The prostate is a
compound tubuloalveolar exocrine gland of the male reproductive system. The function of the prostate is to secrete a
fluid, milky or white in appearance along with spermatozoa
and seminal vesicle fluid. Benign prostatic
hyperplasia, abbreviated as BPH, is nonmalignant enlargement of the prostate
gland and mostly found in older men. Since women do not have a prostate, they
cannot get BPH. On the other end, Young men almost never experience symptoms of
an enlarged prostate. Histological evidence of the disease is noted in 8% of
men in their 30s, and the prevalence rapidly increases to more than 70% after
the age 60 years. BPH can be a progressive
especially if left untreated. A study reports on a newly
discovered venous route by which free testosterone reaches the prostate in
extremely high concentrations, promoting the accelerated proliferation of
prostate cells, leading to the gland's enlargement. Another study suggests that
BPH is caused by malfunction of the valves in the internal spermatic veins
manifesting as varicocele, a phenomenon which has been shown to increase
rapidly with age, roughly equal to 10-15% each decade of life.
As BPH progresses,
overgrowth occurs in the central area of the prostate called the transition
zone, which wraps around the urethra. This pressure on the urethra can cause
lower urinary symptoms that have been the basis for diagnosing BPH. Typical presenting symptoms of BPH are urinary hesitancy, weak
stream, nocturia, and incontinence. According
to a report, the overall incidence rate was 15 per 1000 man-years. The
incidence increased linearly with age from three cases per 1000 man-years at
the age of 45-49 year to a maximum of 38 cases per 1000 man-years at the age of
75-79 years. After the age of 80 years, the incidence rate remained constant.
For a symptom-free man of 46 years, the risk to develop Lower Urinary Tract Syndrome
(LUTS)/BPH over the coming 30 years, if he survives, is 45%. The overall
prevalence of LUTS/BPH was 10.3%. The prevalence rate was lowest among males
45-49 years of age (2.7%) and increased with age until a maximum at the age of
80 years (24%). In the 20th century, open surgical management of
BPH became popular. A relatively high-morbidity and expensive procedure, open
prostatectomy was gradually replaced by transurethral resection of the prostate
(TURP) as the standard surgical treatment of small to medium sized BPH. High
success rates, lower costs and shorter recovery times after TURP were among the
factors contributing to the gradual replacement of open prostatectomy; however,
TURP is associated with considerable complications, including the need for
blood transfusions in 2.0-4.8% of patients and the occurrence of transurethral
resection (TUR) syndrome in 0-1.1% of patients. Eight-year
follow-up data on a large cohort of 23,123 men who underwent TURP showed a
cumulative incidence of repeat endourological interventions of 14.7%.
The incidence of TUR syndrome increases with a gland size greater than 45g and
resection times longer than 90 min.
TURP represents the accepted standard of surgical therapy for the
management of symptomatic bladder outlet obstruction due to BPH. Limited or Channeling TURP is also a
recognized form of adjunctive treatment in the patients with Prostate cancer
The procedure is used in such patients to relieve urinary retention,
though about 50% of patients will pass urine per urethram without catheters
after varying lengths of time after hormonal ablation therapy alone. Channeling TURP is associated with
complications, which include urinary bladder perforation. However, the procedure has become
safer over the years in many institutions; hence the complications rates from
the procedure have dropped significantly..
80-kg Asian male was presented to the local hospital, Wah Cantt. Pakistan. He
was experiencing Urinary Retention with severe pain & burning sensation of
lower urinary tract since last day. The vital signs showed blood pressure (BP)
120/80 mmHg; Temperature 98°F; Pulse rate 74-beats/minute (bpm). Laboratory tests including
Blood complete panel report (CP), Urine test and Ultrasound Reports (Fig. 1) came
out to be normal. He was a non-smoker and used to work in an environment with
no known exposures to chemicals, fumes, dust and other environmental or
occupational allergens. He had no known history of allergy to any drug.
1. Ultrasound reports or patient
On the basis of his medical investigation (primary diagnosis) the physician
prescribed one week therapy including Noroxin (Norfloxacin) 400mg Tabs (oral) bid
(two times a day); Prostreat
Hydrochloride) 0.4mg caps (oral) Once at night; Spasrid
Tabs (oral) tid (three times a day).
After one week the patient visited the doctor again with chief complaint
Abdominal pain, Constipation,
Abdominal discomfort, and Urine overflow. Laboratory tests including Urine
test, Blood CP and Ultrasound (Fig. 2) were conducted again. For new diagnosis,
Physician prescribe further one week of therapy, continuing Noroxin (Norfloxacin)
tabs & Prostreate (Tamsulosin HCl)
tabs from previous regimen with addition of Voltaren (Diclofenac
sodium) 50mg tabs (oral) bid (Two Times a
day); Ezilax (Lactulose) 2-tabs (oral) once at bed time; Zentel (albendazole)
200mg suspension (oral); Secnil Forte (secnidazole) 1g tabs
(oral) 2-tabs oid (once a day). Revisit after one week was advised.
2. Ultrasound Reports of patient.
Due to lack of any improvement in condition, patient had to
consult some other medical specialist. After making a diagnosis, he prescribed Detoxical
(Lactulose) syrup (oral) 2-table spoon tid (three times a day); Tres-Orix Forte (cyanocobalamin
+ cyproheptadine HCl
+ Thiamine HCl +
Vitamin B1) syrup (oral) 1-tables spoon bid (two times a day). On
revisit, the physician changed the treatment regimen to Cardura (doxazosin
mesylate) 2mg tabs (oral) oid (once a day) 1-tab before dinner; Kalfot (Famotidine)
20mg tabs (oral) bid (two times a day); Librax (chlordiazepoxide HCI +
clidinium bromide) caps (oral) bid (two times a day).
As condition became worse, the patient switched to an urologist at
CMH Rawalpindi, Pakistan. He was primarily diagnosed for BPH (benign prostate
hyperplasia). Lab tests including ultrasound & quick catheterization were
advised. Ultrasound reports (Fig. 3-A, 3-B) showed enlarged prostate of weight
93 grams. On the basis of lab reports, the urologist suggested Turp (Transurethral
resection of the prostate) and prescribed Leflox (Levofloxacin)
tabs (oral) 250mg bid (two times a day); NISE (Nimesulide) tabs (oral) 100
mg bid (two times a day); and Citralka
Citrate) Syrup (oral) 1.315g/5ml 2-table spoon oid (once a day) at
The Turp (Transurethral resection of the prostate) was conducted
and he was discharged next day with Leflox
250mg bid (two times a day) ; Dicloran (Diclofenac Sodium);
and Citralka (Sodium Acid
After three days, the catheter was removed and Leflox (Levofloxacin)
was administered up to 10 days and the treatment continues with Citralka
Citrate) Syrup (oral) 1.315g/5ml 1-table spoon bid (two times a
day). Later, the dissected tumor was analyzed and reports showed no malignancy.
This is a case study of
gradually progressing BPH in an elderly patient. At first, the patient’s condition
wasn’t complex to grip but even after using the suggested treatment for a week,
condition didn’t improve. So a new treatment plan was recommended. Even at that
time, the disease wasn’t making progress and could’ve been handled with appropriate
medical care. Herbal remedies might also improve the condition.
Stephen Bent et al.
reported that saw palmetto did not
improve symptoms or objective measures of benign prostatic hyperplasia. The BNF
(British National Formulary) is one the standard books used to design the
treatment plans. While BNF confirm the prescribed dose regimen
of tablet Norfloxacin, capsule Tamsulosin,
tablet Diclofenac sodium. Currently, a1-adrenergic
receptor (a1-AR) antagonists are commonly
prescribed by physicians as first-line agents to treat BPH, a common condition
of aging men. a1-AR antagonists exert
their effects by blocking a1-AR-mediated
contraction of the prostatic smooth muscle cells and bladder neck. Available alpha-blockers include Doxazosin,
Prazosin, and Terazosin are a1-AR
antagonists that show equal affinity for all a1-AR
subtypes. On the basis of primary
diagnosis, Tamsulosin was prescribed which does not interfere with blood
pressure control and has a low potential to cause vasodilation. It is more expensive than the other
alpha-blockers currently available. Also, the therapeutic dose is reached more
quickly, so he may have quicker symptom improvement. As patient’s examination
shows no signs of hypertension so it wasn’t necessary but prescribing the
medicine was safe. It is to be noted that the patient was also prescribed
Albendazole and Secnidazole which are anti-infective for
the treatment of a variety of worm infestations. During
the last 10 years, there have been numerous medical and surgical therapies with
demonstrated efficacy in relieving BPH symptoms. Alpha-blockers improve BPH
symptoms relatively rapidly, whereas 5-alpha reductase inhibitors have a slower
onset of action. However, the latter may decrease prostate size and affect the
course of BPH. Gerald L Andriole et al. examine
safety and tolerability data from a number of recently completed clinical
trials with the novel, dual 5a-reductase inhibitor when used
in combination with an a1-blocker, the drug-related adverse event
profiles were as would be expected for the individual agents.
Passage of time and
usage of suggested medication caused propagation of condition to the next stage
instead of treating it. Further regimen included tablet Doxazosin and tablet
Famotidine, capsule chlordiazepoxide HCI (short-term use in anxiety and adjunct
in acute alcohol withdrawal) in combination with clidinium bromide (anticholinergic
drug). However the
prescribed dosage was found to be according to specifications, even for the
Ahmed Fawzy et al. accounted that doxazosin
is significantly superior to placebo in the treatment of BPH in normotensive
patients, with the patient experiencing significant relief early after
initiation of therapy.
John D. McConnell et
al. reported in a study that Among men with symptoms of urinary
obstruction and prostatic enlargement, treatment with finasteride for four
years reduces symptoms and prostate volume, increases the urinary flow rate,
and reduces the probability of surgery and acute urinary retention. John H.
Wasson et al. stated that for men with moderate symptoms of
benign prostatic hyperplasia, surgery is more effective than watchful waiting
in reducing the rate of treatment failure and improving genitourinary symptoms.
Watchful waiting is usually a safe alternative for men who are less bothered by
urinary difficulty or who wish to delay surgery.
The severity of symptoms made the situation worse enough to
require a surgical procedure (TURP) for the treatment. Trans urethral resection
of the prostate (TURP) has been recognized as an adjuvant therapy in the
management of advanced prostate cancer. This is mainly to create a channel in
the obstructive tumor thereby relieving the urinary retention. TURP is
considered the benchmark for surgical therapies, and although it is an
inpatient procedure with high initial costs, these may be offset by long-term
durability of symptom relief.
Common complications include hemorrhage, sexual dysfunction,
strictures, and hyponatremia, which may result from absorption of the hypotonic
irrigant. Men with BPH should undergo a digital rectal examination &
urinalysis to screen for other urologic disorders while should be referred for
a surgical consultation if medical therapy fails; if refractory urinary
retention, persistent hematuria, or bladder stones develop; or if the patient
chooses primary surgical therapy.
Not all cases of BPH are diagnosed at its initial stages. Our
report emphasizes the hidden danger of misdiagnosing and allowing the condition
to progress over a period of time with expenditures of unnecessary medication for
such cases in general population of an under developed country like Pakistan. This
case presentation shows not only that a sound original diagnosis might have
prevented the need of an operation but also points out the need for a good
clinical evaluation and the use of appropriate investigative studies in order
to avoid unnecessary operations and complications.
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