BPH
Introduction
Introduction to prostate hyperplasia in the elderly Hyperplasia of prostate: short for benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy. However, from a pathological point of view, the cells increase to hyperplasia, and the cells enlarge to hypertrophy. The pathology of benign prostatic hyperplasia is confirmed to be an increase in cells, rather than cell hypertrophy. Therefore, the correct name should be benign prostatic hyperplasia, referred to as benign prostatic hyperplasia. Prostatic hyperplasia is a common disease in men over 50 years old. basic knowledge The proportion of the disease: the domestic incidence rate of 50 years or older is about 50% Susceptible people: the elderly Mode of infection: non-infectious Complications: urinary incontinence
Cause
The cause of benign prostatic hyperplasia in the elderly
Causes:
The true cause has not yet been elucidated. There are several theories: dihydrotestosterone theory, male-estrogen synergy theory, embryo re-awakening theory, stem cell theory, interstitial-epithelial interaction theory, in which the role of dihydrotestosterone is most valued. At present, various antiandrogen therapies are based on this theory.
Pathogenesis
The prostate is a male luminal gland between the bladder and the genitourinary tract. The adult male's prostate is shaped like an inverted chestnut. It can be divided into the bottom, the body and the tip. The prostate has a longitudinal diameter of 3 cm. The diameter is 4cm, the anteroposterior diameter is 2cm, the bottom of the prostate is upwards, and the anterior part is tightly connected to the bladder neck. The urethra runs through it, the seminal vesicle adheres to the posterior part, the tip of the prostate is downward, the tip is small, and the urethra membrane The fusion of the part ends with the urinary genital warts, the body between the bottom and the tip is the body, the front of the body is more convex, the back is flatter, and there is a shallow groove in the center, called the central fossa of the prostate. For the left and right 2 leaves, the rectal examination can be used to understand the condition of the prostate through the anterior rectal wall of the rectum and the posterior left and right lobe of the prostate to understand the prostate. The weight of the adult prostate is about 20g.
Pathology
Human prostate is mainly composed of glandular tissue and non-glandular tissue. The main part of glandular tissue is related to prostate function and disease. Mcneal (1988-1990) combines the morphological function and pathology of prostate. Name the prostate, the gland part can be divided into 4 areas, the peripheral area accounts for 70% to 75% of the gland, the central area, which accounts for 25% of the gland (both are the peripheral part of the prostate), and the migration area accounts for The gland is 5% to 10%, and the area around the urethra is less than 1%. The transition zone and the area around the urethra are specific sites of benign prostatic hyperplasia.
Pathologically, benign prostatic hyperplasia, also known as prostatic nodular hyperplasia, is the most common tumor-like lesion in the prostate. The onset of nodules may be the spontaneous reversal of stromal cells to the embryonic stage, and its growth potential may be matrix. The interaction between the epithelium is caused by the formation of prostatic hyperplasia, which is rare in people under the age of 50, but increases with age until 70 to 80 years old, nodular hyperplasia in the prostate. That is, it begins to occur in the transitional zone of the prostate and the tissues around the urethra. The nodules in the tissues around the urethra are similar to those in the embryonic phase, and are the matrix components, while the nodules in the transition zone are glandular components, and the growth of benign prostatic hyperplasia is 3 An independent process:
1 nodule formation.
2 The transition zone is diffusely enlarged.
3 nodules increased, Mcneal found that patients aged 50 to 70 years, although the transition zone increased by 1 times, but the nodules only accounted for 14%, the diffuse increase in the transition zone is less than 70 years old, 70 years old At the beginning, until the 80-year-old nodule increased significantly, it was the main cause of prostate hyperplasia during this time.
General observation: hyperplasia of the prostate generally has walnuts or chicken eggs, even larger, like the size of goose eggs, smooth surface, nodular, tough, elastic, normal prostate weight of about 20g, up to 30 when proliferating ~80g, even can weigh more than 100g, in the body, the surrounding normal prostate tissue can be squeezed to form a fibrous "surgical envelope", the surgical capsule is tough, elastic, and there is a tissue between the nodular hyperplasia The obvious demarcation is conducive to the removal of proliferative tissue during surgery, but prostate cancer can still occur in the remaining prostate. The cut surface view: some small nodules are mainly fibromuscular components, which are pale, homogeneous, and smooth. It is soft and can spill a small amount of milky white liquid. Some nodules are honeycomb or sponge. The acinus is cystic. The size of benign prostatic hyperplasia is not proportional to the degree of urinary flow obstruction, that is, the degree of prostate symptoms, but directly with the enlarged part. Relationships, such as: the adenoids around the urethra, the adenoids in the glands around the urethra invade, then slowly proliferate, multi-directional proximal urethra development, burst into the bladder to form the so-called mid-lobe hyperplasia Urethral hyperplasia, even when the gland increases less than 10g, can cause severe obstruction case.
Microscopic observation: hyperplastic nodules include the original components of the prostate itself, glandular fibrous tissue and smooth muscle, but the proliferation is uneven. The earliest prostatic hyperplasia is interstitial hyperplasia, and the interstitial smooth muscle of the nodules increases. The elastic fiber is reduced, followed by the proliferation of glandular components, and the glandular body often has irregular expansion, even in the form of cysts, sometimes intraluminal papillary processes, which contain red-stained protein secretions, sometimes forming small calcifications. Body, glandular epithelium is flat or columnar, the nucleus is regular, the nucleolus is not obvious, the cytoplasm is lightly stained, the gland is surrounded by the intact basement membrane, the periphery of the nodule has no obvious fibrous envelope, and there is no boundary between the normal prostate. In recent years, nearly 25% of enlarged gland infarctions have been observed. Cellular infection causes cellulitis, acinar dilatation, catheter obstruction causes secretion retention, focal atypical hyperplasia, epithelial metaplasia, It is a meaningful pathological feature of benign prostatic hyperplasia.
2. Pathological typing
According to the proportion of glandular epithelium and fibrous tissue and smooth tissue of proliferating glands, prostate hyperplasia can be divided into several different subtypes:
(1) sclerosing adenosis: similar to the lesion of the same name in the breast, the nodule boundary is clear, composed of glands and epithelium of various sizes and shapes, the gland is usually compressed, often has mucin-like interstitial formation, epithelial-peripheral Basement membrane and basal cells.
(2) fibrous adenoma-like type: glandular, smooth muscle and fibrous tissue are hyperplasia.
(3) adenoma-like type: mainly glandular hyperplasia, like adenoma, less interstitial, no real surface capsule, so it is not a true adenoma.
(4) fibroproliferative type: mainly fibrous tissue hyperplasia, glandular hyperplasia is relatively light, sometimes smooth muscle hyperplasia and fibrosis is mild, like leiomyoma, these types are different stages of disease development, often in the same case Mixed together, can not be classified, some invisible lesions can be seen in the tissue of BPH resection, ranging from a few millimeters to a few centimeters. The more the lesions are replaced by fibrous scar tissue, and the squamous epithelialization is often seen around the infarct. .
Prevention
Elderly prostate hyperplasia prevention
Preventive medicine is a focus of many medical fields, and it is well used in many therapeutic fields, especially in preventive cardiology. At present, urology has begun to attract attention.
Risk factor
There have been many reports on the risk factors of benign prostatic hyperplasia, but the conclusions are very inconsistent. First, the age factor is closely related to the occurrence of benign prostatic hyperplasia, which has been introduced before, but there are many other factors that may affect the occurrence of benign prostatic hyperplasia. These factors are as follows: Smoking, genetics, diet, obesity, drinking, sexual life, socioeconomic status, hypertension, psychosis, etc. Although there are many studies on these factors, their relationship with the occurrence of benign prostatic hyperplasia has not been determined, such as smoking, tobacco Nicotine can increase the level of testosterone in humans. It seems that smoking can increase the risk of benign prostatic hyperplasia. Mild smoking (1 pack/d) is not easy to be associated with moderate to severe urinary tract symptoms. Moderately smokers (1 to 1.4 packs/d) ), no significant correlation with benign prostatic hyperplasia, severe smoking (> 1.5 packs / d), increased chances of lower urinary tract symptoms, there are reports that smokers have less chance of prostatectomy than non-smokers, but also believe that this Because chronic obstructive pulmonary disease prevents surgery, heavy drinking can lower serum testosterone levels, reduce testosterone production and increase clearance, liver Insufficient function can also reduce serum testosterone and bismuth-high ketone. Foreign autopsy shows that cirrhosis with prostatic hyperplasia is lower than non-cirrhosis. Because the most common cause of cirrhosis in foreign countries is alcoholism, its low incidence is liver. As a result of the dual effects of sclerosis and alcoholism, it has been reported that patients with hypertension and those taking Rauvolfia hypertension have a higher incidence of benign prostatic hyperplasia and surgery.
Studies have shown that there is a genetic predisposition to benign prostatic hyperplasia. Recent studies have shown that the possibility of simultaneous benign prostatic hyperplasia (14.7%) is significantly higher than that of fraternal twins, and the possibility of benign prostatic hyperplasia (4.5%); another study It shows that the incidence of moderate to severe urinary tract symptoms has a certain family tendency. The incidence of prostatic hyperplasia in Jews is higher than that of non-Jewish people. Blacks are higher than whites. Another family history of benign prostatic hyperplasia has been reported. The symptoms of prostate are more serious than those without family history. The results showed that benign prostatic hyperplasia may be related to heredity. Other history of urinary tract infection, pH 6.0, diabetes, sexual life intensity, vasectomy, low body mass index, cultural education level, etc. are considered as possible risk factors, but still There is a debate.
2. Prevention strategy
(1) Census strategy: The whole society census is beneficial for the prevention of symptoms of benign prostatic hyperplasia. It can strengthen the health promotion and education for community residents, increase self-examination of the masses, early detection of disease and treatment awareness, and improve the level of diagnosis and treatment of community medical staff. Correctly guide the community to self-prevention of disease, transfer the relevant patients to the higher level hospital for further diagnosis and treatment, and recommend that men over the age of 50 should conduct regular inspections every year.
(2) Avoidance of risk factors: Since there are many risk factors that can affect the occurrence of benign prostatic hyperplasia, then avoiding risk factors becomes a corresponding strategy to prevent benign prostatic hyperplasia, but if young, genetic, these clear risk factors are unavoidable, and We can avoid potential risk factors such as improving bad habits, reasonable diet, paying attention to psychological balance, conducting health education, and advocating self-care.
(3) Chemical prevention: Since prostatic hyperplasia takes a long time from the occurrence to the development, it is possible to prevent the occurrence of prostatic hyperplasia. The regulation is to inhibit the conversion of testosterone to be active in the prostate. Dihydrotestosterone (DHT) drugs, in theory, can prevent the growth of testosterone on prostate cells.
Complication
Elderly patients with benign prostatic hyperplasia Complications, urinary incontinence
Commonly, there are filling urinary incontinence, secondary infection and formation of stones, kidney damage and so on.
Symptom
Symptoms of benign prostatic hyperplasia in the elderly Common symptoms Bladder emptying incomplete bladder irritation Prostatic hyperplasia Bladder stones nocturia increased urgency appetite weak blood urine urinary weakness
The size of benign prostatic hyperplasia is not directly proportional to the symptoms, so it can often be seen in the clinic. The clinical symptoms of benign prostatic hyperplasia are very obvious, but the signs are not obvious. The rectal prostatic hyperplasia is not obvious, and there is also obvious prostate hyperplasia during physical examination. No obvious clinical symptoms, or atypical symptoms, usually appear after the age of 50, the symptoms are determined by the degree of obstruction, the speed of the disease development, and whether the infection and stones are combined, the symptoms are light and heavy, the hyperplasia does not cause obstruction or light Degree obstruction is completely asymptomatic and has no significant effect on health. Prostate hyperplasia is mainly manifested in two groups of symptoms, namely bladder irritation and obstruction symptoms.
1. Bladder irritation
Prostate irritation includes frequent urination, urgency, nocturia, and urge incontinence. These symptoms of benign prostatic hyperplasia are caused by the complex interaction between the prostate and the bladder. Prostatic hyperplasia is an increase in urethral resistance. The bladder needs to overcome its resistance to discharge the urine, so that the detrusor pressure is increased, resulting in compensatory hypertrophy of the smooth muscle of the bladder wall. Although the detrusor can maintain the normal discharge of urine, its function is not completely normal, and the bladder irritation may be Bladder outlet obstruction, non-obstructive detrusor instability, and irritating symptoms: frequent urination, urgency, frequent urinary frequency is the clinical symptoms of patients with benign prostatic hyperplasia, normal males urinate every 3 to 5h, bladder capacity is 300 ~ 500ml, the elderly prostate prostatic hypertrophy is due to detrusor decompensation, the bladder can not be completely empty, residual urine volume increased, the effective capacity of the bladder is reduced, so that the urination time is shortened, first the number of nocturia increased, each time urine Not much amount, followed by frequent urination during the day, increased number of nocturia, due to unstable detrusor or kidney loss Caused by normal urinary rhythm, nighttime vagus nerve excitement, decreased bladder tension, increased residual urine volume, may also be the cause of increased urine, 50% to 80% of patients still have urgency or urgent urinary incontinence, if accompanied Bladder stones, or infection, frequent urination, urgency is more obvious, and accompanied by dysuria.
2. Obstructive symptoms
The prostate continues to increase, the urethral resistance increases, and the bladder outlet obstruction occurs. When the bladder is difficult to compensate, there will be urinary fistula, the urinary line becomes thin, and the force is weak, the urination is laborious, the urine flow is intermittent, the terminal drip, and the urination time is prolonged. Insufficient emptying, urinary retention and overflow urinary incontinence, all of which are obstructive symptoms of benign prostatic hyperplasia.
Due to prostatic hyperplasia, compression of the urethra, increased urethral resistance, bladder detrusor must be excessively contracted to begin to maintain urination, patients may have urinary delay, weakness, short range, fine urinary line, prolonged urination, if the obstruction is further aggravated, patients should maintain Urinary pressure must be added to the urination. As the abdominal pressure decreases, the flow of urine is interrupted. For example, after the urine drops, the residual urine of the bladder appears when the bladder detrusor is decompensated. When the residual urine volume of the bladder increases, the bladder expands excessively. When the pressure is increased, there may be overflow urinary incontinence. When the night is asleep, the pelvic floor muscles are loose, the urine is more likely to overflow by itself, and nocturnal enuresis occurs. The patient must maintain abdominal pressure to maintain urination, and as the abdominal pressure decreases, There is a interruption of urinary flow, such as post-urine drip, bladder residual urine in the detrusor of the bladder. When the bladder excess urine volume increases, the bladder is over-expanded, and when the pressure increases, overflow urinary incontinence may occur. When sleeping at night, the pelvic floor muscles are slack, the urine is more likely to overflow on its own, and there is nocturnal enuresis. The sympathetic nerves in the body make the prostate gland And increased shrink tension, so some patients usually not more than residual urine, but in the cold, drinking, holding back urine, or other reasons causing sympathetic, acute urinary retention may also occur.
Obstructive syndrome caused by benign prostatic hyperplasia may not be completely caused by bladder outlet obstruction. These symptoms may also occur in aging changes in bladder structure and function. Older women also have frequent urination, urgency, delayed urination, weakness, and emptying. But there is no outlet obstruction.
3. Other clinical symptoms
(1) Hematuria: Most of the elderly male patients over 60 years old with benign prostatic hyperplasia may have different degrees of gross hematuria, usually the onset or terminal hematuria. The cause of hematuria is capillary congestion and small blood vessel dilation on the prostate mucosa. When pulled by a proliferating gland, when the bladder contracts, the dilated blood vessels rupture causing hematuria, occasionally a large amount of bleeding, the blood clot can fill the bladder and need urgent treatment, cystoscopy, metal urinary catheter, acute urinary retention catheterization The bladder is suddenly decompressed, causing mechanical damage, so it is easy to cause severe hematuria. Therefore, when doing the above treatment or examination, it should be explained to the patient's family. At the same time, avoid rough operation, and the speed and quantity of urine should be strictly controlled. Master, prevent the occurrence of major bleeding and sudden drop in bladder pressure leading to sudden drop in blood pressure and cardiovascular and cerebrovascular accidents.
(2) symptoms of urinary tract infection: hyperplasia of prostatic hyperplasia, obstruction is easy to cause urinary tract infection, when there is cystitis, urinary pain can occur, while urgency, frequent urination, dysuria and other symptoms aggravate, obstruction increases urinary retention and causes upper urinary tract Sewerage, ureteral reflux can be secondary to urinary tract infection, fever, low back pain, systemic poisoning symptoms, kidney function will be further damaged, some patients have no symptoms of urinary tract infection, but a large number of white blood cells can be found in the urine Or pus cells, there may be bacterial growth in urine culture, so in the case of benign prostatic hyperplasia, whether it is conservative treatment or surgical treatment, and also requires active anti-inflammatory treatment.
(3) stones: prostatic hyperplasia leading to lower urinary tract obstruction, especially in the presence of residual urine, crystal particles in the urine, white blood cells, exfoliated cells or small stones in the upper urinary tract discharged into the bladder, prolonged bladder stagnant time, become the core The formation of stones, prostatic hyperplasia with bladder stones can be more than 10%, bladder stones can cause perineal pain, severe pain during urination, sudden interruption of urine flow, easy to cause infection, accelerate stone growth, often have light or heavy Hematuria, some patients only complained of benign prostatic hyperplasia without special symptoms.
(4) Detrusor compensatory symptoms: Some patients with benign prostatic hyperplasia develop further into extensive structural and functional damage of the bladder wall with obstruction. Most of the detrusor is replaced by extracellular matrix, and some patients have bladder diverticulum. More severe bladder emptying, at this time, the symptoms of dysuria are aggravated, mainly because of the weakness of the detrusor, not because of anatomical obstruction.
(5) Acute urinary retention: severe bladder pain caused by sudden fullness of the bladder. Acute urinary retention does not mean that the detrusor compensatory insufficiency has progressed to the end stage. A well-compensated bladder can also take alpha-adrenergic drugs and prostate infection. As well as the bladder over-expansion induced, indwelling catheterization can restore bladder function, such as acute urinary retention caused by prostatic hyperplasia, early surgery to remove the obstruction can be completely restored.
(6) Renal dysfunction: lower urinary tract obstruction of benign prostatic hyperplasia, urinary retention, no notice or disapproval did not receive timely and reasonable treatment, resulting in upper urinary tract obstruction, ascending hydronephrosis and renal insufficiency, a few Patients with benign prostatic hyperplasia, no clinical symptoms, were only found during routine physical examination, or complained of loss of appetite, anemia, elevated blood pressure, or lethargy, dysfunction, etc. at the time of the examination. Caused by obstructive hydronephrosis, renal dysfunction, so if elderly men with unexplained symptoms of renal insufficiency, should first rule out the possibility of prostatic hyperplasia.
(7) Others: due to prostatic hyperplasia can cause increased urethral resistance, long-term dysuria caused by increased abdominal pressure, inguinal hernia, prolapse or internal hemorrhoids, masking the symptoms of benign prostatic hyperplasia, resulting in diagnosis and treatment errors.
4. Symptom assessment
The diagnosis and treatment of benign prostatic hyperplasia requires a quantitative standard. The United Nations World Health Organization commissioned an international conference in Paris to develop a universally recognized universal prostate symptom based on the prostate symptom index developed by the American Urological Association. The evaluation criteria, the International Prostate Symptom Score (I-PSS), has a total of 7 questions related to urinary symptoms. The patient answers and selects one of the 6 answers that gradually increase the symptoms in the table. The total score is 0. ~35 points (asymptomatic to severe symptoms), so far there is no strict standard for the grouping of mild, moderate, severe symptoms, the following can be used as reference: 0 ~ 7 = mild, 8 ~ 19 = moderate, 20 ~ 35=Severe, the Quality of Life Assessment (SL) meeting also developed a question to assess quality of life, with answers ranging from happy to bad (0-6).
The I-PSS score and SL were performed before and after treatment for each patient with benign prostatic hyperplasia, and the efficacy was objectively evaluated.
At present, some scholars believe that there are deficiencies in the I-PSS score, and some contents need to be further improved. For example, the I-PSS score misses the key problem of urinary incontinence, and it mainly focuses on temporary symptoms. In the absence of a serious record of the situation, I-PSS ignores the emotional annoyance associated with the symptoms, which means that there is an inappropriate risk of selection. This score is often used to judge the result, and the designer has no such purpose, and the I-PSS is urinating. The attention of the symptoms exceeds the abnormality of the urine storage. Some scholars believe that this is inconsistent with the facts. It may cause the patient to accept the risk of unnecessary and inappropriate treatment. If the symptoms are heavy but do not bother the patient, whether it is necessary to treat. Therefore, in summary, I-PSS needs to be further improved. It is necessary to create a symptom integration method that is simple, subtle, taking into account the degree of symptoms and affecting the quality of life. Only by having these assessment methods can the quality of life of patients affected by the disease be obtained. A true reflection and a potential benefit for the patient from treatment.
Benign prostatic hyperplasia (BPH) is a common disease in elderly men. Although prostatic histology can also detect hyperplastic lesions in young and middle-aged people, the appearance of symptoms is closely related to age. According to statistics, 45-year-old males have 23% of prostate syndrome. From 60 to 85 years old, it accounts for 78%. From the study of the natural course of benign prostatic hyperplasia, it is found that the symptoms of prostate hyperplasia increase with age, but not all cases show progressive aggravation. Some patients may be asymptomatic or even have some Some patients have reduced symptoms, indicating that the appearance of benign prostatic hyperplasia is not proportional to the degree of hyperplasia found in histology. The natural history of benign prostatic hyperplasia can be divided into preclinical and clinical stages. The former has pathological changes of benign prostatic hyperplasia, but it does not appear. Clinical symptoms, entering the clinical period, as the disease progresses, a series of clinical symptoms may appear, but the symptoms appear different from person to person in the morning and evening, and there is often no obvious relationship with the size of the prostate, and the site of benign prostatic hyperplasia, fatigue, inflammation, sexual life and Irritating foods and other urinary system diseases.
Examine
Examination of benign prostatic hyperplasia in the elderly
Urine routine examination
Urine analysis can be used to determine the presence or absence of hematuria, proteinuria, pyuria, urine sugar, etc., which can reflect the presence or absence of co-infection and renal dysfunction.
2. Renal function test
Renal function is a necessary examination item. Generally, serum creatinine can be measured, which can reflect whether prostate hyperplasia has caused renal dysfunction, estimate the prognosis of treatment, and choose the best treatment plan.
3. Imaging examination
(1) Ultrasound examination: Ultrasound examination of the prostate can generally be performed through the abdomen, pubis, urethra and rectum. The morphology, structure, edge contour, internal echo, volume estimation weight and residual urine volume can be observed. Ultrasound examination, the scan can clearly show the prostatic hyperplasia, especially the prostatic hyperplasia into the bladder part, the bladder needs to be filled when the examination, the residual urine volume can be calculated by checking and filling after filling, and the internal structure of the abdominal prostate is examined. Poor resolution, transurethral ultrasound scan can accurately distinguish the central adenoma and the surrounding non-adenoma tissue and capsule, but need to be inserted into the urethra by electric resection, this test is traumatic, so it is less used, Rectal ultrasound scans are the most accurate and are currently more commonly used.
1 abdominal ultrasound examination: Because the prostate is located in the deep pelvic cavity, the probe on the pubic bone needs to be angled to the tail. After the pubis of the bladder, the prostate can be detected. Therefore, it is difficult to observe the whole appearance and internal structure of the gland, but this method is simple. It can be repeated many times, and it is easy for patients to accept because it has no discomfort and damage. It is also suitable for general hospitals. Ultrasound can measure the maximum front and back of the prostate, upper and lower and transverse diameter, due to the method of inspection, experience and instrument type. The difference between the ultrasonic measurements is different, but the normal prostate transverse diameter is 3.5 ~ 4.5cm, the anteroposterior diameter is 1.5 ~ 2.5cm, the upper and lower diameter is about 3cm, the prostatic hyperplasia is more than the former posterior diameter hyperplasia, the normal prostate is chestnut type. If it is regarded as an approximate ellipsoid, the value measured by ultrasonic wave is calculated by the formula as V = vertical diameter × transverse diameter × front and rear diameter × 0.523. If it is regarded as a sphere, the formula is V=4/3×radius Cubic, normal prostate weight is 15 ~ 20g, greater than 40g is generally considered to increase, the formula is W = V × 1.05, W is the weight, V is the prostate volume, 1.05 is the prostate specific gravity, near Over the years, with the development of ultrasonic instruments and computer technology, the application of computer technology, analysis and processing of images, automatic measurement of prostate volume, and application of three-dimensional reconstruction technology for prostate volume measurement have emerged to improve accuracy.
The residual urine was measured by abdominal B-ultrasound. Szabo et al. used gray-scale ultrasound to measure the residual urine of 26 patients with dysuria. The patient took the supine position and the probe measured the upper and lower diameter of the bladder on the pubis. The average value, according to the volume = 4 / 3 × (the cube of the average of the two diameter lines), the amount of residual urine is determined, the error between the actual residual urine volume is only 5 ~ 10ml, and the Piters has residual urine in 11 cases. According to the results of the patient's measurement, if the residual urine reaches 100ml, the accuracy of B-ultrasound is 97%, and the residual urine is 150ml, the accuracy rate is 100%. The residual urine is not damaged by B-ultrasound, and the catheterization may be avoided. The risk of infection is easy to repeat multiple times, but the measurement is not accurate enough when the residual urine volume is low.
2 transrectal ultrasound examination: one is a seat scanning device, the patient takes a seat when inspecting; the other is a handle-type scanning device, the patient takes a lithotomy position or a knee chest position, the sitting position is more comfortable for the patient, and the prostate is at the pelvic floor. The position is relatively stable and does not move with breathing or insertion of the probe. In 1978, Watanabe clearly showed the cross-sectional image of the prostate with a chair-type ultrasonic tomographic rectal examination, accurately measuring the diameters and observing the interior of the gland. In the case of reflex, the procedure is to prescribe the patient's bowel movements and, if necessary, to wash the intestines. The probe is located in the center of the examination chair, and the rubber capsule is outsourced to empty the water and gas in the capsule. The capsule is coated with liquid paraffin and the patient sits in the examination chair. Above, the examiner raises the ultrasonic probe, adjusts its angle, and slowly inserts the probe into the rectum 6 cm, injects 100 ml of airless water into the rubber capsule, so that the capsule is in close contact with the rectal wall, and the depth of the probe is adjusted, starting from the bottom of the prostate. Scan once every 0.5cm section, pay attention to measure the height of the prostate protrusion into the bladder, obtain 3 diameter values, record the envelope and internal reflection, about 15min each time. In the scanning method rectal examination of the prostate circumferential most accurate when the micturition sonogram of BPH can show modified intraurethral, shift to reflect the dynamic changes of bladder outlet obstruction.
The B-ultrasound image of benign prostatic hyperplasia changes with the development of the lesion. In the moderate hyperplasia, the cross-section is half-moon or kidney-shaped. When it is hyperplastic, it is round. The prominent prostate in the plane of the bladder is surrounded by the bladder wall. The prostate reflex and the bladder are dark. The boundary line is clear, the gland is round, located in the center of the posterior part of the dark area of the bladder. In the middle and lower part of the prostate, the prostate section is half-moon shaped. The proliferating glands can be symmetrical or asymmetrical, but the adjacent sections of the scan should be shaped. Similar, this can be differentiated from prostate cancer. After the hyperplasia, the changes of the diameters are obvious, the left and right diameters are obvious, and the left and right diameters are not changed. The acoustic image of the prostate surgical capsule is complete, regular, continuous, encompassing the whole Gland, a small uniform light spot, the sonogram of the proliferative gland around the urethra may appear rough and uneven reflection, such as combined with stones, inflammation, infarct or ductal acinar expansion, complex audio and image Figure, Watanabe's prostate volume measured by rectal circumferential scan is about equal to its weight. In 26 cases, it was compared with the surgically resected specimen. The results were consistent and the error was small. 5% OF stressed measured by rectal examination and prostate size B ultrasonography results are inconsistent, the larger the prostate, the error more remarkable, therefore, not as digital rectal examination and accurate ultrasonography.
Ultrasound examination can also understand the changes of the bladder. When the urinary tract under the prostatic hyperplasia is obstructed, the ultrasound image of the bladder can appear: the bladder wall is thickened, not smooth, and there may be the formation of trabecular and diverticulum. The residual urine volume increases, and the severe renal hydronephrosis may occur. The renal parenchyma becomes thinner. In recent years, some scholars have found that the bladder weight is increased due to thickening of the bladder wall during obstruction, so scholars believe that if the bladder is larger than 35g, That is, there is bladder outlet obstruction (BOO).
Color Doppler imaging is also helpful in the diagnosis of benign prostatic hyperplasia. Elderly male benign prostatic hyperplasia (BPH) is a benign neoplastic hyperplasia. Therefore, hyperplastic tissue blood supply is more abundant than normal tissue, and is abundant in color Doppler imaging. Obviously, the increased blood flow may occur in the peripheral and central regions of the inner gland and the surgical capsule that are compressed, and there is a clear boundary between the transition zone, and the calcifications arranged in a curved or curved arrangement may be present on the boundary line. Low-resistance type, more regular, linear arrangement, according to the type of prostatic hyperplasia (diffuse proliferative and nodular hyperplasia) and hyperplasia, blood flow can be increased or diffuse.
(2) urography: urography is divided into intravenous pyelography and retrograde pyelography, intravenous pyelography is the most common and most valuable method of urinary tract examination, and retrograde pyelography for patients with poor or inappropriate venous pyelography, The purpose of intravenous pyelography for patients with benign prostatic hyperplasia is to exclude the presence or absence of urinary tract ureteral dilatation caused by lower urinary tract obstruction and to estimate renal function, and to understand whether there is glomerular hyperplasia and diverticulum in the bladder.
Before intravenous pyelography, the patient fasted and banned water to enhance the concentration of the kidneys, making the images clearer, the contrast was stronger, and avoiding accidental misuse caused by vomiting. The iodine allergy test was not discomfort, and the intravenous injection was 60% to 76%. Compound diatrizoate 20 ~ 40ml, lower abdomen pressure, 8min, 15min after filming, such as renal pelvis, ureteral development is satisfactory, remove abdominal pressure plus gas belly X tablets, intravenous pyelography can clearly show the function of the kidneys and observable Whether the prostate function damages the kidney function (expressed as prolonged display time) whether there is hydronephrosis, and the contrast agent is discharged into the bladder, which can show that the proliferating part of the prostate protrudes into the bladder and causes signs of bladder neck filling defect. It can cause the bladder triangle and the bottom of the bladder to shift and raise it. The lower edge of the bladder shows a smooth arc compression or bilateral phenomenon. The posterior segment of the ureter of the bladder is hook-shaped, and some compression of the ureter causes the upper urinary tract expansion. Water, the patient can urinate and then take the abdominal plain film to observe the existence and approximate extent of residual urine, but because the specific gravity of the developer is different from the specific gravity of the urine. Easy because of the mixture caused by false, and therefore through the information provided by urography can not be directly used as the basis of diagnosis, perfectly normal urography can not exclude the presence of benign prostatic hyperplasia.
(3) Prostatic angiography: This method can determine the size, density and nature of the prostate. To some extent, it is insufficient to supplement other methods. This method is difficult for patients to accept and is currently less used in clinical practice.
(4) Prostate CT examination: Prostate CT examination has important auxiliary diagnosis and differential diagnosis significance for benign prostatic hyperplasia.
The normal prostate CT cross-sectional scan image is located at the lower edge of the pubic symphysis. It is round or oval, with clear boundary and uniform density. It is soft tissue density. The CT value is about 40Hu. The CT scan cannot correctly and clearly distinguish the prostate. In the 3-part structure, the prostate is scanned 15 to 20 minutes after the prostate injection of the contrast agent, and the gland can be divided into the peripheral zone and the central zone according to the density difference.
In the elderly, the prostate artery diameter is enlarged in the CT image of benign prostatic hyperplasia. The prostate is 10 to 30 cm above the pubic bone. It is spherical or elliptical according to the degree of enlargement. The sides are symmetrical and the density is uniform. After the enhancement, the acute hyperplasia of the central prostate is scanned. The relative density increases, and some of the prostate is scattered in small dots or strips of calcification. The CT value is above 100 Hu. According to the size of benign prostatic hyperplasia, the fat gap exists, thinning or disappearing. The seminal vesicle triangle is normal. When the prostate hyperplasia is obvious, the bladder bottom is compressed. Displacement upwards, sometimes protruding into the bladder, like a bladder tumor can simultaneously scan the kidney to see if there is hydronephrosis.
(5) MRI of benign prostatic hyperplasia (MRI): The normal prostate MRI is as follows: the prostate gland is like an inverted cone, the bottom is the widest under the bladder, and the tip to the caudal side is adjacent to the urethral membrane. Combination, posterior rectum, bilateral symmetry, size, transverse diameter at the base of about 4cm (elderly 5cm) anteroposterior diameter 2cm (elderly 4.3cm), upper and lower diameter (long diameter) 3cm (old age 4.8cm), no more than pubic bone Combined with 1cm, the prostate structure can be divided into 3 parts on the MRI, namely the peripheral area, the central area and the transitional area, the peripheral area accounts for 70% of the prostate; the posterior part of the prostate, the thickest part of the prostate, the transition area surrounds the urethra About 50%, therefore, when the horizontal axis scans, the highest layer only includes the central area, and the central area shrinks with age. On the contrary, the transition area increases with age.
The vast majority of benign prostatic hyperplasia occurs in the transition zone, which increases the size of the prostate. MRI can measure the volume of enlarged prostate. T1W has a slightly longer uniform low signal, T2W is equal signal, low signal or high signal, and middle With or without a bit of a higher signal (in the hyperplastic nodules, such as muscle fiber components, mainly as a low-signal signal, such as glandular components, it is a high signal) many hyperplastic nodules often due to compression and atrophy T2W is a circular signal band, which is the surgical capsule seen during surgery. The hyperplastic nodules in the transitional zone are gradually enlarged, which can cause pressure atrophy in the peripheral area, even on MRI. BPH not only increases the prostate. Large, but can be nodular into the bladder forward, forming soft tissue at the bottom of the bladder, but non-specific, bladder seminal vesicles can compress the anterior wall of the rectum, but maintain a normal interval.
(6) Prostate cystoscopy: cystoscopy for the diagnosis and differential diagnosis of benign prostatic hyperplasia, understanding the extent of lower urinary tract obstruction, etc. is of great value, when patients with benign prostatic hyperplasia appear lower urinary tract obstruction symptoms, venous urine Road angiography shows the formation of trabecular trabeculae, residual urinary or pelvic ureteral hydrops and the elderly with gross hematuria as the main symptom, cystoscopy is more necessary, when a normal cystoscopy occurs after urinary tract infection, in addition to light weight and In addition to aseptic technique, it is best to have the patient in the hospital for examination. After the patient has been prepared for surgery, the cystoscopy is included as part of the surgical plan so that the surgical procedure can be selected and surgically performed as soon as possible after the diagnosis.
During cystoscopy, patients with benign prostatic hyperplasia can feel the urethra prolonged during the process of inserting the sheath sheath. The distance from the fine sputum to the neck of the bladder is 2 cm in normal period, and can be increased to more than 5 cm when the prostatic hyperplasia is obvious. The degree of hyperplasia of each leaf changes. When both sides of the leaf proliferate, the normal concave surface of the bladder neck disappears, and the V or A shape of the gland is increased. It is often seen that the glandular lobes increase to the front of the cystoscope, and when the middle lobe proliferates, The bottom of the bladder is sunken, the posterior lip is obviously bulged, the ureteral hypertrophy, bulge, trabecular and diverticulum formation are evidence for the diagnosis of lower urinary tract obstruction. The cystoscopy determines the size of the prostate has certain difficulties, and the size of the object changes, Can cause an estimated error.
4. Urodynamic examination
Urodynamic examination is important for the diagnosis of benign prostatic hyperplasia. It can determine the degree of obstruction, prostate urethra and internal and external sphincter resistance, detrusor function status, detrusor pressure, urethral pressure according to measured urine flow rate. Curves, as well as sphincter EMG data, can be used to analyze whether prostate syndrome is caused by obstruction or irritation. It can be seen whether there is detrusor instability, impaired contractile function and bladder compliance.
BPH's traditional diagnosis method, in addition to medical history, symptoms and signs, the most important means of examination are digital rectal examination, B-ultrasound and endoscopy, these tests determine the size of the prostate, estimate the amount of residual urine and observe the situation in the bladder These aspects are essential, but these methods are basically morphological diagnosis and lack accurate judgment of urinary function. In fact, the BOO degree is not proportional to the prostate size at BPH, and the smaller prostate obstruction is not necessarily heavy.
The degree of dysuria is determined by the degree of obstruction and bladder function. BOO, bladder weakness and BOO combined with bladder weakness can cause dysuria, while BOO is lighter and the bladder is fully compensated, it can be normal urination, therefore, simple According to the obstructive symptoms and the size of the prostate, it is not enough to accurately determine the degree of obstruction. Therefore, the traditional diagnostic method can not accurately know the bladder function, and can not accurately know the BPH obstruction and obstruction.
(1) Measurement of urine flow rate: It is a quantitative index (ML/S) for urinary status. The examination is simple and painless. It is the most useful indicator for objective evaluation of urination status, but the single urine flow rate index cannot directly reflect the degree of obstruction; some people Factors such as urine volume, psychology, and urinary line effects have a greater impact on the test results.
(2) Filling bladder pressure measurement: continuous recording of bladder volume-pressure relationship and bladder sensory function to determine the function of urinary function, normal storage period, bladder tolerance, and intravesical pressure less than (or equal to) 15 cm water column, no Abnormal contraction, bladder sensation normal, if there is no inhibitory contraction, intravesical pressure is too high or bladder urinary capacity is too small, respectively, called USB, low compliance bladder and bladder hypersensitivity, normal urination, detrusor should be continuous and powerful Contraction, if the detrusor systolic pressure is always less than (or equal to) 15 cm water column, bladder weakness should be considered.
(3) urethral pressure map: continuous recording of the length of the urethra after storage and the pressure distribution of the posterior urethra to determine the BPH obstruction and obstruction degree, bladder neck pressure, bladder neck length, prostate pressure and The proximal part of the prostate (equivalent to the pressure of the fine sputum and the length of the fine neck to the bladder neck), the length of the prostate, the maximum urethral pressure (equivalent to the urethral pressure of the membrane) and the area of the urethra closure, etc., the shape of the image can be divided into slope type, ladder type There are 3 types of saddle type. The slope type is mainly found in the small prostate, especially male children and young people. The saddle type is mainly found in BPH.
(4) Synchronous examination of pressure/flow rate: Simultaneously record the bladder pressure and urine flow rate to reflect the obstruction and its degree. This test is the best way to reflect the obstruction. There are many studies on this test, which can be evolved. A variety of parameters, commonly used parameters for the calculation of urethral resistance and detrusor contractility.
(5) urethral resistance: minimum urethral resistance is one of the commonly used indicators, it refers to the urethral resistance at the maximum urinary flow rate, high bladder pressure and low urinary flow rate, urethral resistance will increase, indicating the presence of obstruction, also useful Pressure and urinary flow rate parameters are generated by a pressure-flow rate diagram and a pressure flow rate function diagram to reflect urethral resistance.
(6) Detrusor contraction ability: In addition to open detrusor pressure, maximum detrusor pressure and maximum urinary flow rate detrusor pressure and other classic parameters, there are equal volume detrusor pressure, detrusor open contraction force , detrusor contraction strength and maximum detrusor contraction velocity and other parameters.
The above parameters reflect the detrusor contraction function from different sides.
(7) In the urodynamic examination of BPH, the following tests can also be performed:
1 urinary urethral pressure map: synchronous recording of bladder pressure and urethral pressure during urination, which has certain value for the determination of obstruction.
2 pressure urethral external sphincter electromyography synchronous examination: that is, when performing pressure measurement, synchronous recording of external urinary sphincter electromyogram to reflect the coordination between detrusor and external urinary sphincter, and the determination of detrusor sphincter dyssynergia value.
(8) Significance of urodynamic examination in the diagnosis of BPH:
1 differential diagnosis: many senile diseases have frequent urination, nocturia and dysuria, whether it is BPH obstruction, urinary motility test can provide reliable differential diagnosis for the following diseases and BPH:
A. Bladder weakness: common in nerve damage, diabetes, myogenic and idiopathic bladder weakness, such diseases have dysuria, low bladder pressure, but no urethral obstruction.
B. Detrusor urethral sphincter dyssynergia: mainly seen in spinal neuropathy and damage, characterized by urinary sphincter squeezing when the detrusor contracture urination does not relax, resulting in dysuria, confirmed by electromyography and pressure flow rate simultaneous examination.
C. Unstable bladder: brain atrophy, senile dementia, cerebrovascular disease, Parkinson's disease, etc. can cause unstable bladder. These patients have frequent urination, but not necessarily urethral obstruction.
2 to determine the degree of BPH obstruction and bladder function: filling cystometry and urethral pressure map parameters, can accurately determine this point, thus guiding the choice of treatment, for those with better obstruction and mild bladder function, consider more conservative Treatment.
3 determine the obstruction site guidance selection procedure: determine the detrusor function prediction efficacy and complications and causes.
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5.
(1)()
ABCCABC
(2)(PSA)PSAPSABPHPSABPH
PSAPSA(00.4ng/ml)7651PSATandem-RIMX PSA404902.5ng/ml;505903.5ng/ml;606904.5ng/ml;707906.5ng/mlPSAPSAPSA2.65.9TURP6PSA
Diagnosis
Diagnostic criteria
1.
50
2.(DRE)
4cm3cm2cmRous(1985)22025g;232550g;345070g;475g
26%34%
Differential diagnosis
