ABSTRACT

Corresponding Author:
Dr. Abhilash Singh,
D-333, Second Floor,
Anand Vihar,
East Delhi-110092,
Delhi, India.
E-mail: drabhilashsingh03@gmail.com

ABSTRACT

AIMS AND OBJECTIVES

To study the incidence of Benign Prostatic Hyperplasia (BPH) in reference to age of the patients, to study the common symptoms and signs of BPH and classify on the basis of American Urological Association Symptoms Score (AUASS), to evaluate the role of various investigations, to study the relation of weight/volume and size of prostate, and to grade the prostate on the basis of AUASS.

MATERIAL AND METHODS

Total 138 patients with symptoms of BPH were selected and detailed history was elicited with special reference to AUASS, according to which BPH was graded, investigated properly, and managed accordingly.

RESULTS

Overall incidence of BPH out of total patients admitted (8562) in surgical wards during period of one year was found 1.61%. Majority of the patients were in the age group 61-70 years and average age in present study was 67.8 years. According to AUASS, most of the patients (62.32%) had moderate grade symptoms (Score 8-19) followed by patients (37.68%) had severe symptoms (Score 20-35). On digital rectal examination, 73.18% of the patients had grade II prostate, 14.42% had grade III, and grade I in 12.31%. The blood urea and serum creatinine levels were normal in majority of the patients, 62.77% and 58.69% respectively. On USG prostate, most of the patients (65.81%) had prostatic weight in range of 41-60 grams and majority of the patients (47.22%) had PVR volume of urine ranging between 101-200 mL. Weight of prostatic specimen on prostatectomy showed that most of the patients (64.86%) had prostatic weight in range of 41-60 grams. On histopathological examination of prostatectomy samples, it was found that 91.90% of specimens showed BPH and rest 8.10% were suggestive for carcinoma prostate.

CONCLUSION

BPH is a condition intimately related to ageing, which needs treatment when symptoms are bothersome and reduces the quality of life. Patients with mild-to-moderate enlargement of the prostate in 5^th and 6^th decade of life often respond to watchful waiting and medical treatment. Patients presenting with acute or chronic retention with or without haematuria finally needs surgical intervention.

KEYWORDS

Benign Prostatic Hyperplasia, Prostate, American Urological Association, AUASS, IPSS, Lower Urinary Tract Symptoms.

INTRODUCTION

Senile enlargement of the prostate or BPH is an ancient and universal ailment of the ageing population. This geriatric problem is a very distressing and disabling disease and should be properly managed keeping in view the already waning physical reserve of the patient. The causes of BPH are not fully known, but the overgrowth of smooth muscle tissue and glandular epithelial tissue is attributed to a number of different causes such as ageing, late activation of cell growth, genetic factors, and hormonal causes.¹ The prostate is a walnut-sized gland made of two lobes or regions enclosed by an outer layer of tissue, which surrounds the urethra, the canal

DISCUSSION

BPH is a well-known condition characterised by prostatic growth accompanied by LUTS.² Prostatic enlargement happens to almost all men as they get older, but only 10% are likely to need a surgeon. Urinary discomfort amounting from simple frequency to acute retention and uraemia in old people are recognised since long due to of prostate gland.^5,12

Incidence of BPH

BPH is the most common benign tumour in men and its incidence is age related.¹³ A recent AUA guidelines (2003) suggests an increase in the incidence of BPH worldwide and predicts by the age of 60 years more than 50% of men will have microscopic evidence of the disease and by the age of 85 years as many as 90% of men will be affected.^4,14 and nearly all men develop microscopic BPH by the age of 90 years.¹⁵

Age Incidence

The average age of patients in present study was 67.8 years. The youngest patient was of 45 years old and oldest was of 95 years. Although, BPH is uncommon before age 40, roughly 50% of men develop BPH related symptoms at 50 years of age. The incidence of BPH increases by 10% per decade and reaches 80% at approximately 80 years of age.^16,17 The estimated prevalence is 25% in men aged 40 to 79 years.¹⁸ The slightly higher age incidence in western countries may be attributed to the longer life span of their population.⁴

Presenting Complaints

BPH clinically manifest as LUTS consisting of irritative symptoms (hesitancy, a weak and interrupted urinary stream, straining to initiate urination, a sensation of incomplete bladder emptying).¹ It has been classically stated that from 25 to 50% of individuals with microscopic and macroscopic evidence of BPH will progress to clinical BPH.¹⁹ In the present series, major complaints of BPH were increased frequency of micturition, urgency, nocturia, urge incontinence, enuresis, burning micturition, pyuria, haematuria, hesitancy, poor stream, dribbling, sense of incomplete emptying, intermittency, chronic and acute retention of urine. Among these, nocturia, straining, increased frequency, and micturition was present in 100% of cases. Prolonged obstruction may eventually lead to acute urinary retention (AUR), recurrent urinary tract infection, haematuria, bladder calculi, and renal insufficiency.²⁰

AUA Grading

The prevalence of urinary symptom associated with BPH was studied in community-based nationwide sample of 2011 Frenchmen 50-80 years old, symptoms was assessed by AUA index. After exclusion of prostatic cancer, 6.5% of subject reported having undergone prostate surgery. Nocturia and repeated voiding within 2 hours were the most prevalent symptoms in 67% and 13% and respective ranked between 1 and 7, 8 and 19, and 20 or more.^4,6

It is evident from above table that in western countries more number of the patients presents early for health assistance than our region and it proves that the patients in this region do not seek medical advice unless in dire emergency. In present study, about 61.85% patients were presented with retention of urine.

DRE done in all patients to estimate the approximate size of prostate gland and screening for carcinoma prostate. Prostatic size does not correlate with symptom severing, degree of obstruction, or treatment outcome significantly.^5,7 In present study, all the patient were found to have enlarged prostate and most of the patients i.e., 73.18% scored grade II followed by Grade III in 14.42% and grade I in 12.31% that means patients present in our setup on later stage of disease.

Investigations

In present study, average preoperative haemoglobin was 11.4 gm% ranging from 7.2-16 gm%. This clearly denotes the moderate anaemia and need for blood transfusion in higher percent of cases undergone for operative procedures. Blood urea and serum creatinine levels estimation gives an idea of the renal functions in case with enlarged prostate and which was found to be raised in some patients due to BPH or other associated diseases. In present series, the values are slightly higher than those reported by other workers possibly because majority of the cases came with retention of urine of long duration. Patients of BPH or LUTS are more prone to develop vesical calculus possibly because of chronic retention/stasis of urine.¹⁴

USG Abdomen and Prostate: 1. Prostatic Weight: In present series, it was noted that most of the patients (65.81%) had prostatic weight in range of 41-60 grams and belongs to moderate AUASS group. Next most common group (15.38%) was of patients having 20-40 grams prostate. It shows that most of the patients present in later stage of disease. It is also important to mention here that the most of the patients who presented with complaints of BPH had moderate grade on AUASS System in present series and as the size of prostate increases with age, severity of symptoms shifted towards moderate-to-severe grades. 2. Post-Void Residual volume: In present study, on USG examination, most of the patients (47.22%) had PVR volume of urine ranging between 101-200 mL, next most common group (16.66%) belongs to range of 201-300 mL. Studies indicate that residual urine normally ranges from 0.09 to 2.24 mL with mean being 0.53 mL, 78% of normal men have PVR volume less than 5 mL, and 100% have volumes of less than 12 mL. Residual urine volume does not correlate well with other signs of symptoms of prostatism.⁶

Prostatic carcinoma is more common in India compared to other Asian Countries.²¹ Incidence of prostatic cancer increases rapidly with age than any other cancer. Thus, the numbers of prostate cancer cases are expected to increase as average age of men is increasing.²²

SUMMARY AND CONCLUSION

BPH is a condition intimately related to ageing. Although, it is not life threatening, its clinical manifestation, LUTS reduces the patient’s quality of life. BPH needs treatment when symptoms are bothersome and reduces the quality of life. Treatment offered to patients was watchful waiting with medical treatment (Drugs) or surgical treatment. Patient with mild-to-moderate enlargement of the prostate in 5^th and 6^th decade of life often respond to watchful waiting and medical treatment. Drugs like alpha-receptor antagonist and 5-alpha reductase inhibitor has inconstant results with definite symptomatic improvement, which may not correspond to investigatory results. Patients presenting with acute or chronic retention with or without haematuria finally needs surgical intervention. TURP remains gold standard treatment, yet many centres offers open prostatectomy as one-stage or two-stage procedures.

ACKNOWLEDGMENT

We are very much thankful to the Prof. Dr. G. P. Shrivastava, Ex H.O.D., Department of Surgery, Govt. Shyam Shah Medical College and associated S.G. Memorial Hospital, Rewa, Madhya Pradesh, India, for providing us the opportunity to study the cases and also encouraging us to report the study.

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