The normal prostate is walnut-sized organ
composed of glandular tissue that makes ejaculatory fluid, its only known function.
Benign Prostatic hyperplasia (BPH) is nonmalignant adenomatus
overgrowth of the periurethral prostate gland. Using size (. 30mL & urinary score) the prevalence of BPH in men aged 55-74
is 19%, but only 4% of them have urinary problems. Based on autopsy studies BPH
is found in 8% of the men aged 31-40; 40-50% for men 51-60, and > 80% in men over 80. 38% of men 40-79 experience moderate
to severe symptoms, and one in 4 men in their 8th decade will require treatment for BPH. On rectal examination the prostate usually is enlarged and has a rubbery consistency, and in many cses
has lost the median furrow. BPH causes elevated PSA in 30-50% of the time.
Multiple fibroadenomatous nodules develop
in the periurtheral region of the prostate rather than in the fibromuscular prostate, which is displaced by progressive growth
of the peripheral nodules growth. Overgrowth that obstructs the flow of urine
will increase the risk of calculus formation in the bladder, infection in the bladder, prostate, and upper urinary tract,
and hydronephrosis and compromised renal function.
* accumulation of urine in the
kidney because of an obstruction in the ureter.
PATHOPHYSIOLOGY:
BPH first develops in the transitional zone of the prostate. The transitional
zone lies immediately external to the preprostatic sphincter. The Prostatic stromal
{supporting framework or matrix of a cell} and epithelial cells maintain a paracrine* type of communication whereby the growth
of the Prostatic epithelium can be regulated by cellular interaction with the basement membrane and stromal cells. There is strong evidence that stromal cell production of an excretory protein regulates epithelial cell
differentiation. BPH may therefore be due to defect in a stromal component that
normally inhibits epithelial proliferation. Androgens play a permissive role
in BPH; thus castrated boys, when they age, do not develop BPH. However, administering
exogenous testosterone is not associated with a significant increase in BPH. Dihydrotestosterone
(DHT), a metabolite of testosterone and a critical mediator of prostatic growth is synthesized in the prostate from circulating
testosterone by the action of the enzyme 5α-reductase, type 2. The enzyme
is localized principally in the stromal cells. DHT binds to the androgen receptors
and signals the transcription of growth factors for the stromal cells, and in a paracine* fashion by diffusion to epithelial
cells. mitogenic to the epithelial and stromal cells. The importance of DHT in causing nodular hyperplasia is supported by the clinical observations that an
inhibitor of 5α-reductase, which reduces DHT content, is given for BPH, and it reduces the prostate volume and in many
cases relieves BPH symptoms.
An additional vector is probably estrogen. This is based on the fact that BPH occurs when men generally have elevated estrogen
levels and relatively reduced free testosterone levels, and when prostate tissue becomes more sensitive to estrogens and less
responsive to DHT.
* Paracrine: Of, relating to promoted by, or being a substance secreted by a cell and acting on adjacent cells.
DIANGNOSIS:
Rectal examination (palpation
of the prostate through the rectrum) may reveal a markedly enlarged prostate.
Often, blood tests are performed
to rule out prostatic malignancy: elevated prostate specific antigen (PSA) levels needs further investigations such as reinterpretation
of PSA results, in terms of PSA density and PSA free percentage, rectal examination and transrectal ultrasonography. These
combined measures can provide early cancer detection.
Ultrasound examination of
the testicles, prostate and kidneys is often performed, again to rule out malignancy and hydronephrosis.
TREATMENT:
Various medical interventions including
5α reductase inhibitors and α-adrenergic blockers and a combination of both have been tried with modest success. Industry sponsored studies of α-adrenergic blockers show a 20-30% increase in
urinary flow rate and a 20-50% improvement in symptom scores. 5α-reductase
inhibitors (Finasteride) inhibits the conversion of testosterone to dihydrotestosterone in the prostate. A 1-year placebo-controlled study of 1229 men with BPH demonstrated no improvement in IPSS (questionnaire)
and flow rate over placebo, and only a small improvement in volume of prostate (Cronn 701).
Transuretheral resection of the prostate (TURP) is standard. TURP results
in Erectile dysfunction in 5-35%; incontinence 1%; and retrograde ejaculation in 5-10%.
Less invasive procedures include intraurethral stents, balloon dilation, microwave thermotherapy, high-intensity focused
ultrasound thermotherapy, laser ablation, electrovaporization, and radiofrequency vaporization. The choices among these less invasive treatments have not been firmly established, and long-term ability
to alter the natural history of BPH is under study.
In a study of 556 men with moderate symptoms
of BHP a comparison of treatment with transurethral resection of the prostate (TURP) to that of watchful waiting. During a 3-year follow up, 8% of the TURP & 17 of the watchful waiting failed treatment.
Saw Palmetto (Serenoa repens) is the most
common herbal treatment for health of prostate and bladder. However, a randomized,
placebo-controlled study showed that saw palmento was associated with epithelial cell contraction, especially in the transition
zone. However, no significant improvement in symptom score or flow rate was observed
(Cronn 701).
Prostatitis
Prostatitis refers
to a disparate group of disorders some result from bacterial infection, and others from a poorly understood combination of
noninfectious inflammatory factors and/or spasm of the muscle of the urogential diaphragm.
Diagnosis is clinical, along with microscopic examination and culture of urine samples obtained before and after prostate
massage. If bacterial, the post-message sample will be positive for bacteria
and white blood cells. Treatment is with fluoroquinolone {antibiotic derived
from quinolone} (300 mg po bid of ofloxacin) if cause is bacterial. Urine
samples for inflammatory will contain only WBC; non-inflammatory no WBC. Non-bacterial
causes are treated with warm sitz baths, muscle relaxants, and anti-inflammatory drugs or anxiolytics {preventing or reducing
anxiety}.
Non-bacterial cause of prostatitis is
more common and can be inflammatory or non-inflammatory. Acute bacterial prostatitis
often produces systemic symptoms as fever, chills, malaise, and myalgias {muscle weakness}, while chronic may occur without
symptoms. For chronic possibly pelvic pain and tenderness on examination.
The information and medical advice contained
in this site is evidence based; therefore, are very few articles that deviate from standard medical wisdom. Of articles critical of current practices the nearly all of them are on drug therapies and the pernicious
effect of the for-profit motive upon the generation of information concerning drugs.
The amount of harm done by big PHARMA’s intrusion into medical science and its consequences upon treatments is
a national disgrace.
Wikipedia:
PSA levels between 4 and 10 ng/mL
(nanograms per milliliter) are considered to be suspicious and should be followed by rectal ultrasound imaging and, if indicated,
prostate biopsy. PSA is false positive-prone (7 out of 10 men in this category will still not have prostate cancer) and false
negative-prone (2.5 out of 10 men with prostate cancer have no elevation in PSA).[15] Recent reports indicate that refraining from ejaculation 24 hours or more prior to testing will improve test
accuracy.
Most men who choose watchful waiting
for early stage tumors eventually have signs of tumor progression, and they may need to begin treatment within three years. An annual biopsy is often recommended by a urologist for a patient who has selected
watchful waiting when the tumor is clinically insignificant (no abnormal DRE or PSA). The tumors tiny size can be monitored
this way and the patient can decide to have surgery only if the tumor enlarges which may take many years or never.
