Guidelines For The Diagnosis And Treatment Of Benign Prostatic Hyperplasia With Integrated Chinese And Western Medicine
Aug 26, 2024
Benign prostatic hyperplasia (BPH) refers to the histological proliferation of prostate stroma and glandular components and anatomical enlargement of the prostate (BPE) in middle-aged and elderly men (over 50 years old), characterized by bladder outlet obstruction (BOO) in urodynamics and lower urinary tract symptoms (LUTS) in clinical manifestations. BPH belongs to the category of "sperm retention" in traditional Chinese medicine.
Traditional Chinese Herb Good For Treat BPH-Click Here To Get More Details
The occurrence of BPH is a long, slow, and complex process. Its specific formation mechanism is still unclear. At present, the two related factors that are more recognized in the medical community are aging and normal testicular function [1]. The histological incidence of BPH increases with age, usually occurring after the age of 40 [2], exceeding 50% at the age of 60, and as high as 83% at the age of 80 [3]. Similar to the histological manifestations, symptoms such as dysuria also increase with age. LUTS symptoms are the most common cause of impairment and reduction in quality of life［4］, and most elderly men have at least one LUTS symptom［5］.
1 Diagnosis
1. 1 Clinical manifestations
Clinical symptoms are mainly LUTS, including storage symptoms, urination symptoms and post-urination symptoms. Storage symptoms include frequent urination, urgency, urinary incontinence and increased nocturia; urination symptoms include hesitant urination, dysuria and intermittent urination; post-urination symptoms include incomplete urination and post-urination dripping.
1. 2 Western medicine diagnosis
Male patients over 50 years old who come to the hospital with LUTS as the main complaint should first consider the possibility of BPH, inquire about the medical history in detail for initial evaluation, and make a clear diagnosis in combination with laboratory and imaging examinations.
1. 2. 1 Medical history
① Characteristics, duration and associated symptoms of LUTS. ② History of surgery, trauma, especially pelvic surgery or trauma. ③ Past medical history, including history of urogenital tract infection, diabetes, neurological diseases, and heart disease that may be related to nocturia. ④ Medication history, to understand whether the patient is currently or recently taking drugs that affect bladder outlet function or cause LUTS. ⑤ General condition of the patient. ⑥ International prostate symptom score (IPSS) See Table 1. IPSS is currently recognized internationally as the best means to judge the severity of symptoms in BPH patients. IPSS is a subjective reflection of the severity of lower urinary tract symptoms in BPH patients. It has no significant correlation with maximum urine flow rate (Qmax), postvoid residual urine volume (PVＲ) and prostate volume [3]. ⑦ Quality of life score (QoL) See Table 2. QoL score (0 to 6 points) is to understand the patient's subjective feelings about his current LUTS level, the degree of trouble caused by LUTS and whether he can tolerate it.
Table 1 International Prostate Symptom Score (IPSS)
| No. | Question | No Symptoms | Mild | Moderate | Severe | Very Severe |
|---|---|---|---|---|---|---|
| 1 | Do you have any urinary symptoms? | 0 | 1 | 2 | 3 | 4 |
| 2 | Are there any obstructions or straining when you urinate? | 0 | 1 | 2 | 3 | 4 |
| 3 | Do you have any intermittent urinary symptoms? | 0 | 1 | 2 | 3 | 4 |
| 4 | Do you have any incomplete bladder emptying? | 0 | 1 | 2 | 3 | 4 |
| 5 | Do you have any post-void dribbling? | 0 | 1 | 2 | 3 | 4 |
| 6 | Do you use any medication or device to help with urination? | 0 | 1 | 2 | 3 | 4 |
| 7 | From when you first wake up to when you first urinate, is the delay very long? | No | 1 time | 2 times | 3 times | 4 times |
Table 2 Quality of life index (QoL) scores
| Question | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied | Extremely Dissatisfied |
|---|---|---|---|---|---|---|
| How satisfied are you with the current status of your urinary symptoms? | 0 | 1 | 2 | 3 | 4 | 5 |
1. 2. 2 Physical examination
1. 2. 2. 1 Examination of external genitalia
Exclude urethral stenosis or other diseases that may affect urination (such as phimosis, anterior urethral scar stenosis, penile tumor, etc.).
1. 2. 2. 2 Digital-rectal examination (DRE)
DRE is one of the important examination items for BPH patients and should be performed after the bladder is emptied. DRE can understand the size, shape, texture, presence of nodules and tenderness of the prostate, whether the central groove becomes shallow or disappears, and the tension of the anal sphincter.
1. 2. 2. 3 Local nervous system examination
Examination of the perianal and perineal peripheral nervous system helps to exclude neurogenic bladder dysfunction.
1. 2. 3 Laboratory examination
1. 2. 3. 1 Urinalysis
For LUTS patients, it can determine whether there is urinary tract infection, hematuria, proteinuria and glycosuria.
1. 2. 3. 2 Serum prostate-specific antigen (PSA) is mainly used to identify prostate cancer.
1. 2. 3. 3 Serum creatinine (Cr) and urea nitrogen (UN)
Bladder outlet obstruction caused by BPH can cause renal damage, leading to increased Cr and UN. If there are lesions such as hydronephrosis and ureteral dilatation and reflux, this test is recommended when renal insufficiency is suspected [6].
1. 2. 4 Uroflowmetry
It can preliminarily determine whether there is obstruction in the lower urinary tract, but there are many influencing factors, so pay attention to identification.
1. 2. 5 Imaging examination
1. 2. 5. 1 Ultrasonography
It can understand the shape, size, abnormal echo, degree of protrusion into the bladder, the pathological conditions of the kidneys, ureters, and bladder, and (PVR). The amount of PVR is of great reference value for determining the degree of lower urinary tract obstruction. Transrectal ultrasound (TＲUS) can accurately measure the volume of the prostate (the calculation formula is 0.52 × anterior-posterior diameter × left-right diameter × upper-lower diameter) [7].
1.2.5.2 Intravenous urography
If LUTS patients are accompanied by recurrent urinary tract infections, microscopic or macroscopic hematuria, suspected hydronephrosis or ureteral dilatation and reflux, or urinary tract stones, intravenous urography should be performed. However, this examination should be prohibited if the patient is allergic to contrast agents or has renal insufficiency.
1.2.5.3 Urethrogram
This examination is recommended when urethral stricture is suspected.
1.2.6 Urodynamics
Urodynamics is the "gold standard" for diagnosing BOO and can help understand bladder function [8]. Before BPH patients undergo surgery and minimally invasive treatment, urodynamics is recommended if the following conditions occur: ① urine volume ≤ 150 ml; ② under 50 years old or over 80 years old; ③ PVR ＞ 300 ml; ④ suspected neurogenic bladder caused by neurological disease or diabetes; ⑤ bilateral hydronephrosis; ⑥ previous history of pelvic or urethral surgery.
1.2.7 Urethracystoscopy
It can help understand the characteristics of urethral or bladder neck obstruction caused by prostate enlargement and exclude urethral and bladder related diseases.
1.2.8 Differential diagnosis
This disease needs to be differentiated from diseases such as bladder neck fibrosis, neurogenic bladder and urethral dysfunction, urethral stenosis, bladder tumors, prostate cancer and chronic prostatitis.
1. 3 TCM diagnosis
1. 3. 1 Basic pathogenesis
Kidney qi deficiency is the root cause of the disease. Blood stasis, damp heat, phlegm and other pathological products are produced in the development of BPH. They affect each other and are mutually causal, which is a syndrome of deficiency and excess.
Deficiency is mainly kidney deficiency and qi deficiency, while excess is mainly damp heat, blood stasis and phlegm. The changes in pathogenesis are correlated with the course of the disease, age, etc.: In the early stage, the deficiency of the body and the mild evil are mainly kidney qi deficiency; in the middle stage, the deficiency of the body and the excess of the evil are mainly kidney deficiency and damp heat or blood stasis; in the late stage, the deficiency of the body and the strong evil, damp heat or blood stasis are more obvious.
1. 3. 2 Syndrome differentiation
It is mainly divided into basic syndrome and complex syndrome. Syndrome differentiation is often mixed with deficiency and excess, with complex syndrome being the most common. According to literature analysis [9-13], the syndromes with higher frequency are kidney qi deficiency, damp heat
invasion, qi stagnation and blood stasis, and spleen qi weakness. Among the complex syndromes, the most common syndromes are kidney deficiency and blood stasis, kidney deficiency and damp heat, spleen and kidney deficiency, damp heat and blood stasis. Diagnostic criteria for TCM syndrome: The syndrome is established if there is 1 main symptom, 2 secondary symptoms and tongue and pulse. According to the principle of 2 points for 1 main symptom and 1 point for 1 secondary symptom and tongue and pulse, the syndrome is established if the cumulative score is ≥5 [14].
