Detrusor instability
Introduction
Introduction Detrusor instability is a symptom of benign prostatic hyperplasia.
Cause
Cause
(1) Causes of the disease
Essential conditions for benign prostatic hyperplasia are advanced and functional testes, but the true cause has not yet been elucidated. At present, there are several theories: the dihydrotestosterone theory, the male-estrogen synergy theory, the embryo re-awakening theory, the stem cell theory, and the interstitial-epithelial interaction theory. Among them, the role of dihydrotestosterone is the most important, and various anti-androgen therapies are currently based on this theory.
(two) 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 Departmental fusion, ending in urogenital spasm. The body between the bottom and the tip is a convex part, the front of the body is more convex, and the back is relatively flat. There is a shallow groove in the center, which is called the central groove of the prostate. The groove divides the back of the prostate into left and right leaves, which can be referred to by the rectum. The anterior rectal wall of the rectum touches the posterior left and right lobe of the prostate and the central groove of the prostate to understand the condition of 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 synergy between the epithelium results in the formation of prostatic hyperplasia. This lesion is rare in people under the age of 50, and increases with age until 70 to 80 years old. The nodular hyperplasia in the prostate begins to occur in the transitional zone of the prostate and the tissue around the urethra. The nodules in the tissue are similar to the interstitial components of the embryonic stage, and are the matrix components, while the nodules in the transition zone are glandular components. There are three independent processes for the growth of benign prostatic hyperplasia: 1 nodule formation. 2 The transition zone is diffusely enlarged. 3 nodules increase. Mcneal found that patients aged 50-70 years, although the transition area doubled, but the nodules only accounted for 14%, the diffuse increase in the transition area is less than 70 years old, starting at 70 years old, until the 80-year-old knot Significantly increased, is 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 proliferating tissue during surgery, but prostate cancer can still occur in the remaining prostate. Cutaway view: Some small nodules are mainly fibromuscular components, which are pale, uniform in quality, smooth in cut surface, soft in texture, and can spill a small amount of milky white liquid. Some nodules are honeycomb or sponge, and acinar is cystic. The size of benign prostatic hyperplasia is not proportional to the degree of urinary tract obstruction, that is, the degree of prostatic symptoms, but is directly related to the enlarged part. For example, the stromal nodules around the urethra are invaded by the acinar cells in the gland around the urethra. Slow hyperplasia, multi-directional development of the proximal urethra, burst into the bladder to form the so-called mid-lobe hyperplasia of the urethra, even if the gland enlargement is less than 10g, it can cause serious obstruction.
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 different sizes and shapes. The glands are usually compressed, often with 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 hyperplasia, like leiomyoma. These types are different stages of disease development and are often mixed together in the same case and cannot be classified. Infarcts can be seen in some BPH-removed tissues ranging from a few millimeters to a few centimeters. The more the lesion is replaced by fibrous scar tissue. Squamous epithelialization is often seen around the infarct.
3. Pathophysiology
Lower urinary tract obstruction caused by benign prostatic hyperplasia can lead to a series of pathological changes in the bladder and upper urinary tract. The size of benign prostatic hyperplasia is closely related to the presence or absence of lower urinary tract obstruction. The symptoms caused by different parts of benign prostatic hyperplasia The severity of the disease is also different. If the significant increase of the bilateral lobes of the prostate has not reached the degree of flexion and elongation of the urethra of the prostate, the clinical symptoms may be very slight. If the hyperplasia is in the area around the urethra, even if it is very mild. Hyperplasia can also cause very serious obstructive symptoms. In clinical practice, although there are very serious dysuria, bladder outlet obstruction symptoms, but rectal prostatic hyperplasia may not be significant, it can be called "non-prostatic hyperplasia" Prostate disease."
When the prostate hyperplasia causes bladder outlet obstruction, the bladder's purulent and urinary function can be affected accordingly. The bladder reflexively establishes a stress-compensation-decompensation process to overcome the obstruction of the outlet and the detrusor begins. Hyperplasia, when the bladder is highly irritated, patients may have urgency and urge incontinence. During the compensation period, the patient's symptoms begin to develop and urinating occurs because the bladder changes pressure to overcome bladder outlet obstruction. Interruption of urination, urinary bifurcation, and post-urine dripping are caused by strong contraction of the detrusor. When the bladder wall changes, the deltoid muscle and ureteral fistula hyperplasia, the ureteral fistula extends to both sides, the ureter is displaced to the posterior side, increasing the resistance in the ureteral lumen, resulting in stenosis, resulting in bilateral ureteral hydrops Similarly, the detrusor also has different degrees of hyperplasia, forming beam-like protrusions on the bladder wall, which is compensated for hypertrophy. When urinating, the intravesical pressure can reach 50-100cmH2O, which promotes the formation and development of the bladder diverticulum. These factors continue to cause the detrusor to lose compensatory function. As a result, the residual urine increases, the effective capacity of the bladder decreases, and there is no tension. Dilation, thinning of the bladder wall, bladder detrusor hypertrophy, prolongation of the ureteral bladder wall segment, can lead to ureteral obstruction, ureteral wall segment can be shortened after bladder decompensation, bladder residual urine volume increases, and even urinary retention occurs, accompanied by Severe symptoms and filling urinary incontinence, due to continuous increase in intravesical pressure, urinary tract sphincter function and urinary reflux, followed by ureteral and renal pelvic dilatation, hydronephrosis, affecting renal function, long-term hydronephrosis, Increased pressure in the renal pelvis causes thinning of the renal cortex, impaired renal function, and infection, stones, and renal failure. The patient developed clinical manifestations of significant hypertension, water retention, and other uremia.
Prostatic hyperplasia is mainly manifested in bladder outlet obstruction (BOO), which means that bladder outlet obstruction is the root cause of pathophysiological changes of benign prostatic hyperplasia. On this basis, bladder dysfunction occurs, and ureteral dilatation causes severe damage to renal function.
Prostate hyperplasia first causes mechanical abnormalities in bladder outlet obstruction, as well as dynamic factors. The mechanical factors are caused by the enlargement of the transverse cross-sectional area of the urethra and the prolongation of the urethra. The dynamic factors are caused by the tension of the prostatic urethra, prostate tissue and the prostate capsule. The main factors affecting this tension by the alpha receptor are through physiological And pharmacological studies have shown that human prostate muscle cells can stimulate smooth muscle contraction through 1 receptor, and increased tension causes bladder outlet obstruction. The human prostate contains more alpha 1 adrenergic receptors, and 98% of the alpha 1 receptors are present in the prostate stroma. An important part of benign prostatic hyperplasia is the proliferation of the stroma (smooth muscle and connective tissue), and the smooth muscle. Some scholars have studied patients with clinically benign prostatic hyperplasia, performed biopsy before drug treatment, measured the smooth muscle density per unit area of prostate, and then treated with -blockers, and the symptoms improved after treatment with patients. The smooth muscle density per unit area of the prostate is related to the improvement of the maximum urinary flow rate (QMX). This result suggests that bladder outlet obstruction is mainly caused by contraction of the smooth muscle of the prostate, increased tension, and the severity of urinary symptoms and the prostate. The size is not proportional, sympathetic 1 receptor blocker can effectively relax the bladder neck and prostate smooth muscle without affecting the detrusor function, thus quickly releasing the obstructive symptoms of benign prostatic hyperplasia. Endothelin is also found in the prostate. Vascular endothelin is the strongest smooth muscle contraction agent in the human body, which can cause slow and strong contraction of the prostate smooth muscle. This contraction cannot be eliminated by the alpha blocker. The above description of the smooth muscle contraction of the prostate, in addition to the alpha receptor, there are other substances that affect smooth muscle contraction and relaxation, and further research is needed.
On the basis of bladder outlet obstruction (BOO), secondary bladder function abnormalities, common types of bladder dysfunction are:
(1) Unstable bladder (USB): unstable bladder refers to spontaneous or induced detrusor non-inhibitory contraction in the urinary retention period, and more than half of patients with benign prostatic hyperplasia have unstable bladder symptoms, causing no The reason for stabilizing the bladder is not fully understood, but after removal of bladder outlet obstruction after surgical treatment, 65% to 70% of patients with unstable bladder symptoms disappear, which may indicate that bladder outlet obstruction is the main cause of unstable bladder. However, there are other reasons, such as pathological or central nervous system dysfunction with age, detrusor dysfunction with increasing age, and some unexplained idiopathic unstable bladder function symptoms. Unstable bladder is the main cause of urinary retention, such as frequent urination, urgency, and urge incontinence. It has a close relationship with persistent urinary frequency, urgent urinary incontinence, and bladder spasm after prostatectomy.
(2) Impaired detrusor contraction: Detrusor muscle is caused by acute and chronic urinary retention, which causes the detrusor to be weakened by contraction, thinning or fibrosis. Most of these patients have severe dysuria symptoms. After the surgical removal of the prostate, the recovery of urinary function is also poor. According to the animal experiment, after the obstruction occurs, the bladder detrusor also undergoes significant changes, and the detrusor nerve endings are reduced, which is called partial denervation, and the bladder volume increases, but the muscles The contraction strength is relatively reduced, and when the detrusor muscle is partially denervated, the neuronal cells and muscle cells that control the input and output of the bladder can be enlarged, and even the nerve dorsal root cells of the lumbar 6 to 1 are also significantly increased. Increased spinal reflex, bladder involuntary contraction. After the obstruction is relieved, the bladder muscles gradually return to normal, and the neurons can only be partially restored to their original state. After surgical removal of the prostate in patients with benign prostatic hyperplasia, some patients may not be able to improve their urination symptoms. In recent years, it has been observed by electron microscopy that collagen fibers between muscle cells and myocytes are increased, the distance between cells is increased, and the number of cell junctions is reduced, resulting in disturbance of signal transduction between cells, affecting detrusor contraction, and for benign prostatic hyperplasia. There has been a more in-depth study of changes in the urinary muscles.
(3) Low compliance bladder: Low compliance bladder refers to an increase in bladder volume with a small urinary retention period, ie, a higher bladder pressure. The more common cause is thickening of the bladder wall, fibrosis, stiffness, and bladder expansion. A low compliance bladder can also occur when the detrusor is contracted by inflammation or other stimuli. Patients with low compliance bladder have not improved urination due to elevated intravesical pressure. Conversely, sustained intravesical hypertension will impede urine delivery to the upper urinary tract, resulting in damage to the upper urinary tract.
Three types of bladder dysfunction, such as unstable bladder, detrusor damage, and low compliance bladder, may occur alone or in combination with either or both. Unstable bladder and low-compliance bladder usually have bladder hypersensitivity, impaired detrusor contraction, and bladder retardation and high compliance bladder. Dysuria is one of the main symptoms of benign prostatic hyperplasia. The degree of dysuria is determined by the degree of obstruction and bladder function. Bladder outlet obstruction, bladder weakness, bladder outlet obstruction, and bladder weakness can all cause dysuria. In fact, the degree of bladder outlet obstruction and dysuria in prostate hyperplasia are not proportional to the size of benign prostatic hyperplasia. Bladder outlet obstruction is light, and when the bladder is fully compensated, it can be expressed as normal urination. On the contrary, if the bladder contraction force is poor, even if there is a light bladder outlet obstruction, it may cause heavier urination.
Due to bladder outlet obstruction secondary to bladder dysfunction, resulting in upper urinary tract dilatation, impaired renal function, a large number of bladder residual urine and continuous intravesical pressure is the two basic causes of upper urinary tract expansion. According to the main characteristics of bladder function changes can be divided into two categories: one is high-pressure chronic urinary retention, characterized by low compliance bladder and intravesical pressure continue to be at a high level, prone to upper urinary dilatation, surgical removal of the prostate The upper urinary tract function recovery is poor after the obstruction is relieved; the other type is low-pressure chronic urinary retention, which is characterized by impaired bladder sensory function and a large amount of residual urine. The effect on upper urinary tract function is higher. To be light, it happens slowly. There is also a mixed type of both at the same time, which is characterized by more residual urine. When the bladder is under pressure, when the bladder is filled to the residual urine volume, the intravesical pressure is rapidly increased, and the bladder internal pressure is compared before the residual urine volume is reached. low.
With the natural development of benign prostatic hyperplasia and urodynamics, it is found that in clinical and pathological diagnosis of benign prostatic hyperplasia, 20% to 25% of cases have no bladder outlet obstruction, but there are different degrees of Symptoms, in some cases, these symptoms are indeed associated with benign prostatic hyperplasia, symptoms disappeared or relieved after surgical treatment, but some symptoms disappeared insignificantly, indicating the clinical symptoms of benign prostatic hyperplasia, there may be non-bladder outlet obstruction factors, Like other tissues and organs of the body, with the aging of the age, the bladder itself will undergo biological aging, resulting in unstable bladder, low compliance bladder and impaired detrusor function, and bladder dysfunction with benign prostatic hyperplasia. Similar abnormal changes, which can produce almost the same clinical manifestations as benign prostatic hyperplasia, can also make the clinical symptoms less obvious due to the coexistence of the above-mentioned aging factors and benign prostatic hyperplasia. In short, the pathophysiological changes of benign prostatic hyperplasia are not simply factors of bladder outlet obstruction.
Examine
an examination
Related inspection
Urine routine r-sperm protein assay (r-sm)
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 symptoms are not typical. Symptoms usually appear after the age of 50. Symptoms depend on the degree of obstruction, the rate of development of the lesion, and whether the infection and stones are combined, the symptoms are light and heavy, the hyperplasia does not cause obstruction or mild 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 obstructive symptoms.
1. Bladder irritation
Prostate irritation symptoms include frequent urination, urgency, nocturia, and urge incontinence. The symptoms of these benign prostatic hyperplasia are caused by the complex interaction between the prostate and the bladder. The prostatic hyperplasia is an increase in urethral resistance. The bladder needs to overcome its resistance to expel the urine and increase the detrusor pressure. The smooth muscle of the bladder wall is compensatory hypertrophy. Although the detrusor can maintain the normal discharge of urine, its function is not completely normal. Bladder irritation may be associated with bladder outlet obstruction and non-obstructive detrusor instability. And the symptoms of irritability: frequent urination, urgency. Frequent urination is the earliest clinical symptom of patients with benign prostatic hyperplasia. Normal men urinate 1 time every 3 to 5 hours, and the bladder capacity is 300 to 500 ml. The prostatic hyperplasia of the elderly is due to decompensation of the detrusor muscle, the bladder can not be completely empty, the residual urine volume is increased, the effective capacity of the bladder is reduced, and the urination time is shortened. First, the number of nocturia is increased, and the amount of urine is not much. The urinary frequency also occurs during the day, and the number of nocturia increases. It may be caused by detrusor instability or loss of kidneys and normal circadian rhythm. Night vagus nerve is excited, bladder tension is reduced, residual urine volume is increased, and urine may increase. The reason is that 50% to 80% of patients still have urgency or urgent urinary incontinence. If accompanied by bladder stones, or infection, frequent urination, urgency, and accompanied by dysuria.
2. Obstructive symptoms
Prostate enlargement continues to increase the urethral resistance, bladder outlet obstruction, when the bladder is difficult to compensate, there will be urinary fistula, urinary line thinning, and weakness, urinary effort, intermittent urine flow, terminal drip, prolonged urination time, 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 slow urination, weakness, short range, fine urinary line, prolonged urination time. If the obstruction is further aggravated, the patient must maintain abdominal pressure to maintain urination. As the abdominal pressure decreases, there is a disruption of the flow of urine, such as post-urine drip, and bladder residual urine occurs when the bladder detrusor is decompensated.
When the residual urine volume of the bladder increases, the bladder is over-expanded, and when the pressure is increased, overflow urinary incontinence may occur. When sleeping at night, the pelvic floor muscles are slack, and the urine is more likely to overflow on its own, causing nocturnal enuresis. Patients must maintain abdominal pressure to maintain urination. As the abdominal pressure decreases, there is a disruption of the flow of urine, such as post-urine drip, and bladder residual urine occurs when the bladder detrusor is decompensated.
Sympathetic nerve excitation in the body causes the contraction and tension of the prostate gland to increase, so some patients usually have less residual urine, but acute urinary retention can also occur when the sympathetic nerve is excited by cold, alcohol, urine or other causes.
Obstructive syndrome caused by benign prostatic hyperplasia may not be completely caused by bladder outlet obstruction, and 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 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 on the prostate mucosa and small blood vessel dilation and is pulled by hyperplastic glands. When the bladder contracts, the dilated blood vessels rupture and cause hematuria. Occasionally a large amount of bleeding, blood clots can fill the bladder and need urgent treatment. Cystoscopy, urinary catheter, acute urinary retention, catheterization, sudden decompression of the bladder, causing mechanical damage, it is easy to cause severe hematuria, so in the above treatment or examination should be explained to the patient's family, while operating Roughness should be avoided, and the speed and amount of urine should be strictly controlled to prevent the occurrence of major bleeding and sudden drop in bladder pressure, resulting in sudden drop in blood pressure and cardiovascular and cerebrovascular accidents.
(2) symptoms of urinary tract infection: hyperplasia of prostatic hyperplasia, obstruction is very easy to cause urinary tract infection, cystitis can occur, urinary pain can occur, while urgency, frequent urination, dysuria and other symptoms aggravated. Obstruction aggravates urinary retention and causes upper urinary tract water. Ureteral reflux can be secondary to urinary tract infection, fever, low back pain, systemic poisoning symptoms, and renal function will be further damaged. Some patients have no symptoms of urinary tract infection, but A large number of white blood cells or pus cells can be found in the urine, and bacteria can grow in urine culture. Therefore, in the case of benign prostatic hyperplasia, whether it is conservative treatment or surgical treatment, active anti-inflammatory treatment is required.
(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, the incidence of benign prostatic hyperplasia with bladder stones can reach 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 with 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 detrusor decompensation has progressed to the end stage, and a well-compensated bladder can also be induced by taking alpha-adrenergic drugs, prostate infection, and over-expansion of the bladder. Indwelling catheterization can restore bladder function. Such as acute prostatic hyperplasia, acute urinary retention, 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, which was found to be benign prostatic hyperplasia. Caused by obstructive hydronephrosis, renal dysfunction. Therefore, if elderly men have unexplained symptoms of renal insufficiency, the possibility of prostatic hyperplasia should be ruled out first.
(7) Others: Because of prostatic hyperplasia, urethral resistance may increase, and long-term dysuria may lead to increased abdominal pressure. Inguinal hernia, prolapse or internal hemorrhoids may occur, which may mask the symptoms of benign prostatic hyperplasia and cause errors in diagnosis and treatment.
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). There are no strict criteria for the grouping of mild, moderate, and severe symptoms so far. The following can be used as reference: 0 to 7 = mild, 8 to 19 = moderate, and 20 to 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 question about urinary incontinence, and it focuses on temporary symptoms, so that there is no record of seriousness. I-PSS ignores the troubles associated with symptoms, which means that there is an inappropriate risk of choice. This score is often used to judge the results, and the designer has no such purpose. In addition, I-PSS pays more attention to urinary symptoms than abnormal urine storage. Some scholars believe that this is inconsistent with the facts. It is possible to expose the patient to the risk of unnecessary and inappropriate treatment. If the symptoms are heavy but do not bother the patient, is it necessary to treat? Therefore, in summary, I-PSS needs to be further improved, and 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 with these assessment methods can we get a true reflection of the quality of life of patients affected by the disease and give patients potential benefits from treatment.
Benign prostatic hyperplasia (BPH) is a common disease in elderly men. Although the prostatic histology of young and middle-aged people can also detect hyperplastic lesions, the appearance of symptoms is closely related to age. According to statistics, 45-year-old males have 23% of prostate syndrome, while those aged 60-85 account for 78%. From the study of the natural course of benign prostatic hyperplasia, prostate hyperplasia is aggravated with age, but not all cases For progressive exacerbation, some patients may be asymptomatic or even partially relieved, indicating that the appearance of prostatic hyperplasia is not directly related 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 no clinical symptoms appear. It enters the clinical stage. As the disease progresses, a series of clinical symptoms may appear, but the symptoms appear. It varies from person to person in the morning and evening, and is often not related to the size of the prostate. It is associated with areas of benign prostatic hyperplasia, fatigue, inflammation, sexual life and irritating foods, and other urological diseases.
Physical examination:
1. Comprehensive medical examination
Men over the age of 50, have frequent urination, increased nocturia, fine urinary lines, short range, especially the difficulty of progressive urination, urinary retention, should be considered for benign prostatic hyperplasia. Patients with senile benign prostatic hyperplasia often have other chronic diseases, and detailed physical examination should be performed, especially attention to cardiopulmonary functions such as hypertension, arteriosclerosis, emphysema and diabetes. If combined with hydronephrosis, attention should be paid to renal function, so detailed physical examination, laboratory tests, cardiopulmonary and renal function tests are necessary. Systemic examination should pay attention to the general condition of the patient, such as whether the reaction is slow, whether there is anemia, edema, whether there is hypertension or abnormal heart and lung function, abdominal examination, whether there is a mass in the upper abdomen, and whether the lower abdomen is formed due to overfilling of the bladder. In the mass, there is no tenderness and snoring pain in the kidney area, whether there is inguinal hernia, abnormal anal sphincter tension, and presence or absence of nucleus.
2. Digital rectal examination (DRE)
Rectal diagnosis is a simple and valuable method for diagnosing benign prostatic hyperplasia. It should be performed after emptying the bladder urine. For each patient, rectal and neurological examinations should be performed. Size, texture, depth of the central groove, with no nodules, smooth surface, with or without tenderness, can the seminal vesicle touch and the mass in the rectum, and understand the contractile force of the rectal sphincter to eliminate the nervous system diseases that cause similar symptoms .
The size of the normal prostate is about 4cm in the lateral diameter, 3cm in the longitudinal diameter, and 2cm in the anteroposterior diameter. In the case of prostatic hyperplasia, the rectal examination can reach the transverse diameter or longitudinal diameter of the gland, or both, and the surface of the prostate. Smooth, sharp edges, medium hardness, tough and elastic, full and spherical. The central sulcus becomes shallow or disappears, and is described in different clinical methods to estimate the degree of benign prostatic hyperplasia. Rous (1985) proposed rectal digital diagnosis of prostate size and estimation method. I degree: gland size of benign prostatic hyperplasia is normal. Gland 2 times, estimated weight is 20 ~ 25g; II degree: hyperplasia of the gland is 2 to 3 times normal, the central groove may become shallow or disappear, estimated weight 25 ~ 50g; III degree: hyperplasia of the gland is normal 3 to 4 times, the diagnosis can barely touch the bottom of the prostate, the central sulcus disappears, the estimated weight is 50 ~ 70g; IV degree: the hyperplasia of the gland is more than 4 times normal, the diagnosis can not touch the bottom of the gland, the weight is More than 75g. Professor Wang Yijing from Shanghai Second Medical University proposed simple diagnostic criteria. The normal prostate is the size of chestnuts, the pigeon eggs are 1 degree, the eggs are II degrees, the duck eggs are III degrees, and the eggs are more than IV degrees. It must be pointed out that the rectal examination has a certain error on the size of the prostate and the actual size of the prostate. In addition to the clinical experience of the examiner, the amount of residual urine also has a certain influence, such as increasing the prostate to the bladder, so-called The middle lobe is enlarged, and the enlargement of the prostate is not obvious when the rectal examination is performed. Therefore, it is necessary to use a combination of other methods to comprehensively diagnose the disease.
If the texture of the prostate is hard, the surface is not smooth, uneven, and even the nodules can be touched. It should be considered whether there is prostate cancer or prostatitis. The diagnosis rate of prostate cancer is not high. If necessary, prostate puncture is feasible. Biopsy to confirm the diagnosis. Only 26% to 34% of prostate cancer patients found by histological examination are suspected of being diagnosed in the rectal examination, but digital rectal examination is still an indispensable examination method.
Diagnosis
Differential diagnosis
Detrusor hyperreflexia: Overactive bladder (OAB) is a common disease, pons and intermedullary lesions, often manifested as detrusor hyperreflexia plus detrusor external sphincter dyssynergia, characterized by urine Urgent, with or without urge incontinence, often accompanied by frequent urination and nocturia. The Chinese Medical Association Urology Branch Urinary Control Group "Clinical Guiding Principles of Overactive Bladder" is defined as: OAB is a syndrome consisting of frequent urination, urgency, and urge incontinence. These symptoms can occur alone or in any combination. The form appears. During urodynamic examination, some patients in the bladder storage period, the bladder detrusor involuntary contraction, causing an increase in intravesical pressure, called detrusor overactivity. The two are both connected and different.
Detrusor-free reflex: Detrusor-free reflex is one of the types of neurogenic bladder detrusor function. Normal urination activity is caused by the spinal reflex center and sympathetic, parasympathetic, and body nerves. The bladder urethral dysfunction caused by damage to the central nervous system or peripheral nerves that control urinary function is called neurogenic bladder. According to the detrusor function, it is divided into two categories: 1 detrusor hyperreflexia; 2 detrusor no reflection. Neurogenic bladder urethral dysfunction is a type of dysfunction of the bladder and/or urethra caused by neuropathy or damage, often accompanied by a coordinated disorder of bladder and urethral function. Neurogenic bladder and urethral dysfunction produces complex urination symptoms, and poor urination or urinary retention is one of the most common symptoms. The resulting urinary tract complications are the leading cause of death in patients.
Urinary distress: urination has an unpleasant and painful feeling, urgency and urinary urgency, or frequent urination, but not particularly urgent, there is still a feeling of urine after the end of urine, common in acute urinary retention. The lower abdomen is full of sorrow and pain, urinary distress, want to urinate, uneasiness and other painful symptoms.
