The case study presented here demonstrates a clear diagnosis of Benign Prostratic Hypertrophy or BPH.
Pathophysiology: The disease condition known as benign hypertrophy of the prostate usually develops initially in the transition zone of the periurethral region of prostate. This zone usually consists of separate lobules of tissues lying external to the sphincter. Majority of ducts of the transitional zone of urethra lie on the lateral part of urethral wall. It is important to note that it is the point of urethral angulation near verumontanum. Near the origin of this transition zone, there are glands of periurethral region. These are usually confined in the preprostatic opening. According to a renowned researcher, majority of the BPH nodules are found either in transitional zone or in the periurethral zone. In terms of histopathology, the name hypertrophy of the prostate can be called as a misnomer. The condition is more of hyperplasia rather than being hypertrophy. Histological study revealed increased number of cells rather than increase in the size of the cells. Studies conducted on dogs related to thymidine uptake indicated increase in synthesis of DNA.
There are ample amount of evidences to believe that the development of benign prostatic hypertrophy needs the presence of androgens along with aging factor. The males who are usually castrated before they reach puberty or who are found to be affected by different types of genetic diseases impairing activity of the androgen are found to be less prone to develop the disease condition (McConell, 2013)
Signs & Symptoms: Some of the common symptoms of a benign hyperplastic prostate are increase in the frequency of urination, problems with initiating the stream of urinary flow, reduced strength of urinary stream or weakness of urinary slow, dribbling of urine post urination, feeling that bladder has not been completely evacuated, desire to urinate right after urinating and painful urination. Other symptoms may be nocturia or increased frequency of urination at night and sudden and sudden uncontrollable urge for urination. On examination (per rectal), an enlarged prostate can be palpated (WebMD, 2014).
Progression Trajectory: The condition progresses with symptoms being at minor severity and reaches up to its maximum level with highly enlarged prostate and much worse symptoms. According to a review published by some experts, this is a progressive disease condition defined by worsening of symptoms, deteriorated rate of urinary flow, increased prostatic volume and ultimately resulting into acute retention of urine. The condition ultimately leads to the point where surgery becomes mandatory, either as a form of treatment for acute urinary retention or for symptomatic relief. Various clinical trials have deemed renal insufficiency and repeated episodes of urinary tract infection as a marker of progression of the disease condition (Emberton et al., 2008)
Diagnostic Testing: The following tests may be required in order to confirm the diagnosis
Digital rectal examination: A per rectal digital examination, as discussed above will confirm the enlargement of the prostate through palpation.
Urine Examination: Both routine and microscopic urine examination are required to be carried out. It is important to rule out other conditions which may present with similar manifestation. A timely diagnosis can save a disease condition from progressing further and may also help in an early resolution of the disease condition.
Blood Test: A detailed blood examination can help in identifying a probable renal insufficiency. It will be helpful to identify the stage of the disease progression.
PSA or Prostate Specific Antigen Blood Test: Normally, the prostate secretes some amount of prostate specific antigen. This level increases further in cases where there is enlargement of the prostate. However, such increase may also result from other conditions like infections or surgeries. It is thus important to rule out these conditions before reaching to a final diagnosis.
Neurological Examination: A detailed neurological examination may help in diagnosing other conditions related to nervous system which may lead to similar symptoms.
Urinary Flow Test: Flow of urine is monitored with the help of a machine that determines the speed of the urinary flow.
Post voidal residual volume test: This test measures the ability of the patient to completely void his bladder. The test is an ultrasound based examination of the bladder.
24 hour voiding diary: A diary maintained regarding the output of urine over a 24 hour cycle can be helpful in determining the flow of urine over a day.
In more complicated cases, the following tests may be required:
Transrectal biopsy
Prostate biopsy
Urodynamic & Pressure flow studies
Cytoscopy
Intravenous Pyelogram or CT urogram (Mayoclinic.org, 2016)
Treatment Options: In majority of the cases where the symptoms are not severe enough to hamper the quality of life (QoL), a watchful wait can be considered as a safe option, only in cases where the day to day life of the patient is hampered as a result of his illness, a surgical approach is needed
The normal prostatic development reaches up to a level of 11 grams in males. However, in case of a benign hyperplasia, the same may reach up to higher levels. The extent to which prostatic enlargement can occur varies from person to person.
The condition leads to an immense mental trauma for the patient. The patient becomes irritable due to frequent urges to urinate especially at night. The decreased flow of urine leads to continuous dribbling of urine making it embarrassing for the patient. The patient feels demotivated and keeps himself away from the society for the fear of being insulted.
It is important to explain the patient and his family regarding the probable prognosis of the disease condition. The patient should be made well aware of all the consequences and adversities that he may come across (both emotional and physical).
An interdisciplinary approach may help in keeping the disease condition under control. A counsellor may help in combating with the psychological aspects of the disease condition. A nephrologist may on the other hand help in diagnosis renal insufficiency or any other condition which may mark the worsening of the disease condition.
A supporting family may help in comforting the patient and help him coping up with the disease more comfortably. Whereas, hesitation and embarrassment may pose as barriers in the way of treatment of the patient. He may not be comfortable talking about his condition openly, thus this may reduce the efficacy of the provided treatment.
The care plan must initiate with a thorough examination, covering the mental symptoms. Further, it should progress to emotional counselling of the patient and his family about the disease condition and the necessary aids that can be provided to keep the patient mentally well. Then we can move on to the important management steps that can prove to be helpful to the patient. The patient must be advised to avoid drinking water after 5pm. He should be asked to void his bladder as soon as he feels the urges to do so. Prostatic massages may also help in relieving the symptoms up to some extent.
References
Benign prostatic hyperplasia (BPH) Tests and diagnosis - Mayo Clinic. (2016).
`Mayoclinic.org. Retrieved 23 August 2016, from http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/tests-diagnosis/con-20030812
Benign Prostatic Hyperplasia (BPH)-Symptoms. (2014). WebMD. Retrieved 23 August 2016,
Emberton, M., Cornel, E., Bassi, P., Fourcade, R., Gómez, J., & Castro, R. (2008). Benign
prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management. International Journal Of Clinical Practice, 62(7), 1076-1086. http://dx.doi.org/10.1111/j.1742-1241.2008.01785.x
McConell, J. (2013). The Pathophysiology of Benign Prostatic Hyperplasia. Journal Of
Andrology, 12(6). Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/j.1939-4640.1991.tb00272.x/abstract
