The process of prostate enlargement begins at the age of 35 and develops at a different rate. At the age of 50, 50% of men develop prostate hyperplasia, while at the age of 70 the percentage is 70-75%. Half of these men have a clinically significant disease and need to be treated.
Increasing the size of the prostate results in compression of the urethra and its partial occlusion. As a result, resistance to urination increases and the bladder contracts in order to push the urine out. This leads first to hypertrophy of the muscle fibers of the bladder (effort bladder) while in more advanced stages it leads to instability of the bladder and then to its complete atony.
“At this stage the bladder is no longer able to push urine out even if the prostate barrier disappears. The stagnation of urine inside the bladder gradually leads to kidney damage and renal failure. Germs grow inside the urinary tract resulting in frequent and persistent urinary tract infections. “There is also the development of stones inside the urinary tract with concomitant pain when urinating and hematuria”, says Dr. Konstantinos Paidaros, MD, FEBU, Surgeon Urologist and Director of the Lithiation Department at the Metropolitan Hospital.
Symptoms: Symptoms are also called lower urinary tract symptoms (LUTS). They are divided into urinary storage symptoms (irritants) and urinary excretion symptoms (obstructive).
Irritant symptoms
Urgency: When the need to urinate is intense and can not be postponed. The patient can not be easily held and must go to the toilet urgently.
Frequency and burnout: The patient urinates very often in small quantities while urination is accompanied by a burning sensation or pain.
Nocturia: The intense sensation of urination that wakes the patient at night. It is the most classic symptom and affects the sleep, mood and quality of life of the patient.
Obstructive symptoms
Difficulty both at onset and during urination: The patient is pressed to urinate while the flow of urine is slower and less intense.
Feeling of incomplete emptying: After the end of urination, the patient feels that his bladder is not completely empty and goes to urinate again in a short time.
Intermittent urination: Urination stops and starts again abruptly.
Urinary retention: Urination becomes impossible and a catheter needs to be inserted in order to empty the bladder.
Diagnosis: It is very important to get an accurate history and to complete a special questionnaire in order to evaluate the symptoms and classify them as mild, moderate and severe.
Clinical examination: The size and texture of the prostate is assessed as well as whether it is painful to the touch.
Laboratory Tests: General and urine culture, PSA, urea and creatinine are necessary for a complete assessment of the condition.
Imaging exams: “Ultrasound of the kidneys-bladder-prostate before and after urination is the main test with which we evaluate the condition of the kidneys, the bladder, the size of the prostate and the residue after urination. Urometry complements the ultrasound findings, while, in selected cases, urodynamic testing diagnoses the presence of a neurogenic bladder.
Cystoscopy: Under direct vision we assess the size and general condition of the prostate. We also check the inside of the bladder and diagnose its possible hypertrophy as well as concomitant diseases such as diverticula, lithiasis and papillomas.
Finally, with cystoscopy we identify and correct possible urethral strictures which are also the cause of severe dysuric problems. “Cystoscopy is performed without anesthesia, easily, quickly and painlessly and is a valuable test with a very important role in the diagnosis of serious urological diseases”, explains the doctor.
Therapeutic approach: When the symptoms are mild, regular monitoring with appropriate examinations per year or every six months is enough. However, when the symptoms are moderate or severe and especially when they affect the quality of urination and therefore the patient’s daily life, then treatment options should be considered.
Medication: There are two categories of medications:
-A-inhibitors: They work by relaxing the muscle fibers of the prostate and the neck of the bladder, thus facilitating the exit of urine. The maximum of their action occurs within a month from the start of treatment. Their side effects are hypotension, fatigue, dizziness and headache as well as recurrent ejaculation.
-5-a reductase inhibitorsThey work by blocking the enzyme that induces the production of DHT, the hormone responsible for prostate enlargement. The effects of these drugs are slow to be perceived, as they require at least six months of treatment. Side effects include decreased sexual desire, erectile dysfunction and ejaculation.
In selected cases, drugs of both categories can be combined either with each other or with other drugs such as antimuscarinics, anti-inflammatory and antibiotics, in order to achieve the optimal therapeutic effect.
Endoscopic and minimally invasive treatments
The most advanced methods of minimally invasive treatment of benign prostatic hyperplasia allow the patient to get rid of the severe symptoms of the disease but also the risk of a possible severe development such as renal failure.
With the application of the most advanced technology it is possible to remove the prostate gland with great precision and safety and with minimal perioperative burden. Without incisions, using the opening of the urethra, bloodless and painless, with hospitalization that does not exceed 24 – 48 hours, and with the patient returning immediately to his daily activities.
TURis method
This is a revolutionary method of cutting and sublimating tissue in a saline environment (In Saline). It is performed transurethrally, ie by the natural route, without incision or holes. It is widely used for the removal of the prostate gland but also for the removal of tumors (papules) of the bladder. It harmoniously combines, depending on the nozzle of the tool we will choose, the high-precision bloodless cutting (bipolar loop) and the completely bloodless sublimation (plasma vaporization).
The advantages of the method are the increased safety, the accuracy of the operation, the minimization of the blood loss and the reduction of the surgical time. Postoperative pain is zero.
Despite the fact that from time to time various similar methods appear in the foreground, TURis continues to be the method of choice (gold standard) in the surgical treatment of benign prostatic hyperplasia, without any limitations in terms of indications.
When do we proceed with surgery
Absolute indications are complete and partial urinary retention, prostate hematuria, recurrent prostatitis, bladder lithiasis and diversion, and a large residual urine that can lead to renal failure.
Medication in many cases is not able to dramatically and permanently improve the symptoms of prostate hyperplasia.
When these symptoms are so severe that they affect the quality of urination and consequently the patient’s daily life, the only appropriate solution is invasive treatment.
In conclusion:
“Benign prostatic hyperplasia is a common condition in men. Improper and delayed treatment can lead to serious complications. “When the medication is not effective, surgical treatment of the disease is required and TURis is the most appropriate method”, concludes Mr. Paidaros.
Writes:
Dr. Konstantinos Paidaros, MD, FEBU,
Urologist Surgeon and Director of the Lithiation Department at the Metropolitan Hospital
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