Benign Prostatic Hyperplasia

Introduction

The male organ or gland which produces a fluidly substance for carrying and nourishing your sperms during your sex act, is called Prostate gland. Prostate gland lies just below the urinary bladder and surround the urethra, which delivers urine from bladder and genital secretions from internal genital organs. It is very common occurrence for this gland to become enlarge in size with your advancing age. The most common variety of this increase in size of your prostate gland is known as Benign prostatic hyperplasia (BPH) or hypertrophy.

It is termed benign as it does not spreads even though its size increases like a tumor. It will keep growing after you get older than 25 years of age. Not infrequently it starts producing troublesome urinary symptoms after you reach the age of 50. Your doctor will make rectal examination  and inform you that you have developed BPH(benign prostatic hyperplasia). It may be regarded as one of the effects of male aging.

Ÿ  Incidence : It is estimated that if you are 60 years old, your chances of developing BPH is 50%, which rises to 90% as you age to 70 years.

Ÿ   Symptoms    :  Your severely enlarged prostate will cause you urinary complains, as it will press tight on your urethra. But sometimes, even if your prostate is not much enlarged it can create all the following troublesome complaints confined to urinary discharge:

                            

 ·delayed urine stream:  your urethra is clamped by enlarged   prostate. That makes you strain for urine stream. Commonly termed hesitancy..                                                                                                      .                               

·       Retention of urine  : At some stage ,due to straining , bladder  becomes weak and urine is not completely emptied out and  remains in your bladder.

                                     

  ·      Blood in urine    :  This is an indication that either you   have infection or some stone formation in your bladder due to retained, concentrated urine.                                              

•    Dribbling of urine :  you may loose control on your  bladder   as blockage by enlarged prostate results in left over  urine to constantly irritate your bladder. You may constantly  leak through urethra or fail to hold urine.

  ·    Weakening of stream of urine  : Due to pressure of  your  hypertrophied prostate on urethra, you fail to attain stream of  urine.

           .                                    

·     Frequency of micturation at night : retention of urine in your bladder irritates and cause more frequent desire to urinate during day and night.

 Causes and Risk factors

The major reason for your prostate to enlarge is a physiological or normal aging phenomenon. It keeps growing even after 25 years, but when it produces pressure symptoms on your urinary tract flow system, it is noticed and diagnosed as BPH.

Ÿ        Testes and BPH     : It has been observed that men whose testes have been removed do not develop benign prostatic hyperplasia. This just indicates some stimulating effect of your testes on your BPH.(National Kidney and Urologic information, US department of health.)

Ÿ        Hormones          :    With aging you start to loose your male hormone, testosterone. But ,the small amount of female hormone that is being produced now dominates. This female hormone, estrogen is secreted  through out your life and is known to enhance the activity of substances which promote cell growth in animal gland

Ÿ    Dihydrotestosterone      : This hormone is produced by your prostate and with age its concentration lowers . Interestingly, it has been observed that, while men loose testosterone, some still show higher concentration of DHT(dihydro-testosterone). This may result in your prostate growth. Men who do not have high DHT, don’t develop benign prostatic hypertrophy.

Risk factors

Ÿ          Age        : Your age is the main risk factor in development of enlarge prostate or benign prostattic hypertrophy(hyperplasia). The more older you get , more likely to  chance for you to suffer from BPH,  and viz-a viz(other way round). At 50 years you have 50% greater risk of BPH.

Ÿ         Family history    :  Your susceptibility increases if any of your siblings(father or brothers) have benign prostatic enlargement.

Ÿ         Heart diseases risk and BPH :  your chances of getting an enlarged prostate at later years of your life, if you have risk factor which play major role in heart disease. They can be, over weight, high cholesterol levels, high blood pressure, lower concentration of HDL( cardio-protective lipoproteins), diabetes and disease of peripheral arteries.

Ÿ          Race    :  If you belong to white race, you are at higher susceptibility of having benign prostatic hyperplasia with severe symptoms. You have more on risk of being on surgeon’s list for prostate removal due to BPH. Asians are least likely to have benign enlargement of prostate.

 complications

Your benign prostatic hyperplasia rarely causes any serious complication. When in case you start having severe symptoms attributed to your BPH, they are from pressure of your enlarged gland on urethra. These are entirely due to partial or complete blockage of your urine flow.

Ÿ                 Urinary retention   :  You may develop sudden and complete inability to pass urine, called acute urinary retention(AUR). This situation may cause severe pain at your bladder region( pubic area), which needs emergency measures like passing urethral catheter or supra-pubic needle at your bladder to empty your bladder and relieve the severe pain. If  your benign prostatic hyperplasia is blocking the urethra partially, then slow retention of urine in your bladder will complicate into CUR( chronic urinary retention).

Ÿ                   Urinary tract infection      :   The residual urine in your bladder may become seat of infection. This may produce some worrying symptoms of blood in your urine,  and painful micturation. It may cause ascending infection to your kidneys, resulting in its functional disturbances and damage.  If untreated, this kidney infection may cause waste products of protein metabolism to accumulate, which can make your health to get worse.

Ÿ           Urolithiasis (stone in urinary tract)  : The retained urine in your bladder because of BPH, is concentrated. The crystals of mineral present in this residual urine clump to form bladder stones. The stone may travel down to your urethra and block passage of urine. It is considered an emergency and needs immediate bladder relief via catheter.

Ÿ            Kidney damage    : benign prostatic hyperplasia and its blocking effect on your urine outflow passage secondarily causes damage to your kidneys. This is due to chronic(of long standing) back pressure of residual urine, on kidney’s normal filtration process.

You should keep this in mind, that, your benign prostatic hyperplasia will not effect your sexual ability nor it will become cancerous( progress to cancer). It will also not rreduce your fertility.

 Pharmaceutical therapies

                            It has been observed that you will consult your doctor not before you have urinary symptoms start bothering you. Your health care provide will not only take into account the extent and severity of your urinary complaints, but he will also have a physical examination done to make an initial assessment of your prostatic enlargement. He may advise test which will give a more confirm clue to diagnose your BPH.

Ÿ                        If your symptoms are milder and not bothering(American Urological Association score 0-7), all you will be advised is to make few changes in your daily routine, such as fluid intake, self controlling bladder urge, and avoiding night hours of tea, coffee or any liquid etc. you will not be given any medication or surgical options. All you will be asked is to keep regular follow up to your doctor. In case your symptoms get worse report.

Ÿ                       If your symptoms associated with BPH are not bothering you much (AUA score 8 or more) , your doctor advises you watchful waiting with or without medication. If symptoms get severe, specially night time visit or painful urination you will be given options for either surgery or transurethral prostate ablation(removal).

Ÿ                       In case you are unable to pass urine, or have blood in urine or stone in your bladder you will be cured of your symptoms by surgical means only.

                        

                         

                                                                                                                                                                     Medicine you will commonly be prescribed are following ;    

Ÿ                    Alpha (sympathetic) blockers     :  They will make easier flow of your urine from blocked urethra due to BPH. This effect is exerted by relaxation of smooth muscle of your enlarged prostate in BPH and bladder neck, loosening its grip on your urethra. They are given when you symptoms are moderate and bothersome. You will feel much better when the alpha blocker is given to you in combination with 5-alpha reductase. They give good result in improving symptoms in nearly 2-3 weeks. Commonly used alpha blockers are;

Ÿ                    Alphazosin

Ÿ                    Doxazosin 

Ÿ                    Silodozosin

Ÿ                   Tamsulosin

Ÿ                   Terazosin

Side effects of these alpha blockers you may face are, dizziness, fatigue and weakness, fainting due postural hypotension( lowering of BP after sudden standing from sitting position), headcahes, nausea, and upward semen discharge into bladder( retrograde ejaculation).

Ÿ                         5-alpha reductase inhibitors   :     The mode of action of these agents work through inhibition of testosterone conversion to dihydrotestosterone(DHT). DHT is shown in studies to be responsible for growth of your prostate. Hence by this action 5-alpha reductase reduces the size of  your benign prostatic hyperplasia to nearly 25% in about a year time. As mentioned their effects are better taken advantage of when given with alpha receptor blocking medicines.

Following are common drugs of this group ;

Ÿ                    Finasteride

Ÿ                    Dutasteride

Side effects of 5-alpha reductase inhibitors may cause , loss of sexual desire( libido), difficulties in ejaculation,  erection problems, and enlargement and tenderness of your breasts.

Ÿ                        Tedalafil  : This medicine has been in use for some years for erectile dysfunction. It has been approved recently for your benign prostatic hyperplasia. It is a phosphodiasterase-5(PDE5) inhibitor. Tedalafil has proven efficacy in relieving or minimizing your BPH related urinary symptoms. It is not prescribed with nitrites(nitroglycerine) or alpha blockers, as sudden and severe drop of your blood pressure may occur.

Side effects of tedalafil use are, headache, dyspepsia, back pain, muscular pain, nasal congestion, flushing and painful limbs. Loss in hearing and visual impairment have also  been reported. In such cases your doctor should immediately be informed for further advise.

Herpes and Folliculitis: Their Co-existence

The inflammation of hair follicles termed follicultis can effect an individual of any age, region or sex. It also can be initiated by one or more micro-organisms at a given instance. It is the damaged hair follicle, which is a pre-requisite to initiate folliculitis. It can then be invaded by staphylococcus aureus, the commonest infecting agent, fungus such candida, pityrosporum or malassezia , demodex mite, or virus of herpez class.

Herpes virus itself causes skin eruption. Its two different entities are seen in young children and adult age groups. Varicella (chickenpox) is one type which appears as systemic illness with typical skin eruption on face, trunk and other body parts. The rash  is quite distinct from typical folliculitis. It is vesiculo-papulo-pustular and a black scabbing at the end of this eruptive illness. All  forms of rash can be seen at one time on different parts of body. Face and trunk are mostly crowded with typical chickenpox rash as its commonly known name. This variety of herpes vericella skin eruption is most commonly confined to kids and young adults. The rash and the accompanying systemic illness is highly contagious in herpes vericella infection, either as droplets infection through coughing, sneezing or even the vesicular lesion can spread the illness.

The red pimple of folliculitis is papulo-pustular in appearance and it is seen in hairy parts of body, where injury to follicles gives way to invasion by micro-organism residing on skin as normal flora. Folliculitis can spread from one individual to another due to unhygienic lifestyle. Sharing the same toiletries, swimming pools, hot bath tubs are the common mode of its spread.

As for management is concerned, vericella (chicken pox) is self limiting, and rash resolve in about week to ten days time. Only supportive treatment is enough. Itching is controlled by some soothing agent, such as calamine lotion. A local anti-viral cream (zovirex) is also used when extensive facial eruption occur.

Treatment protocol for simple folliculitis stresses more on adopting better hygiene in daily life. Anti-septic soap baths and concurrent use of some solution of anti-infective property must be used along with warm damp washout of effected skin will help in faster healing. Itching is controlled with anti-allergic formulations.

Folliculitis and herpes varicella share common symptoms of severe itching and therefore spread from one part to another part of body. Same virus reactivates many years of being dormant after primary infection but it is localized to nerves and the rash is also distributed in same pattern of nerves. This is commonly called herpes zoster or shingles. Severe pain is predominant in shingles.

In some instances, herpes simplex virus itself causes inflammation of follicles commonly at bearded area. This  can become stubborn in responding to conventional methods of treatment unless a definitive diagnosis is made by isolating virus by doing smear of skin lesion and positive culture for infecting virus. Anti-viral drugs can effectively treat folliculitis of HSV, given for 5-10 days. Isolation of infected individual until active phase is over can save many  from getting troublesome skin condition

Types of Folliculitis & Their Remedy

Human skin is in most part covered with hair, whether small and silky or long and relatively tough. In all kinds they grow from small follicles, which has roots or attachments to deeper skin tissue. This gives some hint of what may occur if any damage takes place to follicles, opening an entry point for number of micro-organism harboring on normal skin or from  unhealthy environment. When a person gets folliculitis it can take the following shape or severity:

1) Superficial folliculitis,  80%  cases of folliculitis ,in which damage and subsequent infection remains limited to upper layer of skin,  as superficial pustular lesions. This may just appear as raised red area over skin in region of hair, a bump usually it is called. It has no specific location, as any area having hair follicle can become infected, like facial region specially shaving area including chin, scalp, buttocks, thighs, axilla, and trunk.

Treatment is based  on simple conservative approach, with more emphasis on taking shower regularly with some potent anti-bacterial soap, or regular application of benzyl peroxide, a potent local broad spectrum anti-bacterial preparation which effectively fasten healing process to full recovery without residual scaring or hair loss.

Occasionally, the simple form heals with simple measure but may leave a hardened nodular bump without any sign of redness or pain, seen at shaving area and also over the chest more commonly in dark skinned individuals.

As simple folliculitis or milder form is more itchy and tender,  using diphehydramine or some other anti-allergic and  pain killer is advisable. Applying moist hot compresses also help in clearing dead tissues as well as reduce itching.

2) Deep folliculitis, may morphologically be specific, occurring on its own causes or as complication of superficial folliculitis. The hallmark of deeper folliculitis is that infecting organism  penetrates deeper layers of  skin through damaged hair follicle, which in all probability may effect other parts of body once spread is not adequately treated. As it can be caused by different  classes of microbes, it can be discussed  individually. Even in all these different settings the basic principle of personal hygiene will apply, and use of conservative remedies used in superficial or simple folliculitis.

a) Bacterial folliculitis Most common micro-bacterium is staphylococcus , and anti-biotics of choice for treating folliculitis  by this organism are ciphalexin, dicloxicillin, or flocloxacillin in dose range of 250-500mg four times daily for ten days. Hot tub folliculitis is common incidence in person using public hot tub baths and swimming pools. The organism involved in such settings is usually pseudomonas aeruginosa  usually can be controlled with benzyl peroxide wash twice daily may suffice. But when it gets widespread as it commonly happens, suitable anti-biotic cover for 7-10 days is needed. Ciprofloxacillin is best choice, and dose  is 500mg two times /day.

b) Fungal folliculitis, most commonly on scalp, needs to be treated by topical ketoconazole shampoo 3-5 times per week/ econazole applied locally twice daily untill  condition heals up completely. If specific fungus is identified as in more severe infection oral anti-fungal drugs, such as fluconazole or itraconazole is given in dose range of 100mg -200mg once or twic daily for minimum of two weeks. As in most instances bacterial infection concurrently exist oral anti-biotics is also advisable as adjuvant treatment.

c) Viral folliculitis such as caused by herpes , has acyclovir available as treatment of choice in 200mg dose four times per day for 5-10 days duration.

d)Abscess can be one form of complicated   folliculitis, when  large collection of pus not only causes swelling of small bump but spreads into surrounding and deeper tissue. Most commonly  it is seen in facial and armpit region where not only the folliculitis becomes enlarged into swelling filled with increased amount of pus, even the lymph node draining the particular area becomes tender and enlarged too. The definitive approach to treatment is incision and drainage of pus filled cavity, until it is devoid of infected substance, sometimes surgeon may leave a sterile gauze to prevent refilling of space till healing is complete.  Use of anti-biotic may or may not be needed.

What ever type, severity , location folliculitis presents with, the corner stone of treatment is meticulous personal hygiene ,of which there is no alternative.