in this article:
Benign prostatic hyperplasia (BPH) is one of the most common diseases associated with the aging process in men, particularly aged >50 years, but only a few predictors have been identified. In recent years, the focus has been on the role of prostate inflammation in the pathogenesis and progression of BPH.
Prostate and its function in male organism
The prostate, or prostate gland, is an anatomical structure located just below the bladder, in front of the rectum. The size and morphology are similar to those of a chestnut. The urethra runs through the prostate, the channel that carries the urine and the seminal fluid outwards. Near the prostate there are important muscles, called sphincters, that actively intervene in urination and in the same ejaculation. By contracting, they are able to stop the flow of urine and favor the expulsion of the sperm at the moment of the orgasm.
The prostate, like all the glands, has the function of producing and secreting substances useful to the organism. Specifically, it intervenes in the synthesis and secretion of a particular liquid, called prostatic fluid, which at the moment of ejaculation is poured into the urethra, combining with other secretions. The combination of all these components gives rise to the seminal fluid, which escapes from the penis to the climax of the sexual act (ejaculation).
The spermatozoa, produced in the seminiferous tubules of the testicles, benefit from the prostatic fluid, which serves to increase survival and motility. The semen, or seminal fluid, contains in fact numerous components with buffer function (to neutralize the acidic environment of the vagina), lubricating and nourishing. In addition to the prostate, other seminal glands participate in the formation of the seminal fluid: urethral bulbs and seminal vesicles. As a whole, prostatic secretions make up about 99% of the sperm volume.
In addition to ensuring greater vitality to the approximately 50-200 million sperm placed in the vagina at the ejaculation, sperm secretions protect the male reproductive system from pathogens. They contain in fact immunoglobulins, lysozyme and other compounds with antibacterial activity.
A particular component of the sperm is zinc; since this mineral reaches important concentrations in the prostatic fluid, even if certain data on its role in reproduction are lacking, it is often added to supplements dedicated to the health of the male reproductive system.
Soy proteins, on the other hand, appear to play a protective role in the development of prostate cancer, as is the lycopene present in tomatoes. More generally, prostate health is guaranteed by a sober and balanced diet, rich in vegetables, fruit and particularly careful not to exceed the consumption of saturated fats, snacks, sweets, red meats and fried food. Supplements with zinc, selenium and other antioxidants may be useful.
During the course of life, the prostate may be affected by various diseases. The most common are inflammatory ones, usually of bacterial origin (prostatitis), hypertrophic (benign prostate hyperplasia or IBP) and tumors (prostatic adenocarcinoma). While prostatitis often affect youth, the other two conditions are more common in senescence. For this reason, after 45-50 years, it is good practice to perform preventive urological examinations, in order to identify any pathologies in the bud and to intervene promptly to prevent its evolution.
To perform its function better, the prostate needs to receive adequate hormonal stimuli. These stimuli are mediated by dihydrotestosterone (DHT), a derivative of the best known testosterone obtained by the action of an enzyme called 5-alpha-reductase type 2, particularly expressed at the prostate level. The same enzyme allows the development of the genitals in the masculine sense during fetal life and, if present in excess, can lead to an abnormal development of the prostate.
This disorder, known as prostate enlargement, is particularly common in men over the age of 50. Because of its particular anatomical position (we have seen that the prostate develops below the bladder and around the urethra), a similar enlargement can cause micturition disorders. Fortunately, today there are drugs, such as finasteride and dutasteride, which inhibit the action of the 5-alpha-reductase enzyme, blocking the production of DHT and favoring the resolution of prostate disorder in the long term.
What is prostate enlargement?
Among the diseases affecting the prostate, benign prostate hyperplasia or prostate adenoma is the most widespread. This is especially true after 50-60 years. As the years go on, in fact, the central part of the prostate tends to become bigger until it is even 2-3 times longer than normal measures. With age, the rate of estrogen increases and, since the muscle part of the prostate has a large number of estrogen receptors, it also increases the risk of hypertrophy.
The absence of correlation with social and cultural status, with blood group, smoking habit, alcohol abuse, cardiovascular disease, diabetes, cirrhosis of the liver and hypertension has been scientifically demonstrated. Unlike prostatic carcinoma (which usually originates in the peripheral portion), hypertrophy develops in the central prostate.
The growth of the prostate gland tends to restrict the prostatic urethra increasingly, the part of the organ that starts with the internal urethral orifice of the bladder and ends at the apex of the penis at the external urethral orifice. This causes the first warning symptom to be, almost always, the difficulty in urinating. The bladder is forced to work harder to try to expel urine and, over time, weakens, loses efficiency and is subject to diverticula (bladder hernias). Furthermore, the difficulty in expelling liquids can cause part of the waste substances to remain in the bladder, giving rise to possible infections and calculi.
The first diagnostic test to verify the presence of prostate enlargement is, even today, rectal exploration: a simple, non-invasive and very reliable investigation. The positive outcome of the examination is given by the sight of a hardened, painful prostate and, in the case of prolonged obstruction, of dilation of the ureters and of the renal cavities related to the return of urine from the bladder to the kidney or from the inability to normally drain the urine towards the bladder. Prostate enlargement should be differentiated from prostatic carcinoma; this makes the role of the doctor of fundamental importance.
The urologist, in fact, during the visit must make an accurate differential diagnosis between the two diseases. Other diagnostic tests are: PSA (specific prostate antigen), a blood test used to evaluate the concentrations of prostate antigen; urinalysis (to ascertain the presence of leukocytes: white blood cells that indicate the presence of an infection); urology ultrasound (study of the state of the kidneys, bladder and prostate by means of a probe connected to a device, called an ultrasound), to be carried out with a full bladder.
Benign prostate hyperplasia is a term improperly used as a synonym of benign prostatic hyperplasia or prostatic adenoma. It is a uniquely male disorder, characterized by an increase in the size of the prostate. It is called hyperplasia the numeric increase of cells that make up a tissue. More precisely, in the prostatic adenoma the stromal and parenchymal units are localized in the center of the organ, in the periurethral glands and in the transition zone. As a consequence of hyperplasia, nodules are formed which press against the urethra and increase the resistance to the flow of urine.
The most frequent complication of benign prostate hyperplasia is the difficulty in urination. In turn, this disorder leads to progressive hypertrophy of the bladder muscle (increase in cell thickness and tissue) and subsequent instability or weakness (atony). Benign prostatic hyperplasia increases the levels of specific prostate antigen and the degree of inflammation. However, it is not a cancerous form.
Adenomatous prostatic growth begins at approximately 30 years of age. 50% of men show the first signs at 50 years. It becomes clinically significant in 40-50% of males. Among the ‘over 50’, benign prostatic hyperplasia is one of the ten most relevant and economically incisive diseases (statistical value detected in the USA).
Benign prostate hyperplasia causes, symptoms and treatment
Prostatic adenoma is a disease characterized by benign enlargement of the prostate, which typically involves the periurethral area (around the urethra). Over time, the increase in volume of the prostate gland causes irritative symptoms and various problems with urine outflow. The prostatic adenoma is found above all with advancing age, as a consequence of the physiological aging process, due to hormonal changes or other concomitant diseases.
The initial manifestations of this pathology include increasing difficulty in the act of urination (dysuria) and increase in daytime (pollachiuria) and nocturnal (nocturia) micturitions. These signals must act as an alarm bell and cause the patient to undergo an accurate clinical examination, which is also important to rule out any pathologies that occur with such a symptomatic picture (including prostate cancer).
Moreover, if neglected, the enlarged prostate can compress the urethral canal, causing a partial obstruction and interfering with the ability to urinate. Thus, prostate adenoma can result in a series of long-term complications, such as urinary retention, bladder calculosis and chronic renal failure. Treatment depends on the extent of the condition and may include different pharmacological or surgical options, with the aim of improving the patient’s symptomatology and quality of life.
The prostate (or prostate gland) is a small, exclusively male organ, which belongs to the reproductive system, located just below the bladder. Its main function consists in the production of a part of the seminal fluid, therefore it contributes to preserving the vitality of the spermatozoa. More in detail, the prostate gland partially surrounds the first part of the urethra (a conduit that carries urine outside the body, during urination), like a donut, at the neck of the bladder and merges with the two ducts ejaculators that cross it. Precisely because of this position and the relationships with the neighboring organs, the enlarged prostate can cause problems with urination, ejaculation or defecation.
Prostatic adenoma (also known as benign prostate hypertrophy or benign prostate hyperplasia) coincides with an enlarged prostate, not associated with tumor formations. In fact, at the origin of this condition there is a benign proliferation, therefore not cancerous. As such, the increase in prostate volume is caused by the growth of the number of prostate cells that compress the tissues around (especially at the level of prostatic urethra), without infiltrating them.
Prostatic adenoma is commonly known as benign prostate hyperplasia (BPH) or enlarged prostate. More correctly, the condition is also called benign prostatic hyperplasia, because the volumetric enlargement of the prostate is due to an increase in the number of cells that make up the same organ.
Prostate adenoma is a disease caused by an increase in prostate volume due to the increase in the number of cells in the same organ. This proliferation is benign in nature: unlike a tumor, in fact, this condition compresses the surrounding tissues without infiltrating them. The prostatic adenoma originates mainly from the central portion of the gland, in the transition zone surrounding the urethra (note: the carcinoma tends to develop starting from the peripheral area of the prostate).
Under normal conditions, the prostate generally has dimensions and shape similar to those of a chestnut, with the base facing up (attached to the lower surface of the bladder) and the apex facing down. With the passing of the years or the coexistence of some pathologies, the prostate can get bigger, then increase in volume. In people who suffer from prostate adenoma, in the absence of treatment, the gland can even exceed two to three times its normal size.
The causes of prostatic adenoma are not yet fully known, but it is now established that typical alterations of aging are involved in the pathology of the pathology. As we age, in fact, the prostate tends spontaneously to change its consistency and volume, in response to hormonal variations and numerous growth factors that stimulate the benign proliferation of prostate cells. For example, the release of small amounts of estrogen and the increase of dihydrotestosterone (or DHT, testosterone metabolite) seem to favor the appearance of prostatic adenoma.
Prostatic adenoma is a very frequent alteration, which accompanies the normal aging process, therefore it is found especially in older men. In particular, this condition begins to develop after age 40 and occurs mainly after the age of 50. The incidence of prostatic adenoma increases proportionately with advancing age, reaching the highest levels in the eighth decade of life. In fact, it is estimated that between 70 and 80 years this pathology affects up to 80% of the male population.
In prostatic adenoma, the increase in prostate volume ends up compressing the urethra (a channel that carries urine from the bladder to the outside). This results in various problems affecting the urinary tract. As anticipated, the enlarged prostate is slowly progressive, so the symptoms of prostatic adenoma usually present themselves gradually. It should be noted, however, that this pathology does not always evolve with the same modality and speed. Furthermore, the increase in the volume of the prostate does not necessarily lead to significant disorders and, sometimes, no symptoms are felt.
Prostatic adenoma: how it manifests itself
Prostatic adenoma involves irritative and obstructive symptoms such as:
- Disuria (difficulty in urination);
- Urgent urgency (inability to delay the act of urinating);
- Increased frequency of daytime (pollachiuria) and nocturnal (nocturia) micturitions;
- Difficulty in starting to urinate (voiding hesitation);
- Decreased urinary and / or intermittent jet strength (flow of weak urine, slow or which stops several times);
- Sense of incomplete bladder emptying;
- Presence of small amounts of blood in the urine (haematuria);
- Blood emission in the seminal fluid (hemospermia);
- Pain after ejaculation or during urination (stranguria);
- Problems in erection and maintenance;
- Dripping after finishing urinating;
- Urine retention (inability of the patient to excrete urine in the bladder).
Irritative and obstructive urinary symptoms that occur in prostatic adenoma can also occur in the presence of bladder problems, urinary tract infections or prostatitis (inflammation of the prostate). These disorders can also be a sign of much more serious diseases, such as prostate cancer. For this reason, it is always advisable to contact your doctor, for the most appropriate checks in your case.
Prostate enlargement: possible consequences
In the context of prostatic adenoma, the narrowing of the urethra and the urinary retention are responsible for problems with the correct outflow of the urine: the patient must exert abdominal thrust to be able to expel them and empty the bladder. Because of this overwork, the bladder wall slowly tends to weaken and, over time, it is even possible to arrive at acute urinary retention, or the impossibility of urinating. Prolonged obstruction of the urethra may even impair renal function, leading to organ failure.
Another complication to consider is the incomplete emptying of the bladder, which determines the stagnation of a urinary residue in which bacteria can proliferate and sediment any crystalline aggregates. For this reason, prostate adenoma exposes to a greater risk of urinary infections, prostatitis, pyelonephritis and calculations due to the crystallization of salts in the post-voidal residue.
When to seek urgent medical help
In the context of prostatic adenoma, the events that should not be underestimated, which must lead to prompt medical intervention, include:
In the presence of symptoms suggestive of a prostatic adenoma, it is advisable to contact your doctor. Through a urological examination it is possible to ascertain the real presence of the prostate volume increase and to exclude other pathologies that can give a superimposable symptomatology, such as prostatitis or tumor.
For the correct evaluation of prostatic adenoma some specific clinical examinations are necessary, including:
- Urine examination with urine culture;
- Dosage of PSA (specific prostatic antigen) in the blood;
- Digito-rectal exploration of the prostate (palpation of the prostate through the rectum).
The PSA is used to evaluate the possibility of malignancy, while rectal exploration provides information on the volume and consistency of the gland. The urinalysis, on the other hand, allows to verify the renal function or to exclude the presence of urinary tract infections, able to produce a symptomatology similar to that of prostatic adenoma.
To determine the extent of the disease, the patient can undergo more detailed examinations, such as:
- Uroflowmetry: measures the rate of urinary flow and the volume of urine emitted during urination, thus providing an idea, albeit coarse, of any damage to the bladder;
- Trans-rectal prostatic ultrasound, followed by biopsy: it confirms or excludes the presence of a malignant tumor and is a useful tool for assessing the correct volume of the prostate, especially important for the purpose of a possible surgical operation.
Prostate enlargement treatment and remedies
The therapeutic strategies adopted for the management of prostatic adenoma are different and depend substantially on the extent of the condition and the associated symptomatology. If the disease does not cause particular disorders to the patient, it can simply be monitored over time; on the contrary, in the presence of complications, pharmacological or surgical treatment is mandatory.
In the early stages of prostatic adenoma, it is possible to intervene with the use of two main categories of drugs:
1. Alpha-antagonists: reduce muscle tone in the prostate and bladder neck, facilitating, in essence, the passage of urine in the urethra. Among the alpha-blocking drugs most used in the treatment of prostate adenoma are alfuzosin, doxazosin, tamsulosin and terazosin.
2. 5-alpha reductase inhibitors: inhibit the volumetric growth of prostatic adenoma by suppressing androgen stimulation. Drugs such as finasteride and dutasteride act in practice by blocking the transformation of testosterone into its active form, dihydrotestosterone (DHT), which participates in the enlargement of the prostate.
The major problems of the use of drugs for the treatment of prostatic adenoma are associated with possible side effects. These include erectile deficits, retrograde ejaculation and gynecomastia for 5-alpha reductase inhibitors, while hypotension, migraine, vertigo, headache and asthenia are common among users of alpha-blockers. Depending on the case, the drugs may be sufficient to control the patient’s symptoms and slow down the progression of prostatic adenoma, but it should be noted that the effectiveness of these tends to decrease with long-term use.
Similarly to the 5-alpha-reductase inhibitors, even if with modest effectiveness, some phytotherapics also act, like the extracts of Serenoa repens and African Pigeo.
When drug therapy is ineffective, surgical therapy is used. The choice of the type of procedure to be performed by the patient is essentially based on the dimensions of prostatic adenoma.
The suitability or otherwise of the various surgical techniques is influenced above all by the extent of prostatic adenoma; in general, the greater the glandular volume, the more invasive the intervention will be.
The most used technique for the treatment of prostatic adenoma is the transurethral endoscopic resection (or TURP). As the name suggests, it is a prostate reduction performed by endoscopy, i.e. without incisions. In practice, a special instrument is introduced into the urinary canal through the penis to cut the prostatic adenoma ‘sliced’. In this way, the internal part of the enlarged prostate can be removed.
If the size of the prostate is excessive, however, it is necessary to proceed with an open surgery called adenonectomy. This intervention involves the removal of the entire prostatic adenoma by a cutaneous, trans-bladder or retropubic incision.
Partial or total surgical removal of the prostate may lead to complications for patients. Among these, the one that usually worries more patients is the risk of erectile dysfunction. However, according to recent studies this risk is considered void or even lower than patients who choose not to operate. A very frequent adverse effect after surgery is, instead, retrograde ejaculation; in practice, during ejaculation, the seminal fluid, instead of coming out of the urethra, flows back into the bladder, causing infertility.
To treat prostate adenoma, it is possible to resort to alternative techniques, less invasive, but of variable effectiveness. These procedures aim to destroy part of the glandular tissue without damaging what will remain on site. For this purpose, depending on the method used, laser beams (as in the HoLAP procedure) are concentrated, radio waves (transurethral ablation with radiofrequency or TUNA), microwaves (e.g. TUMT or transurethral thermotherapy with microwaves) or chemical substances, directly to the internal prostate.
Prostate adenoma prevention basically consists of early diagnosis. This is possible undergoing periodic checks after 40-50 years of age or, promptly, when the first ailments occur.
Benign prostatic hyperplasia causes
The causes of benign prostate hyperplasia often include the presence of a set of risk factors:
The disease is linked to seniority, probably due to fibrosis and weakening of the prostatic muscle tissue necessary to expel secreted fluids (which contain predisposing molecules). Lesions of prostatic muscle fibers (unavoidable with old age) are not easily repairable; the tissue is replaced by non-contractile collagen fibers, jeopardizing the expulsion of liquids and promoting ‘stagnation’.
They are the male sex hormones produced mainly by the testicles. Statistically, castrated men show a lower incidence of benign prostatic hyperplasia. This suggests that androgen hormones play a predisposing role. However, exogenous testosterone is NOT always linked to the onset of the disease.
Is a testosterone metabolite synthesized in the prostate. It is part of the composition of ‘fluids secreted by the prostate’ mentioned in point 1. An excessive concentration of DHT promotes the risk of hyperplasia. By inhibiting the cellular enzyme (called 5α-reductase) at the base of the testosterone-DHT conversion, a reduction in prostate volume and related symptoms is achieved.
Some studies indicate that nutrition may influence the development of benign prostate enlargement. However, confirmation of the results requires further study. Some studies in China suggest that excessive protein intake, especially of animal origin, could be a risk factor for benign prostatic hyperplasia. In these researches, men over 60 years old living in rural areas and having a predominantly plant-based diet showed an incidence of benign prostatic hyperplasia that is LOW compared to citizens who consume more animal proteins.
Prostate enlargement diet
The diet for prostate enlargement is preventive.
- Abolition of alcohol or global reduction up to the limit allowed by the guidelines.
- Nutritional balance and energy supply within the limits of normality; in the event of overweight, a caloric reduction is required for weight loss.
- Moderation of the global protein component.
- Breakdown of proteins: 2/3 of plant origin and 1/3 of animal origin.
Ethyl alcohol is a molecule produced by Saccharomyces yeasts during fermentation of carbohydrates. The human organism is NOT able to use it for energetic purposes. The liver converts it into fatty acids that are deposited on the inside and in the adipose tissue. For this reason, the excess of alcohol correlates to fatty liver and overweight. Ethylism also causes psychophysical dependence and systemic intoxication of severity related to the extent of the abuse. The toxic effects on tissues mainly concern: the brain, the mucosa of the digestive tract and the liver. Ethyl alcohol is also harmful for the developing fetus in pregnant women.
Universally, moderate use is recommended. Research institutions recommend different levels based on age, gender and special or pathological physiological conditions. Assuming that the only harmless dose of ethyl alcohol is 0, we could state the following:
‘A healthy adult male should not exceed 2-3 alcoholic units a day, to be consumed preferably at the main meals. An alcoholic unit matches a 125ml glass of wine or a 330ml blonde beer or a 40ml hard alcohol. The amount of alcohol contained in an alcoholic unit is about 12g. Those wishing to prevent benign prostatic hyperplasia should limit themselves to taking the recommended daily dose; however, a thorough diagnosis provides for the total abolition of alcohol ‘.
Overweight can be defined as an excess of adipose tissue, which increases body weight beyond the normal limits. Adipose tissue is an energy reserve of fats, which increases with the excess of calories; these are supplied by: lipids, carbohydrates, proteins and alcohol. Overweight is promoted by sedentary lifestyle, nutritional imbalance, alcoholism and consumption of junk foods.
The most severe forms of overweight are called obesity. It is a risk factor for many metabolic diseases, namely: hyperglycemia, LDL (bad) cholesterol, triglyceridemia and arterial hypertension. Obesity is also involved in the aetiology of several autoimmune, articular, dermatological, reproductive system disorders, etc. Among these, benign prostatic adenoma also appears. The weight excess is estimated by different methods and, in ordinary people, mainly thanks to the calculation of body mass index (BMI), in English BMI. The overweight proper said is evidenced by a score equal to or greater than 25; from 30 onwards the condition is called obesity.
To combat overweight and reduce the risk of benign prostate hyperplasia it is necessary to apply lifestyle adjustments; e.g.:
- Introduce fewer calories than those that allow you to maintain constant weight.
- Balance the diet avoiding excess carbohydrates and fats.
- Eliminate junk foods.
- Eliminate alcohol abuse.
- Perform motor activity every day.
Proteins are energetic macronutrients found in most foods, both animal and vegetable. The ‘bricks’ that compose them (amino acids) perform many biological functions: plastic, bioregulation, energy, etc. On the other hand, a long-term protein excess can trigger side effects, especially when foods are of animal origin (meat, milk and dairy products, fishery products, eggs). Proteins are not all the same and are cataloged according to biological value. This parameter examines the content in essential amino acids, or those ‘bricks’ that the human organism is not able to produce independently.
In general, the proteins of greatest biological value are those animals (meat, fishery products, eggs, milk and derivatives). In the past it was recommended a consumption of animal proteins equal to at least 1/3 of the total. Today, the collective trend has become that of abuse. Moreover, among the foods of plant origin there are ‘exceptions’, i.e. foods that contain proteins of high biological value. Some examples are soy and certain marine algae, which have an extremely valuable amino acid profile.
Among other things, the vegetable peptides of the most common foods (for example cereals and legumes such as: rice and peas, wheat and beans, etc.) can be associated with each other, offsetting their biological value. By varying the diet it is possible to obtain all the essential amino acids in the right quantities and without resorting to large portions of meat, cheese, etc.
To conclude, those of animal origin are extremely nutritious foods; on the other hand, excess should be considered potentially harmful even for benign prostate enlargement. In the Western diet, too large and frequent portions are consumed, which may prove to be a risk factor for the onset of this disorder.
The recommended protein limit is different based on age, any special physiological conditions and the research body that disseminates the recommendation. Respecting what is specified in the table below, it is possible to avoid the protein excess of animal origin.
TYPE OF FOOD
FREQUENCY OF CONSUMPTION
|Fresh meat||2 times a week||100g|
|Meats stored||1-2 times a week||50g|
|Fresh Fish Products||2 times a wee||150g|
|Fish Products Preserved||1-2 times a week||50g|
|Whole eggs||1-2 times a week||50g|
|Milk and Yogurt||Twice a day||125-150ml|
|Fresh cheeses||1-2 times a week||100g|
|Seasoned cheeses||1-2 times a week||50g|
The portions of meat, fish, eggs and cheeses are to be considered whole if used as the main course of the meal (for example, the second course of dinner). On the contrary, they have to be halved if they have a less important function (for example, a small dish after the first course at lunch).
Diagnosing benign prostate hyperplasia: methods used
The Suprapubic Ultrasound Of The Prostate
The suprapubic ultrasound of the prostate – or suprapubic prostatic ultrasound – is a rather common examination, which is usually carried out to determine the volume of this gland and highlight any abnormalities that may signal the presence of prostatic diseases. The suprapubic ultrasound of the prostate is a non-invasive, painless and does not require any special precautions or warnings; for this reason it is usually well tolerated by patients.
As mentioned, the suprapubic ultrasound of the prostate is performed to investigate the size and the presence of possible abnormalities of the prostate.
These investigations are carried out in order to:
- Perform a diagnosis of benign prostate enlargement;
- Evaluate the presence of inflammatory diseases such as prostatitis;
- To investigate the causes of increased levels of PSA (Specific Prostatic Antigen), a particular type of enzyme produced by the prostate;
- Evaluate the presence of any prostate tumors.
Despite the various possible applications, in most cases this type of prostate ultrasound is performed to diagnose a possible benign prostate enlargement. In fact, with suprapubic ultrasound – in addition to the size of the prostate – it is also possible to evaluate the characteristics of the bladder, which is often affected by the enlargement of this gland. In addition, suprapubic ultrasound of the prostate allows the study of urinary residue in the bladder following urination. This data is very useful because, usually, in the case of benign prostate hyperplasia the residual post-urination in the bladder tends to increase.
In some cases, however, the suprapubic ultrasound of the prostate can be performed as a preliminary examination before performing a transrectal ultrasound scan, a slightly more invasive examination but which can provide more detailed and precise information on the characteristics of the prostate (compared to simple ultrasound suprapubic) and during which it is also possible to perform a prostate biopsy.
Suprapubic ultrasound of the prostate is a relatively simple test that requires no special precautions or care. However, the exam must be performed with a full bladder. For this reason, the patient should drink about a liter of water at least one hour before the ultrasound is performed. At the end of the examination, the doctor will ask the patient to dye, in order to empty the bladder and be able to evaluate the urinary residual post-urination.
The suprapubic prostatic ultrasound is performed through the use of an ultrasound device equipped with a normal ultrasound probe, which is positioned, precisely, in the suprapubic area, indicatively between the navel and the base of the penis. By positioning and moving the probe in this area, the doctor will therefore be able to investigate the characteristics of the prostate and bladder, evaluating the size, the morphology, the presence of any abnormalities and determining the urine residue following the urination.
Digital Rectal Exploration of the Prostate
Digital rectal exploration of the prostate consists of palpation of the prostatic surface through the introduction of the gloved index finger into the patient’s anus. This operation is performed by the doctor specializing in urology and is essential for the diagnosis of prostate cancer.
Along with the specific prostatic antigen (PSA) blood assay, digital rectal prostate exploration is a first-level investigation to identify those who presumably, although not necessarily, have developed prostate cancer. In this sense, the diagnostic confirmation or denial can only come from the results of a further examination, the prostate biopsy, during which small samples of prostate tissue are taken to be examined in the laboratory.
Digital rectal exploration of the prostate is not a particularly enjoyable experience, but neither is it that burdensome or embarrassing. It is done in a few minutes and concretely increases the chances of discovering a prostate cancer at an early stage, although to be honest it is a test far from infallible.
The aim of the procedure is the tactile perception of enlargements, irregularities, nodosities and increases in consistency (hardness) of the gland, which make it possible to distinguish between a healthy prostate, benign prostate hyperplasia and a prostate carcinoma. Unfortunately, however, digital rectal prostatic exploration remains an imprecise examination, although still very useful. Despite the good specificity, due to the often contained tumor size or a localization unreachable with digital rectal exploration, the ability to identify the sick subjects is reduced; on average, in fact, out of 100 prostate cancers only 20 are found on palpation.
If you are more than 45/50 years old, especially in the presence of close relatives (children, fathers, brothers) with prostate cancer, contact your doctor to evaluate the opportunity to undergo an annual urological examination of digital prostatic rectal examination, combined with serum dosage of PSA.
Not all doctors agree that this screening approach (PSA + digital exploration) is useful in asymptomatic subjects or those without important risk factors; in fact, this procedure involves some non-negligible risks:
Specific Prostatic Antigen – PSA
The PSA – acronym of Prostate Specific Antigen, Italianized in Specific Prostatic Antigen – is a protein synthesized by prostate cells. Small concentrations of prostate antigen are normally present in the serum of all men and can be assessed by a simple blood test. PSA Test
PSA is a quantifiable protein in the blood, produced exclusively by the prostate. For this reason, the specific prostate antigen can be used as an indicator of prostatic diseases. From a physiological point of view, the function of the PSA is to keep the seminal fluid liquid after ejaculation, so that the spermatozoa can move more easily in the female genital tract.
The PSA is quantifiable in the blood and is used as a marker of potential prostate problems, also and especially in the context of early diagnosis tests of the male population. The dosage of the PSA is indicated periodically to all men, starting from 50 years of age. In fact, this examination can help – in association with the urological or andrological examination – to identify forms of prostate cancer in the initial stages.
The PSA is a specific marker of the organ, but not of the pathologies affecting it; in fact, high levels are recorded both in the presence of benign conditions (a prostatitis, a benign prostatic hyperplasia, etc.), and of neoplastic prostate processes. Together with rectal exploration and transrectal or suprapubic ultrasound, the PSA helps to detect prostate tumors, both benign and malignant. In the event of positivity, a prostatic biopsy is usually performed.
In addition to the diagnosis, the specific prostatic antigen test is performed even after the detection of the tumor, to check the progress of the treatment or to highlight the possible recovery of the disease.
However, it should be kept in mind that PSA also increases in benign conditions, such as benign prostate hyperplasia and prostatitis (inflammation of the prostate). In addition, the specific prostate antigen also increases due to recent sexual activity, palpation of the prostate for specialist examination, use of catheters and intake of certain drugs, such as allopurinol.
To improve the diagnostic specificity of PSA, in cases where the limit value is exceeded, the specific free prostate antigen (free-PSA) is also measured. Under normal conditions, there are blood levels of PSA below 4 nanograms per milliliter of blood (reference range: 0.0-4.0 ng / ml). However, if the cells of the prostate are damaged, the concentrations in the bloodstream may increase. High levels of PSA are found during various prostatic diseases, such as:
A 50% reduction in PSA levels is found in men taking 5-alpha-reductase inhibitors (such as finasteride and dutasteride), a class of drugs used in the treatment of benign prostate hyperplasia and baldness. Obesity has been related to a lowering of circulating PSA.
Specific prostate antigen concentrations are measured in the laboratory after a simple blood sample. The patient can undergo blood withdrawal after a 3-hour fast. To reduce the risk of error, it is important not to take the test when you have an ongoing urinary tract infection. Also, you should not perform intense physical activity or have sexual intercourse in the 48 hours prior to the PSA dose, as both of these conditions can raise the levels of the parameter in your blood.
The dosage of plasma PSA has a low degree of specificity: when its levels exceed a certain threshold (> 3-4 ng per ml of blood) most likely something does not work at the prostate level; however, in the absence of further diagnostic investigation, it is impossible to establish with certainty the benignness or malice of the condition.
With reference to prostate cancer, the PSA dosage often returns false positives. These are cases in which high PSA values suggest the existence of prostate cancer, subsequently denied by the various investigations. In other words, the finding of high PSA levels is not sufficient to diagnose prostate cancer, especially in older men.
If the suspicion of cancer is confirmed by other diagnostic tests, the PSA dosage is a good indicator of tumor extension. In particular, when the PSA is only slightly increased or even normal it is unlikely that the tumor is very extensive.
Most men with elevated blood levels of specific prostate antigen are not affected by cancer. Data in the hand, only 25 – 35% of patients undergoing prostate biopsy (after finding high PSA) is actually a carrier of prostate cancer, while a quarter of those affected by this form of cancer does not show significant increases in PSA.
Monitoring of the specific prostatic antigen is useful for assessing the patient’s response to the therapy undertaken, which when positive is accompanied by a reduction in PSA values. The serum dosage must be performed before the other diagnostic tests of control, since these, as we have seen, can significantly increase the PSA values (after prostatic biopsy you can record increases up to 50 times, with a slow return to normal in the 30- 60 days later).
Periodic monitoring of PSA is very important. In fact, repeated measurements can help to differentiate between benign and malignant forms, and the more rapid the increase in values. For this reason the concepts of PSA velocity and PSA doubling time have been introduced, both of which are infectious by various elements, such as intra and interlaboratory variations, and biological ones not related to the underlying pathology (a recent ejaculation, for example, can increase blood levels of PSA). Since their independence from prostate cancer is more likely in the presence of marked hypertrophy of the gland, elevated PSA values may be related to prostate volume (PSA).
Useful elements to evaluate the clinical significance of a high PSA can be collected by evaluating the proportion between free PSA and PSA bound to transport proteins. It has been seen that benign conditions, such as prostate enlargement, predominantly increase the free quota, while prostate cancer produces above all an increase in bound PSA. Therefore, in a man who contrasts high levels of PSA linked to low values of free PSA, the presence of a prostate tumor is probable, while the opposite condition suggests a benign origin. In other words if:
- Ratio of free PSA to low total PSA (<0.20) → high risk of malignancy
- Ratio between free PSA / total normal or elevated PSA (> 0.20) → low risk of malignancy
In light of the above, the interpretation of the blood values of PSA is a very complex and constantly evolving subject, naturally reserved for expert urologists. Faced with a rise in the values of PSA, the doctor will therefore have to examine a whole series of elements, in order to direct the patient towards specific diagnostic tests, personalized treatments for a simple periodic monitoring.
In March 2013, on the occasion of the meeting of the European Association of Urology in Milan, Italy, a satellite symposium was held titled ‘Beign Prostatic Hypertrophy (BPH) and Inflammation, from Lab to Clinic’ (Benign Prostatic Hypertrophy (HBP) ) and inflammation, from the laboratory to the clinic), with the aim of reviewing the latest data on the link between inflammation and HBP. This document is based on one of the presentations of this symposium. A structured literature search on PubMed was conducted and the emphasis was placed on the results of the past 10 years.
Enlarged prostate and male sexuality
Prostate and sexual relationships: the correlation between prostate and erection is not well known. It is for this reason that when you have strong disappointments in the sexual sphere it becomes easy to fall into a state of stress and depression. This does nothing but accentuates and aggravate the physiological damage.
Erection problems arise as a result. And this is not a connection known by many people. It is important that every man is interested in the relationship between erectile dysfunction and the prostate. As prostate health problems are statistically very frequent and may already occur around the age of 30, or even earlier.
In case of prostate problems, the situation for the person affected is often aggravated by the fact that prostatitis is almost always accompanied by erectile problems. Sometimes they are real cases of total impotence. Total lack of erection, both during and away from sexual intercourse. Psychological problems can also occur over time – like lack of sexual self-esteem or sexual performance anxiety. There is no doubt about the direct correlation between prostate diseases and erection.
If you suspect you have a prostate problem and suspect that your prostate and erection relationship is compromised, it is good to go to your doctor to do specific tests. To check what kind of prostate trouble it is, or if it is a completely different problem. It will then be the task of the andrologist or urologist to establish the appropriate drug therapy.
But it must be said that the pharmacological treatments are aimed primarily at the suppression of symptoms. Rather than eliminate the real root causes of various prostate problems. In fact, drugs very often do not prove effective. This causes the relationship between prostate and erection to be increasingly evident and compromised.
In other cases, instead, they have effect but only temporarily, because after some time the same prostatitis reoccurs. As it has not acted at the root on the triggering causes, often such problems can be related to nutrition and lifestyle.
The link between benign prostatic hyperplasia and inflammation
BPH is characterized by progressive hyperplasia of the stromal and glandular cells and, clinically, is defined by the symptoms of the lower urinary tract. Over the last few years, the evidence supporting a link between prostatic inflammation and HBP has been increasing. Inflammatory infiltrates observed in patients with HBP are mainly composed of chronically activated T lymphocytes. The cytokines and growth factors released by the inflammatory cells create a proinflammatory environment, which can support the fibromuscular growth observed in the BPH and may also be responsible for inducing a state of relative hypoxia, caused by the increased demand for oxygen from the cells proliferating.
Several clinical studies have confirmed the presence of inflammatory infiltrate in men with BPH, which has been shown to be involved in the pathogenesis, in the clinical picture and in the progression of this disorder. Emerging evidence seems to confirm that systemic inflammation may also play a role in IBP, since a significant correlation between prostate diameter and volume and the number of metabolic syndrome components was found in men with metabolic syndrome.
Conclusions: It is clear that a number of different mechanisms are involved in the development and progression of the BVB. Inflammation of the prostate is an important element because it seems to be involved in the pathogenesis, symptomatology and progression of the disease.
Use of TURP laser in prostatic hyperplasia: prostate vaporisection
Benign prostatic hyperplasia (BPH) is an extremely frequent pathology in the male population, often chronic and progressive. The need for HBP treatment is mainly based on two aspects:
An important void symptomatology that negatively influences the patient’s quality of life (increase in the daytime and nocturnal frequency, urgency, and the voiding of the voiding jet)
A risk of complications related to obstruction to bladder emptying (bladder muscle deterioration with risk of acute and chronic urine retention, bladder diverticula, recurrent urinary infections, secondary calculus, hydronephrosis, recurrent haematuria)
Very often the first therapeutic approach is pharmacological, mainly with alpha1 adrenergic blockers (to relax the bladder neck and prostatic urethra and facilitate the emptying of the bladder) or with inhibitors of the 5 alpha reductase (to block the growth of the prostate gland).
Both therapies, both alone and in combination, can have side effects and above all act in an initial phase of the pathology, sometimes more with a preventive role on the progression that curative in the most advanced forms. 5 alpha reductase inhibitors act on the prostate volume and its progression while alpha1 blocker therapy has no effect on the progression of prostatic hyperplasia and prostate gland.
In case of failure of the pharmacological therapies or of a diagnosis of already advanced HBP, the resolution is based on endoscopic surgery.
The indication for endoscopic resection of prostatic hyperplasia is mainly based on one or more of these situations:
- Failure of pharmacological therapies with persistent symptoms and obstruction to bladder emptying
- Post-voiding residual detectable at suprapubic ultrasound> 100 cc
- Uroflowmetric values of maximum velocity
- Complications such as acute retention of urine with catheterization, bladder diverticula, secondary calculi, secondary urinary recurrent infections, secondary recurrent haematuria, secondary hydronephrosis
HBP surgery consists of an endoscopic trans-urethral procedure with which the hyperplastic tissue obstructing the prostatic urethra is removed. Therefore the prostate gland is not completely removed (necessary intervention in case of neoplasia) but only released from the inside by the hyperplastic tissue, so as to allow again a void free of obstacles.
The surgery, acting by endoscopy, generally has no impact on the patient’s sexual function but produces the loss of ejaculation by antegrade.
Use of the tulle laser in prostatic hyperplasia and its advantages
While at first the use of lasers in the endoscopic surgery of the HBP had lower results than the classic transurethral resection of the prostate (TURP), the new generations of lasers allow today to have some advantages.
This change is due to the passage from lasers that acted without removing the hyperplastic prostatic tissue (vaporizing or necrotizing action in place without removal) to lasers which, on the other hand, while they are vaporizing also remove the hyperplastic tissue. The removal of the vaporized tissue allows to have advantages both on the results obtained (especially in the long term) and on the post-operative irritative side effects (remaining the vaporized tissue with high energy, it can produce irritative and also obstructive effects for a variable period after intervention).
The two types of laser currently used the most and which allow the removal of the prostatic tissue of HBP, are the one with tulle and the one with holmium.
The advantages of the use of the tulle laser in the surgery of the HBP (vaporization of the prostate with a tulle laser) are:
An endoscopic intervention (without incisions or external accesses) remains via the urethral tract
The normal endoscopic instrumentation that each urology institute has to perform the TURP is used, to which is added the laser source and the tulle laser fiber
as in Bipolar TURP irrigation is used for the physiological solution with advantages also on the problems of electrolytic reabsorption. It has a rapid action on the tissue reducing the operative times in the larger prostate. It removes the tissue while vaporizing it, allowing to obtain excellent results on the obstruction to the bladder emptying caused by the HBP
Its vaporizing action reduces the risk of bleeding (practically absent in the standard patient) even in those who use anticoagulant or anti-aggregating therapies; reduces postoperative hospitalization even 24 hours after surgery (longer times if using anticoagulants or prostate of very high volume); reduces postoperative catheterization also 24 hours after surgery (longer times if using anticoagulants or prostate of very high volume).
Prostate enlargement prevention
In order to be able to intervene to the first symptoms referable to a beginning of prostatic enlargement it is important to have a regular medical examination after 40-50 years of age, in particular if there is a familiarity for prostatic hypertrophy. Diet can affect prostatic hypertrophy and related symptoms positively or negatively.
To sum up what has been already said above:
Drink plenty of water, at least 1.5 liters per day to dilute the urine and reduce the risk of bacterial infections caused by stagnation of urine in the bladder. The amount of water must be delayed over time; too much water in a short time can cause acute retention of urine due to the urine outflow resistance. This condition can occur, for example, when the prostatic patient undergoes pelvic ultrasound (the examination requires a full bladder to be performed correctly). The acute stagnation of urine resolves with the insertion of the catheter into the urethra and the consequent emptying of the bladder.
Prefer a low protein diet (meat) and richer in carbohydrates (starch). Prefer a diet rich in fruits and vegetables and minimize consumption of red meat, fat, processed foods and rich in sauces and spices, coffee, chocolate. These foods in fact have an irritating action on the urinary tract. In a study that assessed dietary risk factors on the incidence of prostatic hypertrophy, the high consumption of red meat and fatty foods was found to increase the risk of symptomatic BPH, decreased instead by a diet rich in fruits and vegetables. The micronutrients that showed a possible ‘protective’ role towards prostatic hypertrophy were found to be the group of carotenes (carotene, alpha-carotene, beta-carotene, cis beta-carotene), vitamin C and iron; on the other hand, sodium and zinc have a ‘promoter’ effect. In another study, zinc was associated, together with lycopene and vitamin D, to ‘weak’ evidence of a reduction in the risk of prostatic hypertrophy.
It is probable that alterations of zinc homeostasis in prostate tissue may be involved in the development of diseases such as prostatic hypertrophy and prostate cancer. It has been observed that the levels of zinc in hypertrophic prostate tissue are 2 times higher than those found in normal tissue, while they are 3 times lower in cancer than in hypertrophic and about half in cancer than in normal tissue..
Maintain a regular bowel movement. Avoid alternating episodes of diarrhea and constipation. The blood circulation of the prostate is closely interconnected with that of the last section of the intestine (hemorrhoidal veins): alterations in the rectum (intestinal irritation, stagnation of the stool) can therefore have repercussions even at the prostate level.
The sexual activity practiced in a constant way and without excess guarantees the well-being of the man, improving the state of health. It then falls into the pillars of a healthy lifestyle consisting of proper nutrition, constant and effective physical activity and finally satisfying sexual activity. Good sexual activity can help, for example, to lower blood pressure and have a better quality of sleep. It also helps to the heart as it increases the heartbeat.
In addition to burning calories, the production of testosterone linked to sexual activity strengthens bones and muscles, while low levels of this hormone are linked to reduced libido, fatigue and depression. The production of endorphins also lowers stress levels. Some studies appeared to have linked a medium-high frequency of ejaculation with a lowering of the risk of developing tumors. Instead, a study identifies this correlation as the result of artifacts in studies. There would therefore be no beneficial role for ejaculation in relation to the prostate, its volume or the onset of cancer.