BENIGN PROSTATIC HYPERPLASIA : A COMMON PART OF AGING

Introduction: It is common for the prostate gland to become enlarge as a man ages. This condition is known as benign prostatic hyperplasia or benign prostatic hypertrophy. Incidence: Though prostate continues to grow during most of a mans life, the enlargement doesnt usually causes problems until late in life. BPH rarely causes symptoms before age 40 but more than half of men in their sixties and as many as 90% in their seventies and eighties have some symptoms of BPH. From 40 years of age the prostate increases in volume by 2.4 cm3 per year on average. The process begins in the periurethral (transitional) zone and involves both glandular and stromal tissues to a variable degree. As the prostate enlarges the layer of tissues surrounding it stops expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine causing more frequent urination. Eventually the bladder weakens and loses the ability to empty itself, thus some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many problems associated with BPH. Causes: The causes of BPH is not well understood. BPH occurs mainly in older men and it does not develop in men whose testis were removed before puberty. For this reason some researchers believe that the factors related to aging and the testis may spur the development of BPH. Some theories: Men produce testosterone and small amount of oestrogen throughout their lives. As the men ages the amount of active testosterone in the blood decreases leaving a higher proportion of estrogen. Studies done in animals have suggested that BPH may occur because the high amount of estrogen within the gland increases the activity of substances that promote cell growth. Dihydrotestosterone (DHT): A substance derived from testosterone in the prostate may help control its growth. DHT is formed by the reduction of testosterone by an enzyme 5- -reductase which has two isoenzymes. The 5- -reductase type 2 is predominant isoenzyme in the prostate. Scientists have noted that men who do not produce DHT do not develop BPH. However some research has indicated that even with a little drop in the bloods testosterone level, older men continue to produce it and its high level accumulate in the prostate. This accumulation of DHT may encourage the growth of cells.

Clinical features:

The primary symptoms of BPH are due to the prostate obstructing the urethra & gradual loss of bladder function that results in incomplete emptying of the bladder and the secondary symptoms comprising urinary frequency, urgency of micturition. The symptoms of BPH vary but the most common ones involve changes or problems with urination such as:Frequent and urgency in urination - cannot wait to pass urine. Urinary hesitancy and weak urination - a hesitant interrupted weak stream. Difficulty starting urination. Urinary leakage or urinary dribbling. Nocturnal urination - frequency increased at night because patient is unable to evacuate the bladder in one go and returns soon as the patient lies down again. y Urinary blockage - Patient may present more dramatically with acute urinary retention & develop a painful distended bladder. y y y y y Investigation: Digital rectal examination (DRE):- it gives a general idea of the size and condition of the gland. An enlarged prostate or BPH that is not Cancerous will likely feel smooth. Rectal ultrasound & Prostate biopsy :- to determine whether an abnormal looking area is indeed a tumor the probe and ultrasound image can be used to guide a biopsy needle to the suspected tumor. Urine flow study:- A reduce flow often suggests BPH. Cystoscopy :- Helps to determine the size of gland and identify the location and degree of the obstruction. Prostate specific antigen (PSA) blood test :-PSA test measure the blood level of prostate specific antigen enzyme produced by the prostate. Specifically , PSA as a serine protease.PSA one of the best way to screen prostate cancer & also discrimination of cancer from BPH. Interpretation of PSA: y y y y 0-4 ng/ml- normal 4-10 ng/ml- slightly elevated 10-20 ng/ml- moderately elevated > 20 ng/ml- highly elevated

An elevated PSA does not mean a men has prostate cancer. Condition other than cancer including an infection or benign enlargement of prostate can result in higher than normal levels. In such case PSA test should be repeated after a short time to see if the level returns to normal. Complications:Urine retention. Bladder or kidney damage. Bladder stone. Urinary incontinence.

Treatment : Medical:Prostate <40 cm3: -adrenoceptor blocker Prostate >40cm3:5- -reductase inhibitor  Non- surgical intervention:Thermotherapy:- transurethral microwave procedures & transurethral needle ablation.  Surgical: Transurethral resection of prostate (TURP) Holmium laser enucleation Open prostectomy