CASE REPORT

Benign Prostate HyperplasiaDevyana Enggar1, Marta Hendry21Clinical Senior Clerkship, School of Medicine, Medical Faculty of Sriwijaya University, Dr. Mohammad Hoesin General Hospital, Palembang

2Department of Urology, School of Medicine, Medical Faculty of SriwijayaUniversity, Dr. Mohammad Hoesin General Hospital, Palembang

Background: Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate When sufficiently large, the nodules impinge on theurethraand increase resistance to flow ofurinefrom the bladder. This is commonly referred to as "obstruction," although the urethral lumen is no less patent, only compressed. Resistance to urine flow requires the bladder to work harder during voiding, possibly leading to progressive hypertrophy, instability, or weakness (atony) of the bladder muscle. Althoughprostate specific antigen levels may be elevated in these patients because of increased organ volume andinflammationdue to urinary tract infections, BPH does not lead to cancer or increase the risk of cancer. An estimated 50% of men havehistologicevidence of BPH by age 50 years and 75% by age 80 years; in 4050% of these men, BPH becomes clinically significant. Clinical Presentation: A 65-year-old male patient came to polyclinic of urology of Muhammad Hoesin General Hospital in Palembang with chief complain of unable to urinate. From the history of current illness, the patient complain disjoined urination accompanied by a feeling unsatisfied after urinating since 2 years ago, and 1 year ago the patient unable to urinate. The patient also woke up at night for urinate. There is no abnormality in defecation or fever, nausea, and vomiting. From rectal examination, there was an enlarged prostate. Laboratory findings show slight increase in ureum and creatinine. From USG examination of this patient showed sign of enlargement of prostateDiscussion: disjoined urination that accompanied by feeling unsatisfied after urination may cause by the enlargement of the prostate. From the anamnesis, there are some problems in lower urinary tract. The urinary retention confirmed by USG. The USG showed there is enlargement at the prostate.Conclusion: The prevalence of BPH is increase with age and occur in man. The BPH caused by changes in hormone balance and in cell growth. It can be treated by medication or surgery.Keywords: prostate, BPH Background

Prostate is a compound tubulo-alveolarexocrine glandof themale reproductive system. A healthyhuman male prostate is classically said to be slightly larger than awalnut. The mean weight of the normal prostate in adult males is about 20grams. It surrounds the urethrajust below theurinary bladderand can be felt during arectal exam. The prostate can be divided in two ways: by zone (peripheral zone, central zone, transition zone, anterior fibro muscular zone) or by lobe (anterior lobe, posterior lobe, lateral lobe, median lobe). Benign prostatic hyperplasia(BPH) is an enlarged prostate gland. The prostate gland surrounds the urethra, the tube that carries urine from the bladder out of the body. As the prostate gets bigger, it may squeeze or partly block the urethra. BPH closely related to the increase of dihydro-testosterone and aging. Several hypotheses are suspected as the cause of prostate hyperplasia are: 1) DHT (dihydro- testosterone) production. In the prostate gland, type II 5 alpha - reductase metabolizes circulating testosterone into DHT, which works locally, not systemically. DHT binds to androgen receptors in the cell nuclei, potentially resulting in BPH. 2) Imbalance between estrogen-testosterone. In the older age, testosterone levels are decrease, while estrogen levels are relatively fixed, so the comparison between estrogen and testosterone relative increase. 3) Stromal-epithelial interactions. After stimulation of stromal cells DHT and estradiol, stromal cells synthesize a growth factor that in turn affects the stromal cells themselves, which led to the proliferation of epithelial cells and stromal. 4) Reduction in apoptosis prostate cell. Decreasing in the number of apoptosis prostate cells cause the number of prostate cells as a whole increasing, resulting in prostate mass accretion. 5) stem cell theory. In the prostate gland that known as a stem cell. The cells that have the ability to proliferate very extensively. Life of these cells depend on androgen hormones, which, if the level is decreased (eg castration), causing apoptosis. So that the proliferation of cells in BPH alleged inaccuracies stem cell activity resulting in excessive production of stromal cells and epithelial cells. BPH is a common problem that affects the quality of life in approximately one third of men older than 50 years. BPH is histologically evident in up to 90% of men by age 85 years. The enlargement of the prostate causing the narrowing luminal prostatic urethra and impede the flow of urine the causing high intravesical pressure. To be able to secrete the urine, bladder have to contract more strongly to resist the obstruction, causing change in bladder anatomic, such as: detrusor muscle hypertrophy, trabeculation, selula formation, sakula and bladder diverticula. The change at the structure of the bladder is perceived as a complaint in the lower urinary tract. High intravesical pressure transmitted to all parts of the bladder, there is no exception to the estuary of the ureter. Pressure on the estuary of the ureter raises the backflow from the bladder into the ureters or vesicoureteric reflux. If continued would lead to hydroueter, hydronephrosis even renal failure.

Clinical manifestations of LUTS consists of symptoms of obstruction and irritative symptoms. Obstruction symptoms include: hesitancy, decreased or intermittent force of urinary stream, intermittency, a sensation of incomplete emptying, dripping after urination. While the irritating symptoms consist of: frequency, nocturia (awakening at night to urinate), urgency and dysuria. Complications occur less commonly but may include acute urinary retention (AUR), impaired bladder emptying, the need for corrective surgery, renal failure, recurrent urinary tract infections, bladder stones, or gross hematuria. TheInternational Prostate Symptom Score (IPSS)is an 8 question (7 symptom questions + 1 quality of life question) written screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of the disease benign prostatic hyperplasia(BPH). The seven symptoms questions includefeeling of incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining andnocturia, each referring to during the last month, and each involving assignment of a score from 1 to 5 for a total of maximum 35 points.On physical examination maybe obtain bladder full and palpable cystic mass in the supra symphysis area due to urinary retention. Rectal toucher or Digital Rectal Examination (DRE) is the most important examination for BPH, because we can assess anal sphincter tone, enlargement or prostate size and suspicion of malignancy such as nodules or hard palpability. In this examination assessed the magnitude of the prostate, consistency, central basin, symmetry, induration, crepitus, and presence or absence of nodules. DRE in BPH showed chewy consistency, such as touching the tip of the nose, right and left lobes symmetric, and there is no nodule. Whereas in prostate carcinoma, prostate consistency hard and palpable nodules, and may be not symmetry between the prostate lobes. Examination of urine culture is useful for looking for any kind of germs that cause infections and also to determine the sensitivity of bacteria to multiple antimicrobials tested. Urine cytology is used for histopathological examination urothelium cells are separated and entrained urine. Blood sugar tests to detect diabetes mellitus which can cause abnormalities in the bladder innervation. Abdominal plain radiography is useful to search for opaque stones in the urinary tract, stone / kalkulosa prostate or show shadow bladder filled up with urine, which is a sign of urinary retention. Intravenous Pyelogram (IVP) account for the: 1) kidney disorders or ureter (hydroureter or hydronephrosis), 2) estimate the size of the prostate gland which is indicated by indenting the prostate (displacement bladder by the prostate gland) or ureter distal portion that is shaped like a hook (hooked fish), 3) complications that occur in the bladder such as: trabeculation, diverticular or bladder saculation. IVP examination is no longer recommended for BPH, Ultrasound examination transrectal ultrasound (TRUS), used to determine major and prostate volume, the possibility of malignant prostate enlargement as a hint to perform aspiration biopsy of the prostate, determining the amount of residual urine and look for other abnormalities in the bladder.The goal of therapy: 1) fix micturition complaints, 2) improving the quality of life, 3) reduce obstruction infravesica, 4) restore kidney function, 5) reducing the volume of residual urine after micturition, 6) preventing disease progressives. First we can used medicine, the goal therapy are reducing the resistance of the prostate smooth muscle -adrenergic blocker and reduces prostate volume by lowering testosterone levels via 5- reductase inhibitors. We also can do the operation treatment, the indication for the surgery such as: 1) the patient do not show ant changes after medical treatment, 2) experiencing urinary retention, 3) urinary tract infection repeated, 4) hematuria, 5) kidney failure disease, 6) the incidence of urinary tract stones or other complications as a result of lower urinary tract obstruction. The type of surgery that we can use: 1) open prostatectomy, the most invasive and is recommended for very large prostate ( 100gr), 2) endourology surgery. This operation can be either resection (Trans Urethral Resection of the Prostate / TURP), incision (Trans Urethral Incision of the Prostate / TUIP), or evaporation. In addition to invasive measures mentioned above, now developed minimally invasive procedure, which has an especially high risk for surgery, such actions include: thermotherapy, Trans Urethral Needle Ablation of the Prostate (TUNA), stenting, High Intensity Focused Ultrasound (HIFU) as well as with balloon dilatation (Transurethral Balloon dilatation / TUBD).

Clinical presentation

Chief complain unable to urinateRecent History

2 years before admission, patient complained disjoined urination accompanied with sensation incomplete emptying bladder urination. The patient frequently urinate about half the time, strain to start urination, feeling pain while urinating (-), change of urine color (-), stone or sand found while urinating (-), colic pain (-), the urinary stream weak when urinating. The defecation is normal and there is no fever, nausea, or vomitting. The history of herniorraphy operation in 2013. Since then he used the catheter to urinate. All of the physical examination was considered normal. From rectal toucher was found that prostate enlargement. Laboratory examination show normal limit for routine blood. Except for ureum (51) and the creatinine (2.61) that a little higher than normal value. From the USG examination showed there is no stone and mass at the bladder, doesnt showed radio opaque stones in the kidney and the prostate enlargement 47.6mm x 43.8mm x 45.9mm, doesnt seem the lesion.

Figure 1. BNO

Figure 2. USG-TUGThis patient was diagnosed with Benign Prostate Hyperplasia (BPH). The treatment for this case is with TURP. Prognosis for this patient, quo ad vitam is bonam and quo ad functionam is bonam. Discussion

From the anamnesis, Mr. Suripto, 64 years old, patient complained disjoined urination accompanied with sensation incomplete emptying bladder urination. The patient frequently urinate about half the time, strain to start urination, feeling pain while urinating (-), change of urine color (-), stone or sand found while urinating (-), colic pain (-), the urinary stream weak when urinating. The defecation is normal and there is no fever, nausea, or vomitting. The history of herniorraphy operation in 2013, history of trauma (-), DM (-), hypertension (-). Since then he used the catheter to urinate. According to physical examination, the vital sign was within normal limit. From the rectal examination, was found that rectal mucosa was smooth, TSA was good, chewy consistency, no pain, and palpable prostate enlargement. There is no bulging or tenderness in suprapubic region show there is no urine retention. From the additional examination, the laboratory examination, both routine blood and clinical chemistry show normal value except there is a slight increase in except the ureum (51) and the creatinine (2.61). From the radiology examination, BNO examination doesnt showed radio opaque stones in the kidney and the USG From the anamnesis, physical examination, and additional examination, the patient is diagnosed with retentio urine caused by benign prostate hyperplasia.

The prognosis for this patient, in term vitam is bonam, and in term of functionam is bonam.ConclusionBPH involves hyperplasia of prostatic stromalandepithelialcells, resulting in the formation of large, fairly discrete nodules in the transition zone of the prostate. This is commonly referred to as "obstruction," although the urethral lumen is no less patent, only compressed. Resistance to urine flow requires the bladder to work harder during voiding, possibly leading to progressive hypertrophy, instability, or weakness (atony) of the bladder muscle. An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years; in 4050% of these men, BPH becomes clinically significant. The BPH can be removed from with medicine, solved by open prostatectomy and endourology surgery (resection-Trans Urethral Resection of the Prostate / TURP), incision-Trans Urethral Incision of the Prostate / TUIP), or evaporation). References1. Purnomo, Basuki B. 2011. Dasar-Dasar Urologi Edisi ketiga. Malang: Seto Agung.2. Purnomo BB. 2012. Dasar-Dasar Urologi. Edisi Ketiga. Jakarta: CV. Agung Seto3. Purnomo, Basuki. 2003. Dasar-dasar Urologi SMF/Lab Ilmi Bedah. RSUP. 4. Tanagho, Emil A dan Jack W. McAninch.2008. Smiths Generat Urology. 17th Edition. McGraw-Hill Companies: New York

5. Benign Prostat Hyperplasia. www.google.com. Last Updated : 10 february 2015

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