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Prostate gland enlargement

Definition
By Mayo Clinic staff Prostate gland enlargement is a common condition as men get older. Also called benign prostatic hyperplasia (BPH) and prostatic hypertrophy, prostate gland enlargement can cause bothersome urinary symptoms. Untreated prostate gland enlargement can block the flow of urine out of the bladder and can cause bladder, urinary tract or kidney problems. There are several effective treatments for prostate gland enlargement. In deciding the best option for you, you and your doctor will consider your particular symptoms, the size of your prostate, other health problems you may have and your preferences. Your choices may also depend on what treatments are available in your area. Treatments for prostate gland enlargement include medications, lifestyle changes and surgery.

Symptoms
By Mayo Clinic staff Prostate gland enlargement varies in severity among men and tends to gradually worsen over time. Prostate gland enlargement symptoms include: Weak urine stream Difficulty starting urination Stopping and starting while urinating Dribbling at the end of urination Frequent or urgent need to urinate Increased frequency of urination at night (nocturia) Straining while urinating Not being able to completely empty the bladder Urinary tract infection Formation of stones in the bladder

Reduced kidney function The size of your prostate doesn't necessarily mean your symptoms will be worse. Some men with only slightly enlarged prostates have significant symptoms. On the other hand, some men with very enlarged prostates have only minor urinary symptoms. Only about half the men with prostate gland enlargement have symptoms that become noticeable or bothersome enough for them to seek medical treatment. In some men, symptoms eventually stabilize and may even improve over time. When to see a doctor If you're having urinary problems, see your doctor to check whether your symptoms are caused by an enlarged prostate and find out what tests or treatment you may need. If you're unable to pass urine at all, seek immediate medical attention. If you don't find urinary symptoms too bothersome and they don't pose a health threat, you may not need treatment. But you should still have your symptoms checked out by a doctor to make sure they aren't caused by another problem such as prostate cancer.

Causes
By Mayo Clinic staff

Comparing normal and enlarged prostate glands

The prostate gland is the male organ that produces most of the fluid in semen, the milky-colored fluid that nourishes and transports sperm out of the penis during ejaculation (orgasm). It sits beneath your bladder. The tube that transports urine from the bladder out of your penis (urethra) passes through the center of the prostate. So, when the prostate enlarges, it begins to block (obstruct) urine flow. Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow. Doctors aren't sure exactly what causes the prostate to enlarge. It may be due to changes in the balance of sex hormones as men grow older.

Risk factors
By Mayo Clinic staff The main risk factors for prostate gland enlargement include:

Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than 40. By 55, about 1 in 4 men have some signs and symptoms. By 75, about half of men report some symptoms.

Family history. Having a blood relative such as a father or brother with prostate problems means you're more likely to have problems as well.

Where you're from. Prostate enlargement is more common in American and Australian men. It's less common in Chinese, Indian and Japanese men.

Complications
By Mayo Clinic staff Prostate gland enlargement becomes a serious problem when it severely interferes with your ability to empty your bladder. If this is the case, you'll probably need surgery. Complications of enlarged prostate include: Acute urinary retention. Acute urinary retention is a sudden, painful inability to urinate. This may occur after you've taken an over-the-counter decongestant medication for allergies or a cold. When you are unable to urinate at all, your doctor may thread a tube (catheter) through your urethra into your bladder. Or, your doctor may put in a suprapubic tube a catheter that drains your bladder through the lower abdomen. The type of catheter you need will depend on your particular circumstances. Some men with an enlarged prostate require surgery or other procedures to relieve urinary retention. Urinary tract infections (UTIs). Some men with an enlarged prostate end up having surgery to remove part of the prostate to prevent frequent urinary tract infections. Bladder stones. These are mineral deposits that can cause infection, bladder irritation, blood in the urine and obstruction of urine flow and are generally caused by the inability to completely empty the bladder. Bladder damage. This occurs when the bladder hasn't emptied completely over a long period of time. The muscular wall of the bladder stretches and weakens and no longer contracts properly. Often, symptoms of bladder damage improve after prostate surgery or other treatment, but not always. Kidney damage. This is caused by high pressure in the bladder due to urinary retention. This high pressure can directly damage the kidneys or allow bladder infections to reach the kidneys. When an enlarged prostate causes obstruction of the kidneys, a condition called hydronephrosis a swelling of the urine-collecting structures in one or both kidneys may result. Most men with an enlarged prostate don't develop these complications. However, acute urinary retention and kidney damage in particular can be serious health threats when they do occur.

Preparing for your appointment

By Mayo Clinic staff You're likely to start by seeing your primary care doctor for urinary symptoms caused by an enlarged prostate. However, in some cases when you call to set up an appointment, you may be referred directly to a doctor who specializes in urinary issues (urologist). Because appointments can be brief, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and know what to expect from your doctor. What you can do Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. Keep track of how often and when you urinate, how much liquid you drink, and if you feel you're completely emptying the bladder when you urinate. Bring a list of all medications, vitamins or supplements that you're taking. Bring a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot. Know what tests and treatments you've had for enlarged prostate or urinary problems. For example, if you've had infections, how often have you had them and what medications worked in the past? Bring your prostate-specific antigen (PSA) test results if you've ever had your PSA checked. Write down questions to ask your doctor. Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. For an enlarged prostate evaluation, some basic questions to ask your doctor include: Is an enlarged prostate or something else likely causing my symptoms? Other than the most likely cause, what are other possible causes for my symptoms? What tests do I need? Are there risks to any of these tests? What are my treatment options? What are the risks with each type of treatment?

What are the alternatives to the primary approach that you're suggesting? I have these other health conditions. How can I best manage these conditions together? Are there any restrictions on sexual activity that I need to follow? Do I need to see a urologist? Is there a generic alternative to the medicine you're prescribing me? Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting? In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask any additional questions that come up during your appointment. What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

When did you first begin noticing urinary symptoms? Have your urinary symptoms been continuous, or occasional? Have your symptoms gradually worsened over time, or did they come on suddenly? How bothersome are your symptoms? How often do you urinate during the day? How often do you need to get up at night to urinate? Do you start and stop when urinating, or feel like you have to strain to urinate? Is it difficult for you to begin urinating? Have you ever leaked urine? If so, when? Do you have a frequent or urgent need to urinate? Does it ever feel like you haven't completely emptied your bladder? Do you ever have blood in your urine? Have you had urinary tract infections? Is there any burning when you urinate? How do you know when you have a urinary tract infection? Do you have type 2 diabetes?

Have you ever had any trouble getting and maintaining an erection (erectile dysfunction), or other sexual problems?

Do you feel pain in your bladder area? Have you ever had surgery or another procedure that involved insertion of an instrument through the tip of your penis into your urethra?

Do any of your blood relatives (such as your father or brother) have a history of enlarged prostate, or prostate cancer, or kidney stones?

What medications do you take, including any over-the-counter medications or herbal remedies? Are you on any blood thinners such as aspirin, warfarin (Coumadin) or clopidogrel (Plavix)?

Tests and diagnosis

By Mayo Clinic staff An initial evaluation for enlarged prostate will likely include: Detailed questions about your symptoms. Your doctor will want to know about other health problems you may have, what medications you're taking and whether there's a history of prostate problems in your family. Your doctor may have you complete a questionnaire such as the American Urological Association (AUA) Symptom Index for BPH. Digital rectal exam. This exam can allow your doctor to check your prostate by inserting a finger into your rectum. With this simple test, your doctor can determine whether your prostate is enlarged and check for signs of prostate cancer. Neurological exam. This is a brief evaluation of your mental functioning and nervous system. It can help identify causes of urinary problems other than enlarged prostate. What this exam involves will depend on your specific condition. Urine test (urinalysis). Analyzing a sample of your urine in the laboratory can help rule out an infection or other conditions that can cause similar symptoms. Your doctor may use additional tests to rule out other problems and help confirm enlarged prostate is causing your urinary symptoms. These can include: Prostate-specific antigen (PSA) blood test. It's normal for your prostate gland to produce PSA, which helps liquefy semen. When you have an enlarged prostate, PSA levels increase. However, PSA levels can also be elevated due to prostate cancer, recent tests, surgery or infection (prostatitis).

Urinary flow test. This test measures the strength and amount of your urine flow. You urinate into a receptacle attached to a special machine. The results of this test over time help determine if your condition is getting better or worse.

Postvoid residual volume test. This test measures whether you can empty your bladder completely. This is often done by using an ultrasound test to measure urine left in your bladder. Or, it may be done by inserting a tube (catheter) into your bladder after you urinate.

Transrectal ultrasound. An ultrasound test provides measurements of your prostate and also reveals the particular anatomy of your prostate. With this procedure, an ultrasound probe about the size and shape of a large cigar is inserted into your rectum. Ultrasound waves bouncing off your prostate create an image of your prostate gland.

Prostate biopsy. With this procedure, a transrectal ultrasound guides needles used to take tissue samples of the prostate. Examining tissues from a biopsy under a microscope can be help diagnose or rule out prostate cancer.

Urodynamic studies and pressure flow studies. With these procedures, a catheter is threaded through your urethra into your bladder. Water (or less commonly air) is slowly injected into your bladder. This allows your doctor to measure bladder pressures and to determine how well your bladder muscles are working.

Cystoscopy. Also called urethrocystoscopy, this procedure allows your doctor to see inside your urethra and bladder. After you receive a local anesthetic, a lighted flexible telescope (cystoscope) is inserted into your urethra to look for signs of problems.

Intravenous pyelogram or CT urogram. These tests can help detect urinary tract stones, tumors or blockages above the bladder. First, dye is injected into a vein, and X-rays or CT scans are taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters). The dye helps outline the drainage systems of the kidneys. Other possible causes of urinary symptoms Your doctor will use these tests to make sure there isn't something else causing your problem, or if an enlarged prostate has caused or worsened another problem. Problems that can cause urinary symptoms similar to those caused by enlarged prostate include:

Bladder stones Bladder and urinary tract infections Diabetes Neurological problems Inflammation of the prostate (prostatitis)

Prostate cancer Stroke Muscle and nerve (neuromuscular) disorders Scarring or narrowing of the urethra Prostate cancer is entirely different than prostate gland enlargement, even though they can cause some similar symptoms and may be detected by some of the same tests. Having an enlarged prostate doesn't reduce or increase the risk of prostate cancer. Even if you're being treated for an enlarged prostate gland, you still need to continue regular prostate exams to screen for cancer. Surgery for prostate gland enlargement may identify cancer in its early stages.

Treatments and drugs

By Mayo Clinic staff A wide variety of treatments are available for enlarged prostate. They include medications, surgery and minimally invasive surgery. The best treatment choice for you depends on several factors, including how much your symptoms bother you, the size of your prostate, other health conditions you may have, your age and your preference. If your symptoms aren't too bad, you may decide not to have treatment and wait to see whether your symptoms become more bothersome over time. Medications Medications are the most common treatment for moderate symptoms of prostate enlargement. Medications used to relieve symptoms of enlarged prostate include: Alpha blockers. These medications relax bladder neck muscles and muscle fibers in the prostate itself and make it easier to urinate. These medications include terazosin, doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral) and silodosin (Rapaflo). Alpha blockers work quickly. Within a day or two, you'll probably have increased urinary flow and need to urinate less often. These may cause a harmless condition called retrograde ejaculation semen going back into the bladder rather than out the tip of the penis. 5 alpha reductase inhibitors. These medications shrink your prostate by preventing hormonal changes that cause prostate growth. They include finasteride (Proscar) and dutasteride (Avodart). They generally work best for very enlarged prostates. It may be several weeks or even months before you notice improvement. While you're taking them, these medications may cause sexual side effects including impotence (erectile dysfunction), decreased sexual desire or retrograde ejaculation. Combination drug therapy. Taking an alpha blocker and a 5 alpha reductase inhibitor at the same time is generally more effective than taking just one or the other by itself.

Tadalafil (Cialis). This medication, from a class of drugs called phosphodiesterase inhibitors, is often used to treat impotence (erectile dysfunction). It also can be used as a treatment for prostate enlargement. Tadalafil can't be used in combination with alpha blockers. It also can't be taken with medications called nitrates, such as nitroglycerin. Surgery Your doctor may recommend surgery if medication isn't effective or if you have severe symptoms. There are several types of surgery for an enlarged prostate. They all reduce the size of the prostate gland and open the urethra by treating the enlarged prostate tissue that blocks the flow of urine. The decision about which type of surgery may be an option is based on a number of factors, including the size of your prostate, the severity of your symptoms, and what treatments are available in your area. Any type of prostate surgery can cause side effects, such as semen flowing backward into the bladder instead of out through the penis during ejaculation (retrograde ejaculation), loss of bladder control (incontinence) and impotence (erectile dysfunction). Ask your doctor about the specific risks of each treatment you're considering. Standard surgeries Standard surgeries for an enlarged prostate include: Transurethral resection of the prostate (TURP) TURP has been a common procedure for enlarged prostate for many years, and it is the surgery with which other treatments are compared. With TURP, a surgeon places a special lighted scope (resectoscope) into your urethra and uses small cutting tools to remove all but the outer part of the prostate (prostate resection). TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. Following TURP, there is risk of bleeding and infection, and you may temporarily require a catheter to drain your bladder after the procedure. You'll be able to do only light activity until you're healed. Transurethral incision of the prostate (TUIP or TIP) This surgery is an option if you have a moderately enlarged or small prostate gland, especially if you have health problems that make other surgeries too risky. Like TURP, TUIP involves special instruments that are inserted through the urethra. But instead of removing prostate tissue, the surgeon makes one or two small cuts in the prostate gland to open up a channel in the urethra making it easier for urine to pass through. Open prostatectomy This type of surgery is generally done if you have a very large prostate, bladder damage or other complicating factors, such as bladder stones. It's called open because the surgeon makes an incision in your lower abdomen to reach the prostate. Open prostatectomy is the most effective treatment for

men with severe prostate enlargement, but it has a high risk of side effects and complications. It generally requires a short stay in the hospital and is associated with a higher risk of needing a blood transfusion. Minimally invasive surgery Minimally invasive treatments are less likely to cause blood loss during surgery and require a shorter, if any, hospital stay. These treatments also typically require less pain medication. Depending on the procedure and how well it works for you you may need follow-up treatments. Minimally invasive treatments include: Laser surgery Laser surgeries (also called laser therapies) use high-energy lasers to destroy or remove overgrown prostate tissue. Laser surgeries generally relieve symptoms right away and have a lower risk of side effects than does TURP. Some laser surgeries can be used in men who shouldn't have other prostate procedures because they take blood-thinning medications. Laser surgery can be done with different types of lasers and in different ways. Ablative procedures (including vaporization) remove prostate tissue pressing on the urethra by burning it away, easing urine flow. Ablative procedures may cause irritating urinary symptoms after surgery and may need to be repeated at some point. Enucleative procedures are similar to open prostatectomy, but with fewer risks. These procedures generally remove all the prostate tissue blocking urine flow and prevent regrowth of tissue. One benefit of enucleative procedures over ablative procedures is that removed prostate tissue can be examined for prostate cancer and other conditions. Types of laser surgery include: Holmium laser ablation of the prostate (HoLAP) Visual laser ablation of the prostate (VLAP) Holmium laser enucleation of the prostate (HoLEP) Photoselective vaporization of the prostate (PVP) Options for laser therapy depend on prostate size, the location of the overgrown areas, your doctor's recommendation and your preferences. Choices available also depend on where you seek treatment. Not all facilities have lasers to perform prostate surgery or doctors who have the specialized skills and training to do the procedures.

Transurethral microwave thermotherapy (TUMT) With this procedure, your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode generates heat and destroys the inner portion of the enlarged prostate gland causing it to shrink and ease urine flow. This surgery has a lower risk of complications than does TURP, but is generally only used on small prostates in special circumstances, because re-treatment may be necessary. Transurethral needle ablation (TUNA) With this outpatient procedure, a lighted scope (cystoscope) is passed into your urethra. Your doctor uses the scope to place needles into your prostate gland. When the needles are in place, radio waves pass through them, heating and destroying excess prostate tissue that's blocking urine flow. TUNA basically scars the prostate tissue, which causes it to shrink and open up, easing urine flow. This type of surgery may be a good choice if you bleed easily or you have certain other health problems. Like TUMT, TUNA may only partially relieve your symptoms and it may take some time before you notice results. The risk of erectile dysfunction with the procedure is very low. Prostatic stents A prostatic stent is a tiny metal or plastic device that's inserted into your urethra to keep it open. Tissue grows over the metallic stent to hold it in place. The plastic stent needs to be changed every four to six weeks but keeps you from having to undergo any surgical procedure. In most cases, doctors don't consider stents a viable long-term treatment because they can cause side effects including painful urination or frequent urinary tract infections. The metal stents can be difficult to remove and are used only in special circumstances, such as for someone who can't have surgery. Sometimes, plastic stents may be used temporarily before surgery to make sure you'll be able to urinate after your surgery.

Lifestyle and home remedies

By Mayo Clinic staff Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Try these measures: Limit beverages in the evening. Don't drink anything for an hour or two before bedtime to help you avoid wake-up trips to the bathroom at night. Don't drink too much caffeine or alcohol. These can increase urine production, irritate your bladder and worsen your symptoms. If you take water pills (diuretics), talk to your doctor. Maybe a lower dose, taking them only in the morning, or a milder diuretic or change in the time you take your medication will help ease urinary symptoms. Don't stop taking diuretics without first talking to your doctor.

Limit decongestants or antihistamines. These drugs tighten the band of muscles around your urethra that control urine flow, which makes it harder to urinate.

Go when you feel the urge. Try to urinate when you first feel the urge. Waiting too long to urinate may overstretch the bladder muscle and cause damage.

Schedule bathroom visits. Try to urinate at regular times to "retrain" the bladder. This can be done every four to six hours during the day and can be especially useful if you have severe frequency and urgency.

Stay active. Inactivity causes you to retain urine. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.

Urinate and then urinate again a few moments later. This is known as double voiding. Keep warm. Colder temperatures can cause urine retention and increase your urgency to urinate.

Alternative medicine
By Mayo Clinic staff Studies on alternative therapy for an enlarged prostate have had mixed results. Sometimes these treatments appear to help, while other times, they don't. Saw palmetto extract, which is made from the ripe berries of the saw palmetto shrub, were believed to help reduce the symptoms of an enlarged prostate. But, research has found that the herbal treatment is no more effective than a placebo. Because there's no strong evidence that any herbal treatment can relieve urinary symptoms caused by an enlarged prostate, the American Urological Association doesn't recommend any herbal treatments. In addition, certain herbal products may increase your risk of bleeding or interfere with other medications you're taking. Some of the herbal treatments that have been suggested as helpful for reducing enlarged prostate symptoms include: Saw palmetto extract, made from the ripe berries of the saw palmetto shrub Beta-sitosterol extracts, made from several plants, such as certain grasses and trees Pygeum, an oil made from the bark of an African prune tree Ryegrass extract, made from ryegrass pollen Stinging nettle extract, made from the root of the stinging nettle plant If you take any herbal remedies, be sure to tell your doctor. These may help treat some of your symptoms but are generally less effective than are prescription medications.

http://emedicine.medscape.com/article/437359-overview#showall

Benign Prostatic Hypertrophy

Author: Levi A Deters, MD; Chief Editor: Edward David Kim, MD, FACS

Practice Essentials
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.

Essential update: Prostatic urethral lift relieves symptoms associated with BPH
A study testing the efficacy and safety of the minimally invasive prostatic urethral lift (PUL) procedure found that it relieves lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH). In the study, which involved 206 men with BPH, transprostatic adjustable UroLift implants were permanently implanted to retract obstructing lateral lobes and expand the urethral lumen. All procedures were completed successfully without perioperative serious adverse events. At 3-month follow-up, patients assigned to PUL had significantly greater improvements in American Urological Association Symptom Index, peak urinary flow, quality of life, and BPH Impact Index compared with sham control patients. All of these differences remained significant at 6- and/or 12month follow-up.[1, 2]

Signs and symptoms

When the prostate enlarges, it may constrict the flow of urine. Nerves within the prostate and bladder may also play a role in causing the following common symptoms: Urinary frequency Urinary urgency Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the frequency of urination Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder Decreased force of stream - The subjective loss of force of the urinary stream over time Dribbling - The loss of small amounts of urine due to a poor urinary stream See Clinical Presentation for more detail.

Diagnosis
Digital rectal examination The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH. During this portion of the examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected. Laboratory studies Urinalysis - Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose Urine culture - This may be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality Prostate-specific antigen - Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for this disease and should be screened accordingly (although screening for prostate cancer remains controversial)

Electrolytes, blood urea nitrogen (BUN), and creatinine - These evaluations are useful screening tools for chronic renal insufficiency in patients who have high postvoid residual (PVR) urine volumes; however, a routine serum creatinine measurement is not indicated in the initial evaluation of men with lower urinary tract symptoms (LUTS) secondary to BPH [3] Ultrasonography Ultrasonography (abdominal, renal, transrectal) and intravenous urography are useful for helping to determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency. Generally, they are not indicated for the initial evaluation of uncomplicated LUTS. Endoscopy of the lower urinary tract Cystoscopy may be indicated in patients scheduled for invasive treatment or in whom a foreign body or malignancy is suspected. In addition, endoscopy may be indicated in patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged catheterization, or trauma. IPSS/AUA-SI The severity of BPH can be determined with the International Prostate Symptom Score (IPSS)/American Urological Association Symptom Index (AUA-SI) plus a disease-specific quality of life (QOL) question. Questions on the AUA-SI for BPH concern the following:

Incomplete emptying Frequency Intermittency Urgency Weak stream Straining Nocturia Other tests

Flow rate - Useful in the initial assessment and to help determine the patients response to treatment PVR urine volume - Used to gauge the severity of bladder decompensation; it can be obtained invasively with a catheter or noninvasively with a transabdominal ultrasonic scanner Pressure flow studies - Findings may prove useful for evaluating for BOO Urodynamic studies - To help distinguish poor bladder contraction ability (detrusor underactivity) from BOO Cytologic examination of the urine - May be considered in patients with predominantly irritative voiding symptoms See Workup for more detail.

Management
Pharmacologic treatment Agents used in the treatment of BPH include the following: Alpha-1receptor blockers Alpha-adrenergic receptor blockers Phosphodiesterase-5 enzyme inhibitors 5-alpha reductase inhibitors Anticholinergic agents Surgery

Transurethral resection of the prostate (TURP) - The criterion standard for relieving BOO secondary to BPH Open prostatectomy - Reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery Minimally invasive treatment

Transurethral incision of the prostate (TUIP) Laser treatment - Used to cut or destroy prostate tissue Transurethral microwave therapy (TUMT) - Generates heat that causes cell death in the prostate, leading to prostatic contraction and volume reduction Transurethral needle ablation of the prostate (TUNA) High-intensity ultrasonographic energy therapy - Currently in the clinical trial stage Prostatic stents - Flexible devices that expand when put in place to improve the flow of urine past the prostate Laparoscopic prostatectomy See Treatment and Medication for more detail.

Image library

Normal prostate anatomy. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

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. Cellular accumulation and gland enlargement may result from epithelial and stromal proliferation, impaired preprogrammed cell death (apoptosis), or both. BPH involves the stromal and epithelial elements of the prostate arising in the periurethral and transition zones of the gland (see Pathophysiology). The hyperplasia presumably results in enlargement of the prostate that may restrict the flow of urine from the bladder. BPH is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production. An estimated 50% of men demonstrate histopathologic BPH by age 60 years. This number increases to 90% by age 85 years. The voiding dysfunction that results from prostate gland enlargement and bladder outlet obstruction (BOO) is termed lower urinary tract symptoms (LUTS). It has also been commonly referred to as prostatism, although this term has decreased in popularity. These entities overlap; not all men with BPH have LUTS, and likewise, not all men with LUTS have BPH. Approximately half of men diagnosed with histopathologic BPH demonstrate moderate-to-severe LUTS. Clinical manifestations of LUTS include urinary frequency, urgency, nocturia (awakening at night to urinate), decreased or intermittent force of stream, or a sensation of incomplete emptying. 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. (See Clinical Presentation.) Prostate volume may increase over time in men with BPH. In addition, peak urinary flow, voided volume, and symptoms may worsen over time in men with untreated BPH (see Workup). The risk of AUR and the need for corrective surgery increases with age. Patients who are not bothered by their symptoms and are not experiencing complications of BPH should be managed with a strategy of watchful waiting. Patients with mild LUTS can be treated initially with medical therapy. Transurethral resection of the prostate (TURP) is considered the criterion

standard for relieving bladder outlet obstruction (BOO) secondary to BPH. However, there is considerable interest in the development of minimally invasive therapies to accomplish the goal of TURP while avoiding its adverse effects (see Treatment and Management).

Anatomy
The prostate is a walnut-sized gland that forms part of the male reproductive system. It is located anterior to the rectum and just distal to the urinary bladder. It is in continuum with the urinary tract and connects directly with the penile urethra. It is therefore a conduit between the bladder and the urethra. (See the image below.)

Normal prostate anatomy. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

The gland is composed of several zones or lobes that are enclosed by an outer layer of tissue (capsule). These include the peripheral, central, anterior fibromuscular stroma, and transition zones. BPH originates in the transition zone, which surrounds the urethra.

Pathophysiology
Prostatic enlargement depends on the potent androgen dihydrotestosterone (DHT). 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. In vitro studies have shown that large numbers of alpha-1-adrenergic receptors are located in the smooth muscle of the stroma and capsule of the prostate, as well as in the bladder neck. Stimulation of these receptors causes an increase in smooth-muscle tone, which can worsen LUTS. Conversely, blockade of these receptors (see Treatment and Management) can reversibly relax these muscles, with subsequent relief of LUTS. Microscopically, BPH is characterized as a hyperplastic process. The hyperplasia results in enlargement of the prostate that may restrict the flow of urine from the bladder, resulting in clinical manifestations of BPH. The prostate enlarges with age in a hormonally dependent manner. Notably, castrated males (ie, who are unable to make testosterone) do not develop BPH. The traditional theory behind BPH is that, as the prostate enlarges, the surrounding capsule prevents it from radially expanding, potentially resulting in urethral compression. However, obstruction-induced bladder dysfunction contributes significantly to LUTS. The bladder wall becomes thickened, trabeculated, and irritable when it is forced to hypertrophy and increase its own contractile force. This increased sensitivity (detrusor overactivity [DO]), even with small volumes of urine in the bladder, is believed to contribute to urinary frequency and LUTS. The bladder may gradually weaken and lose the ability to empty completely, leading to increased residual urine volume and, possibly, acute or chronic urinary retention. In the bladder, obstruction leads to smooth-muscle-cell hypertrophy. Biopsy specimens of trabeculated bladders demonstrate evidence of scarce smooth-muscle fibers with an increase in collagen. The collagen fibers limit compliance, leading to higher bladder pressures upon filling. In addition, their presence limits shortening of adjacent smooth muscle cells, leading to impaired emptying and the development of residual urine.

The main function of the prostate gland is to secrete an alkaline fluid that comprises approximately 70% of the seminal volume. The secretions produce lubrication and nutrition for the sperm. The alkaline fluid in the ejaculate results in liquefaction of the seminal plug and helps to neutralize the acidic vaginal environment. The prostatic urethra is a conduit for semen and prevents retrograde ejaculation (ie, ejaculation resulting in semen being forced backwards into the bladder) by closing off the bladder neck during sexual climax. Ejaculation involves a coordinated contraction of many different components, including the smooth muscles of the seminal vesicles, vasa deferentia, ejaculatory ducts, and the ischiocavernosus and bulbocavernosus muscles.

Epidemiology
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. As many as 14 million men in the United States have symptoms of BPH. Worldwide, approximately 30 million men have symptoms related to BPH. The prevalence of BPH in white and African-American men is similar. However, BPH tends to be more severe and progressive in African-American men, possibly because of the higher testosterone levels, 5-alpha-reductase activity, androgen receptor expression, and growth factor activity in this population. The increased activity leads to an increased rate of prostatic hyperplasia and subsequent enlargement and its sequelae.

Prognosis
In the past, chronic end-stage BOO often led to renal failure and uremia. Although this complication has become much less common, chronic BOO secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.

Patient Education
For patient education information, see the Prostate Health Center and Kidneys and Urinary System Center, as well as Enlarged Prostate, Bladder Control Problems, and Inability to Urinate.

http://www.urologyhealth.org/urology/index.cfm?article=144

BPH: MANAGEMENT (BENIGN PROSTATIC HYPERPLASIA/ENLARGED PROSTATE)

What is BPH/LUTS? Benign prostatic hyperplasia (BPH) is a common urological condition caused by the non-cancerous enlargement of the prostate gland as men get older. As the prostate enlarges, it can squeeze down on the urethra. The symptoms associated with BPH are known as lower urinary tract symptoms. This can cause men to have trouble urinating and leads to symptoms of BPH. The symptoms associated with BPH are known as lower urinary tract symptoms (LUTS) Diagnosis of BPH/LUTS As a man ages, his prostate may become larger and start to cause urinary symptoms and other problems. But what are some of those problems? How will a man know if he has an enlarged prostate (also known as BPH)? When should a man see his doctor? What kinds of tests will my doctor perform? The following guide should help answer your questions and help you make an informed decision about what your next steps should be.

What is the prostate?

The prostate is part of the male reproductive system; it is about the size and shape of a walnut normally and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce fluid for the semen.

What are the risk factors for BPH? Risk factors for developing BPH include:

Obesity Lack of physical activity Erectile dysfunction Increasing age Family history of BPH What are the symptoms associated with BPH? Since the prostate is just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. Common symptoms are:

the need to frequently empty the bladder, especially at night. difficulty in beginning to urinate dribbling after urination ends. decreased size and strength of the urine stream sensation that the bladder is not empty, even after a man is done urinating, inability to postpone urination once the urge to urinate begins Pushing or straining in order to urinate. In extreme cases, a man might not be able to urinate at all, which is an emergency that requires prompt attention. Fill out the AUA Symptom Score and share the results with your health care provider. How is BPH diagnosed? BPH Index In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that ask how often the urinary symptoms identified above occur and the amount of bother from these symptoms. This helps measure how severe the BPH is ranging from mild to severe. When a doctor evaluates someone for possible BPH, the evaluation will typically consist of a thorough medical history, an examination of the urinary sediment (urinalysis) a physical examination (including a digital rectal exam or DRE), and use of the AUA BPH Symptom Score Index. In addition, the doctor will generally do a urine test called a urinalysis. There are a series of other studies that may or may not be offered to a patient being evaluated for BPH depending on the patients current medical condition. These include:

prostate specific antigen (PSA) - a blood test to screen for prostate cancer urinary cytology - a urine test to screen for bladder cancer a measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates cystoscopy - a direct look in the urethra and/or bladder using a small flexible scope

urodynamic pressure-flow study - tests the pressures inside the bladder during urination ultrasound of the kidney or the prostate to view the enlargement When should I see a doctor about BPH? A man should see a doctor if he is bothered by any of the symptoms mentioned previously. In addition, he should see a doctor immediately if he has blood in the urine, pain with urination, burning with urination or is unable to urinate. What are some of the medical treatments available for BPH? Watchful Waiting/Active Surveillance This treatment option is good for patients who have mild symptoms of BPH or have moderate to severe symptoms but are not bothered by their symptoms. Patients suffering from kidney problems as a result of BPH, urinary retention (suddenly being unable to urinate), or frequent urine infections, and urinary incontinence are not good candidates for this treatment option. During watchful waiting, a patient is closely monitored by his physician but he does not receive any active treatment. Many patients symptoms can be controlled and/or managed by changing

their current medications and diet. Patients will be examined yearly, and findings from the tests will be used to determine if additional treatment is needed in order to control a patients BPH. The risk of watchful waiting may be that the patients symptoms cannot be reduced after active treatment is started. Medical Therapies Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally; once or twice a day and work almost immediately. Commonly prescribed alpha blockers include:

alfuzosin terazosin doxazosin tamsulosin All of these drugs have the same equal level of effectiveness and side effects. Side effects can include headaches, dizziness, lightheadedness, fatigue and ejaculatory dysfunction. These medications are beneficial for patients who have bothersome to moderate severe BPH. Patients who are undergoing cataract surgery may be advised by their physician against taking this medication until after their surgery. 5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications used to treat BPH. In

select men, finasteride and dutasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent symptoms. Studies suggest that these medications may be best suited for men with relatively large prostate glands. These drugs reduce the risk of BPH complications such as acute urinary retention (suddenly being

unable to urinate) and the eventual need for BPH surgery. Side effects generally are sexually related and include: erectile dysfunction decreased libido and reduced semen released during ejaculation. Finasteride should not be used if men do not have prostate enlargement. Finasertide has been shown to cause more adverse effects in the beginning of its use; however, over a period of time the side effects between finasteride and dutasteride become equal. Combination Therapy: The use of both alpha blockers and 5-alpha-reductase inhibitors have shown to be superior to single drug therapies in men with larger prostates. The combination approach prevents the progression of disease and improves bothersome symptoms. However, this improved benefit may be associated with more side effects (possible side effects from both medications). Anticholinergics: Another medical therapy that is an appropriate and effective treatment alternative for the management of symptoms related to BPH. Complementary and Alternative Medicines/Phytotherapies: These compounds, also know as herbal therapies, are very popular self treatment remedies. Currently there is no dietary supplement, complementary alternative medicine or therapy that is recommended for the management of BPH. Furthermore, the quality and purity of these over-the-counter supplements are not rigorously monitored, adding further uncertainty about the value and safety of these products. Saw palmetto one of the more popular dietary supplements used by men has been shown to provide no benefit over a placebo for the treatment of BPH conditions and LUTS. Minimally Invasive Therapies Since the advent of medical therapy for symptomatic BPH with 5-alpha reductase inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in symptomatic prostatic obstruction has been reduced substantially. However, alpha-blockers do not modify prostate growth, and even the use of prostatic growth inhibitors such as finasteride or dutasteride often fails to prevent the recurrent LUTS of BPH and urinary retention. In the past, these patients would almost certainly have undergone more invasive treatment earlier in the disease process. Transurethral needle Ablation (TUNA) of the prostate This outpatient treatment requires a urologist to insert a cystoscope-like device into the prostate. Each needle in the prostate emits low-level frequency radio waves that is sufficient to create a heat that kills the prostate tissue. The dead tissue from the prostate is absorbed by the body. The reduction in the size of the prostate alleviates the symptoms caused by BPH. In the short term it is a very effective treatment however for long-term treatment patients may need to be retreated for their symptoms. In addition to the issue concerning the long term effectiveness of the treatment, finding the right candidates for the procedure has proven to be a challenge to doctors and is not consistent. One of the advantages of this treatment over others is the minimal sexual side effects short term. Transurethral Microwave Thermotherapy (TUMT)

TUMT is a minimally invasive treatment that uses high-frequency radio waves to cause thermal injury to the prostate while providing relief for bladder obstruction. This treatment has been advanced in the last couple of years with new higher energy devices creating better long term outcomes. Yet, the advancement has done little to reduce the greater adverse outcomes that are generally associated with this treatment options. Surgical Techniques There are many surgical procedures to treat BPH. Surgery is the most invasive approach and is typically reserved for patients suffering from moderate-to-severe BPH related LUTS or complications which arise from BPH (e.g. urinary retention, progressive LUTS, recurrent urine infection). It is generally reserved for patients who have not been able to successfully treat the condition with other treatment options or for those who present with moderate to severe BPH. The following are the generally accepted surgical treatment options:

Transurethral resection of the prostate (TURP) Has excellent outcomes and is the gold standard. All treatment options are generally compared to this approach. It is not safer with bipolar TURP meaning less risk of water intoxication leading to low sodium levels.

Open prostatectomy This surgery involves the removal of the inner portion of the prostate via a suprapubic or retropubic incision in the lower abdominal area. It is reserved for men with significantly enlarged prostate glands. The major risks associated with this treatment are the potential blood loss, need for transfusions, and a longer hospital stays. approach in these patients. Outcomes are generally very effective with this

Transurethral holmium laser ablation of the prostate (HoLAP) Transurethral holmium laser enucleation of the prostate (HOLEP) Holmium laser resection of the prostate (HoLRP) Photoselective vaporization of the prostate (PVP) Transurethral incision of the prostate (TUIP) Transurethral Transurethral vaporization of the prostate (TUVP) Before deciding if any of these treatment options are best make sure to discuss with your physician the following:

Current symptoms and bother from these symptoms Size of prostate The potential benefits and risks associated with any form of treatment including watchful waiting The following are things a patient should consider before deciding on a particular option: presentation (symptoms and how they feel about those symptoms) Size of prostate Surgeons experience

Discussion with physician about the potential risks and benefits Where can I get more information? AUA Guidelines: Management of BPH BPH: Diagnosis BPH: Medical Management BPH: Minimally Invasive Management BPH: Surgical Management Download the free Acrobat reader. Common misspellings/other names used: enlarged prostate, big prostate

Reviewed: January 2011 Last updated: July 2013

http://www.medicinenet.com/benign_prostatic_hyperplasia/article.htm

What is the prostate gland?

The prostate is a small organ about the size of a walnut. It lies below the bladder (where urine is stored) and surrounds the urethra (the tube that carries urine from the bladder). The prostate makes a fluid that helps to nourish sperm as part of the semen (ejaculatory fluid). Prostate problems are common in men 50 and older. Most can be treated successfully without harming sexual function. A urologist is a specialist in diseases of the urinary system, including diagnosing and treating problems of the prostate gland.

How does the doctor detect prostate enlargement?

A doctor usually can detect an enlarged prostate by rectal exam. The doctor also may examine the urethra, prostate, and bladder using a cytoscope, an instrument that is inserted through the penis.

What is benign prostatic hyperplasia?

Comment on thisShare Your Story Benign prostatic hyperplasia is nonmalignant (noncancerous) enlargement of the prostate gland, a common occurrence in older men. It is also known as benign prostatic hyperplasia and abbreviated as BPH.

When does benign prostatic hyperplasia start?

BPH generally begins in a man's 30s, evolves slowly, and most commonly only causes symptoms after 50.

What happens in BPH? What are symptoms of BPH?

Comment on thisRead 1 CommentShare Your Story In BPH, the prostate gland grows in size. It may compress the urethra which courses through the center of the prostate. This can impede the flow of urine from the bladder through the urethra to the outside. It can cause urine to back up in the bladder (retention) leading to the need to urinate frequently during the day and night. Other common symptoms include a slow flow of urine, the need to urinate urgently and difficulty starting the urinary stream. More serious problems include urinary tract infections and complete blockage of the urethra, which may be a medical emergency and can lead injury to the kidneys.

How common is BPH? Are there any risk factors?

BPH is extremely common. Half of all men over 50 develop symptoms of BPH, but only 10% need medical or surgical intervention.

Is BPH a type of cancer?

No! BPH is completely benign. It is not a precursor (a forerunner) to prostate cancer.

Is BPH always treated?

Comment on thisRead 1 CommentShare Your Story No. Treatment of BPH is usually reserved for men with significant symptoms. Watchful waiting with medical monitoring once a year is appropriate for most men with BPH.

How is BPH treated?

There are several different ways to treat BPH:

Watchful waiting is often chosen by men who are not bothered by symptoms of BPH. They have no treatment but get regular checkups and wait to see whether or not the condition gets worse. Medical treatment of BPH is usually reserved for men who have significant symptoms. The available drugs include

alpha blockers relax the smooth muscles of the prostate, and the bladder neck, which helps to relieve urinary obstruction caused by an enlarged prostate in BPH. Side effects can include headaches, fatigue, or lightheadedness. Commonly used alpha blockers in BPH include tamsulosin (Flomax), alfuzosin (Uroxatral), and older medications such as terazosin (Hytrin) or doxazosin(Cardura). These drugs generally will lead to improvement in symptoms within several weeks and have no effect on prostate size; and o 5-alpha reductase inhibitors block the conversion of the male hormone testosterone into its active form in the prostate (DHT). The prostate enlargement in BPH is directly dependent on DHT, so these drugs lead to an approximate 25% reduction in prostate size over six to 12 months. For this reason, improvement in urinary symptoms most commonly takes this long to occur. Examples of 5-alpha reductase inhibitors include Finasteride (Proscar) anddutasteride (Avodart). Side effects of finasteride may include declining interest in sex, problems getting an erection, and problems with ejaculation. Surgery or office procedures may also be used to treat BPH, most commonly in men who have not responded satisfactorily to medication or those who have more severe problems, such as a complete inability to urinate.
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Transurethral resection of the prostate (TURP) has been used for the longest period of time. After the patient is given anesthesia, the doctor inserts a special instrument into the urethra through the penis. With the instrument, the doctor then shaves away part of the inner prostate to relieve the outflow of urine from the bladder. Laser procedures: A number of laser procedures are available, some of which can be performed in the doctor's office with minimal anesthesia. These procedures also involve the removal of obstructing prostate tissue. They are generally associated with less bleeding and quicker recovery than TURP but may not be as effective over the long term in some men. Microwave therapy: This procedure is generally performed in the office and involves the use of microwave energy delivered to the prostate to kill some of the cells leading eventually to shrinkage of the prostate.

Men should carefully weigh the risks and benefits of each of these options. Prostate surgery has traditionally been seen as offering the most benefits for BPH but unfortunately carries the most risks.

Are there other noncancerous prostate problems?

Yes, aside from BPH, there are a number of prostate problems that also have nothing at all to do with cancer. Among these benign disorders of the prostate are acuteprostatitis and chronic prostatitis. Acute prostatitis is a bacterial infection of the prostate. It can occur in men at any age. Symptoms include fever, chills, and pain in the lower back and between the legs. This problem also can

make it hard or painful to urinate. Doctors prescribe antibiotics for acute prostatitis and recommend that the patient drink more liquids. Treatment is usually successful. Chronic prostatitis is a prostate inflammation that tends to recur over time. It is usually not associated with true bacterial infection but causes similar symptoms of pain and discomfort, without fevers or chills. Chronic prostatitis is difficult to treat, and the exact cause is not well understood. Antibiotics may be used in some cases as well as antiinflammatory medications such asibuprofen. In many cases, symptoms will resolve on their own.

Can prostate problems be prevented?

The best protection against prostate problems is to have regular medical checkups that include a careful prostate exam. See a doctor promptly if symptoms occur such as

a frequent urge to urinate, difficulty in urinating, or dribbling of urine.

Regular checkups are important even for men who have had surgery for BPH. BPH surgery does not protect against prostate cancer because only part of the prostate is removed. In all cases, the sooner a doctor finds a problem, the better the chances that treatment will work.

Benign Prostatic Hyperplasia At A Glance

The prostate gland makes a fluid that becomes part of the semen. Benign prostatic hyperplasia (BPH) involves enlargement of the prostate gland. The prostate enlargement in BPH is not malignant. BPH can impede the flow of urine. Symptoms include frequent urge to urinate, difficulty urinating and dribbling of urine. The treatment of BPH is usually reserved for men with significant symptoms. Medical and surgical approaches are available to treat BPH.

http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)

A service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH)

The Prostate Gland

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body. Scientists do not know all the prostate's functions. One of its main roles, though, is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic. [Top]

Benign Prostatic Hyperplasia: A Common Part of Aging

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

Normal urine flow.

Urine flow with BPH.

As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH. Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH. Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5 million visits to physicians for BPH. [Top]

Why BPH Occurs

The cause of BPH is not well understood. No definite information on risk factors exists. For centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH. Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done on animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood's testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH. Some researchers suggest that BPH may develop as a result of "instructions" given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and "reawaken" later in life. These "reawakened" cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth. [Top]

Symptoms
Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as a hesitant, interrupted, weak stream urgency and leaking or dribbling more frequent urination, especially at night The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-thecounter cold or allergy medicines. Such medicines contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility. It is important to tell your doctor about urinary problems such as those described above. In eight out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor's examination. Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence-the inability to control urination. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications. [Top]

Diagnosis
You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist, a doctor who specializes in problems of the urinary tract and the male reproductive system. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common.

Digital Rectal Examination (DRE) This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland. Prostate-Specific Antigen (PSA) Blood Test To rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. The U.S. Food and Drug Administration (FDA) has approved a PSA test for use in conjunction with a digital rectal examination to help detect prostate cancer in men who are age 50 or older and for monitoring men with prostate cancer after treatment. However, much remains unknown about the interpretation of PSA levels, the test's ability to discriminate cancer from benign prostate conditions, and the best course of action following a finding of elevated PSA. A fact sheet titled "The Prostate-Specific Antigen (PSA) Test: Questions and Answers" can be found on the National Cancer Institute website atwww.cancer.gov/cancertopics/factsheet/Detection/PSA. Rectal Ultrasound and Prostate Biopsy If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a few pieces of prostate tissue for examination with a microscope. Urine Flow Study Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH. Cystoscopy In this examination, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system that help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction. [Top]

Treatment
Men who have BPH with symptoms usually need some kind of treatment at some time. However, a number of researchers have questioned the need for early treatment when the gland is just mildly enlarged. The results of their studies indicate that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early problems. If the condition begins to pose a danger to the patient's health or causes a major inconvenience to him, treatment is usually recommended. Since BPH can cause urinary tract infections, a doctor will usually clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk. The following section describes the types of treatment that are most commonly used for BPH.

Drug Treatment Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. The FDA has approved six drugs to relieve common symptoms associated with an enlarged prostate. Finasteride (Proscar), FDA-approved in 1992, and dutasteride (Avodart), FDA-approved in 2001, inhibit production of the hormone DHT, which is involved with prostate enlargement. The use of either of these drugs can either prevent progression of growth of the prostate or actually shrink the prostate in some men. The FDA also approved the drugs terazosin (Hytrin) in 1993, doxazosin (Cardura) in 1995, tamsulosin (Flomax) in 1997, and alfuzosin (Uroxatral) in 2003 for the treatment of BPH. All four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin and alfuzosin were developed specifically to treat BPH. The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), recently found that using finasteride and doxazosin together is more effective than using either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67 percent, compared with 39 percent for doxazosin alone and 34 percent for finasteride alone. Minimally Invasive Therapy Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery. Transurethral microwave procedures. In 1996, the FDA approved a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure. The procedure takes about 1 hour and can be performed on an outpatient basis without general anesthesia. TUMT has not been reported to lead to erectile dysfunction or incontinence. Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy. Transurethral needle ablation. Also in 1996, the FDA approved the minimally invasive transurethral needle ablation (TUNA) system for the treatment of BPH. The TUNA system delivers low-level radiofrequency energy through twin needles to burn away a welldefined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA system improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed. Water-induced thermotherapy. This therapy uses heated water to destroy excess tissue in the prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment balloon rests in the middle of the prostate. A computer controls the temperature of the water, which flows into the balloon and heats the surrounding prostate tissue. The system focuses the heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the body.

High-intensity focused ultrasound. The use of ultrasound waves to destroy prostate tissue is still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity focused ultrasound. Surgical Treatment Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used. Transurethral surgery. In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra. A procedure called transurethral resection of the prostate (TURP) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. During the 90-minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period. One possible side effect of TURP is retrograde, or backward, ejaculation. In this condition, semen flows backward into the bladder during climax instead of out the urethra. Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established. Open surgery. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use. With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland. Laser surgery. In March 1996, the FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known. Newer procedures that use laser technology can be performed on an outpatient basis. Photoselective vaporization of the prostate (PVP). PVP uses a high-energy laser to destroy prostate tissue and seal the treated area. Interstitial laser coagulation. Unlike other laser procedures, interstitial laser coagulation places the tip of the fiberoptic probe directly into the prostate tissue to destroy it.

[Top]

Your Recovery After Surgery in the Hospital

The amount of time you will stay in the hospital depends on the type of surgery you had and how quickly you recover.

Foley catheter

At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is put in the bladder, which keeps it in place. This catheter is usually left in place for several days. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These spasms may be difficult to control, but they will eventually disappear. You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection. However, some recent studies suggest that antibiotics may not be needed in every case, and your doctor may prefer to wait until an infection is present to give them. After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing. [Top]

Do's and Don'ts

Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing-even with transurethral surgery, where the incision can't be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk with your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision. Here are some guidelines: Continue drinking a lot of water to flush the bladder. Avoid straining when having a bowel movement.

Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative. Don't do any heavy lifting. Don't drive or operate machinery. [Top]

Getting Back to Normal After Surgery

Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely. During the recovery period, the following are some common problems that can occur. Problems Urinating You may notice that your urinary stream is stronger right after surgery, but it may take awhile before you can urinate completely normally again. After the catheter is removed, urine will pass over the surgical wound on the prostate, and you may initially have some discomfort or feel a sense of urgency when you urinate. This problem will gradually lessen, and after a couple of months you should be able to urinate less frequently and more easily. Incontinence As the bladder returns to normal, you may have some temporary problems controlling urination, but long-term incontinence rarely occurs. Doctors find that the longer problems existed before surgery, the longer it takes for the bladder to regain its full function after the operation. Bleeding In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually stops with a short period of resting in bed and drinking fluids. However, if your urine is so red that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to contact your doctor. [Top]

Sexual Function After Surgery

Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of cases. However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again. Complete recovery of sexual function may take up to 1 year, lagging behind a person's general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function. Erections Most doctors agree that if you were able to maintain an erection shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, surgery cannot usually restore function that was lost before the operation. Ejaculation Although most men are able to continue having erections after surgery, a prostate procedure frequently makes them sterile (unable to father children) by causing a condition called retrograde ejaculation or dry climax. During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening

to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine. In some cases, this condition can be treated with a drug called pseudoephedrine, found in many cold medicines, or imipramine. These drugs improve muscle tone at the bladder neck and keep semen from entering the bladder. Orgasm Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before. Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk with a counselor during the adjustment period after surgery. [Top]

Is Further Treatment Needed?

In the years after your surgery, it is important to continue having a rectal examination once a year and to have any symptoms checked by your doctor. Since surgery for BPH leaves behind a good part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age. Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may require a surgical procedure similar to transurethral incision (see section on Surgical Treatment). More often, scar tissue may form in the urethra and cause narrowing. The doctor can solve this problem during an office visit by stretching the urethra. Prostatic Stents A stent is a small device that is inserted through the urethra to the narrowed area and allowed to expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra. It is designed to relieve urinary obstruction in men and improve the ability to urinate. The device is approved for use in men for whom other standard surgical procedures to correct urinary obstruction have failed. BPH and Prostate Cancer: No Apparent Relation Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute and the American Cancer Society recommend that all men over 40 have a rectal examination once a year to screen for prostate cancer. After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a nonaggressive type of cancer, and no treatment is needed. [Top]

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) was established by Congress in 1950 as one of the National Institutes of Health (NIH), whose mission is to improve human health through biomedical research. NIH is the research branch of the U.S. Department of Health and Human Services.

The NIDDK conducts and supports a variety of research in diseases of the kidney and urinary tract. Much of the research targets disorders of the lower urinary tract, including BPH, urinary tract infection, interstitial cystitis, urinary obstruction, prostatitis, and urinary stones. The knowledge gained from these studies is advancing scientific understanding of why BPH develops and may lead to improved methods of diagnosing and treating prostate enlargement. One such study was the MTOPS Trial , which ended in 2003. The results are summarized above under the Drug Treatment section. [Top]

Additional Reading
American Urological Association. Guideline on the management of benign prostatic hyperplasia: Chapter 1: Diagnosis and treatment recommendations. The Journal of Urology. 2003;170(2 Pt 1):530537. National Cancer Institute. The prostate-specific antigen (PSA) test: Questions and answers. www.cancer.gov/cancertopics/factsheet/Detection/PSA. Reviewed August 17, 2004. [Top]

Glossary
Anesthesia: A substance that prevents pain from being felt, given before an operation. Anus: The opening of the rectum where solid waste leaves the body. Bladder: The muscular bag in the lower abdomen where urine is stored. Catheter: A tube inserted through the penis to the bladder in order to drain urine from the body. Cystoscope: A tube-like instrument used to view the interior of the bladder. Ejaculation: Discharging semen from the penis during sexual climax. Gland: An organ that makes and releases substances to other parts of the body. Hormone: A substance that stimulates the function of a gland. Impotent: Unable to have an erection. Incontinence: The inability to control urination. Obstruction: A clog or blockage that prevents liquid from flowing easily. Rectum: The last part of the large intestine (colon) ending in the anus. Reproductive system: The bodily systems that allow men and women to have children. Scrotum: The sac of skin that contains the testes. Semen: The fluid, containing sperm, which comes out of the penis during sexual excitement. Sterile: Unable to father children. Testes: The male reproductive glands where sperm are produced. Ultrasound: A type of test in which sound waves too high to hear are aimed at a structure to produce an image of it. Urinary tract: The path that urine takes as it leaves the body. It includes the kidneys, ureters, bladder, and urethra. Urination: Discharge of liquid waste from the body. Urethra: The canal inside the penis that urine passes through as it leaves the body. [Top] The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.

National Kidney and Urologic Diseases Information Clearinghouse

3 Information Way Bethesda, MD 208923580 Phone: 18008915390 TTY: 18665691162 Fax: 7037384929 Email: nkudic@info.niddk.nih.gov Internet: www.kidney.niddk.nih.gov The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

NIH Publication No. 07-3012 June 2006 [Top] Page last updated: March 23, 2012

http://yayanakhyar.wordpress.com/2008/04/25/bph-ppj/

Benign Prostatic Hyperplasia (BPH) / Pembesaran Prostat Jinak (PPJ)

Posted on April 25, 2008 by Yayan_Akhyar

Authors : Mayenru Dwindra, S. Ked, Yayan Akhyar Israr, S. Ked. Fakultas Kedokteran Universitas Riau. 2008. Anatomi dan Histologi Prostat Kelenjar prostat adalah salah satu organ genitalia pria yang terletak di sebelah inferior buli-buli dan membungkus uretra posterior. Bila mengalami pembesaran organ ini menekan uretra pars prostatika dan menyebabkan terhambatnya aliran urin keluar dari buli-buli (7). Prostat merupakan kelenjar aksesori terbesar pada pria; tebalnya 2 cm dan panjangnya 3 cm dengan lebarnya 4 cm, dan berat 20 gram. Prostat mengelilingi uretra pars prostatika dan ditembus di bagian posterior oleh dua buah duktus ejakulatorius (8). Secara histologi prostat terdiri atas 30-50 kelenjar tubulo alveolar yang mencurahkan sekretnya ke dalam 15-25 saluran keluar yang terpisah. Saluran ini bermuara ke uretra pada kedua sisi kolikulus seminalis. Kelenjar ini terbenam dalam stroma yang terutama terdiri dari otot polos yang dipisahkan oleh jaringan ikat kolagen dan serat elastis. Otot membentuk masa padat dan dibungkus oleh kapsula yang tipis dan kuat serta melekat erat pada stroma. Alveoli dan tubuli kelenjar sangat tidak teratur dan sangat beragam bentuk ukurannya, alveoli dan tubuli bercabang berkali-kali dan keduanya mempunyai lumen yang lebar, lamina basal kurang jelas dan epitel sangat berlipat-lipat. Jenis epitelnya berlapis atau bertingkat dan bervariasi dari silindris sampai kubus rendah tergantung pada status endokrin dan kegiatan kelenjar. Sitoplasma mengandung sekret yang berbutir-butir halus, lisosom dan butir lipid. Nukleus biasanya satu, bulat dan biasanya terletak basal. Nukleoli biasanya terlihat ditengah, bulat dan kecil (8). Kelenjar prostat terbagi atas 5 lobus :

1. Lobus medius

2. Lobus lateralis (2 lobus)

3. Lobus anterior

4. Lobus posterior (9). Menurut konsep terbaru kelenjar prostat merupakan suatu organ campuran terdiri atas berbagai unsur glandular dan non glandular. Telah ditemukan lima daerah/ zona tertentu yang berbeda secara histologi maupun biologi, yaitu: (10) 1. Zona Anterior atau Ventral

Sesuai dengan lobus anterior, tidak punya kelenjar, terdiri atas stroma fibromuskular. Zona ini meliputi sepertiga kelenjar prostat.

2. Zona Perifer

Sesuai dengan lobus lateral dan posterior, meliputi 70% massa kelenjar prostat. Zona ini rentan terhadap inflamasi dan merupakan tempat asal karsinoma terbanyak.

3. Zona Sentralis.

Lokasi terletak antara kedua duktus ejakulatorius, sesuai dengan lobus tengah meliputi 25% massa glandular prostat. Zona ini resisten terhadap inflamasi.

4. Zona Transisional.

Zona ini bersama-sama dengan kelenjar periuretra disebut juga sebagai kelenjar preprostatik. Merupakan bagian terkecil dari prostat, yaitu kurang lebih 5% tetapi dapat melebar bersama jaringan stroma fibromuskular anterior menjadi benign prostatic hyperpiasia (BPH). 5. Kelenjar-Kelenjar Periuretra

Bagian ini terdiri dan duktus-duktus kecil dan susunan sel-sel asinar abortif tersebar sepanjang segmen uretra proksimal (10).

http://dokterugm.wordpress.com/2010/04/24/benigna-prostatic-hiperplasia-atau-pembesaranprostat-jinak-atau-bph-atau-ppj/

Benigna Prostatic Hiperplasia atau Pembesaran Prostat Jinak atau BPH atau PPJ
Posted on April 24, 2010 by dokterugm

A. ANATOMI DAN FISIOLOGIS Prostat merupakan sebuah organ fibromuskuler sebesar kemiri yang berfungsi sebagai kelenjar aksesoris dan mengelilingi urethra pars prostatika. 2,6 Kelenjar prostat merupakan kelenjar yang terdiri atas dari jaringan kelenjar dinding uretra yang mulai menonjol pada masa pubertas. Biasanya kelenjar prostat dapat tumbuh seumur hidup. Secara anatomis prostat berhubungan erat dengan kandung kemih, uretra, kedua ureter, vas deferens dan vesikula seminalis. Prostat terletak diatas panggul sehingga uretra yang terfiksasi dalam diafragma tersebut, dapat terobek bersama diafragma bila terjadi cendera. Prostat dapat diraba pada pemeriksaan colok dubur.6 Selain mengandung jaringan kelenjar, kelenjar prostat banyak mengandung jaringan fibrosa dan jaringan otot. Kelenjar ini ditembus oleh uretra dan kedua duktus ejakulatorius, dan dikelilingi oleh suatu pleksus vena. Kelenjar limfe regionalnya adalah kelenja limfe hipogastrik, sakral, obturator, dan iliaka ekstern. Anatomi Prostat sediri adalah sebagai berikut : - Terletak dileher atau inferior vesika urinaria dan membungkus uretra posterior. - Berat normal + 20 gram - Lowsley membagi prostat menjadi 5 lobus : 1. Lobus lateral kanan dan kiri 2. Lobus posterior 3. Lobus medius 4. Lobus anterior, atrofi saat bayi lahir - Mc Neal membagi dalam zona : 1. Zona anterior 2. Zona transisional ( tempat BPH ) 3. Zona sentral 4. Zona perifer - Aliran arteri dari : 1. Cabang a. Vesicalis inferior ( terpenting ) 2. a. Rectalis media 3. Cabang a. Iliaca interna - Vena dan penyaluran limfe : Vena-vena bergabung membentuk plexus venosus prostaticus sekeliling sisi dan alas prostat. Plexus prostaticus akan bermuara ke vena iliaca interna. Pembuluh limfe terutama berakhir pada nodi lymphoidei iliaca interna dan nodi lymphoidei sacrales. - Persyarafan : 1. Sistem simpatis dari plexus hipogastricus inferior 2. Sistem parasimpatis dari nervi splanchnici pelvici (nervi erigentes) [S2-S4] B. BENIGNA PROSTAT HIPERPLASIA a. Pengertian Hiperplasia prostat merupakan hiperplasi kelenjar periurethal ( sel sel glanduler dan interstitial ) dari prostat. Sel sel kelenjar prostat akan terdesak menjadi gepeng dan disebut sebagai kapsul surgical. Hiperplasi prostat jinak (BPH) adalah kelainan yang sering terdapat pada kelenjar prostat. Prevalensinya menigkat sejalan dengan peningkatan usia pria. Insidens di negara berkembang meningkat karena adanya peningkatan umur harapan hidup. Lebih sering terjadi setelah berusia lebih dari lima puluh tahun dan

berhubungan dengan pembesaran prostat jinak. Dibawah pengaruh testoteron dan usia, prostat meningkat dalam ukuran dan dapat menyebabkan penyumbatan keluarnya aliran air kemih. b. Etiologi Etiologi BPH belum jelas namun terdapat beberapa faktor resiko umur dan hormon androgen. Sebenarnya hiperplasia prostat jinak merupakan hiperplasia kelenjar prostat. Karena proses pembesaran prostat terjadi berlahan lahan maka efek perubahan juga terjadi berlahan pula. Pada tahan awal setelah terjadi pembesaran prostat, resistensi pada leher vesika dan daerah prostat meningkat, dan detrusor menjadi lebih tebal. Penonjolan serat detrusor kedalam kandung kemih dengan sistokopi akan terlihat seperti balok yang disebut trabekulasi (buli buli balok). Mukosa dapat menerobos keluar diantara serat detrusor. Tonjolan mukosa yang kecil disebut sakula sedangkan yang besar disebut divertikel. Fase penebalan detrusor ini disebut fase kompensasi otot dinding. Apabila keadaan berlanjut maka detrrusor menjadi lelah dan tidak mampu lagi berkontraksi sehingga menjadi retensi urin. Kelenjar periurethal dapat mengalami hiperplasi, pada umumnya dikemukan beberapa teori: 1. Hipotesis stem sel ( Isaac 1984,1987 ) Berdasarkan teori ini pada keadaan normal kelenjar peiurethal dalam keadaan keseimbangan antara yang tumbuh dengan yang mati (stedystate). Sel baru biasanya tumbuh dari sel stem. Oleh karena suatu sebab seperti faktor usia, gangguan keseimbangan hormonal, atau faktor pencetus yang lain, maka sel stem tersebut dapat berprolifeasi lebih cepat, sehingga terjadi hiperplasi kelenjar periurethal. 1. Hipotesis kebangkitan kembali Teori kedua ialah teori Reawakening dari jaringan kembali seperti perkembangan pada tingkat embriologik, sehingga jaringan peiurethal dapat tumbuh lebih cepat daripada jaingan yang lain sekitarnya. Teori ini dikemukakan oleh Mc Neal (1978), yang juga membagi prostat manjadi bagian zona sentral, zona periferal dan zona peralihan. 1. Hipotesis keseimbangan estrogen dan testoteron Testoteron sebagaian besar dihasilkan oleh kedua testis, sehingga timbulnya pembesaran prostat memerlukan adanya testis normal (Huggins 1947, Moore 1947). Testoteron dihasilkan oleh sel leydig atas pengauh hormon Luteinizing hormon (LH), yang dihasilkan oleh kelenjar hipofisis. Kelenjar hipofisis ini menghasilkan hormon LH atas rangsangan Luteinising Hormon Releasing Hormon (LHRH). Disamping testis kelenjar anak ginjal juga menghasilkan testoteron atas pengaruh ACTH yang juga dihasilkan oleh hipofisis. Jumlah testoteron yang dihasilkan oleh testis kira kira 90% dari seluruh produksi testoteron, sedang yang 10 % dihasilkan kelenjar adrenal. Sebagaian besar testoteron dalam tubuh dalam keadaan terikat dengan protein dalam bentuk Serum Binding Hormon (SBH). Dengan bertambahnya usia akan terjadi peubahan imbangan estrerogen dan testoteron , hal ini disebabkan oleh bekurangnya produksi testoteron dan juga terjadi konvesi testoteron menjadi menjadi estrogen pada jaringan adipose di daerah perifer dengan pertolongan enzim aromatase. Estrogen inilah yang menyebabkan terjadinya hiperplasi stroma, sehingga timbul dugaan bahwa testoteron diperlukan untuk inisiasi terjadinya proliferasi tetapi kemudian estrogenlah yang berperan dalam perkembangan stroma. Kemungkinan lain adalah perubahan konsetrasi relatif testoteron dan estrogen akan menyebabkan produksi dan pontensiasi faktor pertumbuhan yang lain yang dapat menyebabkan pembesaran prostat. Berdasarkan otopsi diluar negeri perubahan mikroskopik pada prostat sudah dapat diidentifikasi pada pria usia 30 40 tahun. Perubahan mikroskopik ini bila terus berkembang akan berkembang menjadi patologik anatomik, yang pada pria usia 50 tahun pada otopsi ternyata angka kejadiannya sekitar 50% dan pada usia 80 tahun angka tersebut mencapai sekitar 80%. Sekitar angka 50 % dari angka tersebut diatas akan berkembang menjadi penderita pembesaran prostat manifes. 4. Hipotesis Dihidrotestoteron (DHT) Hanya 10% testoteron dalam keadaan bebas dan testoteron inilah yang memegang perananan dalam inisiasi dalam pembesaran prostat. Testoteron bebas ini dengan petolongan enzim 5 alfa reduktase akan dihidrolase menjadi Dihidrotestoteron (DHT). Dalam bentuk DHT inilah akan yang akan diikat oleh reseptor yang ada dalam sitoplasma sel prostat sehingga membentuk DHT-Reseptor kompleks ini akan akan masuk kedalam inti sel dan akan mempengaruhi Asam Ribo Nukleat (ARN) untuk menyebabkan sintesis protein sehingga dapat terjadi proliferasi sel ( Mc connel,1990)

1. Hipotesis Growth faktor (faktor interaksi stroma dan epitel) Hal ini banyak dipengaruhi oleh Growth factor. Basic Fibroblast Growth Faktor (b-FGF) dapat menstimulasi sel stroma dan ditemukan dengan konsentrasi lebih besar pada pasien dengan pembesaran prostat jinak. b FGF dapat dicetuskan oleh mikrotrauma karena miksi, ejakulasi atau infeksi. c. Patofisiologi Proses pembesaran prostat terjadi secara berlahan lahan sehingga perubahan pada saluran kemih juga terjadi secara berlahan lahan. Pada tahap awal terjadi pembesaran prostat , retistensi pada leher buli buli dan daerah prostat meningkat, serta otot detrusor menebal dan mereggang sehingga timbul sakulasi atau diverkulasi. Fase penebalan detrusor ini disebut fase kompensasi. Apabila keadaan berlanjut, maka detrusor menjadi lelah dan akhirnya mengalami dekompensasi dan tidak mampu lagi untuk berkontraksi sehingga terjadi retansi urin yang selanjutnya dapat menyebabkan hidronefrosis dan disfungsi saluran kemih atas. Adapun patofisiologi dari masing masing gejala adalah : - Penurunan kekuatan dan kaliber aliran yang disebabkan resistensi uretra adalah gambaran awal dan menetap dari BPH. - Hesitancy terjadi karena detrusor membutuhkan waktu yang lama untuk dapat melawan resistensi uretra. - Intermittency terjadi detrusor tidak dapat mengatasi resistensi uretra sampai akhir miksi. Terminal dribbling dan rasa puas sehabis miksi akan terjadi karena jumlah residu urin yang banyak dalam buli buli. - Nokturia dan frekuensi terjadi karena pengosongan tidak lengkap pada tiap miksi sehingga interval miksi menjadi lebih pendek. - Frekuensi biasa terjadi pada malam hari (nokturia) karena hambatan normal dari korteks berkurang dan tonus spingter dan uretra berkuang selama tidur. - Urgensi dan disuria jarang terjadi, dan jika ada disebabkan oleh ketidakstabilan detrusor sehingga terjadi kontraksi involunter. - Inkontinensia bukan gejala khas, walaupun dengan berkembangnya penyakit urin keluar sedikit sedikit secara berkala karena setelah buli buli mencapai compliance maksimum, tekanan dalam buli buli akan cepat naik melebihi tekanan spingter. Biasanya ditemukan gejala dan tanda obstuksi dan iritasi. Gejala dan tanda obstuksi jalan kemih berarti penderita haus menunggu pada permulaan miksi,miksi terputus, menetes pada akhi miksi,pancaran miksi menjadi lemah, rasa belum puas setelah miksi dan gejala iitatif yaitu betambahnya frekuensi miksi, noktuia, miksi sulit ditahan, dan nyeri pada waktu miksi. Gejala obstruksi disebabkan oleh karena dektrusor gagal berkontaksi cukup lama sehingga kontraksi terputus putus, sedangkan gejala iritatif disebabkan oleh karena pengosongan yang tidak sempurna saat miksi atau pembesaran prostat menyebabkan rangsangan pada vesika., sehingga vesika sering berkontraksi meskipun belum penuh, keadaan membuat sistem skoring untuk menentukan besarnya keluhan klinik penderita prostat Hiperplasia. Disamping skoring menurut Boyarsky, dikenal juga sistem skoring lain misalnya menurut Masden dan Iversen (1983), Flower dan kawan kawan (1988), skoring Denmark (Hald dkk., 1991),skoring Ameica Urological Association (AUA, 1991). Derajat berat gejala klinik prostat Hiperplasia ini dipakai untuk menentukan derajat berat keluhan subyektif , yang ternyata tidak selalu sesuai dengan besarnya volume prostat. Gejala iritatif yang sering dijumpai ialah bertambahnya frekuensi miksi yang biasanya lebih dirasakan pada malam hari. Sering miksi paada malam hari disebut nokturia, hal ini disebabkan oleh menurunnya hambatan kotikal selama tidur dan juga menurunkan tonus sfingter dan uretra. Simptom obstruksi biasanya disebabkan oleh karena prostat volumenya terlalu besar. Apabila vesika menjadi dekompensasi, maka akan terjadi retensi urin sehingga pada akhir miksi masih ditemukan sisa urin didalam vesika, hal ini menyebabkan rasa tidak tuntas pada akhir miksi. Jika hal ini berlanjut setiap saat akan terjadi kemacetan total, sehingga penderita tidak bisa miksi lagi. Oleh karena produksi urin akan terus terjadi maka suatu saat vesika tidak mampu lagi menampung urine sehingga tekanan intravesika akan naik terus dan jika tekanan intravesika ini akan naik terus maka dan apabila tekanan vesika akan menjadi lebih tinggi dari tekanan spingter akan terjadi inkontensia paradoks (overflow incontinence). Retensi kronik dapat menyebabkan terjadinya refluks vesiko urethral dan menyebabkan dilatasi ureter dan sistem pelvio kalises ginjal akan rusak dan adanya infeksi. Disamping kerusakan traktus urinarius bagian atas akibat obstuksi kronik pendeita haus selalu mengedan pada waktu miksi tekanan intraabdomen dapat meningkat dan lama kelamaan akan menyebabkan terjadinya hernia, hemorroid,. Oleh karena selalu terdapat sisa kencing didalam vesika maka akan terbentuk batu dalam

vesika dan batu ini dapat menambah keluhan iritasi dan menimbulkan iritasi dan menimbulkan hematuri. Disamping pembentukan batu retensi kronik dapat menyebabkan terjadinya infeksi sehingga terjadi sintitis dan apabila terjadi refluks dapat terjadi juga pyelonefitis. d. Manifestasi klinik Biasanya gejala gejala pembesaran postat jinak, dikenal sebagai Lower Urinary Tract Symptoms (LUTS) yang dibedakan menjadi gejala iritatif dan obstruktif. Gejala iritatif yaitu sering miksi (frekuensi), terbangun untuk miksi pada malam hari (nokturia), perasaan ingin miksi yang sangat mendesak (urgensi), dan nyeri pada saat miksi (disuria). Sedangkan gejala obstuktif adalah melemahnya pancaran urin, rasa tidak lampias setelah miksi, kalau iksi harus menunggu lampias (hesitancy), harus mengedan (straining), kencing terputus putus (intermittency), dan waktu miksi memanjang yang akhirnya menjadi retensi urin dan inkontinensia karena overflow. Keluhan ini biasanya disusun dalam bentuk skor simptom. Terdapat beberapa jenis klasifikasi yang dapat digunakan untuk membantu diagnosa dan menentukan beratnya penyakit, diantaranya adalah sko internasional gejala gejala prostat WHO (International Prostate Symptom Score, IPPS) dan skor Madsen Iversen. Gejala dan tanda pada pasien lanjut penyakitnya , misalnya gagal ginjal, dapat ditemukan uremia , peningkatan tekanan darah ,denyut nadi, respirasi, foeter uremik, perikarditis, ujung kuku yang pucat, tanda tanda penurunan mental serta neuropathy perifer. Bila sudah terjadi hidronefrosis atau pionefrosis, ginjal teraba dan ada nyeri di CVA (CostoVetebra Angularis). Buli buli yang distensi dapat dideteksi dengan palpasi dan perkusi. Pemeiksaan penis dan uretra penting untuk mencari etiologi dan menyingkirkan diagnosa banding seperti striktura, karsinoma, stenosis meatus atau fimosis. Pada colok dubur harus diperhatikan konsistensi prostat (pada BPH konsistensinya kenyal), adakah asimetris, adakah nodul pada prostat, apakah batas atas teaba. Kalau batas atas masih biasa teraba secara empiris besar jaringan prostat kurang dari 60g. Derajat berat obstruksi dapat di ukur dengan menentukan jumlah sisa urin setelah miksi spontan. Sisa urin dapat diukur dengan cara mengukur urin yang masih dapat keluar dengan kateterisasi. Sisa urin juga dapat dilakukan dengan USG buli buli setelah miksi. Sisa urin setelah lebih dari 100cc biasanya dianggap sebagai batas indikasi untuk melakukan intervasi pada Hiperplasia prostat. Derajat obstruksi dapat juga diukur dengan menguku pancaran urin pada waktu miksi melalui alat uroflowmetri. Kecepatan alian urin dipengaruhi oleh kekuatan kontraksi detrusor , tekanan intra Bulu buli, dan tahanan uretra. Oleh karena itu uroflowmetri tidak dapat membedakan kelainan obstuksi dengan kelainan karena kontraksi detrusor yang lemah. Derajat berat Hiperplasia prostat bedasarkan gambaran klinik : 1. Derajat I, colok dubur : penonjolan prostat, batas atas mudah diraba, sisa volume urin <50ml. 1. Derajat II, colok dubur : penonjolan prostat jelas, batas atas dapat dicapai, sisa volme urin 50 100ml. 3. Batas atas prostat tidak dapat diraba, sisa volume urin >100ml. Cara menentukan pembesaran postat ada beberapa cara yang dapat dilakukan mulai dari hal sederhana, diantaranya: 1. Pemeriksaan bimanual (Digital Rektal Examination), dengan melakukan rektal toucer pada suprrapubik jika teraba pembesaran prostat maka dapat diperkirakan besar prostat > 30gr. 1. Rektal grading, dengan rektal toucher : Stage 0 : prostat teraba < 1cm, berat < 10 gram Stage 1 : prostat teraba 1 2 cm, berat 10 -25 gram Stage 2 : prostat teraba 2 -3 cm, berat 25- 60 gram Stage 3 : prostat teraba 3- 4 cm, berat 60 100 gram Stage 4 : prostat teraba >4 cm, berat >100 gram 1. Clinical grading : Pada pagi hari atau pasien setelah minum banyak disuuh miksi sampai habis, dengan kateter diuku sisa urin dalam buli buli. Normal : sisa urin tidak ada Grade 1 : sisa urin 0 -50 cc Grade 2 : sisa urin 50 150 cc

Grade 3 : sisa urine >150 cc Gade 4 : retensi urin total Grade 1 2 : indikasi konsevatif Grade 3 4 : indikasi operatif 1. Intra uretral grading : Dilakukan pemerikasaan dengan panendoskopi untuk melihatb seberapa jauh penonjolan prostat ke dalam lumen uretra. 1. Intravesical Grading : Dengan menggunakan pemeriksaan cystogram. e. Diagnosis Diagnosis benigna Hiperplasia prostat dapat ditegakan dengan melakukan anamnesis, pemeriksaan fisik, pemeriksaan penunjang pada pasien, diantaranya : 1. Anamnesis - Prostatismus, yang gejalanya sangat khas di temukan pada pasien BPH yaitu : * * Buang air kecil Buang tidak lampias air akibat kecil masih ada residu menetes

* Nocturia, lebih sering pipis pada malam hari yaitu ketika tidur terbangun untuk buang air kecil - Usia > 50 tahun Derajat prostatismus dapat dinilai dengan IPSS Skor 0 7 : derajat ringan dapat dilakukan watchfull waiting Skor 8 19 : derajat sedang indikasi untuk medikamentosa Skor 20 35 : derajat berat indikasi untuk dilakukan operatif Pengukuran derajat berat obstruksi Derajat berrat obstruksi dapat diukur dengan menetukan jmlah sisa urin setelah penderita miksi spontan. Sisa urin dapat ditentukan dengan pengukuran langsung yaitu dengan mengukur sisa kencing sehabis miksi dengan melakukan kateterisasi ke dalam vesika urin dan mengukur berapa sisa urin yang masih dapat keluar dengan kateterisasi tadi, sisa uin dapat diketahui dengan melakukan pemeriksaan ultrasonografi vesika setelah pendeita kencing atau dengan membuat foto post voiding pada waktu membuat IVP. Pada orang normal biasanya sisa sisa urin kosong, sedang pada retensi urin total sisa urin dapat melebihi kapasitas total vesika urinaria. Sisa urin lebih dari 100cc biasanya dianggap sebagai batas indikasi untuk melakukan intervesi pada penderita BPH. Derajat berat obstuksi dapat pla diukur dengan menguku pancaran urin pada waktu miksi, cara ini disebut dengan cara uroflowmwti. Untuk dapat melaukan pemeriksaan uroflow dengan baik diperlukan jumlah urin minimal didalam vesika 125ml sampai 150ml. Angka normal untuk flow rata rata (average flow rate) 10 12 ml/detik dan flow maksimal sampai sekitar 20ml/detik. Pada obstruksi ringan flow rate dapat menurun sampai average flow antara 6 8ml/detik, sedang maksimal menjadi 15mm/detik atau kurang. Dengan pengukuran flow rate tidak dapat dibedakan antara kelemahan detrusor dengan obstruksi intravesikal. 2. Pemeriksaan fisik pada pemeriksaan fisik dapat kita lakukan tindakan diantaranya : - Palpasi suprapubik, akan kita temukan bahwa vesika urinaria penuh dan terdapat rasa nyeri. - Rectal toucher + bimanual, dapat ditentukan pembesaran prostat 3. Pemeriksaan penunjang - Pemeriksaan residu urine : sisa urin post miksi - Pemeriksaan pancaran urin/flow rate, sepeti yang telah dijelaskan seperti diatas. - Pemeriksaan laboratorium Analisa urin dan pemeriksaan mikroskopi urin penting untuk melihat adanya leukosit, baktei dan infeksi. Bila terdapat hematuia, harus diperhitungkan etiologi lain seperti keganasan pada saluran kemih, batu, infesi saluran kemih, walaupun BPH sendiri dapat menyebabkan hematuria. Elektrolit,

kadar ureum dan kreatinin darah meupakan informasi dasar dari fungsi ginjal dan status metabolik. Pemeriksaan Prostate Specific Antigen (PSA) dilakukan sebagai dasar penentuan perlunya biopsi atau sebagai deteksi dini untuk keganasan. Bila nilai PSA < 4ng/ml tidak perlu biopsi. Sedangkan bila nilai PSA 4 10 ng/ml, hitunglah Prostate Spesific Antigen Density (PSAD) yait PSA serum dibagi dengan volume prostat. Bila PSAD lebih besar sama dengan 0,15 maka sebaiknya dilakukan biopsi prostat, demikian pula bila nilai PSA >10ng/ml. - Pemeriksaan pencitraan Tujuan dilakukan pemeriksaan pencitraan ini adalah mempekirakan volume BPH, menentukan derajat disfungsi buli buli dan volume residu urin, dan mencari kelainan patoligi lainnya baik yang berhubungan dengan BPH maupun tidak. Pada saat sekarang pemeriksaan pencitraan pada prostat dapat dilakukan dengan berbagai cara misalnya dengan pemeiksaan radiologik seperti Foto Polos Perut dan Pyelografi Intra Vena yang sangat terkenal dengan istilah BNO daan IVP. Cara pemeriksaan ini dapat memberi keterangan adanya penyakit ikutan misalnya batu saluran kemih, sumbatan ginjal (hidro nefrosis), adanya divetikel pada buli, dan kalau dibuat foto post miksi akan dapat dilihat adanya sisa urin, sedang adanya pembesaran prostat dapat dilih at sebagai Filling deffect pada dasar vesika yang sering disebut adanya identasi prostat. Secara tidak langsung pembesaran prostat dapat pula diperkirakan apabila dasar buli pada gambaran sistogram tampak terangkat atau ujung distal ureter membelok keatas sehingga bebentuk seperti mata kail (fish hook appearance). Apabila fungsi ginjal jelek sehingga ekresi ginjal kurang baik atau penderita sudah dipasang kateter menetap maka dapat dibuat pemeriksaan sistogram retrograd yang dapat pula memberi gambaran identasi prostat. Cara pencitraan yang lain adalah pemeriksaan ultrasonografi (USG). Cara pemeriksaan ini untuk prostat Hiperplasia dianggap sebagi pemeriksaan yang baik oleh karena ketepatannya dalam medeteksi pembesaran prostat, tidak ada bahaya radiasi dan juga relatif murah. Pemeriksaan USG dapat dilakukan secara trans abdominal atau transrektal ( TRUS = Tran Rektal Ultrasonografi ). TRUS dianggap lebih baik untuk pemeriksaan kelenjar Hiperplasia apalagi bila menggunakan transducer yang biplane. Selai n untuk mengetahui adanya pembesaran prostat USG juga dapat medeteksi volume buli buli, mengukur sisa urin, dan patologi lain seperti divertikel, tumor buli yang besar, batu buli. TRUS daapat pula untuk mengukur besarnya prostat yang diperlukan untuk menentukan jenis terapi yang tepat yaitu apabila besarnya lebih dari 60gram digolongkan besar sehingga kalau dilakukan operasi dipilih operasi terbuka. Perkiraan besarnya prostat dapat pula dilakukan dengan pemeriksaan USG suprapubik atau tans uretral tetapi cara tans uretal dianggap terlalu invasif. Pengukuan volume prostat sering disebut volumetri dan biasanya memakai Rumus volume = 0,52 x d1 x d2 x d3, bila kita anggap bahwa bentuk pros tat elipsoid dan d adalah jarak panjang, lebar (pada potongan tansversal), dan panjang postat pada potongan sagital. Pencitraan lain yang dapat juga dibuat ialah pencitraan dengan CTscanning dan Magnetic Resonace Image (MRI), tetapi oleh karena cara pemeriksaan ini mahal dan keterangan yang diperoleh tidak terlalu banyak dibandingkan dengan cara lain maka cara ini dalam praktek jarang digunakan. Pemeriksaan tambahan lain yang seing dikerjakan ialah pemeriksaan sistokopi. Sistokopi sebaiknya dilakukan apabila pad anamnesa ditemukan adanya hematui atau pada pemeriksaan urine ditemukan mikrohematuri, untuk mengetahui kemungkinan adanya tumor didalam vesika tau sumber perdarahan dai atas yang dapat dilihat apabila darah datang dari muara ureter, atau adanya batu kecil yang radiolusen yang ada dalam vesika. Selain itu sistokopi dapat juga memberi keterangan mengenai besarnya prostat dengan mengukur panjangnya uretra pars prostatika dan melihat penonjolan prostat kedalam uretra. Pemeriksaan prostat, prostat diperiksa transrektal dipalpasi digital atau ultrasonografi. Dapat dilakukan pada pasien dengan posisi rekumben lateral atau posisi membungkuk. Prostat normal besarnya dua jari dengan sulkus diantara dua lobusnya. Konsistensi dari prostat normal dan Hiperplasia jinak sama seperti pada eminesia thenar. Sebaliknya, karsinoma prostat teraba sangat keras seperti batu. Krepitasi menandakan adanya batu pada prostat. Peradangan akut dari prostat akan menyebabkan nyeri tekan atau fluktuasi pada pemeriksaan. f. Diferensial Diagnosa Oleh karena sebenarnya proses miksi tergantung pada beberapa faktor diantaranya, yaitu : 1. Kekuatan otot detrusor berkontraksi

Kelemahan detrusor , dapat disebabkan oleh karena kelainan syaraf (neurogenik bladder), misalnya pada lesi medulla spinalis, neuopathy diabeticum, sehabis operasi radikal yang mengorbankan persyarafan didaerah pelvis, alkoholisme, penggunanan obat penenang, ganglion blocking agent, dan obat parasimpatolitik. 1. Elastisitas leher vesika Kekakuan leher vesika dapat disebabkan oleh proses fibrosis (bladder neck contyracture) 1. Resistensi uretra Resistensi uretra dapat disebabkan oleh karena pembesaran prostat jinak atau ganas, tumor dileher vesika, batu di uretra atau striktura uretra. Kelainan kelainan tersebut dapat dilihat bila dilakukan sistokopi. Disamping itu meskipun di Indonesia jarang obstruksi infravesikal dapat disebabkan oleh gangguan fungsi misalnya dissynergia destrusor sfingter. Maka setiap kesulitan miksi yang dialami penderita dapat disebabkan oleh ketiga faktor tersebut. Diagnosis banding obstuksi saluran kemih kaena Hiperplasia prostat : Kelemahan detrusor kandung kemih : - gangguan neurologik * * * pasca kelainan neuopathia bedah medulla diabetes radikal di spinalis mellitus pelvis

* farmakologik (obat penenang, penghambat alfa, parasimpatolitik) Kekakuan leher kandung kemih - fibrosis Resistensi uretra - Hiperplasia prostat ganas atau jinak - Kelainan yang menyumbat uretra - Uretalitiasis - Uretitis akut atau kronik Adapun penyakit penyakit yang gejala gejalanya menyerupai hipertofi prostat jinak diantaranya adalah sebagai berikut berserta klinis dan pemeiksaan yang memebedakan dengan BPH : 1. Ca Prostat Keluhan sesuai gejala saluran kemih bagian bawah (Lower urinary tract symptoms = LUTS), yaitu gejala obstuktif dan iritatif. Kecurigaan umumnya berawal dari ditemukan nodul yang secara tidak segaja pada pemeriksaan rektal. Nodul yang irreguler dan keras harus dibiopsi untuk menyingkirkan hal ini. Atau didapatkan jaringan yang ganas pada pemeriksaan patologi dari jaringan prostat yang diambil akibat gejala BPH. Kanker ini jarang memberikan gejala kecuali bila telah lanjut. Dapat terjadi hematuria, gejala gejala obstruksi, gangguan saraf akibat penekanan atau fraktur patologis pada tulang belakang. Atau secara singkat kita anamnesa dan kita akan dapatkan sebagai berikut : - Terjadi pada usia > 60 tahun - Nyeri pada lumbosakral menjalar ke tungkai - Prostatismus dan hematuri - Rektal toucher : permukaannya berbenjol, keras, fixed 2. Prostatitis Gejala dan tanda prostatitis akut terdiri dari demam dengan suhu yang tinggi, kadang dengan gigilan, neri peineal atau pinggang rendah, sakit sedang atau berat, mialgia, antralgia. Karena pembengkan prostat biasanya ada disuria, kadang sampai retensi urin. Kadang didapatkan pengeluaran nanah pada colok dubur setelah masase prostat. Sedangkan pada prostatitis kronis gejala dan tanda tidak khas. Gambaran klinik sangat variabel, kadang dengan keluhan miksi, kadang nyeri perineum atau pinggang. Dan diagnosa dapat ditegakan dengan diketemukan adanya leukosit dan bakteria dalam sekret prostat. Jadi hal hal yang perlu sekali kita perhatikan agar dapat membedakan dengan BPH yaitu : - Adanya nyeri perineal - Demam - Disuri, polaksiuri - Retensi urin akut

- Rektal toucher : jika ada abses didapatkan fluktuasi (+) 3. Neurogenik Bladder Adapun gejala dan tanda yamg kita peroleh dari anamnesa adalah : - Lesi sakral 2 4 - Rest urin (+) - inkontinensia urin 4. Striktura Uretrha Sumbatan pada uretrha dan tekanan kandung kemih yang tinggi dapat menyebabkan imbibisi urin kelua kandung kemih atau uretra proksimal dari striktura. Gejala khas adalah pancaran urin yang kecil dan bercabang. Gejala lain adalah iritasi dan infeksi seperti frekuensi, urgensi, disuri, kadang kadand dengan infiltat, abses, fistel. Gejala lanjut adalah retensi urin. g.. Komplikasi 1. Lokal Hiperplasi prostat dapat menyebabkan penyempitan lumen ureta posteio yang menghambat aliran urin dan meningkatkan tekanan intravesikal. Buli buli kontaksi lebih kuat untuk melawan tahanan tersebut maka timbul peubahan anatomis yang dinamakan fase kompensata akan terjadi hipetrofi otot detusor, trabekulasi, sakulasi, diverkulasi. Apabila Buli buli menjadi dekompensasi, akan tejadi retensi urin. Karena produksi urin terus berlanjut maka pada suatu saat buli buli tidak mampu lagi menampung urin sehingga tekanan intravesika meningkat, dapat timbul hidroureter, hidronefrosis, dan gagal ginjal. Karena selalu terdapat sisa urin, dapat terbentuk batu endapan pada buli buli. Batu ini dapat menambah keluhan iritasi dan menimbulkan hematuria. Batu tersebut dapat pula menimbulkan sistitis dan bila terjadi refluks dapat terjadi pielonefritis. Ini dinamakan komplikasi lokal dari BPH. 1. General - Peritonitis,bila vesica urinaria pecah dan meyebar ke rongga peritonium - Anemia * - Sindroma Uremia * - Asidosis Metabolik * * bila terjadi gagal ginjal h. Penatalaksanaan 1. Observasi ( wacthfull waiting ) Biasanya dilakukan pada pasien BPH dengan keluhan ringan (Skor Madsen Iversen kurang dari sama dengan 9 ). Nasehat yang diberikan pada pasien adalah mengurangi minum setelah makan malam untuk mengurangi terbangun pada malam hari untuk buang air kecil ( nokturia ), menghindari obat obat dekongestan ( parasimpatolitik ), menguangi minum kopi dan tidak diperbolehkan minum alkohol agar tidak terlalu sering miksi. Setiap tiga bulan kontrol keluhan ( sistem skor), sisa kencing dan pemeriksaan colok dubur. 1. Terapi medikamentosa Prostat Hiperplasia yang telah memberikan keluhan klinik biasanya akan menyebabkan penderita datang ke dokter. Secara klinik biasanya derajat berat gejala klinik dibagi menjadi 4 gradasi yaitu : Derajat satu, apabila ditemukan keluhan prostatismus , pada DRE ditemukan penonjolan prostat dan sisa urin kuang dari 50ml. Derajat dua apabila ditemukan gejala dan tanda sepeti derajat satu , prostat lebih menonjol, batas atas masih teraba, dan sisa urin lebih dari 50ml tetapi kurang dari 100ml. Derajat tiga seperti derajat dua, hanya batas atas prostat atas tidak teraba lagi dan sisa urin lebih dari 100ml. Derajat empat apabila telah terjadi retensi urin total. Pada penderita derajat satu pada umumnya belum memerlukan tindakan operatif tetapi tindakan konservatif, yaitu : 1. Penghambat adrenegik alfa Obat obat yang sering dipakai adalah prazosin, doxazosin, terazosin, alfuzosin atau yang lebih selektif alfa 1a (tamsulosin). Penggunaan antagonis alfa 1a karena secara selektif mengurangi obstuksi pada buli buli tanpa merusak kontraktilitas detrusor. Obat obat ini menghambat reseptor reseptor yang banyak ditemukan pada otot polos trigonum, leher vesica, prostat dan kapsul prostat sehingga terjadi relaksasi di daerah prostat. Hal i9ni akan menurunkan tekanan di daerah uretra pars prostatika sehingga gangguan aliran seni dan gejala gejala akan berkurang. Biasanya pasien merasa bekuang keluhan keluhannya dalam wakt 1 -2 minggu setelah ia

memulai makan obat. Efek samping yang mungkin timbul adalah pusing pusing (dizziness), capek, sumbatan hidung, dan rasa lemah. Selain itu juga dapat menyebabkan penurunan tekanan darah. Jadi dalam pemberian obat ini harus diperhatikan tekanan darahnyauntuk menghindari terjadinya hipotensi yang dapat membahayakan penderita. b. Penghambat enzim reduktase Obat yang dipakai adalah finasteride (proscar) dengan dosis 1 x 5 mg/hari. Obat golongan ini dapat menghambat pembentukan DHT sehingga prostat yang membesaar akan mengecil. Namun obat ini berkerja lebih lambat dari pada golongan alfa bloker dan manfaatnya hanya jelas pada pembesaran prostat yang besar. Efektivitasnya masih diperdebatkan karena baru menunjukkan perbaikan sedikit dari pasien setelah 6 12 bulan pengobatan bila dimakan terus menerus. Salah satu efek samping obat ini adalah melemahkan libido, ginekomastia, dan dapat menurunkan PSA (masking effect). Cara pengobatan konservatif dengan obat yang lain adalah dengan obat obat anti androgen yang dapat mulai pada tingkat hipofisis misalnya dengan pemberian Gn-RH analogue sehingga menekan produksi testoteron oleh sel Leydig berkurang. Cara ini tentu saja menyebabkan penurunan libido oleh karena penurunan testoteron darah. Pada tingkat yang lebih rendah dapat pula diberikan obat anti androgen yang mekanismenya mencegah hidrolise testoteron menjadi DHT dengan memberikan penghambat 5 alfa reduktase inhibitors, sehingga jumlah DHT berkurang tetapi jumlah testoteron tidak berkurang, sehingga libido juga tidak berkurang. Obat anti androgen lain yang juga berkerja pada tingkat prostat adalah obat yang mempunyai mekanisme kerja sebagai inhibitors kompetitif terhadap reseptor DHT sehingga DHT tidak dapat membentuk kompleks DHT- reseptor. Obat ini juga tidak menurunkan kadar testoteron dalam darah, sehingga libido tidak turun. Kesulitan pengobatan konsevatif ini adalah menentukan berapa lama obat harus diberikan dan efek samping dari obat ini. Pengobatab lain yang juga invasive adalah pengobatan dengan memanaskan prostat dengan gelombang ultrasonik atau gelombang radio kapasitif yang disalurkan pada kelenjar prostat dengan antena yang dipasang pada ujung kateter proksimal pada balon. Pemanasan ini dilakukan pada suhu 45 sampai 47 derajat celcius selama 1 sampai 3 jam. Efek dari pemanasan ini akan menyebabkan vakuolisasi pada jaringan prostat dan penurunan tonus jaringan sehingga tekanan uretra menurun sehingga obstruksi berkurang. Dengan cara pengobatan ini menggunakan alat THREMEX II memperoleh hasil perbaikan kira kira 70 80 % pada sptom obyektif dan 50- 60 % perbaikan pada flowrate maksimal. Mekanisme mengenai efek pemanasan prostat ini semuanya belum jelas, salah satu teori yang masih harus dibuktikan ialah bahwa dengan pemanasan akan terjadi perusakan pada reseptor alfa yang berada pada leher vesika dan prostat. Cara pengobatan lain yang juga kurang infasif adalah dilatasi uretra pada prostat dengan memakai balon yang berkembang didalamnya. Cara ini dikenal sebagai Trans Uretrha Baloon Dilatation (TUBD), dan pelopor cara ini adalah Burhenne, Castaneda, Reddy dan Hubert. TUBD ini biasanya memberikan perbaikan sementara. 1. Filoterapi Pengobatan filoterapi yang ada di Indonesia adalah eviprostat. Substansianya misalnya Pygeum africanum, Sawpalmetto, Serenoa repeus, dll. Efeknya diharapkan terjadi setelah 1 2 minggu setelah pemberian 1. Terapi Bedah Waktu penanganan untuk tiap pasien bervariasi tergantung beratnya gejala dan komplikasi. Indikasi absolut untuk terapi bedah adalah : 1. 1. 2. Hematuria Retensi urin berulang

1. 3. Tanda penurunan fungsi ginjal 1. 1. 2. Tanda Infeksi tanda obstruksi saluran berat yaitu divertikel, kemih hidroereter, dan berulang hidronefrosis

3. Ada batu saluran kemih Jenis pengobatan ini paling tinggi efektivitasnya. Intervensi bedah yang dapat dilakukan meliputi : - Transuretrhal Resection of the Prostat (TUR P) - Transuretrhal Insision of the Prostat (TUI P) - Prostatektomi terbuka - Prostatektomi dengan laser dengan Nd-YAG atau Ho-YAG

TUR P masih merupakan standar emas. Indikasi TUR P adalah gejala gejala sedang sampai berat, volume prostat kurang dari 90 g dan pasien cukup sehat untuk menjalani operasi. Komplikasi TUR P jangka pendek adalah perdarahan, infeksi, hiponatremia, atau retensi karena bekuan darah. Sedangkan komplikasi jangka panjang adalah stiktura uretra, ejakulasi retrograde (50 90%) atau impotensi (4 40%). Bila volume prostat tidak terlalu besar atau ditemukan kontraktur leher vesika atau prostat fibrotik dapat dilakukan TUI P. Indikasi TUI P adalah keluhan sedang sampai berat, volume prostat kecil atau normal. Komplikasi bisa ejakulasi retrograde (0 -37%). Apabila diperkirakan prostat sudah cukup besar, sehingga reseksi diperkirakan tidak selesai dalam waktu 1 jam maka sebaiknya dilakukan operasi terbuka. Operasi terbuka dapat dilakukan dengan transvesikal yaitu dengan membuka vesika dan prostat dinuklease dari vesika. Keuntungan cara ini dapat sekaligus mengangkat batu vesika atau diverkulektomi apabila ada divertikel yang cukup besar. Kerugian cara ini harus membuka vesika sehingga memerlukan kateter lebih lama sampai luka pada dinding vesika sembuh. Cara terbuka operasi lain adalah Retropubik menurut Terence Millin yaitu Route suprapubik dengan cara membuka kapsul prostat tanpa membuka vesika kemudian prostat dienukleasi dari retropubik. Cara ini mempunyai keuntungan tanpa membuka vesika sehingga pemakaian kateter tidak lama bila membuka vesika, kerugiannya tentu saja karena tidak membuka vesika jika diperlukan tindakan lain yang dikerjakan dalam vesika tidak dapat dilakukan. Kedua cara tersebut jika dibandingkan dengan TUR P masih kalah denga mordibitas yang lebih lama dan ada sayatan, tetapi dapat dikerjakan tanpa alat alat istimewa, cukup dengan alat alat bedah yang standar. Seperti yang dijelaskan diatas cara pengobatan endoskopi yang lebih ringan dari TUR P adalah TUI P. Cara pengobatan ini secara endoskopi juga menyayat memakai alat seperti TUR P tetapi memakai alat seperti penggaruk, sayatan dimulai dari dekat muara sampai dekat verumontanum dan harus cukup dalam sampai ketemu kapsul prostat. TUI P ini mempunyai keuntungan lebih cepat dari TUR P, Hiperplasia derajat empat tindakan pertama yang harus dikerjakan adalah membebaskan penderita dari retensi urin total dengan cara memasang kateter ata sistotomi setelah itu baru dilakukan pemeriksaan lanjut untuk melengkapi diagnistik kemudian terapi defenitif dapat dengan TUR P satu operasi terbuka. Untuk penderita yang keadaan umumnya tidak baik atau tidak memungkinkan operasi dapat dilakukan tindakan konsevatif. Karena pembedahan tidak mengobati penyebab BPH, maka biasanya penyakit ini dapat timbul lagi 8 10 tahun kemudian. 1. Terapi invasif minimal - Transuretrhal Microwave Thermotherapy (TUMT) Jenis operasi hanya dapat dilakukan pada beberapa rumah sakit besar. dilakukan pemanasan prostat dengan gelombang mikro yang disalurkan ke kelenjar prostat melalui suatu transducer yang diletakkan di uretra pars prostatika. - Dilatasi Baloon Tansuretrhal (TUBD) Dilatasi uretra didaerah prostat dengan memakai balon didalamnya dan biasanya mengalami perbaikan sementara. - High Intensity focused Ultrasound Pada perkembangan akhir akhir ini dicoba pula ablasi prostat menggunakan laser. Roth dan Aretz (1991) mempopulerkan Transuretral Ultrasound Guided Laser Induced Prostatectomy (TULIP), yang kemudian disempurnakan dengan membuat alat deflektor sinar laser 90 derajat sehingga sinar laser dapat diarahkan ke kelenjar prostat yang membesar. - Ablasi Jarum Transuretrhal (TUNA) - Stent Prostat Pemasangan Stent pada uretra pars prostatika merupakan cara mengatasi obstruksi transvesikal yang kurang invasif, yang merupakan alternatif sementara apabila kondisi penderita belum memungkinkan mendapat terapi yang lebih invasif. Akhir akhi ini dikembangkan juga stent yang dapat dipertahankan lebih lama misalnya proges urospiral (Parker dkk) atau Wallstent (Nording, A.L. Paulsen). i.. Pengertian insidensi dan prevalensi secara epidemiologi klinis. Berdasarkan riwayat alamiah penyakit kejadian penyakit dapat dibedakan menjadi dua yaitu insidensi dan prevalensi. Insidensi adalah kejadian penyakit yang baru saja memasuki fase klinik sedangkan prevalensi merupakan kejadian penyakit pada suatu saat atau pada suatu periode waktu tertentu baik yang memasuki fase

klinik maupun yang telah beberapa waktu lamanya berkembang sepanjang fase klinik. Para dokter menggunakan istilah ini sebagai angka kejadian atau kasus baru (insidensi) dan angka kekerapan pada kasus baru dan kasus lama (prevalensi) Ukuran insidensi penyakit dapat dibedakan menjadi dua macam yaitu insidensi komulatif dan laju insidensi. Insidensi komulatif merupakan parameter yang menunjukkan taksiran probabilitas (resiko) seorang terkena penyakit diantara semua orang yang beresiko terkena penyakit tersebut.11 Laju insidensi adalah ukuran yang menunjukkan kecepatan kejadian (baru) penyakit pada populasi. Laju insidensi merupakan proporsi antara jumlah orang yang menderita penyakit dan jumlah orang dalam resiko x lamanya ia dalam resiko.11 Prevalensi ada dua jenis,yaitu prevalensi titik dan prevalensi periode . Prevalensi titik adalah proporsi dari individu-individu dalam populasi yang terjangkit oleh penyakit pada suatu titik waktu. Prevalensi periode merupakan perpaduan antara prevalensi titik dengan insidensi.Prevalensi periode adalah probabilitas individu dari populasi untuk terkena penyakit pada saat dimulainya pengamatan atau selama jangka waktu pengamatan. Insidensi dan prevalensi merupakan relasi yang sangat erat.Prevalensi merupakan fungsi dari laju insidensi dan durasi dari fase klinik sampai fase akhir penyakit.Perubahan prevalansi pada suatu titik waktu lainnya adalah refleksi perubahan laju insidensi , durasi penyakit atau kedua-duanya B. KUALITAS HIDUP 1. Teori Kualitas Hidup Seseorang dalam kehidupannya mempunyai rencana, adanya rencana dan tujuan memungkinkan seseorang memenuhi kebutuhannya, inilah yang menyebabkan seseorang merasa berarti. Kualitas hidup seseorang tercermin dari jurang perbedaan antara harapan dan rencana hidup seseorang dengan kenyataan yang dialami. Hal ini tergantung pada pengalaman sebelumnya, perilaku hidup saat ini dan harapan serta ambisi masa yang akan datang. Jurang perbedaan antara harapan dan kenyataan mungkin dapat diperkecil dengan perbaikan fungsi melalui terapi atau mengurangi pengharapan dengan memberikan penerangan tentang pembatasan yang disebabkan penyakit dan resiko terapi dalam hubungan dengan keuntungan yang diperoleh(22). 2. Definisi Kualitas hidup adalah derajat kepuasan hati karena terpenuhinya kebutuhan hidup baik kebutuhan eksternal maupun persepsinya. Kualitas hidup merupakan integrasi dari kapabilitas, keterbatasan, keluhan dan ciri-ciri psikologis yang menunjukkan kemampuan seseorang untuk melakukan bermacam-macam peran dan merasakan kepuasan dalam melakukan sesuatu(23). 3. Ruang Lingkup Kualitas Hidup Secara tradisional, keberhasilan suatu tindakan terapi diukur dengan angka morbiditas dan mortalitas. Pengukuran dilakukan secara obyektif tanpa memperhatikan rasa atau subyektivitas dari penderita yang menjalani terapi, maka dibuatlah suatu cara pengukuran kualitas hidup menyangkut indikator subyektif dan indikator sosiomedis(22). Kualitas hidup meliputi: a. Status fisik : tingkat kegiatan, kejernihan berpikir, seksualitas, tingkat kesuburan, keluhan nyeri, mual dan muntah b. Status psikologis : perasaan nyaman, depresi, kecemasan c. Hubungan sosial : dengan pasangannya, keluarga, teman d. Status ekonomi 4. Instrumen Pengukur Kualitas Hidup Instrumen untuk mengukur kualitas hidup, selain yang digunakan secara umum juga ada yang spesifik. Hampir semua merupakan kuesioner yang harus diisi sendiri oleh penderita, dirancang untuk mengurangi bias dari pengamat. Setiap pertanyaan dari instrumen kualitas hidup mengandung item dari ruang lingkup diatas dengan jawaban: ya atau tidak (dichotomous) atau tingkatan (scale) : sangat, agak, sedikit atau visual analog berupa garis lurus, kemudian penderita menentukan sendiri nilai tertingginya (extreme) dari keluhan(24). Karnofsky Perforamance Status Scale (KPS) adalah salah satu instrumen untuk mengukur kualitas hidup. KPS ini mempunyai 11 skala, dari yang mempunyai fungsi normal (100) sampai kematian (0). Salah satu instrumen kualitas hidup yang cepat, mudah digunakan, mempunyai reliabilitas dan validitas yang baik adalah indeks kualitas hidup. Hal-hal yang diukur oleh indeks kualitas hidup adalah aktivitas dalam

seminggu terakhir dan harapan dalam minggu terakhir. Cara pengukuran kualitas hidup dengan menggunakan indeks kualitas hidup adalah sebagai berikut; 1. Aktivitas pada minggu terakhir Dapat bekerja, belajar, aktivitas lain seperti atau mendekati normal . nilai: 2 Dapat bekerja, belajar atau aktivitas lain tapi harus mendapat bantuan orang lain atau waktu / lama bekerjanya berkurang dengan nyata . nilai: 1 Tidak mampu bekerja, belajar dalam keadaan apapun .. nilai: 0 1. Kehidupan sehari-hari selama minggu terakhir Dapat makan, mencuci, kekamar kecil, berpakaian sendiri, mampu mengendarai mobil sendiri, atau naik kendaraan umum (bus, kereta) tanpa dibantu .. nilai: 2 Dapat makan, mencuci, kekamar kecil, berpakaian, dapat bepergian dengan kendaraan (bus, kereta) tapi harus dibantu orang lain . nilai: 1 Tidak mampu merawat diri sendiri, atau tidak mampu bepergi an nilai: 0 1. Kesehatan selama minggu terakhir Tampak sehat atau penderita merasa sehat pada sebagian besar waktu nilai: 2 Penderita seringkali merasa lesu, kurang tenaga atau seringkali merasa tidak sehat . nilai: 1 Badan selalu terasa sakit, lemah atau dalam keadaan tidak sadar .. nilai: 0 1. Dukungan (support) selama minggu terakhir Penderita mempunyai hubungan baik dengan orang lain dan memperoleh dukungan kuat paling tidak dari satu anggota keluarga dan/atau teman nilai: 2 Penderita menerima dukungan terbatas dari keluarga dan teman-teman oleh karena kondisi penderita .. nilai: 1 Jarang mendapat dukungan dari keluarga, sahabat atau hanya kalau betul-betul diperlukan, atau penderita dalam keadaan tidak sadar .. nilai: 0 1. Harapan hidup selama minggu terakhir Penderita mempunyai harapan yang positif, dapat menyesuaikan dengan keadaan lingkungan sekitarnya . nilai: 2 Kadang-kadang merasa sedih karena tidak dapat sepenuhnya menyesuaikan dengan keadaan dirinya sendiri dan lingkungan sekitarnya atau merasa . nilai: 1 cemas dan tertekan perasaannya

Betul-betul bingung atau sangat takut, atau kecemasan atau depresi yang menetap, atau penderita dalam keadaan tidak sadar .. nilai: 0 Untuk mendapat nilai kualitas hidup, nilai harus dijumlahkan. Indeks kualitas hidup mempunyai nilai antara 0 10, makin tinggi nilainya berarti kualitas hidup penderita makin baik(25). 5. Kualitas Hidup dan Pembedahan Masa Depan Penilaian kualitas hidup pada prosedur pembedahan menjadi semakin penting. Teknik-teknik operasi terbaru bermunculan untuk memperbaiki kualitas hidup tanpa perbaikan angka kemampuan hidup atau angka kesakitan. Pembedahan juga sering sebagai tindakan pencegahan atau paliatif, maka disini penilaian kualitas hidup merupakan suatu sumbangan pemikiran dalam menentukan terapi.