Dr. Kardi Suteja, SpU
There is also a “loss” to be a normal man because only normal men will experience an enlarged prostate. Conversely, men who are not normal, for example, those who do not have testes or have been castrated (both testicles removed) certainly will not experience prostate enlargement. But fortunately, not all prostate enlargement results in urinary disorders. Benign prostate enlargement (BPH = benign prostatic hyperplasia) is significantly related to age. In men aged 41-50 years the incidence increases to 20%. While in men aged 51-60 years the incidence is 50%. Meanwhile, 90% of older men over 80 years experience BPH. If someone says life begins after forty, then life in this case is prostatic problems.
Prostate enlargement is a major cause of urinary disorders in men aged 40 years and over. But not all urinary disorders are caused by prostate enlargement. It should also be remembered, not all prostate disorders result in urinary disorders. Urinary disorders is a short hand for lower urinary tract syndrome (LUTS) or a collection of symptoms of the lower urinary tract. Urinary disorders can occur due to a blockage of the urethra under the bladder or weakness of the bladder muscle contractions. Benign prostate enlargement is one of the causes of lower urinary obstruction resulting in high urethral resistance.
Urinary Disorders Symptoms
Lower urinary tract syndrome does not always inflict the same intensity for everyone. Some are heavy and prominent and some are mild so the patient is unaware of the symptoms. The symptoms are: urine must wait a long time (hesitancy), weak emission of urine, urine is always pushing (stream), dribbling urinate, urinating in a hurry (urgency), incomplete bladder emptying, urinating suddenly jammed (retension) , urinating jammed constantly, urinating intermittently (intermittency), urine is not smooth, there is always residual, often waking up at night to urination (nocturia), frequent urination during the day (frequency) and recurrent bladder infections.
One of the early symptoms of urinary obstruction under the bladder is the difficulty to start urinating even though the bladder is full. Patients must wait before urine passes despite the strong urge to urinate. The more severe the blockage, the longer the symptoms are. Urinary obstruction due to prostate and narrowing of the urethra (urethral stricture) are the most common causes.
Urgent and hard urinary urge is due to excessive bladder sensitivity and activity as a result of the blockage, inflammation, or neurological disorders. In most cases, the patient can still control urinating urgently, but sometimes due to a very strong urge the urine can leak uncontrollably.
Weak urinary streams and decreased calibre of urinary streams occur due to increased urethral resistance even though there has been an increase in pressure in the bladder. This can be evaluated by uroflowmetry (urine measurement). With uroflowmetry objective figures will be obtained to determine if the flow of urine is normal.
The urine does not come out at once, and the flow is intermittent as a result of the increasingly heavy urinary obstruction. It feels like the bladder has been emptied but then urine follows out again several times. Every urine feels not smooth, there is always residual urine that cannot be removed. This will develop into a recurrent bladder infection.
Congested urine suddenly makes the patient feel pain in the area above the pubic bone and urinary pressure can be extraordinary. The bladder feels full and feels protruding. These symptoms usually force the patient to come for help to the doctor.
Congestion that occurs slowly chronically does not result in patients suffering from severe pain. Their lower abdomen behind the pubic bone just feels uncomfortable. The disturbance is felt when starting urination that feels very long and decreases the emission and calibre of urine. Because the bladder is too full, urine leakage can occur continuously. Similar to that in reservoirs, water always swells out because the container is too full (overflow). This kind of situation is often caused by neurological disorders in the bladder.
Urinary jets that occur suddenly accompanied by severe pain in the urethra are usually caused by stones in the bladder. Urine flow may stop suddenly because of stones that clog the bladder neck, so the path for urine to exit becomes completely blocked. But then it can flow again if there is a change in the patient’s position. This means that the orientation of stones in the bladder neck also shifts and provides its own way out of urine.
Uroflowmetry examination is an examination of the dynamics of the simplest voiding process. This examination can be measured by the amount of urine urinated, the average urine flow rate, the maximum emission rate, and the length of time urinating. The most important thing to know about urinary disorders is observing urine volume and maximum urinary flow rate. The normal value of the maximum urine flow rate depends on age and the amount of urine urinated.
Prostate Examination
The prostate, which is a glandular tissue with connective tissue and muscle, is located just below the bladder neck. On the back it is only separated by two thin layers with the rectum, so a lot of information is obtained by digital rectal examination. Important information that can be obtained with digital rectal examination are: the size of the prostate, prostate consistency, prostate shape, whether the prostate lobes are symmetrical left and right, whether there is a suspicious lump of malignancy or whether the prostate is painful as a sign of infection. In addition, rectal fit can be used to examine indirectly the innervation in the bladder neck.
There is still a more accurate examination for prostate examination, namely ultrasonography through the rectum (Trans rectal Ultrasonography = TRUS). TRUS, in addition to being more accurate in measuring prostate volume, can also be used to determine the possibility of a malignant prostate tumor or dilation of the blood vessels of the prostate edge indicating prostate infection.
If a tumor is suspected through examination of pictures of the prostate, with TRUS, prostate tissue can be taken (biopsy) to be sent to the pathology laboratory as a sample to determine the presence or absence of malignant tumors in the prostate.
Medicine and Surgery
Recognition of symptoms and signs as well as good diagnostic methods are very important, so it is hoped that the possibility of malignancy of the prostate or bladder can be detected. PSA (prostate-specific antigen) examination on suspicion of prostate malignancy and smear examination (bladder tumor antigen) on suspected bladder tumors often must be done if the patient’s condition and supporting examination is possible.
By scoring symptoms by the doctors according to international standards, the severity of symptoms will be classified into three, namely mild, moderate, and severe. In the group with mild symptoms patients can be given drugs, or even, depending on how light the circumstances are, just through observing (watchful waiting). In the moderate symptoms case, it is necessary to look at the results of more objective examinations, i.e. during digital rectal placement, how the prostate volume is, during uroflowmetry, or how the urinary flow curve is. If results are still around normal limits, the administration of drugs can be done. But the right drug and target should be chosen. It must be taken into account whether in the long run therapy with drugs can provide symptom improvement and in economic terms it is not more expensive than the standard treatment.
There are two indications for surgery: relative indications and absolute indications. Relative indications of surgery are fulfilled if the symptom score is between moderate to severe, the urinary flow curve is far from normal and the residual urine with the ultrasound examination is more than 100 cc.
If there are symptoms of a kidney due to prostate, enlarged kidney due to prostate, kidney stones and urinary tract due to prostate, perforated infections of the urinary tract, bladder-pocket (diverticles), bloody urine and recurrent urinary urine then there is no need to see the symptom score again. Immediately there is an absolute indication for the operation. To enforce this absolute indication, surely a laboratory or radiological examination must be carried out.
Until now International standard and main (golden standard) for the treatment of benign prostate enlargement is transurethral resection of the prostate (TUR-P). The patient does not need to be dissected from the lower abdomen. With an endoscope inserted through the urethra, prostate tissue is removed systematically.
Because the number of patients with benign prostate enlargement is more in accordance with the increase in the life expectancy of our society, effective and efficient treatment strategies are needed.
Dr. Kardi Suteja, SpU. is a specialist in urological surgery at Karsuneka Clinic Denpasar and several private hospitals in Bali.