Benign Prostatic Hyperplasia Diagnosis, Treatment And Health Management Guide Ⅰ
Oct 25, 2024
Benign prostatic hyperplasia (BPH) is a common chronic disease with urination disorder in middle-aged and elderly men, and is one of the most common diseases in the clinical diagnosis and treatment of urology. From a histological perspective, BPH generally occurs after the age of 40, and the incidence increases year by year with age. The incidence of BPH in men aged 51 to 60 is about 20%, and the incidence of BPH in men aged 61 to 70 is 50%, and it is as high as 83% at the age of 81 to 90 [1]. With the improvement of living standards, the demand of BPH patients for treatment effects is gradually changing, and it is extremely important to standardize the diagnosis and treatment of BPH and health management. Therefore, the Chinese Medical Association's Andrology Branch organized relevant clinical experts to jointly study and formulate this guideline based on existing clinical evidence, providing standardized diagnosis and treatment guidance and reference for BPH patients, especially those with sexual function needs.
A NEW HERB CISTANCHE IMPROVES SEXUAL FUNCTION
1 Pathogenesis
BPH is mainly manifested by histological hyperplasia of prostatic stroma and glandular components, anatomical enlargement of prostate volume (BPE), and bladder outlet obstruction (BOO) in urodynamics. BPH causes elongation, compression deformation, stenosis and increased urethral resistance of the posterior urethra, resulting in bladder hypertension and lower urinary tract symptoms (LUTS) [2-4]. LUTS include storage symptoms, voiding symptoms and post-micturition symptoms. Storage symptoms include frequent urination, urgency, incontinence, and increased nocturia; voiding symptoms include hesitation, difficulty, and intermittent urination; post-urination symptoms include a feeling of incomplete urination and dripping after urination. Middle-aged and elderly men with LUTS are more likely to suffer from erectile dysfunction (ED) [5], and ED is associated with the severity of LUTS [6-7].
2 Diagnosis and evaluation
Strongly recommended examinations include: history inquiry, International Prostate Symptom Score (IPSS), physical examination, urine routine examination, serum prostate specific antigen (PSA) test, transrectal or transabdominal ultrasound examination.
Recommended optional examinations include: urinary flow rate and residual urine measurement, quality of life (QOL) score, overactive bladder symptom score (OABSS), etc.
Recommended examinations in special circumstances include:
①Renal function test. For patients with a history of renal impairment and related risk factors, such as patients with hydronephrosis caused by urine retention, renal function testing is recommended [8-9].
②Upper urinary tract ultrasound examination. For patients with a history of excessive bladder residual urine, hematuria, and urinary tract stones, upper urinary tract ultrasound examination is recommended [8].
③Urethra cystoscopy. For patients with a history of microscopic or macroscopic hematuria, a history of urethral stricture, or a history of bladder cancer, a urethra cystoscopy should be performed. For patients who need urethra cystoscopy, a flexible bladder endoscope can be used if conditions permit to reduce the patient's pain [10].
④Urodynamic examination. The main purpose is to explore the functional mechanism of LUTS symptoms in patients, to indicate whether the patient has risk factors that lead to adverse clinical outcomes, and to provide more basis for making clinical decisions. Since urodynamic examination is an invasive examination, it is only recommended in specific patients. Urodynamic evaluation is strongly recommended for patients with a history of neurological disease, history of radical pelvic surgery, or suspected neurogenic lower urinary tract dysfunction [8, 11-12].
⑤ Imaging urodynamic examination. It can provide more anatomical and functional information than conventional urodynamics. If the clinician believes that it is necessary to understand the patient's pathophysiological mechanism, this examination can be selected [8].
⑥ Evaluation of sexual function problems. For younger patients or patients with sexual function needs, it is recommended to improve.
International Index of Erectile Function (IIIEF) score, serum testosterone measurement, and nocturnal penile erection hardness test are used to evaluate the current patient's erectile function status and can be used for ED screening, severity assessment, and follow-up after treatment [7, 13-14].
A NEW HERB CISTANCHE IMPROVES SEXUAL FUNCTION
AND PREVENTS YOUR BPH
3. Drug treatment
For early BPH patients who only have occasional mild frequent urination or nocturia, regular check-up observation and health education can be adopted, including improving lifestyle and eating habits. As the symptoms of the disease worsen, drug treatment is the primary intervention measure to relieve symptoms and delay disease progression. Drug treatment is often classified into chemical drugs, traditional Chinese medicine and plant drugs.
3.1 Chemical drugs
3.1.1 α receptor blockers
Currently, the drugs used in clinical practice are mainly selective and highly selective α1 receptor blockers that can relieve urinary symptoms and produce fewer adverse cardiovascular reactions [15]. α1 receptor blockers can improve symptoms within a few hours to a few days after treatment without affecting prostate volume and serum PSA levels [16-17], but the use of IPSS to evaluate symptom improvement is generally recommended 4 to 6 weeks after medication. If there is no significant improvement in symptoms after continuous use of α1 receptor blockers for 4 to 6 weeks, the dosage form, dose, or different types of α receptor blockers can be considered [18]. Common adverse reactions include dizziness, headache, fatigue, drowsiness, postural hypotension, abnormal ejaculation, etc. [19-20]. Postural hypotension is more likely to occur in the elderly, patients with cardiovascular disease, or patients taking vasoactive drugs at the same time.
Note: Patients taking α1 receptor blockers may experience floppy iris syndrome when undergoing cataract surgery. Therefore, it is recommended to stop taking α1 receptor blockers before cataract surgery, but there is no clear standard for how long to stop taking the drug before surgery [21-22].
3.1.2 5α-reductase inhibitors
5α-reductase inhibitors are a class of drugs that inhibit the activity of 5α-reductase and reduce the production of dihydrotestosterone. They are an effective means of treating androgen-dependent diseases and are currently the main drugs that can reduce the size of the prostate [23]. Currently, there are two types of 5α-reductase inhibitors that have been used: steroidal and non-steroidal.
Steroidal compounds all have a steroidal tetracyclic structure. Representative drugs are finasteride and dutasteride from the aminosteroid class and eristeride from the androstenol class. Finasteride inhibits type II 5α-reductase, dutasteride can inhibit both type I and type II 5α-reductase (dual blocker), and eristeride is a potent non-competitive type II 5α-reductase inhibitor [24]. Current studies have shown that finasteride and dutasteride are similar in clinical efficacy, and both can reduce prostate volume and reduce LUTS to a certain extent. In China, eristeride is transliterated as aprilate, and there is also increasing evidence that it has good clinical efficacy [25-26].
Non-steroidal 5α-reductase inhibitors are mostly derived from steroidal structure simulations, that is, removing one or more rings in the steroidal structure and further modifying the structure, and are less used.
The most common adverse reactions of 5α-reductase inhibitors include ED, abnormal ejaculation, low libido and other symptoms such as gynecomastia and breast pain [16, 27-28]. They should be used with caution in younger BPH patients or patients with higher sexual function needs.
Note: 5α-reductase inhibitors can reduce serum PSA levels. There is no definitive clinical evidence on their effect on the incidence of prostate cancer. There is sufficient clinical evidence to prove that taking them for more than 6 months can reduce PSA levels by about 50%. When conducting PSA screening for patients using 5α-reductase inhibitors, the effect of the drug on PSA should be considered [29-31].
A NEW HERB CISTANCHE IMPROVES SEXUAL FUNCTION
AND PREVENTS YOUR BPH
3.1.3 M receptor antagonists
M receptor is the abbreviation of muscarinic receptor. When acetylcholine binds to this type of receptor, it can produce a series of parasympathetic nerve endings excitation effects. There are 5 subtypes of M receptors, of which M2 and M3 are dominant in the detrusor muscle. The M2 subtype is more abundant, but the M3 subtype is more important in the bladder contraction function of healthy people [32-33]. M receptor antagonists can relieve detrusor overexcitation and reduce bladder sensitivity, thereby improving the storage symptoms of BPH patients [34]. Currently, the commonly used non-selective M receptor antagonists for M2 and M3 receptors are tolterodine, oxybutynin, etc., and the selective M3 receptor antagonists are mainly solifenacin.
Adverse reactions of M receptor antagonists include dry mouth, dizziness, constipation, dysuria and blurred vision, which often occur within 2 weeks of medication and in patients aged ≥ 66 years. They are related to the subtypes of M receptors distributed in other organs. Selective M receptor antagonists have relatively few adverse reactions. Note: Most studies show that M receptor antagonists should be used with caution when the residual urine volume is ≥ 200 ml, and cannot be used when the detrusor muscle is weak. It is contraindicated for patients with urinary retention, gastric retention, narrow-angle glaucoma and allergies to M receptor antagonists.
3.1.4 Phosphodiesterase type 5 (PDE5) inhibitors
PDE5 inhibitors can increase the intracellular cyclic guanosine monophosphate content, thereby reducing the tension of the detrusor, prostate and urethral smooth muscle. Currently, tadalafil 5 mg, once a day, has been approved for the treatment of male LUTS. Several randomized controlled studies have shown that taking PDE5 inhibitors can significantly reduce IPSS, alleviate LUTS, and improve patients' quality of life [35-37]. There is a lack of long-term follow-up studies on the use of PDE5 inhibitors alone to treat BPH, and there are no reports on their association with the control of prostate volume and disease progression. Therefore, the current recommendation level for the treatment of BPH with PDE5 inhibitors is relatively low.
Note: Patients with recent unstable angina, myocardial infarction (<3 months) or stroke (<6 months), myocardial insufficiency, hypotension, poor blood pressure control, or obvious liver or kidney dysfunction are not recommended to take PDE5 inhibitors.
3. 1. 5 β3 receptor agonists
β3 receptor agonists can selectively excite the β3 receptors of the bladder, relax the detrusor, increase urine storage capacity and urination interval, without affecting bladder emptying, and reduce the occurrence of acute urinary retention. Compared with placebo, it can Significantly improve patients' symptoms of frequent urination, urgency and urge urinary incontinence [38-41].
Note: Common adverse reactions of β3 receptor agonists include hypertension, headache, nasopharyngitis, etc. Therefore, β3 receptor agonists are contraindicated in patients with uncontrolled severe hypertension (systolic blood pressure > 180 mmHg, and/or diastolic blood pressure > 110 mmHg), and blood pressure should be monitored during medication [42].
3. 2 Traditional Chinese medicine and plant medicines
BPH is classified as "Jinglang" in traditional Chinese medicine. Its basic pathogenesis is loss of triple energizer and poor gasification of the bladder. This disease can be divided into deficiency and excess according to the cause. The actual symptoms include excessive lung heat, blood stasis in the lower burner, liver stagnation and qi stagnation, and damp-heat in the bladder. The deficiency syndromes include kidney yang deficiency and central qi depression. Jinglong is more common in the elderly. Clinically, it often shows a mixture of deficiency and excess, and the symptoms are characterized by progressive aggravation with age. To treat deficiency, we should mainly focus on nourishing the kidneys, so that the yin and yang of the kidneys can be balanced, and the opening and closing of the kidneys can be opened and closed appropriately; the treatment of deficiency should be based on the principle of "the six fu organs are used to unblock", focusing on the application of unblocking methods. Water channels, while using methods of promoting blood circulation and removing blood stasis, softening and dispersing stagnation, to reduce the degree of obstruction. It should be noted that, according to the disease
The changes in the lungs, spleen, liver, and kidneys are different, and treatment is based on syndrome differentiation. Recommendations for using Chinese patent medicines and botanical drugs according to different syndrome differentiation types of BPH are as follows.
3. 2． 1 Damp and hot betting certificate
Main symptoms: frequent urination, urgent urination, burning during urination, short and red urine, and persistent drainage. Secondary symptoms: fullness in the lower abdomen, thirst and no desire to drink. Tongue and pulse: red tongue, yellow and greasy coating, slippery pulse. Treatment Principles: Clear away heat and dampness, relieve bladder pain
bladder. Recommended prescription: Bazheng Powder plus or minus. Recommended Chinese patent medicine: Longjin Tonglin Capsules [43], Ningmitai Capsule[44].
3. 2． 2 Qi stagnation and blood stasis syndrome
Main symptoms: difficulty urinating, thinning or dripping urine. Secondary symptoms: urethra pain, occlusion, or lower abdominal fullness and pain, and occasionally hematuria. Tongue and pulse: The tongue is dark or has petechiae and ecchymosis, and the coating is white or
Thin yellow, stringy or astringent pulse. Treatment principles: promote qi and blood circulation, clear the orifices and promote diuresis. Recommended prescription: Agarwood powder. Recommended Chinese patent medicine: Astragalus capsule [45].
A NEW HERB CISTANCHE IMPROVES SEXUAL FUNCTION
AND PREVENTS YOUR BPH
3. 2． 3. Damp-heat syndrome
Main symptoms: Soreness and weakness in the waist and knees, frequent urination, urgency of urination, painful urination, and thin urinary line. Secondary symptoms: yellow urine, burning sensation in the urethra; bitter mouth and dry mouth, moist scrotum, and tightness and pain in the lower abdomen. Tongue and pulse: dark purple tongue, yellow and greasy coating, stringy and slippery pulse. Treatment Principles: Benefit the kidneys and activate blood circulation, clear away heat and relieve stranguria. Recommended prescriptions: Daidandang Decoction or Chunze Decoction. Recommended Chinese patent medicines: Xia Liqi Capsules [46], Lingze Tablets [47], Qianlieshutong Capsules [48], Qianliexin Capsules [49], Qianlie Jindan Tablets [50].
3. 2． 4. Kidney yin deficiency syndrome
Main symptoms: frequent and unpleasant urination, oliguria, hot red urine. Secondary symptoms: blockage; dizziness, tinnitus, soreness and weakness in the waist and knees, five upset stomachs and heat, and constipation. Tongue and pulse: red tongue with little or yellow fluid, thready and rapid pulse. Treatment Principles: Nourishing kidney yin, clearing the orifices and diuresis. Recommended prescription: Zhibai Dihuang Decoction. Recommended Chinese patent medicines: Zhibai Dihuang Pills and Zuogui Pills [51].
3. 2． 5. Kidney yang deficiency syndrome
Main symptoms: Inability to urinate, residual drainage after urination, and frequent nocturia. Secondary symptoms: dizziness, tinnitus, backache and fatigue. Tongue and pulse: pale red tongue with thin white coating, thin and weak pulse. Treatment Principles: Tonifying the kidneys and replenishing qi, clearing the bladder. Recommended prescription: Jisheng Shenqi Pills. Recommended Chinese patent medicines: Jingui Shenqi Pills and Yougui Pills. Recommended botanical medicine: Qianliekang[52].
