogen-Testosterone Balance
The aging process in men increased estrogen and decreased testosterone resulting in stromal hyperplasia.
Stroma-Epithelial Interactions
Increased epidermal growth factor or fibroblast growth factor and transforming growth factor beta reduction causes stroma and epithelial hyperplasia.
Reduced Cell Death
Increased estrogen causes increased stroma and epithelium of the prostate gland.
Stem cells theory
Stem cells has responsibility in increased cell proliferation.
Pathophysiology
Prostate gland is part of men genital organ located in the reproduction area. The form of this gland is like a nut with normal weight about 20 gram. Prostate gland can be divided into many zones; peripheral, central, transitional, fibromusculer, and periurethra zone. In older age, a man will have imbalance between testosterone and estrogen, testosterone will decrease and convert to estrogen inside adipose tissue. This gland growth is depend on this testosterone hormone, inside prostate gland this hormone will become dehydrotestosteron (DHT) by alpha reductase enzymes.
DHT will trigger m-RNA in gland cell to synthesis protein so that prostate gland will grow. Prostate enlargement will be grow incontrol progressively, then urine tract will be disturbed. In first stage of prostate enlargement will make urine resistant. Then the bladder muscle will compensate and be bigger in contraction. If the bladder contraction is still there, bladder muscle will be fatigue and no longer contract so that the urine retention will occur.
In prostate hyperplasia can be manifested by two signs such as obstruction and irritation. Obstruction sign is caused by bladder muscle can not have contraction any longer (it makes disturbance in urinating, blocked urinating, slow urine flow). Irritation signs are caused by urine remain, its condition will make prostate gland irritate bladder, so bladder muscle become hypersensitive and make urinate frequency is increase, nucruria, and disuria.
Because urine production is always occur in human body, so it will make bladder can not store urine anymore, so intravessica pressure will increase from sfingter and obstruction in it, so overflow incontinence will occur in patient. Chronic retention makes ureter and dilatation. Urether and kidney will be damage and lead to kidney failure. Upper urinary tract will be damage to because of chronic obstruction, it will make the patient use extra energy to urinate, and this circumstances lead to hernia and hemorrhoid. Urine residue in bladder will make a stone, that stone will make irritation inside urinary tracts, thus bloody urine will come out from urinary system. Beside that, urine residue will be optimal place for microorganism, the infection will occur (cystitis and pyelonefritis)
In the assessment, urinary obstruction has signs of obstruction and irritated urinary tract. Some urinary obstruction sign is like hesitancy, frequent in urinating, and bladder full feeling. Assessments in men reproduction system and urethra is needed to detect meatus stenosis, urethra structure, stone of urethra, carcinoma, and also fimosis. Then, the scrotum assessment is needed to identify problem in it such as epidimitis (inflammation of sperm duct).
Bimanual technique assessment in abdomen to identify hydronefrosis and pyelonefrosis. In supra-simfisis area, we can find a tumor. When we palpate we got a ballottement and the client want to urinate when we do percussion test we know about urine residual. There is an assessment called rectal touch, this assessment is touch the prostate through rectum or anus, the purpose of rectal touch is to know consistency of neurology system unit of urethra and enlargement of prostate.
Sign and Symptoms
Although prostate hyperplasia always occurs in older people, but not always accompanied by clinical symptoms. Clinical symptoms occurred because of 2 things: narrowing the urethra causes difficulty in urinating, and retention of urine in the bladder causes bladder dilatation, hypertrophy of the bladder and cystitis.
Clinic manifestation
The first symptoms of BPH are polyuria, dysuria, and nucturia. However, in the early stage, a normal urinating is still possible, or maybe at this stage the bladder empty may no longer be able to complete, due to reduced muscle system and innervation adapt to these conditions. Because obstruction of the urinary tract, renal insufficiency is imminent. Furthermore it remains unclear whether BPH is a predisposing factor for prostate cancer.
The symptoms of BPH can be classified as obstruction and irritation. Obstructive symptoms include hesitancy, intermittent, incomplete urine output, poor urine flow .
Clinical manifestations clients with BPH are:
- Polyuria (frequent urination), because the bladder is only able to spend a little bit of urine.
- Flow of urine becomes blocked, due to the narrowing of the urethra.
- Haematuria (urine containing blood), due to congestion of the bladder base.
- Urine retention
- Hydronephrosis and renal failure, caused by back pressure through the ureters to the kidneys.
Diagnostic Tests
- Rectum Touch: the palpation of the prostate through the rectum or rectal toucher, to see an enlarged prostate.
- Urinalysis: to detect the presence of protein or blood in the urine, specific gravity and osmolarity, as well as examination of the urinary.
- Laboratory tests (blood) is to determine the presence of elevated levels of prostatespecific antigen (PSA).
- Cytoscopy: to know the picture of prostate enlargement and bladder wall changes.
- Transrectal ultrasonography performed to determine the magnification and the presence of hydronephrosis.
- Intravenous Pyelography (IVP): to know the structure of calix, pelvis, and ureter. This structure will be distorted if there is a form cysts, lesions and obstruction.
Treatment
Change lifestyle
Patient should reduced the consumption of alcohol and caffeine containing products.
Medicine
Alpha blockers, an αl-adrenergic receptor antagonists (eg: Doxazosin, terazosin, alfuzosin, and Tamsulosin), can improve the symptoms of BPH. Alpha blockers can relax the muscles in the prostate and bladder, and reduce the degree of resistance urine.
5α-reductase inhibitors (eg, finasteride and dutasride) when used in combination with alpha blockers may decrease the progression of prostate enlargement.
Catheter
Antimicrobial
Surgery
Prostatectomy is surgery to remove all or part of the prostate gland. Prostate abnormalities, such as a tumor or an enlarged prostate gland due to various reasons can obstruct the flow of urine.
There are several forms of surgery on prostate, including:
Transurethral Resection of Prostat (TURP)
Sistocopy a tool inserted through the urethra into the prostate where the surrounding tissue excised. TURP is a surgery performed on BPH and the result is perfect with a 80-90% success rate.
Prostatectomy
Prostatectomy is a surgical procedure to perform an incision in the skin and remove the prostate through the capsule of the prostate adenoma (retropubic prostatectomy), or through the bladder (suprapubic prostatectomy).
Laparoscopy Prostatectomy
A small incision laparoscopy is made in the abdomen and around the prostate, removed carefully where the nerves more easily damaged by retropubic or suprapubic technique. Laparoscopic prostatectomy or retropubic prostatectomy and more economical than a robot assistance.
Robotic-assisted Prostatectomy
Robotic-assisted prostatectomy or robot assisted surgery. Laparoscopy robotic hands controlled by one surgeon. Robot gives the surgeon more ability in, including smaller incisions, mild pain, slight bleeding, lower risk of infection, faster healing time, and a shorter treatment.
Radical Perineal Prostatectomy
Radical perineal prostatectomy is an incision made in the perineum in the middle between the rectum and the scrotum, and then prostate removed.
Radical Retropubic Prostatectomy
Radical retropubic prostatectomy is an incision made in the lower abdomen, and then the prostate removed (lifted) through the back of the pubic bone (retropubic). Radical prostatectomy is one of the actions in prostate cancer.
Transurethral Electrovaporization of the Prostate (TVP)
Transurethral Plasmakinetic Vaporization Prostatectomy (TUPVP)
Laser TURP
Visual Laser Ablation (VLAP)
Transurethral Microwave Thermotherapy (TUMT)
Transurethral Needle Ablation (TUNA)
Complication
- Urinary tract infection
- Acute retention urine
- Obstruction and dilatation of the urethra, hydronephrosis and impaired renal function.
Prognosis
Prognosis in BPH is unpredictable in each individual. Although symptoms tend to increase, BPH prognosis can be a poor prognosis because it can develop into prostate cancer .
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