Benign prostatic hypertrophy, also known as enlarged prostate, BPH or more correctly as benign prostatic hyperplasia, is a volumetric enlargement of the prostate. We speak more correctly of hyperplasia because this enlargement of the gland is due to an increase in the number of cells that constitute it. Beyond the subtleties, the most important aspect to underline is that the enlargement of the prostate is caused by a completely benign physiological proliferation. Unlike a tumor, in fact, BPH compresses the surrounding tissues without infiltrating them and originates mainly from the central portion of the gland. In people suffering from benign prostatic hyperplasia, the prostate can even exceed its normal size by two or three times. size. After several years and in the absence of treatment, this gland can even reach the size of a grapefruit. As shown in the figure, I remind you that the prostate is placed like a sleeve around the urethra, which is the channel that carries the urine from the bladder to the outside. It is therefore not surprising that the enlargement of the prostate ends up compressing the urethra. This compression can create problems in the passage of urine, thus causing various annoying symptoms of the urinary tract.
Benign prostatic hyperplasia is a very frequent alteration, especially in older men. In fact, we are talking about a typical age-dependent disease; in particular, benign prostatic hyperplasia begins to develop after the age of 40 and occurs mainly after the age of 50. The incidence increases proportionally with advancing age, reaching maximum levels in the eighth decade of life. that between 70 and 80 years, benign prostatic hyperplasia affects up to 80% of the male population.
Having established that benign prostatic hyperplasia accompanies the normal aging process, we now pass to the analysis of the causes and predisposing factors. Unfortunately, the exact causes of benign prostatic hypertrophy are not yet known. However, it is now established that they are involved. changes in the hormonal balance, typical of aging. As we age, in fact, the gland spontaneously tends to change its consistency and volume in response to hormonal changes and the action of numerous growth factors. , the release of small amounts of estrogen and the increase in dihydrotestosterone, which is a metabolite of testosterone, seem to favor the onset of BPH.
As for the associated symptoms, the enlargement of the prostate is slowly progressive. The onset of symptoms is, therefore, generally gradual and, as a rule, we have seen that it occurs after the age of 40. However, benign prostatic hypertrophy does not always evolve with the same modality and speed. It should also be added that the enlargement of the prostate does not necessarily lead to significant disturbances and in many cases there are no symptoms. When present, benign prostatic hypertrophy can lead to irritative and obstructive symptoms. Examples of irritative symptoms associated with benign prostatic hypertrophy are the urgent need to urinate and the increased frequency of daytime and nighttime urination, which in medical terms are termed pollakiuria and nocturia, respectively. Alongside difficulties in starting to urinate, other symptoms almost always present are: intermittent urination, decreased urinary stream strength, slow and painful urination (which doctors refer to as stranguria), feeling of incomplete bladder emptying and dripping after finishing. urinating. The growth of the prostate, which increasingly narrows the urethra, can create problems with proper urinary outflow. Consequently, the subject must increase the pressure necessary to empty the bladder. Due to this overwork, the bladder wall tends to gradually weaken and over time it is possible to even reach acute urinary retention, or the inability to empty the bladder. Obviously, this is a urological emergency, which requires the placement of a bladder catheter. Prolonged obstruction of the urethra can even impair kidney function. Another complication to consider is the incomplete emptying of the bladder, which determines the stagnation of a residual urine in which bacteria can proliferate and settle any crystalline aggregates. For this reason, benign prostatic hyperplasia exposes you to a greater risk of urinary infections and kidney stones.
If you have symptoms suggestive of BPH, the first thing to do is contact your doctor. Through a urological examination it is in fact possible to ascertain the real presence of prostatic hypertrophy and exclude other pathologies that may manifest themselves with similar symptoms, such as prostatitis or a tumor. As for the diagnosis, I refer you to the previous video on prostate exams. We can however summarize that for a correct study of the disease a urological examination and some specific clinical examinations are certainly necessary. Among these I remind you the urinalysis, the dosage of the prostate specific antigen (or PSA) in the blood, and the digital-rectal exploration of the prostate. The PSA is used to evaluate the possibility that a malignant tumor is present, while the rectal examination provides information on the volume and consistency of the gland. The urine test, on the other hand, allows you to check kidney function or the presence of infections. To determine the nature and extent of the prostate abnormality, the patient may be subjected to more in-depth examinations, such as uroflowmetry and trans-rectal prostatic ultrasound, followed by biopsy. The uroflowmetry measures the speed of the urinary flow and the volume of urine emitted during urination, thus providing an idea, albeit rough, of any damage to the bladder. Prostate biopsy, on the other hand, allows to confirm or exclude the presence of a malignant tumor .
When benign prostatic hyperplasia does not cause a patient discomfort, it can simply be monitored over time. On the contrary, in the presence of complications, pharmacological or surgical treatment is mandatory. Regarding drugs, there are two main therapeutic categories, which are alpha-blockers and 5-alpha-reductase inhibitors. Alpha blockers, such as alfuzosin, doxazosin, tamsulosin and terazosin, reduce muscle tone in the prostate and bladder neck. They essentially relax the prostate by facilitating the passage of urine into the urethra. On the other hand, 5-alpha-reductase inhibitors, such as finasteride and dutasteride, act differently. These drugs inhibit the volumetric growth of the prostate by suppressing the stimulation of androgens. In practice, they work by blocking the transformation of testosterone into its active form, dihydrotestosterone (DHT), which participates in the enlargement of the prostate. In a similar way, albeit with modest effectiveness, some phytotherapeutic agents also act, such as the extracts of Serenoa repens (also known as saw palmetto) and the extracts of pumpkin seeds and African pigeo. The major problems of using drugs for the treatment of benign prostatic hypertrophy are related to possible side effects. Among these are erectile deficits, retrograde ejaculation and gynecomastia for 5-alpha-reductase inhibitors, while hypotension, migraine, dizziness, headache and asthenia are common among users of alpha blockers. Another common problem is that the efficacy of these drugs tends to decrease with long-term use. When drug therapy is ineffective, surgery is used. type of procedure to undergo the patient with symptomatic BPH is essentially based on the size of the prostate adenoma to be removed. The most used technique is transurethral endoscopic resection or TURP. As the name implies, it is a reduction of the prostate performed by means of endoscopy, ie without incisions.In practice, a special instrument is introduced into the urinary canal through the penis for cut "into slices" the prostate adenoma. In this way it is possible to remove the internal part of the enlarged prostate. Alternative techniques - less invasive but often effective yet to be confirmed - aim to destroy part of the glandular tissue without damaging what will remain in place. For this purpose, depending on the method used, laser rays, radio waves, microwaves or chemicals are concentrated directly inside the prostate. The suitability or otherwise of these alternative techniques is mainly influenced by the extent of prostatic hypertrophy; in general, the greater the degree of hyperplasia, the more invasive the operation will be. For example, if the size of the prostate is excessive, it is necessary to proceed with an open surgery, called adenonectomy. This operation involves the removal of the whole prostate adenoma by skin incision, transvesical or retropubic. Partial or total surgical removal of the prostate can involve some complications for patients. Among these, the one that generally concerns patients most is the risk of erectile dysfunction However, according to recent studies this risk is considered null or even lower than in patients who choose not to have surgery. A very frequent sexual adverse effect after surgery is retrograde ejaculation; in practice, during ejaculation the seminal fluid, instead of coming out of the urethra, it flows back into the bladder causing infertility.
