What are the treatments for prostatic hyperplasia?

Prostatic hyperplasia is one of the most common prostate diseases in middle-aged and elderly men. The older you are, the higher the incidence rate. The treatment of prostatic hyperplasia cannot be a one-size-fits-all approach. A more appropriate and effective treatment should be chosen based on the patient's condition and physical condition.

The harmfulness of prostatic hyperplasia lies in the pathological and physiological changes caused by lower urinary tract obstruction. The pathological individual differences are very large, and not all of them are progressive. Some lesions will no longer develop after reaching a certain degree, so even if mild obstruction symptoms occur, surgery is not always required.

Watch and wait

If the symptoms are mild and the IPSS score is below 7, the condition can be observed and no treatment is required.

Drug treatment

(1) 5α-reductase inhibitors are suitable for the treatment of BPH patients with enlarged prostate and moderate to severe lower urinary tract symptoms. Studies have found that 5α-reductase is an important enzyme for the conversion of testosterone to dihydrotestosterone. Dihydrotestosterone plays a certain role in prostate hyperplasia, so the use of 5α-reductase inhibitors can inhibit hyperplasia to a certain extent.

(2) α1-receptor blockers are suitable for BPH patients with moderate to severe lower urinary tract symptoms. It is currently believed that this type of drug can improve urinary tract dynamic obstruction, reduce resistance and improve symptoms. Commonly used drugs include chlorpheniramine. Common side effects of this type of drug include dizziness, headache, fatigue, drowsiness, postural hypotension, abnormal ejaculation, etc.

(3) Others include M receptor antagonists, herbal preparations, and traditional Chinese medicine. M receptor antagonists block bladder M receptors, relieve excessive detrusor contraction, and reduce bladder sensitivity, thereby improving the urinary symptoms of BPH patients. Herbal preparations such as Prosperide are suitable for the treatment of BPH and related lower urinary tract symptoms.

In summary, a comprehensive assessment of the condition should be made before drug treatment, and the side effects of the drugs and the possibility of long-term medication should also be fully considered. Long-term follow-up should be conducted to observe the effects of drug treatment, and urodynamic tests should be performed regularly to avoid delaying the timing of surgery.

Surgical treatment

Surgery is still an important treatment for BPH, and is suitable for BPH patients with moderate to severe LUTS that have significantly affected their quality of life. Classic surgical methods include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy. Currently, TURP is still the "gold standard" for BPH treatment.

Indications for surgery are: ① Symptoms of lower urinary tract obstruction, obvious changes in urodynamics, or residual urine of more than 60 ml; ② Severe symptoms of unstable bladder; ③ Upper urinary tract obstruction and renal function damage have been caused; ④ Multiple episodes of acute urinary retention, urinary tract infection, and macroscopic hematuria; ⑤ Patients with bladder stones. ⑥ Patients with inguinal temples, severe hemorrhoids or prolapse of the anus, and clinical judgment that it is difficult to achieve treatment effects without relieving lower urinary tract obstruction. For patients with long-term urinary tract obstruction, obvious renal function damage, severe urinary tract infection or acute urinary retention, a urinary catheter should be placed first to relieve the obstruction, and surgery should be performed after the infection is controlled and renal function is restored. If it is difficult to insert the urinary catheter or the long intubation time has caused urethritis, suprapubic cystocentesis can be performed instead. The indications for emergency prostatectomy should be strictly controlled.

Minimally invasive treatment

(1) Transurethral electrovaporization of the prostate (TUVP) is suitable for BPH patients with poor coagulation function and small prostate volume, and is another option for TUIP or TURP. It is mainly due to the innovation of electrode metal materials, which makes its biological thermal effect different from the former. Due to the rapid thermal conversion, it can produce a high temperature of 400°C, which quickly causes tissue vaporization or coagulative necrosis. Its hemostatic characteristics are extremely significant. Therefore, clinical applications show: ① Increased indications: glands weighing more than 60g can be performed. ② Clear surgical field: Due to the significant hemostatic effect, the flushing fluid is clear, which facilitates surgery. ③ Reduced operation time: Since the hemostatic step is reduced, the surgical resection is accelerated and the operation time is shortened. ④ Fewer complications: less water intoxication (thick coagulation layer), clear surgical field reduces accidental injuries, less likely to cause sphincter and capsule damage. ⑤ Faster postoperative recovery: shorter flushing time.

(2) Transurethral plasma bipolar resection of the prostate (TUPKP) and transurethral plasma excision of the prostate (TUKEP) are transurethral prostatectomy procedures that use a plasma bipolar resection system and are performed in a similar manner to monopolar TURP. The main advantages of TUPKP include less bleeding during and after surgery, reduced blood transfusion rate, and shortened postoperative catheterization and hospital stay; TUKEP removes the prostate within the capsule, which is more in line with the anatomical structure of the prostate, and has the characteristics of more complete removal of prostate hyperplasia tissue, low postoperative recurrence rate, and less intraoperative bleeding.

(3) Microwave therapy is suitable for patients who are ineffective with drug treatment (or are unwilling to take long-term medication) and are unwilling to undergo surgery, as well as high-risk patients with recurrent urinary retention who cannot undergo surgery. The treatment goal is achieved by using the principle of microwave thermal coagulation of biological tissues. The placement of the microwave radiation pole can be positioned by rectal ultrasound or under direct vision through a urethroscope. The latter can accurately avoid the external urethral sphincter and reduce the complications of urinary incontinence.

(4) Laser treatment The common feature of laser surgery is that intraoperative bleeding is relatively small, which is especially suitable for patients with high-risk factors, such as advanced age, anemia, and decreased function of important organs. The laser thermal effect is used to coagulate, vaporize or remove prostate tissue, and the method is similar to transurethral intracavitary operation. There are surface irradiation, insertion heat therapy, and the use of laser beam to remove the gland. The treatment that is definitely effective is to use laser to remove the gland and crush and suck the tissue out of the bladder. The long-term efficacy and price-performance ratio remain to be observed.

other

(1) Transurethral Needle Ablation (TUNA) is a simple and safe treatment method suitable for high-risk patients with a prostate volume of <75 ml who cannot undergo surgery. It is not recommended as a first-line treatment for general patients.

(2) Prostate stents are metal (or polyurethane) devices placed in the prostate urethra through an endoscope to relieve lower urinary tract symptoms caused by BPH. They are only suitable for high-risk patients with recurrent urinary retention who cannot undergo surgery as an alternative treatment to catheterization. Common complications include stent migration, calcification, stent occlusion, infection, chronic pain, etc.