Etiology
Prostatic hyperplasia has brought certain impacts on the family and life of the patients. Therefore, if a patient has any prostatic hyperplasia symptom, it is necessary to undergo early examination to identify the cause. The etiology of benign prostatic hyperplasia is still unknown yet. At present, there are five major theories: being affected by androgens and their receptors, imbalance between cell proliferation and apoptosis, being affected by growth factor neurotransmitters, being affected by interaction of prostatic stromal glandular epithelium, and validation factors.
Symptoms
If prostatic hyperplasia is not treated or prevented properly, it might develop into several diseases. The symptom manifestation of prostatic hyperplasia is significant in general, to which the patients must pay more attention. If the prostatic hyperplasia may be detected early, its severe hazard may be avoided.
A long-lasting benign prostatic hyperplasia might develop into a prostatic hyperplasia with calcification. Prostate calcification is a scar left by prostatitis, which is a precursor of prostate stone and a common complication of chronic prostatitis. Prostate calcification is a place for bacteria to hide, which cannot be cleared by drugs, microwaves, etc. This is also one of the reasons why chronic prostatitis recurs and is difficult to cure. Let's take a look which early symptoms a prostatic hyperplasia would have.
1.Increased urination frequency. No matter in daytime or nighttime, the urination frequencies increase much more than usual (3 to 4 times in daytime and 1 to 2 times in nighttime). The urination interval is short and there is a constant urge to urinate.
2.Urination difficulty. The patient with a micturition desire can urinate after having stood in the restroom for a quite while, and the urination is characterized by a trickling stream of urine, acraturesis and sometimes dribbling. As the saying goes: “The renal functions become weak with age, elderly people might make their shoes wet while urinating”. This is actually one of the manifestations of prostate hyperplasia.
3.Night urinary incontinence. When sleeping at night, urine flows out uncontrollably, and in severe cases, this phenomenon might also occur in daytime.
4.Painful and urgent urination. Urine in the bladder cannot be discharged cleanly, which is ease to induce bacterial infections and lead to painful and urgent urination.
5.Urination Interruption. Due to prostatic hyperplasia, crystals in the urine are prone to agglutinate and form bladder stones, which might lead to sudden urination interruption in elderly people. Such urination interruption and the presence of bladder stones are “strong signals” of prostatic hyperplasia.
6.Prolonged rectal prolapse, hemafecia or “hernia”. This is caused by increased abdominal pressure due to prolonged urination difficulty.
7.Hypersexuality. Patients in early stages of prostatic hyperplasia may have hypersexuality not in line with their age or have sexual appetite suddenly becoming stronger. This is often caused by prostatic hyperplasia, which results in prostate dysfunction and further leads to feedback enhancement of testicular function.
Treatment Options
The symptoms in the urinary tract vary with the urinary tract obstruction severity, so appropriate treatment options should be selected according to the disease conditions of the patients. The therapeutic regimens mainly include Wait and Watch, Medication and Surgical Treatment.
Acute treatment
Acute uroschesis caused by prostate hyperplasia requires immediate medical attention, and an emergency catheterization is required, and if necessary, a bladder puncture should be performed for impotence.
General treatment
Wait and Watch: including patient education, lifestyle guidance, regular physical examination, etc. Due to the long course of disease of prostatic hyperplasia, investigations have shown that only a few prostatic hyperplasia patients have experienced urinary retention, renal insufficiency, and similar severe complications. Therefore, for most patients, if the symptoms are mild and the quality of life is not significantly affected, the therapeutic regimen may be Wait and Watch.
Drug therapy
Due to significant individual differences, there is no absolute best, fastest or most effective medication. In addition to commonly used over-the-counter drugs, the optimal drugs should be selected under the guidance of a doctor, while taking into account personal circumstances.
a-receptor blocker
It functions to relax urethral smooth muscle to alleviate bladder outlet obstruction, and is applicable for patients with moderate to severe lower urinary tract irritation symptoms. Commonly used drugs include selective a1 receptor blockers (such as Doxazosin and Terazosin) and highly-selective a1 receptor blockers (such as tamsulosin). After the drugs are administered, attention should be paid to such adverse reactions as dizziness, headache, fatigue, and postural hypotension.
5a-reductase inhibitor
It functions to reduce the content of dihydrotestosterone in the prostate and therefore reduce the prostate volume. It is applicable for patients with larger prostate volume and moderate to severe lower urinary tract symptoms. Common drugs include finasteride and dutasteride. After taking this drug, attention should be paid to such adverse reactions as erectile dysfunction and low libido.
M-receptor antagonist
It can alleviate excessive contraction of detrusor muscle, reduce bladder sensitivity, and therefore improve symptoms such as frequent urination, urgent urination or urge urinary incontinence of prostatic hyperplasia patients. It is applicable for patients with small prostate volume and mild urinary tract obstruction. Common drugs include tolterodine, solifenacin, oxybutynin, etc. After taking this drug, attention should be paid to such adverse reactions as mouth dryness, constipation, urination difficulty and blurred vision. It is forbidden for patients with urinary retention, gastric retention, narrow-angle glaucoma and those allergic to M-receptor antagonists
Vegetable drug and traditional Chinese medicine
Such drugs can effectively alleviate lower urinary tract symptoms without significant side effects. However, their mechanism of action is complex, and it is currently difficult to determine the correlation between the activity of their bioactive components and the therapeutic effect.
Surgical Treatment
For patients with moderate to severe prostate hyperplasia, patients whose lower urinary tract symptoms significantly affect their quality of life, especially those patients that are poorly responsive to medication or have had at least one urinary retention, surgical treatment may be considered. Common surgical methods include.
1.Transurethral Resection of Prostate (TURP)
TURP is to insert a resectoscope via the urethra to resect hyperplastic prostatic tissue. Currently, TURP is still the “gold standard” for treatment of prostatic hyperplasia. It can quickly alleviate such symptoms as urination difficulty, and the patient's urine flow rate after surgery gets improved significantly. A few patients may be complicated with retrograde ejaculation, urinary incontinence, bladder neck contracture, urethral stricture, etc.
2.Transurethral Incision of Prostate (TUIP)
It is to insert a resectoscope via the urethra and creating several small incisions on the prostate to make it easier for urine to pass through the urethra. It is mainly used for elderly patients with small-volume or high-risk prostate hyperplasia. Compared with transurethral resection of prostate (TURP), it has less complications, shorter surgery and hospital stay time but higher long-term recurrence rate.
3.Open Prostatectomy
It mainly applies to patients with significantly enlarged prostate, especially those with bladder stones or bladder diverticulum undergoing one-stage surgery. The bleeding volume, transfusion rate and hospital stay of the open surgery are higher than those of transurethral resection of prostate (TURP), and are now used rarely.
4.Transurethral Laser Surgery
It is a transurethral surgery to denature, solidify, necrotize and/or vaporize prostate tissue proteins guided by a cystoscope and aided by laser so as to relieve obstruction. This surgery has become an important treatment method for prostatic hyperplasia in recent years. According to the type of laser, it may be divided into green laser vaporization, thulium laser vaporization, semiconductor laser resection, holmium laser resection and so on. This technique is suitable for the vast majority of prostate patients, especially high-risk patients (e.g., advanced age, anemia, important organ dysfunction, etc.). It is characterized by relatively less intraoperative bleeding and more thorough removal of prostate tissue, and it has the trend to replace TURP.
5.Transurethral Vaporization of Prostate (TUVP)
It is to use the thermal effect of electric current on the basis of TURP to vaporize the prostate tissue touched. It is suitable for prostatic hyperplasia patients with poor coagulation function and smaller prostate volume. Its hemostatic effect is better, and its long-term complications are similar to those of transurethral resection of prostate (TURP).
6.Transurethral Plasmakinetic Resection of Prostate (TUPKP)
TUPKP is to use a plasma bipolar-resection system and the plasma energy generated by bipolar electrodes in physiological saline to remove prostatic hyperplasia, where the resectoscope is inserted via the urethra. It has such advantages as minimal intraoperative and postoperative bleeding, reduced blood transfusion rate and shortened postoperative catheterization and hospitalization time.
7.Transurethral Plasma Enucleation of Prostate (TUKEP)
TUKEP can implement the intracapsular excision of prostate gland and is characterized by more complete removal of prostatic hyperplasia tissue, low postoperative recurrence rate and less intraoperative bleeding.
Etiology
How is a uterine myoma generated? The formation mechanism of uterine myoma is still unknown at present, but according to a large number of clinical observation and experimental results, uterine myoma is a hormone-dependent tumor. Uterine myoma is likely to occur at reproductive ages and rarely seen prior to puberty, and would atrophy or degrade after menopause, which suggest that their occurrence may be related to female hormones. In addition, studies have found that genetic factors would also affect the incidence rate of uterine myoma.
The causes of uterine myoma include the following three categories:
General Factors
· Age: Uterine myoma often occur in women at childbearing ages, mostly ranging from 30 and 50. It is rare in adolescent women, and tends to atrophy or degrade after menopause.
· Obesity: Obesity can induce metabolic disorders, leading to lack of periodic progesterone regulation and causing abnormal menstrual cycles, which will affect ovulation and increase uterine myoma risk.
· Pregnancy and miscarriage history: Its incidence in women without a history of pregnancy and childbirth is higher than in those with pregnancy and childbirth history, and the onset age is earlier, mainly because multiparity could increase the progestational hormone in the bodies of female population.
· Smoking and drinking: Smoking and drinking are prone to induce uterine myoma. Studies have shown that women smoking one pack of cigarettes a day have a probability six times that of the nonsmoking ones to suffer uterine myomas.
Hormone Level
· High estrogen: Biochemical examinations have confirmed that the estrogen conversion of estradiol in myomas is significantly lower than that of normal muscle tissue, and the concentration of estrogen receptors in myomas is significantly higher than that in surrounding muscle tissue. Therefore, it is believed that the local high sensitivity of tumor tissue to estrogen is one of the important factors affecting the occurrence of myomas.
· High progesterone level: Progesterone has the effect to promote the mitosis of myoma and stimulating fibroid growth. If the progesterone level in a woman's body is high, it is easy to induce uterine myoma.
Genetic Factors
· Cytogenetics showed that 25% - 50% of uterine myomas had cytogenetic abnormalities, such as chromosome segment position exchange, chromosome long-arm rearrangement or partial deletion. Uterine myomas are formed due to proliferation of monoclonal smooth muscle cells, while multiple uterine myomas are formed by different clone cells.
· This disease is common in women aged 30-50 and rare under the age of 20.
· Some patients have uterine myomas but have no conscious symptoms. They can be identified only during physical examinations, and some patients even have their diseases not found at the end. Therefore, the clinically reported incidence rate of uterine myomas is far lower than the true incidence rate. At present, the estimated incidence in women at childbearing ages is up to 25%, according to autopsy statistics, the incidence rate may be up to 50% or higher, and the co-morbidity during pregnancy is 0.1% - 3.9%.
Disease Type
Intramural myoma
The incidence rate is 60% - 70%, and the myomas are located within the uterine muscle wall and surrounded by muscular layer.
Subserosal myoma
The incidence rate is about 20%, and the myomas grow towards the serous surface of the uterus, protruding from the outer surface of the uterus, with serous membrane covered on the surface.
When the myoma is connected with the uterus, it is called pedunculated myoma; If it is separated or detached from the uterus, it is called a free myoma; If it is located on the lateral wall of the uterine body, grows towards the parauterine tissue and protrudes between the two lobes of the broad ligament, it is called a broad ligament myoma.
Submucous myoma
The incidence is about 10% - 15%. The myoma grows into the uterus, protrudes out of the uterine cavity, and is covered by mucosa on the surface, which can cause uterine contraction and can also be squeezed into the vagina through the cervical opening.
Symptoms
Patients mostly have no symptoms and the myomas might be occasionally detected during pelvic examination or ultrasound examination. If there are symptoms, they are closely related to the growth site, speed, presence or absence of degeneration, and complications of myoma, but are less correlated with the size and number of myomas. Patients with multiple submucosal myomas may not necessarily have symptoms, while a smaller submucosal myoma might often cause irregular vaginal bleeding or excessive menstruation. If such symptoms are found, they should be taken seriously to avoid condition worsening and affecting the treatment effect.
The symptoms of uterine myoma include the following:
Menstrual irregularities
The most common uterine myoma symptoms are increased menstrual volume and prolonged menstrual irregularities. They are commonly seen in large intramural myomas and submucosal myomas, which enlarge the uterine cavity, increase the area of the endometrium, and affect uterine contraction. In addition, myomas may compress the veins near the tumor, leading to congestion and expansion of the endometrial venous plexus, and resulting in increased menstrual volume and prolonged menstrual period. When a submucosal myoma is accompanied by necrotic infection, there may be irregular vaginal bleeding or bloody purulent discharge. Long-term menstrual flow increase might lead to secondary anemia, fatigue and palpitations and the like.
Lower abdominal mass
When a myoma is small, no lump will be touched in the abdomen. As the myoma gradually grows, and when it makes the uterus larger than 3-month pregnant uterus or becoming a larger subserosal myoma at the bottom of the uterus, a lump may often be felt, which is more significant in the early morning when the bladder is filled. Lumps may solid and movable, but there would be no tenderness. Giant submucosal myoma might protrude outside the vagina; in such case, the patient should seek medical attention.
Oppression symptoms
When a myoma grows to a certain size, it would compress the surrounding organs. If the myoma is on the anterior wall of the uterus and close to the bladder, it would lead to frequent and urgent urination; huge cervical myoma can cause urination difficulty and even urinary retention; a myoma on the posterior wall of the uterine, especially those in the isthmus or cervical posterior lip, might compress the rectum, causing inhibited defecation or discomfort after defecation; Giant broad-ligament fibroid. Broad-ligament myoma or giant cervical myoma would develop laterally and be embedded in the pelvic cavity to compress the ureter and obstruct the upper urinary tract, leading to ureteral dilation and even hydronephrosis.
Increased vaginal discharge
An intramural myoma will increase the area of uterine cavity, increase the secretion of endometrial glands, which might be accompanied by pelvic congestion leading to an increase in vaginal discharge; Once a submucosal myoma of the uterus or cervix are infected, there might be a large amount of purulent vaginal discharge; If there is ulceration, necrosis or bleeding, there may be bloody or purulent vaginal discharge with foul odor.
Other symptoms
Including lower abdominal distension, low back pain and worsening of menstrual symptoms. In the event of red degeneration, the myoma is often accompanied by acute lower abdominal pain, vomiting, fever and local tenderness; when the subserosal myoma pedicle twists, an acute abdominal pain might occur; when submucosal myoma of the uterus is expelled out of the uterine cavity, an abdominal pain might be induced. Submucosal myoma or intramural myoma causing uterine deformation might induce infertility or miscarriage. Anemia: Long-term excessive menstruation or irregular vaginal bleeding might lead to hemorrhagic anemia, and more severe anemia is often seen in patients with submucosal myomas.
Diagnosis
How to diagnose uterine myomas? Uterine myomas may be diagnosed according to the patient's medical history and signs.
B-mode Ultrasound is the most commonly used auxiliary diagnostic device, which is used most widely and has the least cost and is the optimal choice for uterine myoma diagnosis. It can disclose uterine enlargement, irregular shape, number, location, and size of myomas, and whether the interiors of the myomas are uniform or liquefied, whether the sacs are diseased, etc. It also provides reference for distinguishing whether the myomas are denatured, and helps to differentiate them from ovarian tumors or other pelvic masses.
Magnetic resonance imaging (MRI) can accurately determine the size, number, and location of myomas. If necessary, hysteroscope, laparoscope, hysterosalpingography, etc. may also be selected for auxiliary diagnosis.
Gynecological examination:
Physicians can perform relevant examinations to roughly understand the condition of the uterus, the size, texture and number of masses, the presence of adhesions, as well as the myomas condition of cervix.
Magnetic Resonance Imaging (MRI):
It is the best way to accurately position a uterine myoma, but its high cost limits its clinical application.
Hysteroscope:
Under the hysteroscope, the shape of the uterine cavity and the presence of any neoplasms may be directly observed, and any submucosal myoma and endometrial polyps may be clearly diagnosed and treated simultaneously.
Magnetic Resonance Angiography (MRA), CT Angiography, and Ultrasound Doppler Techniques:
They can disclose the blood supply outside the myoma and uterine and can be used for the evaluation before conservative treatment for uterine artery embolization.
Laparoscope:
When a myoma needs to be differentiated from ovarian tumors or other pelvic masses, a laparoscopic examination may be performed to directly observe the size and shape of the uterus, the tumor growth site and preliminarily determine its nature. Under the laparoscope, the condition of the fallopian tubes may also be checked. Such examination will be performed within 3 to 7 days after menstruation is clean; Do not eat or drink water in the morning on the very examination day.
Hysterosalpingography:
This examination is valuable for the diagnosis of submucosal myoma in the uterus. It can disclose the shape of the uterine cavity and whether the fallopian tubes are unobstructed. A hysterosalpingography should be performed within 3 to 7 days after menstruation is clean, and sexual activity is prohibited 3 days before the examination.
Treatments
The treatment of uterine myoma is required to take into account the patient's age, fertility requirements, symptoms, and location and size of myomas.
General treatment
An asymptomatic myoma does not require for treatment in general, but a myoma examination is required to be performed every 3-6 months; however, if it is found that the myoma is enlarged or the patient has relevant symptoms, appropriate treatment should be considered.
Drug therapy
Due to significant individual differences, there is no absolute best, fastest or most effective medication. In addition to commonly used over-the-counter drugs, the optimal drugs should be selected under the guidance of a doctor, while taking into account personal circumstances.
· When the patients have excessive menstruation, anemia, and compression and the like but are unwilling to undergo surgery;
· Prior to surgery, the patient needs to take drugs to correct anemia, reduce fibroids, and uterine volume;
· When the patient needs to take relevant drugs to reduce the myoma prior to pregnancy;
· After a multiple uterine myoma removal surgery, the patient needs to take certain drugs to prevent myoma recurrence in the near future.
The patient cannot undergo surgical treatment. A patient may receive medication under the guidance of a physician.
Drugs to reduce myoma volume
1.Gonadotropin-releasing hormone analog (GnRH-a)
GnRH-a is not advisable to be taken continuously for long time, but is only applicable for preoperative preconditioning, reducing myoma size and reducing surgical difficulty. Such drug should be administered for 3-6 months so as to avoid severe menopausal symptoms caused by low estrogen level; Low-dose estrogen may also be supplemented simultaneously against this side effect. Long-term use may cause adverse reactions such as osteoporosis, so its long-term use is not recommended.
2.Mifepristone
It is a progesterone antagonist that has been put into clinical trial in recent years to treat uterine myomas, which can reduce the myoma size. It may be used for preoperative medication or for early menopause, but long-term use is not advisable because long-term use might increase the risk of endometrial lesions.
3.Drugs to improve excessive menstruation
Non-steroidal anti-inflammatory drugs;
Hemostatic drugs, such as tranexamic acid Combined oral contraceptive;
Levonorgestrel intrauterine sustained-release system:
Supplement iron to correct anemia.
Surgical Treatment
The surgical treatment for uterine myomas includes myomectomy and hysterectomy, which may be performed via the abdomen or vagina, and an endoscopic surgery (hysteroscopy or laparoscopy) is also available. The choice of surgical mode and approach depends on such factors as patient age, fertility requirements, myoma size and growth site, and medical technical conditions. The physician may recommend the surgical treatment in the following situations:
· Where the uterine myoma is irresponsive to the drugs due to excessive menstruation, abnormal bleeding / anemia;
· Where the myoma leads to infertility and recurrent miscarriage;
· Where the myoma diameter is 2-4cm, but the patient has the fertility demand;
· A large myoma compresses the bladder and rectum, causing a series of symptoms that seriously affect normal life;
· Where the patient has severe abdominal pain, sexual intercourse pain or long-term chronic abdominal pain, acute abdominal pain caused by torsion of uterine fibroid pedicle. Whether the myoma continues to grow or is suspected of worsening after menopause.
When the pregnancy is accompanied by uterine myoma, most of pregnant women do not need special treatment but the sizes of their myomas, the relationship between the myomas and the placenta, as well as maternal and fetal conditions should be regularly monitored. Surgical treatment is required in the following circumstances:
1.Myomas grow rapidly and are suspected of malignancy;
2.Myomas have red degeneration and/or necrosis, while the conservative treatment is ineffective;
3.The myoma pedicle has torsion and a secondary infection occur, and the conservative treatment is ineffective;
4.They myoma enlarges to compresses adjacent organs, resulting in severe symptoms.
Myomectomy
The surgery is to remove uterine myomas while preserving the uterus, and it is mainly used in young women under the age of 40 and hoping to preserve their reproductive function. This surgery is applicable for patients who have larger myomas, excessive menstruation and oppression symptoms, become infertile due to myomas, have submucosal myomas; whose myomas grow rapidly but are not malignantly transformed. Intramural myomas and subserosal myomas are mostly removed under laparoscopy, while submucosal myomas are often removed under hysteroscopy.
Hysterectomy
Suitable for patients that have significant symptoms, has malignant transformation possibility and have no fertility demand. If necessary, frozen tissue slices should be prepared during operation for histological examination. The possibility of such malignant diseases as cervical intraepithelial lesions, cervical cancer, and endometrial cancer must be excluded prior to surgery.
For patients with a large number of myomas, large myoma diameter (>10cm), myomas in special sites, severe pelvic adhesion, having a uterine rupture risk in future pregnancy and having myoma malignant transformation, laparotomy is required.
Other Treatments
Uterine artery embolization (UAE): It is to use a radiation intervention technique to insert an arterial catheter directly into the uterine artery for administering permanent embolic particles to block the blood supply for uterine myomas and delay the growth of myomas to enable the myomas to atrophy or even disappear. UAE is presently applicable for symptomatic uterine myomas such as anemia due to abnormal uterine bleeding.
It is not recommended for any patients having fertility demands.
High-Energy Focused Ultrasound (HIIFU)
HIFU Ultrasonic Knife: Under the guidance of ultrasound or MR, it uses high intensity ultrasound to raise the local temperature in the tumor to above 65℃ to enable the tumor to solidify, necrotize and atrophy so as to alleviate the symptoms. It is a non-invasive therapy suitable for patients who need to preserve the uterus. But there is a myoma residue and recurrence risk.
Similar treatment methods include microwave ablation, etc.
Traditional Chinese Medicine Treatment
At present, there is no evidence-based medical evidence to support the traditional Chinese medicine treatment of this disease, but some traditional Chinese medicine treatment methods or drugs can alleviate the symptoms. It is recommended to seek treatment from a reputable medical institution under the guidance of a physician.
