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On the given scenario, male patient aged 63 has a six months history of difficult to void with urgency that is on diuretic, thiazide and also has mild hypertension (blood pressure 130/80), but no other complain of urethral discharge or any infection accept suffered from urinary tract infection twice in the past and takes Ampicillin. As a base of this scenario, patient has been diagnosed primarily as a "Benign Prostatic Hyperplasia" (BPH).
BPH is a benign condition and commonly found in male patient after 60 years (Walsh P C 1984). Before discussing about the BPH, it is crucial to understand the structures of prostate gland and major functions relating to its glandular functions and reproductive functions. The main goal of this essay is to include a the detail explanation of the different between BPH and prostate cancer, physiologic hyperplasia and pathological hyperplasia and its significance to male patient above 60 years for getting BPH. This essay will also focus on sign and symptoms of BPH, critical analysis of its diagnosis and management which relating to the assessment of urinary outlet for obstruction.
Structurally, the prostate is a small, muscular, rounded male accessory gland which encircles the urethra just lower to the bladder (Martini 2004). It is single doughnut shaped gland and size is about of walnut which is covered by a thick connective tissue capsule made up of a cluster of 30-50 tubuloalveolar glands compound with a mass composed of smooth muscle fibres (Marieb 2004). The prostate gland gets the blood supply by the superior vesical branches of the internal iliac artery, and the nerve and the lymphatic supply by the obturator and
iliac arteries like vein, and sympathetic and parasympathetic nerve fibres respectively (Blandy and Fowler 1996).
Fig1. Prostate gland (Source http://www.prostateuk.org/prostate/aboutprostate.htm)
The prostate is divided into three zones which are peripheral zone, central zone, and transition zone. The peripheral zone is situated at the back of the prostate which is most susceptible part for the both prostate cancer and prostatitis. On the other hand, the common prostatic problem among elderly men is BPH which is developed in the transition zone and encircled the urethra and lies on the centre of the gland (Blandy and Fowler 1996).
Fig2. Three zones of Prostate gland (Source http://www.prostateuk.org/prostate/aboutprostate.htm)
Prostate gland is an exocrine gland of the male reproductive system which secretes a thin, milky fluid that contains nutrient source, several other enzymes like profibrinolysin and prostate surface antigen (PSA) (Guyton and Hall 2006). Its main function is to store and secrete a clear fluid which adds to the semen, which is slightly alkaline and helps to play a role in activating sperm (Leveillee and Patel 2009
On the basis of clinical and histological findings; BPH is defined as clinically manifests by lower urinary tract symptoms (LUTS) and may be related with sexual dysfunction and sometimes urinary incontinence and histologically as a proliferation of glandular epithelial cells, stromal cells, and smooth muscle of the prostate (McNeal J 1988). The BPH is also known as Benign Prostate Hypertrophy where the hyperplasia presumably results in enlargement of the prostate that may restrict the flow of urine from the bladder (Leveillee and Patel 2009). Epidemiologically, in Europe the incidence of symptomatic BPH defers; 40% men suffer on the age of 60 or above and only 14% suffer on their age of 40. More ever 30% men suffer in the UK that means 4 million suffers on the aged more than 40 years from this condition (Bolland 2008).
Although the actual cause of BPH is unknown. The possible risk factors include family history, age, ethnicity, race, nutritional intake and hormonal status (Porth and Matfin 2009). However, aging and hormonal status are believed to be clearly important as the development of symptoms are related with age and increases in prostatic size are apparent on autopsy (Ganong and McPhee 2006). Data from autopsy studies have revealed that the pathologic evidence of BPH increases with age; men from 30s to 39 years less than 10%, 50s to 59 years about 40% to 50%, 60 years more than 70% and 80 years almost 90% (Berry et al 1984). The obstructions of bladder outlet symptoms are hardly ever found in the men below 40 years but among the men older than 65 years are about one third and up to three fourths of men at age 80 years (Ganong and McPhee 2006). Declining levels of androgens relative to estrogen levels are believed to stimulate glandular and stromal hyperplasia (Chandrosoma and Taylor 1998). Although, the hormonal changes are usually thought to be concerned in the hyperproliferation of prostatic cells that can cause enlargement of the prostate, but recent studies suggest that hormonal changes only is not sufficient enough for the development of hyper-plastic prostate gland (Berthon et al 1997). So, the exact causes of its progression are still only poorly understood.
BPH is related with age for the enlargement of prostate gland with the development of large, discrete lesions in the peri-urethral region of prostrate, which compress the urethra and produce symptoms of dysuria where, prostate cancer begins in the peri-pheral zones of the prostate gland and usually is asymptomatic until the disease is far advanced and the tumour has eroded the outer prostatic capsule and spread to adjacent pelvic tissues or metastasized (Porth and Matfin 2009). It is commonly believed that BPH does not appear to result in prostate cancer. However, an individual can develop both BPH and prostate cancer at the same time. One in 12 men over 60 develops the prostate cancer (Siddiqui et al 2004). The sign and symptoms of both prostate cancer and BPH will present the symptoms of LUTS, which includes increased in frequency of voiding, urgency, uncertainty, nocturia, weak or interrupted flow and post-urination dribbling (Siddiqui et al 2004). However, in prostate cancer, patient will present urinary retention, back or leg pain and haematuria (Theodorescu and Krupsk 2009). In metastatic symptoms patient suffers from loss of weight and appetite, pathological fractures including bone pain and edema as well as there will be uremic symptoms because of urethral obstruction due to abnormal growth of prostate gland (Theodorescu and Krupsk 2009).
Hyperplasia is divided into two main categories; which are physiological and pathological hyperplasia. In physiologic hyperplasia, a tissue increases its functional capacity when needed and after the damage or partial resection of tissue mass and on the other hand, pathological hyperplasia is caused by over stimulation of hormone or growth factors acting on target cells (Kumar et al 2004). Common example of pathologic hyperplasia is BPH which is induced by androgens hormone responses and these types of hyperplasia usually are abnormal and the process remains controlled because the hyperplasia regresses if the hormonal stimulation is eliminated which is the normal regulatory control mechanisms that distinguishes benign pathologic hyperplasia from cancer (Guyton and Hall 2006). Therefore, above given condition of BPH can be classified as a pathological hyperplasia. BPH is arises in so many men age above 60 because it is considered as a usual part of aging process due to hormonally dependent on testosterone and Dihydrotestosteron (DHT) production and throughout the childhood prostate gland remains small and begins to grow at puberty under the stimulation of testosterone and at the age of 20 years it reaches an almost stationary size and it stays on the same size till the age of 50 years (Kumar et al 2004). In the stroma of the prostate a by-product of metabolism of testosterone known as DHT is produced, followed by the action of an enzyme called 5Î± - reductase and proliferation of both stroma and epithelium cells is promoted by DHT which binds to androgen receptors on the nuclei of both cell types, leading to the production of growth factors (Stevens et al 2009).
The sign and symptoms of prostate enlargement includes irritate or obstruct the bladder because it's surrounds the urethra just below the bladder which results sensation of frequently emptying the bladder, even after a man is done urinating and sometimes every one to two hours, especially at night (McConnell et al 1994).
The main complaint of BPH is usually troublesome LUTS followed by increased in frequency of voiding, urgency, nocturnal, decreased and intermittent force of flow and the feeling of incomplete bladder emptying, however not all men with histological evidence of BPH will develop LUTS because causative factors might be other, like urinary tract infection (American Urological Association(AUA) 2003). Similarly, not all patients with BPH and LUTS will have prostatic enlargement, and prostatic enlargement may exist in the absence of LUTS (Bolland 2008). On the basis of obstructive and irritative symptoms LUTS are categorized into two types which are shown in the following table below.
Table1. Classification of LUTS adapted from Bolland W (2008)
The guidelines from the agency of Health Care Policy and Research (AHCPR) suggest that the initial evaluation of men for a diagnosis of BPH includes physical examination, history, digital rectal examination, residual volume measurements, urinalysis, urine flow rate and blood test for serum creatinine and PSA (McConnell et al 1994).
The prostate fluid contains large amounts of a substance which is known as PSA and it is an enzyme released by epithelial cells of the prostate gland; its main function is to prevent the coagulation of the sperm in semen and it is also detectable in the blood (Shabbir and Mumtaz 2004). Level of serum PSA in the blood is a valuable marker for prostate size, useful for future prediction of the prostatic growth and risk for acute urinary retention or surgery (Roehrborn et al 2000 cited in Kaplan 2006).There are some controversies regarding testing the PSA level in serum, some of the research suggested that it is optional to test and on the other hand, recent study recommends to test PSA to rule out the BPH which will be the future predictor for getting the cancer (McNaughton-Collins 2005). PSA is organ-specific in nature; therefore, ruling out the PSA level in prostate cancer and BPH sometimes might give false results because it can leak out in the blood circulation (Rosette et al 2004). According to the old studies, PSA level 0.30ng/ml contributes to BPH whereas 0.35ng/ml contributes to prostate cancer (Stemey et al 1986 cited in Rosette et al 2004).
According to the provided clinical history, patient is also showing the obstructive symptoms including hesitancy, poor streaming and feeling of incomplete emptying which can cause secondary hypertrophy in the bladder muscles resulting urgency, frequency and nocturia and finally patient goes to complete retention of urine (Shabbir and Mumtaz 2004). On the given scenario, 63 year old elderly man was complaining of difficult to void since six month which represents that BPH is causing due to benign prostatic obstruction which play a critical role in pathological changes in urinary tract (Rosette et al 2004). Therefore, it is crucial to assess the urinary outlet obstruction to rule out the causes of BPH although the voiding dysfunction experienced by elderly patients is usually not clear (Grayhack 1992 cited in Rosette et al 2004). Urethrocystoscopy is the choice of procedure to rule out the causes of obstruction and it also assess to measure the size and severity of the obstruction, patency of the urethra and bladder neck (Larsen and Bruskewitz 1991 cited in Rosette et al 2004).
The primary target for the BPH treatment is to reduce the sign and symptoms of LUTS, future complication of acute urinary retention and progression of BPH (McNaughton-Collins 2005).The recent updated treatment of BPH includes ballon dilation, laser surgery, prostate stents and pharmacologic treatment using 5Î±-reductase inhibitors; such as finasteride which help to reduce the prostate size by blocking the effects of androgen and Î±1 adrenergic receptor blockers which inhibits contraction of smooth muscle of the prostate ( Porth and Matfin 2009). Other surgical management includes transurethral resection of prostate, needle ablation and microwave therapy. Apart from the surgical and medical management, there are herbal medicines like Saw palmetto plant seems alternative treatment to relieve the BPH related LUTS (Edwards 2008).
In conclusion, according to the given clinical history, patient has suffered from pathological BPH contributed by the LUTS symptoms as there was no other abnormal finding in the vital organs. Although the value of PSA was not mentioned as it is not always significant for the diagnosis of BPH; therefore considering the patient's age factor, it is due to hormonal changes and also patient was suffered from urinary tract infection twice in the past which all contributed to BPH.