Prostate adenoma

Adenoma of prostate gland (adenoma of the cranial part of the prostate, periuretralnuu adenoma) - benign glandular neoplasia. Formerly hypertrophy of the prostate does not comply with the essence and morphological picture of the process.
The etiology and pathogenesis. In different periods were differently interpreted the emergence and development of benign prostatic hyperplasia.
Currently received recognition endocrine theory, or, more correctly, the theory dysfunction between reproductive glands (A. Ya Abrahamian, L. I. Dunaevsky, L. M. Chabad and others). Still E. C. Pelican in 1872 proved that the prostate when emasculation before puberty does not develop, and when emasculation after puberty atrophies. In 1892-1893, F. I. Sinitsyn, on the basis of the relationship between development of the testicles and prostate, treated hypertrophy of the prostate castration. B. C. Klyucharev, V. P. Konoplev and L. M. Chabad confirm the occurrence of endocrine disorders in involution genitals.
Anatomic-morphological base this theory gained in the modern study of cuts prostate [J. C. Gudinski, Veurne (S. G.Vernet)], embryological studies. Anatomic-morphological studies of tracheascopy by M. A. Baron blocks of the prostate (rear Department of the urethra, the neck of the bladder) have shown that the prostate is a body of diverse structure. In it there are various ferrous education that is sensitive to hormonal influences of different nature.
The prostate gland is divided into two parts: the caudal and cranial. Caudal part is actually prostate covering in the form of a horseshoe cranial part [Fig. 5 (Fig. 5-12 surveillance Ya Century Gubinskogo)]. The primary elements of benign prostatic hyperplasia (spheroids) are observed in the cranial part. Than older people, the clearer register such dualistic structure of the prostate (Fig. 6).


Fig. 5. Prostate gland: 1 - cranial part; 2 - the primary elements of prostate adenoma; 3 - caudal part of the prostate.

Fig. 6. The dual structure of the prostate a person older than 70 years. The cranial part of the prostate gland surrounds the gaping urethra; it visible adenomatous nodes. Caudal part of the prostate is somewhat compressed.

Clinically confirmed that adenoma, as a rule, develop in the cranial part, and cancer - in caudal. The study of endocrine effects proves the presence of two areas in the prostate.
It is proved that the epithelium of the caudal part of the prostate and cells of malignant tumors developing in her, developed under the influence of androgens. Adenoma prostate cancer can coexist in the same patient. The terms "malignant degeneration of adenoma" or "reborn adenoma" must be excluded from use.
Clinical course. Most urologists shares clinical course of three stages. Ya Century Gudinski believes that it is necessary to distinguish four stages of the disease (highlighting the stage of III): I stage - precursors (erased initial symptoms), II stage - hyperemia (the period of dysuria and dystonia), stage III - incomplete chronic urinary retention (the period of residual urine), IV stage paradoxical istorii (period incomplete delay of urine stretching sphincter of the bladder). There is also a silent form of prostate adenoma.
I (preclinical) stage is observed more often in patients younger, who suffered from congestum and giperemiei (on the soil infection) urine-Polo-new system. It is known that in the prostate and seminal vesicles are localized congestion and infection with more than a third of all men over 35 years [Leader (A. J. Leader)]. After the age of 50 years with the development of BPH arise early preclinical symptoms in the form of minor violations of urination, and discomfort in the perineum, lower abdomen, in the depth of the posterior urethra. This early symptomology explained earlier BPH phase gistiotitarnaya infiltration in reflexogenic zone inside the triangle, which acts as an irritant factor.
Early sign of prostate adenoma may be premature ejaculation if it occurs after the age of 50, as well as hemospermia. At last it is necessary to exclude prostate cancer.
II stage is characterized by the development of dysuria; you receive frequent urination first night, and later in the afternoon. Typical of this stage is the symptom of imperious urge, which differs from the similar symptoms of cystitis and rear urethritis fact that it is not accompanied by pain and cloudy urine, but its intensity is very high. Commanding leads to urge incontinence, and urinary incontinence after 50 years often indicates a prostate adenoma.
Periodically dysuric phenomena are reduced or disappear, but with the growth adenomas grow. Acceding infection increases dysuria. There is no parallelism between the intensity of dysuria and the size of the prostate. You receive a symptom difficult urination: first, after sleep, the long seat, overflow bladder, if it is impossible to empty it. All that contributes to the stagnation in the venous system of the pelvis (constipation, a cooling of the body and especially the lower extremities, alcohol abuse, sexual excesses), increases the difficulty of urination. Becomes weak flow of urine, especially at the beginning of urination, when a thin stream falls steeply down (sick wets himself to his feet), and sprayed stain underwear. Increase the night pollakiuria and polyuria.
When there is suspicion of BPH should measure the amount of urine and count the number mocheispuskani, as pollakiuriya in the second half of the night is an important symptom of benign prostatic hyperplasia.
General condition of the patient in stages I and II remains satisfactory except in those cases when the night pollakiuria disrupts sleep sick and he becomes nervous, irritable, complains of fatigue, inability to concentrate. Proof that the disease is in stage II, is the absence of residual urine. At the end of stage II appears hypertrophy of the muscular wall of the bladder and trabekuliarnae her reaction detrusor in violation of the tone in the neck of the bladder and the posterior urethra and increased intravesical pressure. All these phenomena are increasing in stage III.
III stage - stage of incomplete chronic retention of urine. The transition II stage III may be hardly noticeable to the patient, but the objective is always expressed by the presence of residual urine, which amount is steadily increasing. In stage III suffer all overlying the urinary system: the detrusor tone starts to fall and hypertrophy of its walls, giving intravesical pressure, decreases muscle fibers stretch and there are numerous small false diverticula. Especially quickly comes decompensation of the bladder wall at the increase of the so-called average share, which, as it blocks the road urinary stream (Fig. 7).

Fig. 7. Mushroom average share of the prostate, which is a hub that overlap urinary stream.

Growing up and to the back adenoma kryukoobraznost lifts and squeezes uksteisele departments ureters, as seen for excretory urography (a symptom of so-called fish hook).
The aforementioned changes, affecting the upper urinary tract, lead to expansion of the ureter and renal pelvis type ureterohydronephrosis; renal papillae flattened, renal parenchyma atrophies from the pressure that results in severe renal function impairment, the outcome of which may be uremia. First, the kidney has lost the ability to concentrate urine and it is necessary to highlight slag plenty of fluids, later suffers ability cultivation. III stage lasts for years, the phenomena of the tension grow so slowly that the patient is enjoying their condition, without increasing the amount of residual urine. This is because of the decrease in contractility of the bladder reduces the sensitivity, and the patients in this age suffer very little (N. N. Goltsov). Gradually, the bubble is stretched and may contain 1,5-2 l of urine, the tension accumulated in the bladder urine overcomes the resistance of sphincters, and urine involuntarily begins to stand out drop by drop, as from the overcrowded vessel.
IV stage - period paradoxical istorii, i.e. paradoxical delay of urine (see Isure). In this period expressed kidney failure with symptoms of intoxication, and as a consequence, there gastrointestinal disorders. Guyon (J. C. F. Guyon) called them urinary dyspepsia". Patients are often treated with erroneous diagnoses: gastritis, enterocolitis, stomach cancer. At the same time or a little earlier develops thirst (polydipsia), resulting azotemii. Dehydration leads to a sharp loss of weight (Fig. 8). Toxic inhibition of liver function is manifested by the yellowness of the tissues. A. I. Pytel indicates that the oppression of neutralizing function of the liver in the second or third stages of BPH is extremely high. After 10-15 days after cystostomy functional activity of the liver is significantly improved.

Fig. 8. The sharp loss of weight in the azotemii on the basis of benign prostatic hyperplasia.

The above factors: dehydration, toxic oppression of the liver, disorders of the gastrointestinal tract, aversion to food, cardiovascular disorders - defined group of patients mask the symptoms of urinary obstruction, what makes some authors to join this group called hidden, or silent, prostatism, which often leads to diagnostic errors. At this early gallbladder symptoms go unnoticed.


Complications. The most common complication in patients who did not undergo catheterization, is full of acute urinary retention. Patients who undergo catheterization, frequent complications of inflammatory nature (cystitis, pyelonephritis, prostatitis, epididymitis). Urinary retention is a severe complication, occurring more frequently in the II and III stages of the disease. It is the result of sudden and severe redness of the pelvic organs (alcohol abuse, hypothermia, exhaustion, long delay urination, prolonged sitting or lying); urinary retention frequent in older people suffering from BPH, forced to remain in bed with heart disease and those who are for the elimination of trauma appoint diuretics, especially mercury funds. Acute urinary retention effect on the General condition of the patient and the whole urinary tract. The sooner will be unloaded the bladder through catheterization, the sooner will recover its function. In a lengthy stretch the bladder may be irreparable defeat its walls.
Emerged in the second stage of acute urinary retention after catheterization (see) may not happen again for a long time, in the third stage of the disease it may be resistant and require surgical treatment. Acute full urinary retention is a symptom of a number of diseases that occur after the age of 50. In addition adenomas, it may be due to prostate cancer, lung prostatitis, bladder neck sclerosis, stricture of the urethra, semiprime in him a stone, a disease of the Central nervous system. All these diseases should be ofdifferential as tactics of treatment varies.
Stagnation in the bladder and upper urinary tract contribute to the emergence of infection, especially in patients that underwent catheterization; cystitis (see) - very frequent and recurrent complication. More important and dangerous complication is pyelonephritis (see); it is registered in almost half of all patients with BPH. Pyelonephritis leads to decreased renal function; recovery and aftercare for such patients last longer and require more care. Frequent inflammatory processes in adenomatosna modified gland and deferentia and orhoepididimit. For prophylaxis the recommended vasectomy all patients with prostate adenoma cancer, requiring catheterization.