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Ans 1) Benign Prostatic Hyperplasia (BPH), it is a common condition affected prostate gland, characterised by the prostate enlargement over the prolonged period. This condition is common in men with age group 40 to 45 years and slowly progresses throughout life (Gunes et al., 2016). The pathophysiology of BPH is complex and multifactorial in nature. The first factor is an alteration in ratios and levels of the endocrine hormones, for instance, androgen, prolactin, estrogen and gonadotropins. The second mechanism is associated with the alteration in the levels of paracrine/autocrine growth stimulatory and inhibitory factors, for example, Fibroblast factors, IGF binding proteins, Nerve growth factor, Insulin-like growth factors, and Transforming growth factor-beta (McCance & Huether, 2014).
Circulating androgen along with aging has the potential to disturb the growth factor signalling pathway. Further, circulating androgen aids in the epithelial and stromal interaction, which create tissue remodelling and growth-promoting environment. The above mechanisms contribute to prostatic enlargement and BPH development (Li et al., 2018). Testosterone is the common circulatory androgen in male. This hormone can be converted into estrogen (estradiol-17 beta) after metabolised by CYP19/aromatase. The growth of the prostate is influenced under the presence of estrogens as prostrate is consider as estrogen targeted organ. Estrogen can lead to differentiation and growth of the prostate. Additionally, estrogen receptors modulators have a potential impact on the proliferation and differentiation of the prostate and development of BPH (Madersbacher et al., 2019). The above-stated interactions and alterations lead to an increase in the volume of prostrate through local inflammation in the remodelled stromal tissue that is associated with altered chemo-attractants, cytokines and reactive nitrogen/oxygen species. This resultant in amplified oxygen demands in the proliferating cells, causing local hypoxia which enhances structural changes in fibroblast cells and angiogenesis. Phenotypical and functional remodelling of the fibroblasts is the main reason for fibrosis and engagement of prostrate (Chughtai et al., 2016).
Ans 2) BPH initiates in the peri-urethral glands (prostate’s inner gland). The prostrate proliferate to nodular mass, a process known as nodular hyperplasia. Additionally, the glandular cell becomes hypertrophied and enlarged in size (McCance & Huether, 2014). The nodular tissue put pressure on the urinary bladder and leads to outflow obstruction. Therefore, the symptoms associated with BPH are increased micturition urgency, delay in starting of micturition, incontinence, painful micturition and reduced urinary stream force (Cakir et al., 2018). Additionally, urethral obstruction due to prostate enlargement can lead to difficulty in emptying complete bladder causing urinary retention, kidney infection, bladder infection, renal insufficiency, hydronephrosis, hydroureter, haematuria, and increased intra-abdominal pressure (Ruan et al., 2017).
Ans 3) Transurethral resection of the prostate (TURP) is the treatment modality for prostate enlargement condition (benign prostatic hyperplasia), causes worrying symptoms and patient is not responding to the medications (Gilling et al., 2019). For TURP procedure, resectoscope device deploys, this device is a thin metal tube with a camera, wire loop and light. This device passes through the urethra until it reaches the prostate. This technique is incision-free as it does not require any cut on the skin. Camera and light aids in visual clarity. Additionally, the wire loop is for cutting the enlarged mass through the electric heating mechanism. After this, a tube known as a catheter is inserted inside the urethra to pump out the fluid inside the bladder for flushing the pieces of prostrate (that has been cut through wire loop) (Ray et al., 2018). Throughout the process, spinal or general anaesthesia is used to ensure painless surgical procedure. After the process, the patient needs to stay at the hospital for 2 to 3 days as per the personalised need of the patient. The catheter deployed in the surgical process will be left because, after surgery, the urethra will be in the healing phase and swollen. After a few days of surgery, the patient will not be able to urinate easily therefore catheter will aid in the maturation process. Further, the patient will feel tired for approximately 1-2 week after hospital discharge. Moreover, the patient needs to take care that he will not perform any hard task during 1-2 weeks after surgery. It is normal to have blood in urine and/or difficulty in micturition (Cindolo et al., 2017).
Ans 4) Benign prostate hyperplasia is associated with growing age. This condition is common in men with age group 40 to 45 years and slowly progresses throughout life. This disorder is considered to be a normal complaint of aging. Not every male get affected by BPH. With aging there is various changes occur in the body organs, for instance, altered sex hormones and growth factors secretion. With aging, the circulatory androgen misbalanced secretion lead to disturbed in the growth factor signalling pathway. Further, circulating androgen aids in the epithelial and stromal interaction, which create tissue remodelling and growth-promoting environment. Moreover, structural changes occur in the fibroblast with age has a potential effect on the stromal fibrosis and mass formation in the prostate gland. Additionally, familial history increases the risk of the development of BPH. BPH is uncommon in the male with no testicles (removed surgically). It can be concluded that BPH is associated with aging, though it is not a normal condition (McCance & Huether, 2014).
Cakir, S. S., Polat, E. C., Ozcan, L., Besiroglu, H., Ötunctemur, A., & Ozbek, E. (2018). The effect of prostatic inflammation on clinical outcomes in patients with benign prostate hyperplasia. Prostate International, 6(2), 71-74.
Chughtai, B., Forde, J. C., Thomas, D. D. M., Laor, L., Hossack, T., Woo, H. H., ... & Kaplan, S. A. (2016). Benign prostatic hyperplasia. Nature Reviews Disease Primers, 2(1), 1-15.
Cindolo, L., Marchioni, M., Emiliani, E., De Francesco, P., Primiceri, G., Castellan, P., & Schips, L. (2017). Bladder neck contracture after surgery for benign prostatic obstruction. Minerva Urologica Nefrologicae. The Italian Journal of Urology and Nephrology, 69(2), 133.
de Assis, A. M., Moreira, A. M., Carnevale, F. C., Marcelino, A. S. Z., de Oliveira Cerri, L. M., Antunes, A. A., ... & Cerri, G. G. (2019). Effects of prostatic artery embolization on the dynamic component of benign prostate hyperplasia as assessed by ultrasound elastography: a pilot series. Cardiovascular and Interventional Radiology, 42(7), 1001-1007.
Gilling, P., Barber, N., Bidair, M., Anderson, P., Sutton, M., Aho, T., ... & Trainer, A. (2019). Two-year outcomes after aquablation compared to TURP: Efficacy and ejaculatory improvements sustained. Advances in Therapy, 36(6), 1326-1336.
Gunes, S., Hekim, G. N. T., Arslan, M. A., & Asci, R. (2016). Effects of aging on the male reproductive system. Journal of Assisted Reproduction and Genetics, 33(4), 441-454.
Li, J., Tian, Y., Guo, S., Gu, H., Yuan, Q., & Xie, X. (2018). Testosterone-induced benign prostatic hyperplasia rat and dog as facile models to assess drugs targeting lower urinary tract symptoms. PLoS One, 13(1), e0191469.
Madersbacher, S., Sampson, N., & Culig, Z. (2019). Pathophysiology of benign prostatic hyperplasia and benign prostatic enlargement: a mini-review. Gerontology, 65(5), 458-464.
McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children. Elsevier Health Sciences.
Ray, A. F., Powell, J., Speakman, M. J., Longford, N. T., DasGupta, R., Bryant, T., ... & Hacking, N. (2018). Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity‐matched comparison with transurethral resection of the prostate (the UK‐ROPE study). BJU International, 122(2), 270-282.
Ruan, Y., Jiang, C. Y., Wang, X. H., Jiang Qi, H. B., & Sun, X. W. (2017). Clinical relevance and implications of autophagy-related proteins in benign prostatic hyperplasia. Int J Clin Exp Pathol, 10(4), 4705-18.
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