The prostate is a male genital organ in the form of a gland which is located under the bladder. It is about the size of a walnut and weighs about 20 grams in a normal male. The function of the prostate gland itself is to produce semen (semen).
Benign prostatic enlargement (PPJ) or often called Benign Prostatic Hyperplasia (BPH) is a benign enlargement of the prostate gland that affects older men. From the results of several studies in America, the incidence of PPJ increases with age. Based on autopsy results, 20% of PPJ sufferers occur at the age of 41-50 years, 50% at the age of 51-60 years and more than 90% at the age of 80 years. While in Indonesia there is no definite incidence.
The risk factors for benign prostate enlargement are still uncertain. Several studies have shown that age, genetics, race, environment and smoking are risk factors for PPJ.
The cause of benign prostate enlargement is still not known with certainty. In general, there are 2 main factors, namely increasing age and the functioning of the leydig cells in the testes as the main androgen hormone producer. In the pathogenesis of PPJ, the reduction of testosterone to dehydrotestosterone (DHT) in prostate cells is a factor in the penetration of DHT into the cell nucleus which can cause inscription on RNA causing protein synthesis. Several animal studies have shown that estrogen plays a role in the initiation of the PPJ process. This estrogen comes from the conversion of testosterone to estrogen with the help of an aromatase enzyme catalyst that can occur in fat tissue. Another opinion put forward is the theory of growth factors which states that there is an overexpression of fibroblast growth factor. Basic fibroblast growth factor (b-FGF) can stimulate stromal cells and the concentration of b-FGF is greater in patients with benign prostate enlargement than normal people due to increasing age. Repeated microtrauma due to micturition, ejaculation or infection can lead to the release of b-FGF, and the proliferative stimulatory properties of b-FGF are greater than inhibition by Transferring growth factor b (TGF- b ).
Disorders that occur in PPJ are obstruction and irritation of the lower urinary tract. The occurrence of symptoms of this blockage can be caused by 2 components, firstly by persistent pressure on the prostatic urethra (static component) and secondly due to the dynamic component caused by increased prostate gland tone which is regulated by the autonomic nervous system. The receptor responsible for contraction of prostatic smooth muscle is the a - 1 adrenoreceptor (a-1-a) which is present in large numbers in the prostate and bladder neck. Activation of these receptors stimulates smooth muscle contractions, thereby increasing prostate and bladder neck tone, resulting in increased urethral pressure and resistance, which in turn causes obstruction of urine flow. To overcome this increased urethral resistance, the detrusor muscle initially compensates by hypertrophy of the bladder detrusor muscle, which then if the blockage continues, the bladder will enter the decompensation phase, marked by the failure of the bladder to excrete urine. High pressure at the opening of the ureter results in a backflow of urine (reflux) from the bladder into the ureter which, if it continues continuously, results in dilation of the ureters (hydroureter) and the kidneys (hydronephrosis) and can even eventually fall into a state of kidney failure.
CLINICAL SYMPTOMS
The prominent clinical symptom in PPJ is lower urinary tract obstruction or often called Lower urinary tract symptoms (LUTS) . These symptoms can be divided into obstructive symptoms, namely: a weak stream of urine, a feeling of not being able to urinate after urinating, having to wait a long time before urinating, having to strain to urinate, and intermittent urination.
Meanwhile irritative symptoms are: Frequent urination, urinating more than 2 times at night, and urination that is difficult to hold.
DIAGNOSIS
Obstructive and irritative symptoms experienced by sufferers are usually arranged in the form of a score. Currently the scoring system that is often used is according to the International Prostate Scoring System (IPSS).
The most important physical examination is a digital rectal examination known as a rectal toucher or digital rectal examination to assess prostate enlargement or protrusion, the consistency of the prostate which in PPJ feels rubbery, whereas if there are nodules or hard parts this is a sign of prostate malignancy. Tenderness is a sign of an infection in the prostate (prostatitis).
The laboratory tests that need to be examined are blood and urine as well as prostate specific antigen (PSA) to detect prostate cancer.
Investigation that should be done is to measure the maximum flow of urine with a uroflowmetry device, while the measurement of residual urine left in the bladder can be measured by placing a catheter after micturition or by using transabdominal ultrasound.
Prostate volume (in cc units) can be measured using Trans Rectal UltraSonography (TRUS). In addition, TRUS can also detect possible malignancy by demonstrating the presence of a hypoechoic area, and if malignancy is suspected, a prostate biopsy can be performed directly with a needle. Transabdominal Ultra Sonography Examination besides being able to examine the prostate in a full bladder, it can also detect the presence of stones in the bladder and detect the part of the prostate that protrudes into the bladder to predict the severity of the blockage. Sometimes other radiological examinations are also needed if bloody urine (hematuria), urinary tract infections, urinary tract stones or decreased kidney function are found.
MANAGEMENT
Usually sufferers will seek help if they are already bothered by complaints of urination or even unable to urinate at all which is actually too late.
The choice of waiting treatment ( watchful waiting ) is carried out by observing periodically every three months, this treatment is only carried out in patients with very mild complaints. The advice given is to reduce drinking after dinner to reduce urination at night, avoid cold medicines such as decongestants (parasympatholytics), reduce drinking coffee and prohibit drinking alcohol so that you do not urinate too often. It is recommended that patients be controlled for complaints ( score system ), uroflowmetry, ultrasound every three months, and if there is a worsening, treatment should be started with or without surgery.
There are 3 kinds of treatment with drugs that are considered rational, namely with a adrenergic blockers, enzyme 5 a reductase inhibitors and phytotherapy. The problem with treatment with these drugs is when should the treatment be started and for how long is the treatment given, in addition to the side effects of the drugs themselves and the price of the drugs that are not affordable for developing countries like Indonesia considering the treatment given is for the long term.
Operative treatment for PPJ is usually aimed at removing or reducing the obstructing prostate tissue. The method of surgical therapy that is known and often performed in Indonesia is by means of open surgery ( open prostatectomy ) which is currently being abandoned or by means of endoscopy which is often called Trans Urethral Resection of the Prostate (TUR-P).
Article written by dr. Johan R. Wibowo, Sp.U (Urological Surgery Specialist at EMC Pulomas Hospital).