Examination methods and treatments for benign prostatic hyperplasia (BPH)
Men over 50 years of age who experience difficulty urinating or increased nocturia should be suspected of having benign prostatic hyperplasia (BPH) and should undergo a series of examinations to confirm the diagnosis.
1. Digital Rectal Examination (DRE): A digital rectal examination is the simplest yet extremely important step in diagnosing benign prostatic hyperplasia (BPH). Before the examination, the bladder should be emptied. A normal prostate is about the size of a chestnut. In BPH, enlargement (increased anteroposterior or transverse diameter) of the lateral or middle lobes can be felt in the rectum. The surface is smooth, and the prostate may bulge into the rectum. The texture is moderate, firm, and elastic. The central sulcus between the lateral lobes becomes shallower or disappears. Sometimes, enlargement of the middle or lower neck lobe of the prostate protrudes into the bladder, which can also cause severe obstruction and lead to typical symptoms of BPH, but the enlarged gland cannot be felt in the rectum. Therefore, even if the patient has obvious bladder neck obstruction, and the prostate is not enlarged on DRE, a diagnosis of BPH cannot be ruled out; further examinations are necessary for confirmation.
2. Residual Urine Measurement: The amount of residual urine can estimate the degree of obstruction and is one of the important indicators for determining whether surgical treatment is necessary. During the examination, the patient should be instructed to empty their bladder as much as possible before immediately measuring the amount. Methods of measurement include: ultrasound measurement, catheterization, and secretion-excretion method. Generally, a residual urine volume of 60 ml or more is considered one of the indications for surgical removal of the prostate.
3. Cystoscopy: Cystoscopy allows direct visualization of the location and extent of prostatic hyperplasia in the bladder neck, thus determining the treatment strategy and surgical method.
4. Cystography is essential when digital rectal examination cannot provide a definitive diagnosis, or when other lesions are suspected within the bladder. There are two methods for this examination: retrograde catheterization and the secretion-excretion method. X-ray findings of cystography in benign prostatic hyperplasia:
(1) The base of the bladder is elevated and protrudes upward in an arc. The bladder is pushed upward and displaced, and the distance between the edge of the bladder outlet and the pubic symphysis is widened, as if there is a filling defect.
(2) The prostatic urethra is elongated. If the lesion is in the middle lobe, the upper part of the prostatic urethra is displaced forward and the lower part is bent backward.
(3) Trabecular chambers or diverticula are visible in the bladder.
5. Ultrasound computed tomography (CT) for the diagnosis of prostate diseases is most suitable using P-mode ultrasound, which can depict the morphology and nature of the gland. There are two approaches to ultrasound examination of the prostate:
(1) Transabdominal wall method: The prostate is probed through the anterior abdominal wall above the pubic bone.
(2) Transrectal method: The rectum with a water-filled bladder is inserted into the anus with an ultrasound probe, and after water is injected and air is expelled, the prostate is probed.
6. Uroflowmetry primarily examines for obstruction in the lower urinary tract at the bladder neck. Statistics show that 71% of bladder neck obstructions are due to benign prostatic hyperplasia (BPH). Generally, a maximum urinary flow rate above 25 ml/s can rule out bladder neck obstruction, a rate between 10 and 25 ml/s suggests obstruction, and a rate below 10 ml/s indicates obstruction. In cases of lower urinary tract bladder neck obstruction caused by BPH, uroflowmetry shows a significant decrease in maximum urinary flow rate, urinary flow time, and total urine volume.
7. CT scan: CT scans have certain advantages over other imaging diagnostic methods in the diagnosis of urological and male reproductive system diseases.
8. Prostate imaging has diagnostic value in certain special cases.
9. Plasma Zinc Measurement: Normal prostate contains high tissue concentrations of zinc, which significantly increases in benign prostatic hyperplasia (BPH). Although there is no correlation between plasma zinc levels and prostate size, it can serve as one of the clinical indicators for diagnosing BPH.
10. Other examinations include urinalysis, kidney function tests, and certain special examinations if necessary.
In elderly patients with prostate problems or difficulty urinating, it is necessary to differentiate the condition from benign prostatic hyperplasia (BPH).
1. Prostate cancer, tuberculosis, stones, cysts, fibrosis, median crest, schistosomiasis.
2. Bladder-related conditions include tumors, stones, bladder trigone hypertrophy, neurogenic bladder, and ureteral orifice cysts.
3. Bladder neck lesions, specifically neck contracture.
4. Urethral conditions include seminal vesicle hyperplasia, urethral stricture (inflammatory or traumatic), tumors, and stones.
The presence or absence of neurogenic bladder is particularly important. Older patients often experience urinary retention due to neurogenic or muscular factors affecting urination, which can prevent normal urination even after complete treatment of benign prostatic hyperplasia. Therefore, considering these factors before surgery can significantly improve the surgical outcome and symptom relief.
Benign prostatic hyperplasia (BPH) that does not cause obstruction does not require treatment. If obstruction exists but does not affect normal physiological function, observation is recommended. However, if normal physiological function is affected (with a significant amount of residual urine present), treatment should be initiated as soon as possible. Treatment methods are as follows:
(1) When the heart fire is excessive, the heart fire should be drained and the bladder should be treated simultaneously: Ophiopogon japonicus, Poria cocos, lotus seeds and Plantago asiatica seeds can be decocted and taken orally.
(2) For excessive bladder fire, use the following formula: Daoshui San (Wang Bu Liu Xing, Ze Xie, and Bai Zhu decoction).
(3) When the fire of the gate of life is weak, use Bawei Dihuang Wan to help the fire of the gate of life.
(4) When Yin deficiency is extreme, replenish Yin: use Pure Yin to Yang Decoction (decocted with Rehmannia glutinosa, Scrophularia ningpoensis, Cinnamomum cassia and Plantago asiatica).
(5) For dryness of lung qi, nourish lung qi: use Shengmai San (ginseng 31g, ophiopogon japonicus 31g, schisandra chinensis 3g, scutellaria baicalensis 6g, decocted and taken orally).
(6) If the diet is irregular and the stomach qi is damaged, the yang qi should be raised: use Buzhong Yiqi Decoction.
2. Hormone therapy: Hormone therapy has some effect on early-stage cases, but opinions differ on the methods of application.
(1) Androgen therapy dosage: Testosterone propionate 25mg, intramuscular injection, 2-3 times a week, for a total of 10 times. Then change to 10mg, intramuscular injection, twice a week, for a total of 10 times. The total dose is about 350-500mg. If necessary, treatment can be repeated after 6 months. For those with acute urinary retention, 25mg once daily intramuscular injection, for 5-6 days or until spontaneous urination is possible. Due to differing opinions on androgen therapy and its limited effectiveness, some have tried combining estrogen and androgen, or using estrogen alone.
(2) Combined use of female and male hormone therapy.
(3) Estrogen therapy: Currently, there is a lot of advocacy for the use of estrogen to treat benign prostatic hyperplasia, which can achieve good results, shrink the gland, make it tougher, and improve urination symptoms to varying degrees.
(4) Anti-androgen therapy.
(5) Progesterone therapy: Progesterone (luteal hormone) has been widely used in recent years. It works by inhibiting the binding and nuclear uptake of androgens to cells, or by inhibiting 5α-reductase to interfere with the formation of dihydrotestosterone. Types include progesterone-17-hexanoate, progesterone-17-hydroxy-19-norhexanoate, medroxyprogesterone acetate, and dimethoprim-progesterone. The last two are the most promising.
3. Other drug treatments
(1) α-Adrenaline: can be blocked by phenoxybenzamine, phentolamine, prazosin, nicergoline, thymolamine, methyldopa, etc.
(2) Bromocriptine: also known as bromocriptine. Prolactin plays a role in the uptake and utilization of androgens by prolactin cells, so the intake of prolactin antagonists can interfere with this process. Early reports on the use of this drug suggested that it could improve prostate irritation symptoms, but not obstructive symptoms.
(3) Spironolactone: also known as spironolactone. Spironolactone is an inhibitor of androgen synthesis that can significantly reduce plasma testosterone and has an anti-androgenic effect.
(4) Adrenocortical hormones.
(5) Pollen: In recent years, bee pollen has been used in China to make Qianliekang tablets, which contain amino acids, vitamins, enzymes, sugars and trace elements. It has a certain curative effect on the prevention and treatment of benign prostatic hyperplasia and the improvement of symptoms.
4. Intraprostatic injection therapy
(1) Injectable medication: 9ml carbolic acid, 9ml glacial acetic acid, 18ml glycerin, and 450ml distilled water. Mix and dispense 3ml into each ampoule for sterilization.
(2) Injection method: Lie on your left side with your right leg bent and your left leg straight. After local anesthesia of the perineum, insert one finger into the anus to locate the top of the prostate. Use a lumbar puncture needle (20 gauge) to penetrate the anesthetized area until it reaches the prostate gland. When injecting the medication, aspirate to ensure there is no blood or urine. There should be slight resistance during the injection. Inject once every 5 days. If there is urinary retention, a catheter should be inserted.
(3) Complications: mild cystitis, urethritis, orchitis and epididymitis.
5. Physical therapy uses various physical methods to cause local edema, congestion, and even tissue atrophy in the prostate, thereby improving urinary symptoms. This is a developing method that requires continuous exploration and improvement, and may become one of the main treatments for benign prostatic hyperplasia in the future. It includes: (1) cryotherapy; (2) microwave therapy; and (3) ultrasound therapy.
6. Management of Acute Urinary Retention: 65% of patients with benign prostatic hyperplasia (BPH) experience acute urinary retention symptoms, which often occur suddenly, causing severe urinary distress and requiring immediate relief. When relieving acute urinary retention, urine should be drained gradually from the bladder; sudden emptying should be avoided, especially in cases complicated by uremia. Sudden bladder emptying can cause abrupt changes in hemodynamics, leading to heart failure, shock, or massive renal hemorrhage, bladder bleeding, or perivesical bleeding. It can also cause urinary retention and electrolyte imbalance. After drainage, electrolyte imbalances must be monitored for 3 days. If necessary, potassium, sodium, and chloride electrolytes should be supplemented. In addition to treating acute urinary retention, pain relief and infection control or prevention are also essential.
The following are some methods to relieve acute urinary retention:
(1) Apply heat to the lower abdomen and perineum.
(2) Acupuncture: Select acupoints such as Zhongji, Pangguanshu, Sanjiaoshu, Yinlingquan, etc.
(3) Catheterization: Catheterization is performed under aseptic conditions.
(4) Drug treatment.
(5) Suprapubic bladder puncture: When a catheter cannot be inserted and there is no other way to resolve acute urinary retention, suprapubic bladder puncture is a temporary emergency measure.
(6) Cystostomy: When acute urinary retention is caused by benign prostatic hyperplasia and a catheter cannot be inserted and there is no condition for prostatectomy, cystostomy can be performed to resolve acute urinary retention.
(7) Emergency prostatectomy: The indications for the surgery are as follows: ① The patient is in good general condition and has no clinical signs of uremia or acidosis; ② There is no serious cardiovascular or pulmonary disease; ③ Non-protein nitrogen is below 50 mg%; ④ CO₂ combining power is within the normal range; ⑤ When performing cystotomy, indigo carmine is injected intravenously and blue urine is discharged from the orifices of both ureters within 8 minutes.
7. Surgical treatment
(1) Surgical indications:
① Benign prostatic hyperplasia (BPH) presents with progressive difficulty urinating, and non-surgical treatment has failed to achieve the desired effect.
② Chronic urinary retention with residual urine volume exceeding 60 ml. Many authors now use bladder function tests such as uroflowmetry, cystometry, and urethral manometry to determine surgical intervention. When the detrusor muscle is in a compensatory phase, surgery should be considered an indication.
③ Obstruction can lead to bladder diverticulum or stones, and hydronephrosis and hydroureter.
④ Chronic or recurrent urinary tract infections caused by obstruction.
⑤ Benign prostatic hyperplasia accompanied by bleeding, especially heavy and recurrent bleeding.
⑥ Acute urinary retention.
(2) Surgical methods: There are currently four commonly used methods.
①Suprapubic prostatectomy.
② Retropubic prostatectomy.
③ Transperineal prostatectomy.
④ Transurethral resection of the prostate (TURP).
In summary, among the various surgical procedures mentioned above, scholars generally consider suprapubic and retropubic prostatectomy to be the most practical. It can essentially resolve all types of benign prostatic hyperplasia (BPH), offers greater flexibility, and allows for cystostomy in emergency situations to temporarily resolve urination problems. If a tumor is found, the surgical scope can be expanded. The complication rate is not significantly higher than other surgical approaches.
(3) Common complications of prostate hyperplasia surgery and their prevention and treatment:
① Bleeding: The following hemostatic measures can be used: a. Packing the prostatic fossa with hot saline gauze. b. Compression of the prostatic fossa using a double-lumen or triple-lumen balloon catheter (Foley catheter). c. Ligation of the bladder neck and prostatic fossa with catgut sutures. d. Local application of medications to the prostatic fossa (such as adrenaline, pituitary hormone, etc.). e. Local cooling of the prostatic region. f. Controlled hypotension. g. Ligation of the internal iliac artery. h. Application of systemic hemostatic agents. i. Local application of hemostatic agents to the prostatic fossa (such as gelatin sponge, compound aluminum solution, etc.).
②Infection: Infections after prostatectomy can occur in three ways: a. Urinary tract infection; b. Genital tract infection; c. Pubic bone infection.
③Urinary incontinence: This can occur in various prostate surgical procedures, but it is less common in retropubic prostatectomy. It is mainly caused by damage to the external sphincter and nerves.
④ Urinary fistula: It occurs when the rectum is damaged during surgery, or when the bladder neck is not wedge-shaped or the prostate is not completely removed during surgery, causing bladder neck obstruction, which leads to the formation of a fistula between the bladder and the abdominal wall, perineum or rectum.
⑤ Urethral stricture: More common in patients undergoing retropubic prostatectomy. Strictures can occur in the navicular fossa, urethral orifice, anterior urethra, bulbar urethra, or membranous urethra. This is mainly caused by a large indwelling catheter and periurethral inflammation. Prevention involves placing a thinner, softer catheter for a shorter duration. Treatment after stricture occurs includes urethral dilation or transurethral resection of the stricture.
⑥ Impact on sexual function: Transperineal prostatectomy has the greatest impact on sexual function.