The human urinary tract is composed of two main organs: the kidneys, which are the organs in charge of producing urine, and the bladder, where urine is stored to later be released through the urethra.The ureters transport urine from the kidneysto the bladder.
Once the bladder has been filled (250-500 ml) the nerves supplying the bladder send a signal to the brain that produces the desire to urinate.Urination begins with contraction of the muscle of the bladder and the relaxation of the sphincters (closing mechanisms) situated at the neck of the bladder and the urethra, permitting the exit of urine through the urinary meatus (the external orifice of the urethra).
The prostate is a sexual accessory gland of the male reproductive system that, in an adult male, is similar in size and shape to a chestnut, weighing between approximately 12 and 20 grams.It is situated below the bladder at the beginning of the urethra, behind the pubic bone and in front of the anal canal.Its structure is similar to a sponge, formed by thousands of small cavities where prostatic secretions are formed and then emptied into the prostatic urethra via dozens of small channels.
In 1953 the Spanish urologist Salvador Gil Vernetdemonstrated that the prostate gland is not homogeneous and is actually composed of three well differentiated zones: the cranial zone and the intermediate zone, where benign growth occurs, and the caudal zone, the primary site of malignant growth.
Its development and growth, which begins in puberty, is controlled by male sexual hormones (testosterone).All mammals have a prostate, but the pathologic processes of benign hyperplasia and cancer develop only in humans and canines.
La glándula prostática produce una secreción que constituye el 25% del volumen del semen, vehiculando y protegiendo los espermatozoides. La secreción está formada por enzimas como el antígeno prostático específico (frecuentemente abreviado como PSA por sus siglas en inglés) y por zinc, prostaglandinas y citratos, principalmente. Durante la eyaculación, la próstata se contrae y, a través de los llamados conductos colectores, vierte su secreción en la uretra prostática, donde se mezclará con las secreciones de las vesículas seminales y de los conductos deferentes para formar el semen. Es decir, la próstata tiene un papel muy importante en la fertilidad y cualquier proceso patológico que pueda dañarla afectará la capacidad reproductiva del varón.
The most common diseases are benign prostatic hyperplasia, prostate cancer and acute or chronic prostatitis.
Benign prostatic hyperplasia (benign prostate enlargement). Beginning at puberty, the prostate experiences a progressive increase in size due to the action of the sexual hormones until it reaches 15-20 grams.From the age of 35, benign growth begins in the zone of the prostate closest to the urethra or the emptying point of the bladder; this process is known as benign prostatic hyperplasia, or BPH.Prostate enlargement can obstruct normal urine flow, narrowing the passage of urine through the neck of the bladder and/or the prostatic urethra.In addition, another factor also contributes to obstruction: an increase in the tension of the muscle fibers that surround the neck of the bladder and the first section of the prostatic urethra like a ring. BPH affects approximately 50% of males between 51 and 60 years of age, increasing to 90% in males 80 years of age, but only results in significant symptoms in 30% of them.
- Androgens: Androgens and male sexual hormones (testosterone and dihydrotestosterone) are necessary for the development of BPH.Patients that have been castrated before puberty or those with genetic disorders in whom androgens either cannot be produced or function improperly do not develop BPH.
- Familiar and genetic factors: It is known that BPH has a hereditary component (autosomal dominant) in 50% of men treated surgically for BPH before the age of 60.In contrast, only 9% of those treated after age 60 have a hereditary factor.
Obesity, excessive consumption of saturated fats and animal proteins, lack of physical exercise and excessive consumption of alcohol are the greatest relative risk factors for disease development.Accordingly, an increase in the consumption of fruits and vegetables (a heart-healthy diet), maintenance of an appropriate weight, physical exercise, cessation of smoking, and consumption of only a moderate amount of alcohol are all recommended.
No, BPH is a benign process and is not a cause of prostate cancer, although these processes sometimes coexist.This is why we recommend getting a blood test to evaluate PSA levels and advise getting a digital rectal exam.
Usually, the patient experiences changes in their urination habits over the years, which are due to benign enlargement of the prostate and changes that the bladder undergoes during aging. On occasion, these processes severely alter urination (obstruction/irritation) and the patient’s quality of life. The most common symptoms are:
- Difficulty starting or needing to use force to urinate
- Feeling that the bladder has not completely emptied after urination
- Difficulty resisting the urge to urinate
- Weak or interrupted urine stream, and prolonged urination
- The need to urinate again shortly after the last urination
- Getting up several times during the night with the urge to urinate
In the initial stages of disease, the bladder is able to compensate for the difficulty of the passage of urine by increasing the force of contraction, but with time the walls become thicker, and a time may come in which it will not be able to expel the urine.
- Clinical history: A specialist will ask a series of questions regarding the urinary symptoms that the patient is experiencing and any medications that he is taking that may affect urination. Also, they will pose a series of questions through the I-PSS (International Prostate Symptom Score) questionnaire, where they score problems with urination (0-35 points) and the impact that the symptoms have on the patient’s quality of life (0-6 points).
- Analysis: Beginning at 40 years of age, it is recommended to periodically assess blood PSA levels (total and free) for the early diagnosis of prostate cancer. PSA levels may increase due to age, benign enlargement of the prostate, or infections of the prostate, which the specialist should consider in each case. A urine analysis is also carried out to evaluate the presence of blood or infection.
- Digital rectal exam: This is done to evaluate the consistency and size of the prostate, and check for any suspicious areas. When PSA levels are low, a rectal exam is not considered necessary for diagnosis.
- Urodynamic testing: The patient urinates into an apparatus that measures the urination flow with respect to a series of parameters (maximal flow, average flow, rate of flow, etc.) that allows us to determine the degree of obstruction.
- Urologic ultrasound: The specialist performs a full ultrasound study of the kidneys, the bladder and the prostate. This can show if the bladder has changes in its thickness due to obstruction and can evaluate for the presence of residual liquid after urination. It also shows greater detail of the prostate, evaluating its size and shape of growth. In some cases, a rectal prostate ultrasound is also carried out, which allows for more precise study of the prostate gland.
No, we only recommend treatment in patients that have a pronounced symptom that alters their quality of life (factors that are evaluated by the I-PSS questionnaire), complications from urine retention, bladder stones, recurring urinary tract infections, blood in the urine, or, less frequently, impaired renal function. A large prostate does not necessarily mean that treatment should be started.
Selection of appropriate treatment, whether it be pharmacological or surgical, will depend on the severity of the patient’s symptoms. Accordingly, early diagnosis allows for conservative treatment, while a late diagnosis exhibiting severe symptoms usually requires more aggressive treatment.
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