Examination methods, differential diagnosis, and treatment with traditional Chinese and Western medicine for benign prostatic hyperplasia (BPH).

What are the diagnostic methods for benign prostatic hyperplasia (BPH)?

Men over 50 years of age who experience difficulty urinating or increased nocturia should be suspected of having benign prostatic hyperplasia (BPH) and should undergo a series of formal examinations to confirm the diagnosis.

(1) Digital rectal examination: Digital rectal examination is the simplest and most important method for diagnosing benign prostatic hyperplasia (BPH). Before the examination, the bladder should be emptied. The normal size of the prostate is about the size of a chestnut. In BPH, enlargement (increased anteroposterior or transverse diameter) of the lateral or middle lobes can be felt in the rectum. The surface is smooth, and the prostate may bulge into the rectum. The texture is moderate, firm, and elastic. The central groove between the lateral lobes becomes shallower or disappears. Sometimes, enlargement of the middle or lower neck lobe of the prostate protrudes into the bladder, which can also cause severe obstruction and lead to typical BPH symptoms, but the enlarged gland cannot be felt in the rectum. Therefore, even if the patient has obvious bladder neck obstruction, and the prostate is not enlarged during digital rectal examination, the diagnosis of BPH cannot be ruled out; further examinations are necessary for confirmation.

(2) Residual urine measurement: The amount of residual urine can indicate the degree of obstruction and is one of the important indicators for determining whether surgical treatment is necessary. The measurement is performed immediately after the patient has emptied their bladder as much as possible. Methods of measurement include ultrasound and catheterization. Generally, a residual urine volume of 60 ml or more is considered an indication for surgical removal of the prostate.

(3) Cystoscopy: Cystoscopy can directly visualize the location and extent of prostatic hyperplasia in the bladder neck, thereby determining the treatment strategy and surgical method.

(4) Cystography: This examination is essential when digital rectal examination cannot provide a definitive diagnosis, or when other lesions are suspected within the bladder. X-ray findings of cystography in benign prostatic hyperplasia:

The base of the bladder is elevated, bulging upwards in an arc. The bladder has been displaced upwards, and the distance between the edge of the bladder outlet and the pubic symphysis has widened, appearing as if there is a filling defect.

The prostatic urethra is elongated. If the lesion is in the middle lobe, the upper part of the prostatic urethra shifts forward, and the lower part bends backward.

Trabecular chambers or diverticula may be present in the bladder.

(5) Ultrasound computed tomography: Ultrasound diagnosis of prostate diseases can depict the morphology and nature of the gland. There are two approaches to ultrasound detection of the prostate:

Transabdominal approach: The prostate is probed through the anterior abdominal wall above the pubic bone.

Transrectal method: An ultrasound probe is inserted into the anus through the rectum with a water-filled bladder. After water is injected and air is expelled, the prostate is probed.

(6) Uroflowmetry: This mainly checks for obstruction in the bladder neck of the lower urinary tract. Statistics show that 71% of bladder neck obstructions are due to benign prostatic hyperplasia (BPH). Generally, a maximum urinary flow rate above 25 ml/s can rule out bladder neck obstruction, a flow rate between 10 and 25 ml/s suggests obstruction, and a flow rate below 10 ml/s indicates obstruction. In cases of bladder neck obstruction caused by BPH, uroflowmetry shows a maximum urinary flow rate, with a significant decrease in both flow time and total urine volume.

(7) CT scan: CT has certain advantages over other imaging diagnostic methods in the diagnosis of urogenital diseases.

(8) Magnetic resonance imaging: Magnetic resonance imaging has certain advantages over other imaging diagnostic methods for the diagnosis of urogenital diseases.

(9) Prostate imaging: It has diagnostic value for certain special cases.

(10) Plasma zinc measurement: Normal prostate contains high tissue concentrations of zinc, and the zinc content increases significantly during benign prostatic hyperplasia (BPH). Although there is no correlation between plasma zinc levels and prostate size, it can be used as one of the clinical indicators for diagnosing BPH.

(11) Other examinations: including routine urine tests, renal function tests and certain special examinations when necessary.

Which diseases should be differentiated from benign prostatic hyperplasia?

(1) Prostate-related diseases: cancer, tuberculosis, stones, cysts, fibrosis, median crest, schistosomiasis.

(2) Bladder-related conditions: tumors, stones, bladder trigone hypertrophy, neurogenic bladder, ureteral orifice cysts.

(3) Bladder neck lesions: neck contracture.

(4) Urethral issues: seminal vesicle hyperplasia, urethral stricture (inflammatory or traumatic), tumors, stones.

Particular attention should be paid to the presence of neurogenic bladder, as older patients often experience urinary retention due to neurogenic or muscular urinary dysfunction, which may prevent normal urination even after complete treatment of benign prostatic hyperplasia. Therefore, considering these factors before surgery can help estimate the surgical outcome.

How to treat benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) that does not cause obstruction may not require treatment. If obstruction exists but does not affect normal physiological function, observation is recommended, but prostate health should be maintained. If normal physiological function is affected (a significant amount of residual urine is present), treatment should be initiated as soon as possible. Treatment methods are as follows:

(1) Traditional Chinese Medicine Treatment

Treatment should be based on syndrome differentiation according to the patient's condition. Traditional Chinese medicine or prepared Chinese medicine may be used as appropriate, and the therapeutic effect is relatively good.

(2) Hormone therapy

Hormone therapy is effective for early-stage cases, but opinions differ on the methods of application.

Androgen therapy dosage: Testosterone propionate 25mg, intramuscular injection, 2-3 times per week, for a total of 10 times. Then reduce to 10mg, intramuscular injection, twice per week, for a total of 10 times. The total dose is approximately 350-500mg. Treatment can be repeated after six months if necessary. For patients with acute urinary retention, administer 25mg once daily intramuscular injection for 5-6 days or until spontaneous urination occurs. Due to differing opinions on androgen therapy and its less-than-ideal effects, some have experimented with combining estrogen and androgen, or using estrogen alone.

Combined use of female and male hormone therapy.

Estrogen therapy: Currently, estrogen therapy is widely advocated for the treatment of benign prostatic hyperplasia (BPH), which can achieve good results, shrink the gland, make it firmer, and improve urinary symptoms to varying degrees.

Anti-androgen therapy.

Progesterone therapy: Progestins (luteal hormones) have been widely used in recent years. They work by inhibiting the binding and nuclear uptake of androgens to cells, or by inhibiting 5α-reductase, thus interfering with the formation of dihydrotestosterone. Types include progesterone-17-hexanoate, progesterone-17-hydroxy-19-norhexanoate, medroxyprogesterone acetate, and dimethoprim-progesterone. The last two are the most promising.

(3) Other drug treatments

alpha-adrenaline: can be blocked by phenoxybenzamine, phentolamine, prazosin, nicergoline, thymolamine, methyldopa, etc.

Bromocriptine: Also known as bromocriptine. Prolactin plays a role in the uptake and utilization of androgens by prolactin cells, so the intake of prolactin antagonists can interfere with this process. Early reports on the use of this drug suggested that it could improve prostate irritation symptoms, but not obstructive symptoms.

Spironolactone: Also known as spironolactone. Spironolactone is an inhibitor of androgen synthesis that can significantly reduce plasma testosterone and has anti-androgenic effects.

Adrenocortical hormones.

Pollen-based products: In recent years, bee pollen has been used in China to produce Qianliekang tablets, which contain amino acids, vitamins, enzymes, sugars and trace elements. These tablets have a certain therapeutic effect on the prevention and treatment of benign prostatic hyperplasia and the improvement of its symptoms.

(4) Intraprostatic drug injection therapy

(5) Physical therapy

This involves using various physical methods to induce localized edema, congestion, and even tissue atrophy in the prostate, thereby improving urinary symptoms. This is a developing method that requires continuous exploration and improvement, and may become one of the main treatments for benign prostatic hyperplasia (BPH) in the future. Methods include: cryotherapy; microwave therapy; and ultrasound therapy.

(6) Management of acute urinary retention

65% of patients with benign prostatic hyperplasia (BPH) experience acute urinary retention, which often occurs suddenly, causing severe urinary distress and requiring immediate relief. When relieving acute urinary retention, the bladder should be emptied gradually, never abruptly, especially in cases complicated by uremia. Sudden bladder emptying can cause abrupt changes in hemodynamics, leading to heart failure, shock, or massive renal hemorrhage, bladder bleeding, or perivesical bleeding. It can also cause urinary retention and electrolyte imbalance. After drainage, electrolyte imbalances must be monitored for 3 days. If necessary, potassium, sodium, and chloride electrolytes should be supplemented. In addition to treating acute urinary retention, pain relief and infection control or prevention are also essential.

Methods to relieve acute urinary retention:

① Apply heat to the lower abdomen and perineum.

② Acupuncture: Select acupoints such as Zhongji, Pangguanshu, and Yinlingquan.

③ Urinary catheterization: Urinary catheterization is performed under aseptic conditions.

④ Drug treatment: Traditional Chinese medicine can often achieve good results when used as appropriate.

⑤ Suprapubic bladder puncture: When a catheter cannot be inserted and there is no other way to resolve acute urinary retention, suprapubic bladder puncture is a temporary emergency measure.

⑥ Cystostomy: When acute urinary retention is caused by benign prostatic hyperplasia and a catheter cannot be inserted, and there are no conditions for prostatectomy, a cystostomy can be performed to resolve the acute urinary retention.

⑦ Emergency prostatectomy: Surgical indications: The patient is in good general condition, without clinical signs of uremia and acidosis; without severe cardiovascular and pulmonary diseases; non-protein nitrogen is below 50 mg%; CO₂ combining power is within the normal range; during cystotomy, indigo carmine is injected intravenously and blue urine is expelled from the orifices of both ureters within 8 minutes.

(7) Surgical treatment

Surgical indications: ① Benign prostatic hyperplasia (BPH) with progressive dysuria, unresponsive to non-surgical treatment. ② Chronic urinary retention with residual urine volume exceeding 60 ml. Currently, many researchers use bladder function tests such as uroflowmetry, cystometry, and urethral manometry to determine surgical intervention. When the detrusor muscle is in a compensatory phase, surgery is considered an indication. ③ Obstruction leading to bladder diverticulum or stones, hydronephrosis or hydroureter. ④ Obstruction causing chronic or recurrent urinary tract infections. ⑤ BPH accompanied by bleeding, especially heavy and recurrent bleeding. ⑥ Acute urinary retention.

Surgical methods: Currently, four methods are commonly used: ① Suprapubic prostatectomy. ② Retropubic prostatectomy. ③ Transperineal prostatectomy. ④ Transurethral resection of the prostate (TURP).

In summary, among the various surgical procedures mentioned above, scholars generally consider suprapubic and retropubic prostatectomy to be the most practical. It can essentially resolve all types of benign prostatic hyperplasia, offers greater flexibility, and allows for cystostomy in emergency situations to temporarily resolve urination problems. If a tumor is found, the surgical scope can be expanded. Complications are not significantly more frequent than with other surgical approaches.

Common complications of prostate enlargement surgery include: ① bleeding; ② infection; ③ urinary incontinence; ④ urethral stricture; and ⑤ impact on sexual function.

In conclusion, regardless of which treatment method is suitable, it should be used under the guidance of a doctor, and attention should be paid to rehabilitation and health care.