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Benign Prostatic Hyperplasia Benign Prostatic Hyperplasia Also known as benign prostatic hypertrophy (BPH) occurs when there is an increase in the size of the prostate gland without the presence of a malignancy; the condition is so common it is considered normal as the man ages. An enlarged prostate can cause compression of the urethra as it traverses the prostate. BPH is the most common prostate problem in men. Most frequently it occurs in men over the age of 50 years. The enlarged prostate can cause urinary symptoms. BPH can impact negatively on a man’s quality of life. BPH is uncommon before the age of 45, affecting men of Afro‐American origin more severely than it does white men. Between the ages of 31 and 50 the prostate gland doubles in size every 4.5a•›years but this rate reduces subsequently. Pathophysiology The cause of BPH is unclear. Enlargement of the prostate is dependent on the androgen dihydrotestosterone (DHT). DHT binds to androgen receptors located in the cell nuclei, potentially resulting in BPH. This results in an oestrogen and androgen imbalance. There are large numbers of alpha‐1‐adrenergic receptors located in the smooth muscle of the stroma and capsule of the prostate, and the bladder neck. BPH is characterized as a hyperplastic process, resulting in prostatic enlargement causing clinical manifestations of BPH. The prostate enlarges with age and is hormone dependent, men who are unable to produce testosterone do not develop BPH. 1 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 lower urinary tract symptoms (LUTS). The bladder wall becomes thickened, trabeculated and irritable when forced to hypertrophy, increasing its own contractile force. This is believed to contribute to urinary frequency and LUTS. The bladder may gradually weaken and its ability to empty completely disappears, causing increased residual urine volume with acute or chronic urinary retention. Obstruction in the bladder leads to smooth‐muscle‐cell hypertrophy. Collagen fibres limit shortening of adjacent smooth muscle cells, leading to impaired emptying and development of residual urine. Signs and symptoms There is an increased frequency of micturition associated with a delay in initiating micturition and a reduction in the force of the urinary stream. As the condition progresses there may be inadequate emptying of the urinary bladder, resulting in dribbling of urine and urinary over flow. The time required by the man to void increases. With advanced BPH the man may be unable to pass urine due to urethral compression. Urinary obstruction can lead to urinary tract infection and if unrelieved, progress to renal failure Investigations A detailed history should be taken and a physical examination. Urinalysis should be done to check for the presence of blood, leukocytes, bacteria, protein or glucose. Urine culture should also be performed, to exclude infectious causes of irritative voiding, if urinalysis indicates an abnormality. Prostate specific antigen (PSA) may be assessed, although 2 screening for prostate cancer remains controversial and should be performed after an informed discussion with the man. Evaluation of electrolytes, blood urea nitrogen and creatinine can be used as screening tools for chronic renal insufficiency in men who have high post‐void residual urine volumes. Abdominal, renal, transrectal ultrasound sonography and intravenous urography help determine bladder and prostate size and degree of hydronephrosis (if any) in those with urinary retention or signs of renal insufficiency. Transrectal ultrasonography (TRUS) of the prostate can determine the dimensions and volume of the prostate. In men with raised PSA levels, TRUS‐guided biopsy may be indicated. Imaging of the upper urinary tracts in those with associated haematuria, history of urolithiasis, elevated creatinine level, high PVR volume or history of upper urinary tract infection is indicated. Drugs Alpha adrenergic blockers reduce the tone in the muscle of the neck of the bladder and should be offered to men with moderateto‐ severe voiding symptoms. There are alpha‐1 receptors that are subdivided into types 1a, 1b and 1c. These should be avoided in men with postural hypotension or micturition syncope. The 5‐alpha reductase inhibitor (5‐ARI) drugs block the synthesis of dihydrotestosterone from testosterone and can reduce symptoms, for example finasteride and dutasteride. They should be offered to men with LUTS and a prostate estimated to be larger than 30a•›g or PSA greater than 1.4a•›ng/mL and a high risk of progression. These medications may have an adverse effect on sexual performance. Surgery 3 Surgery is reserved for those with a large prostate or failure to respond to an adequate trial of medical therapy. Surgery is needed if there is acute urinary retention, failed voiding trials, recurrent gross haematuria, UTI, renal insufficiency due to obstruction or failure of medical treatment. Open prostatectomy – transurethral vaporization of the prostate (TUVP) – is used for prostates larger than 75a•›g, bladder stones or bladder diverticula and patients who cannot be positioned for transurethral surgery. Transurethral resection of the prostate (TURP) is now the standard technique. When successful, it is an excellent operation that does not involve entering the abdomen but it can have complications. Holmium laser enucleation of the prostate (HoLEP) is effective, has a lower morbidity rate and where available is first choice of treatment. Minimally invasive therapies involve heat destruction of prostatic tissue. Where the estimated prostate size smaller than 30a•›g, transurethral incision of the prostate (TUIP) or transurethral needle ablation (TUNA) is an alternative to TURP for those wishing to avoid or who are unfit for more invasive surgery. 4 Testicular torsion Torsion of the testes is an abnormal twisting of the spermatic cord due to rotation of a testes or the mesorchium (this is a fold in the area between the testes and epididymis. This occurs when a testicle rotates, causing twisting of the spermatic cord. There is a reduced blood flow as a result and this causes sudden and often severe pain and oedema that is not relieved by rest and elevation. The condition is most common between the ages 12 and 16 years; however, it may occur at any age, even in utero. Testicular torsion is a urological emergency and requires emergency surgical intervention. If the condition is treated within a few hours, the likelihood of saving the testicle will increase. If the condition is left untreated then permanent damage may ensue; this can impact on the man’s ability to father children. When the flow of blood has been impaired for too long, infarction of the testicle can occur and it becomes so seriously injured that orchidectomy will be required. The prognosis is good with early detection and prompt treatment. The contents of the spermatic cord include the following: •a•¢ Ductus deferens and related vasculature and nerves •a•¢ Testicular artery •a•¢ Pampiniform plexus, this eventually forms the testicular vein •a•¢ Genital branch of the genitofemoral nerve Pathophysiology The onset may be spontaneous or it may occur after physical exertion or physical trauma. The condition is almost always unilateral. Torsion may happen at any time, when sitting or standing, or it may awaken a person from sleep. 5 In neonates, often the testicle has not descended into the scrotal sac, where it becomes attached within the tunica vaginalis. As a result, this mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). The normal contraction of the cremaster muscle causes the left testes to rotate in a counterclockwise manner with the right testes rotating clockwise. Incompetent fusion of the testicle to the scrotal wall typically is diagnosed within the first 7–10 days of life. In those who have an inappropriately high attachment of the tunica vaginalis and an abnormal fixation to the muscle and fascial coverings of the spermatic cord, the testicle can rotate freely on the spermatic cord inside the tunica vaginalis (intravaginal testicular torsion). This congenital irregularity, known as the bell clapper deformity, can cause the long axis of the testicle to be oriented transversely as opposed to cephalocaudal (from head to toe). The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. As the testicle rotates between 90° and 180° this compromises blood flow to and from the testicle. Complete torsion occurs when the testicle twists 360° or more; incomplete torsion occurs with lesser degrees of rotation. It is possible for the degree of torsion to extend to 720°. As the testicle twists venous occlusion occurs and engorgement, along with arterial ischaemia and infarction of the testicle. The degree of testicular torsion plays a role in the viability of the testicle over time. As well as the degree of torsion, the duration of torsion significantly influences the rates of immediate salvage and also late testicular atrophy. Testicular salvage is more probable if the duration of torsion is less than 6–8 hours. If more than 24 hours elapses then testicular necrosis will develop in most patients. Signs and symptoms 6 Excruciating unilateral pain, with a sudden onset followed by inguinal and/or scrotal swelling occurs. As necrosis becomes more complete the pain may lessen. It is unusual for the pain to present in a gradual manner. As torsion can also occur with sports or A physical activity it can be associated with trauma or may happen spontaneously. There may also be gastrointestinal upset accompanied with nausea and vomiting. Where the duration of pain is less than six hours, pyrexia, vomiting, history of trauma or activities, absence of cremasteric reflex and abnormal testicle direction have all been shown to be significantly associated with the diagnosis of testicular torsion. It is unusual for the person to relate problems with micturition or dysuria. Some patients describe previous episodes of recurrent acute scrotal pain that had resolved spontaneously. This is suggestive of intermittent torsion and detorsion of the testicle; in this instance prompt referral to a urologist is essential as those with symptoms who have elective surgical exploration are less likely to develop subsequent torsion and loss of the testicle. Typically, there is reddening of the scrotal skin with oedamtous, tender testes retracted upwards. Lifting the testes up over the symphysis causes an increase in pain. The epididymis may be felt in an abnormal anterior rather than its typical posterior position in the early stages; however, this depends upon the degree of torsion. As the condition progresses the gross swelling prevents this finding. Unilaterally the testes are typically in the ‘bell‐clapper position’ with a horizontal long axis. Investigations The healthcare practitioner undertakes a clinical evaluation which consists of medical history and physical examination; this is often sufficient to diagnose torsion. If testicular torsion is clinically suggested, 7 immediate surgical exploration is required; this is regardless of laboratory studies, a negative finding upon exploration of the scrotum is more suitable than the loss of a testicle, surgical intervention should not be delayed for the sake of further investigation. No single laboratory test has high sensitivity or specificity in diagnosing testicular torsion. Imaging studies (ultrasonography, nuclear scans) may be useful when a low suspicion of testicular torsion exists, otherwise they are of little value. The most important investigation is ultrasound integrated with colour Doppler; this investigation detects the presence/ absence of intratesticular blood flow for the early identification of testicular torsion. Management If manual reduction is unsuccessful, surgical intervention is required within six hours after the onset of injury in order to A preserve testicular function. Surgical detorsion is the definitive treatment for testicular torsion. Testicular torsion is treated with orchiopexy, the testes is anchored to the scrotal wall. There may be a need for orchidectomy. 8