C h a p t e r 3 9
Disorders of the Male Genitourinary System
1009
distention, overflow incontinence may occur with the
slightest increase in intra-abdominal pressure. The
resulting obstruction to urinary flow can give rise to uri-
nary tract infection, destructive changes of the bladder
wall, hydroureter, and hydronephrosis. Hypertrophy
and changes in bladder wall structure develop in stages.
Initially, the hypertrophied fibers form trabeculations
and then herniations, or sacculations; finally, diverticula
develop as the herniations extend through the bladder
wall (see Chapter 27, Fig. 27-4). Because urine seldom
is completely emptied from them, these diverticula
are readily infected. Back-pressure on the ureters and
collecting system of the kidneys promotes hydroureter,
hydronephrosis, and danger of eventual renal failure.
Current practice suggests that the single most impor-
tant factor in the evaluation and treatment of BPH is
the man’s own experiences related to the disorder. The
American Urological Association Symptom Index con-
sists of seven questions about symptoms regarding
incomplete emptying, frequency, intermittency, urgency,
weak stream, straining, and nocturia.
46
The diagnosis of BPH is based on history, physical
examination, digital rectal examination, urinalysis, blood
tests for serum creatinine and prostate-specific antigen
(PSA), and urine flow rate. The digital rectal examina-
tion is used to examine the external surface and size of
the prostate. An enlarged prostate found during a digital
rectal examination does not always correlate with the
degree of urinary obstruction. Some men can have greatly
enlarged prostate glands with no urinary obstruction,
but others may have severe symptoms without a palpable
enlargement of the prostate. Urinalysis is done to detect
bacteria, white blood cells, or microscopic hematuria in
the presence of infection and inflammation. The serum
creatinine test is used as an estimate of the glomerular
filtration rate and renal function. The PSA test is used
to screen for prostate cancer. These evaluation measures,
along with the symptom index, are used to describe the
extent of obstruction, determine if other diagnostic tests
are needed, and establish the need for treatment.
Treatment of BPH is determined by the degree of
symptoms that the condition produces and complica-
tions due to obstruction. When a man develops mild
symptoms related to BPH, a “watchful waiting” stance
often is taken.
44–46
The condition does not always run a
predictable course; it may remain stable or even improve.
Until the 1980s, surgery was the mainstay of treatment
to alleviate urinary obstruction due to BPH. Currently,
there is an emphasis on less invasive methods of treat-
ment, including use of pharmacologic agents. However,
when more severe signs of obstruction develop, surgi-
cal treatment is indicated to provide comfort and avoid
serious kidney damage.
Pharmacologic management includes the use of
5
α
-reductase inhibitors,
α
1
-adrenergic blocking drugs,
or a combination of the two drugs.
44,45
The 5
α
-reductase
inhibitors suchasfinasteride reduceprostate sizebyblock-
ing the effect of androgens on the prostate. Finasteride
causes atrophy of the prostate glandular epithelial cells,
which results in a 20% to 30% reduction in volume.
The onset is slow (3 to 6 months), but long-lasting.
The presence of
α
-adrenergic receptors in prostatic
smooth muscle has prompted the use of
α
1
-adrenergic
blocking drugs (e.g., prazosin, terazosin) to relieve pros-
tatic obstruction and increase urine flow.
Herbal therapies have been used for many years by
men for the treatment of BPH and lower urinary tract
symptoms.
44–46
Several studies have looked at the effects
of these agents, including the extract of the saw pal-
metto berry. Improvements in peak urine flow rates
and nocturia can occur compared with placebo, but the
durability of these effects is unproven. The long-term
toxicity and mechanism of action of these agents remain
NORMAL PROSTATE
NODULAR PROSTATIC
HYPERPLASIA
CARCINOMA
OF PROSTATE
Anterior
Prostatic
urethra
Posterior
Surgical
capsule
FIGURE 39-12.
Normal prostate, nodular benign prostatic
hyperplasia, and cancer of the prostate. In prostatic
hyperplasia, which involves predominantly the periurethral
part of the gland, the nodules compress and distort the
urethra.The expansion of the central prostatic glands leads to
compression of the peripheral parts and fibrosis, resulting in
the formation of the so-called surgical capsule. Prostatic cancer
usually arises from the peripheral glands and compression of
the urethra is a late clinical event. (From Damjanov I, McCue
PA.The lower urinary tract and male reproductive system. In:
Rubin R, Strayer DS, eds. Rubin’s Pathology: Clinicopathologic
Foundations of Medicine. 6th ed. Philadelphia, PA: Wolters
Kluwer Health | Lippincott Williams &Wilkins; 2012:840.)
