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Thursday, 8 March 2012

Etiology,sign, symptoms,Diagnosis and management Benign Prostat Hyperplastic (hyperplasia / hypertrophy)

Introduction
Enlargement of the prostate gland has a significant morbidity in a population of elderly men. The symptoms are a common complaint in the field of urologic surgery.
Prostate hyperplasia is one of the major health problems for men over the age of 50 years and was instrumental in the decline in quality of life. A study says that one third of men aged between 50 and 79 years of experience prostatic hyperplasia.
Exact prevalence in Indonesia is not yet known but is estimated based on foreign literature since age 50 years 20% -30% of patients will require treatment for prostatic hyperplasia. Which obviously depends on the prevalence of child bearing age. Actually, the changes towards the enlargement of the prostate is started early, beginning in mikroskopoik changes which then manifests into macroscopic abnormalities (enlarged gland) and then a new clinical symptoms.
Based on the autopsy rate is microscopic changes in the prostate can be found at the age of 30-40 years. When these microscopic changes constantly evolving there will be changes anatomic pathology. In men aged 50 years and the number of events around 50%, and at the age of 80 years about 80%. Approximately 50% of the numbers mentioned above will cause the symptoms and clinical signs.
The existence of this hyperplasia would lead to urinary tract obstruction and to overcome this obstruction can be done in various ways ranging from the most minor of action that is a conservative (non operative) to the most severe action that is operating.
I. ANATOMY AND PHYSIOLOGICAL
Under normal circumstances the prostate is approximately the size of a walnut. Normal prostate weight in adults is ± 20 grams. Located around the prostatic urethra and bladder neck as well as between the urogenital diaphragm. The apex of the prostate is located on the external urethral sphincter of the bladder. In the anterior symphysis pubis adjacent to but separated by a cavity in the extraperitoneal fat retopubis (Retzius cavity). In the posterior prostatic fascia is separated from the rectum by denonvilliers.




The prostate consists of lobes anterior, posterior, media, and lateral. May be palpable on rectal examination the posterior medial sulcus between the two lateral lobes. Lobes of prostate glands that secrete contains base is added to semen during ejaculation. The prostate gland opening into the prostatic sinus. Dukstus ejaculatory that drains fluid from the seminal vesicles and the vas deferen, entering the top of the prostate and then into the prostatic urethra in the verumontanum.
Prostate blood supply from the inferior vesical artery (branch of internal iliac artery). Prostatic venous plexus is located between the prostate capsule and the outer fibrous sheath. This plexus receives blood from the dorsal penile vein and flow into the internal iliac vein.
When prostate enlargement, it clogs up the organs of prostatic urethra and can block the flow of urine out of the jar. Mc.Neal divided in several zones of the prostate gland, including the peripheral zone, central, transitional, and periurethral fibromuskuler anterior. Most of the prostate hyperplasia occurs in the transition zone, while the growth of prostate carcinomas originate from the peripheral zone.
Gland growth is highly dependent on the hormone testosterone, which in the prostate gland cells of this hormone will be converted into active metabolites dihidritestosteron (DHT) with the help of the enzyme -reductase. DHT is a direct spur of m-RNA in the prostate gland cells to synthesize protein growth factors that stimulate the growth of the prostate gland.
In old age few men have benign prostate enlargement. This situation is experienced by 50% of men aged 60 years and approximately 80% of men aged 80 years. Enlargement of the prostate gland can affect the flow of urine causing micturition disorders.

II. DEFINITION
Benign prostate enlargement (BPH, benign prostatic hyperplasia) is a benign hyperplasia of the gland is an urgent periureteral tissue that causes the prostate to peripheral enlarged prostate. Prostate enlargement is common in men over 50 years.
III. EtiologyUntil now still not known with certainty the cause of prostate hyperplasia, but several hypotheses mentioned that the rat prostate hyperplasia related to increased levels of dihydrotestosterone (DHT) and aging poses. Several theories disuga cause prostate hyperplasia is:
a. Theory of dihydrotestosteroneDihydrotestosterone (DHT) is an androgen metabolite that is essential for the growth of prostate gland cells. Formed from testosterone in the prostate cells by the enzyme 5α-reductase with coenzyme NADPH assistance. Wherewith to form DHT binds to androgen receptors (RA) which forms a complex DHT-RA in the cell nucleus which further protein synthesis occurs growth factor that stimulates the growth of prostate cells.In the BPH enzyme 5α-reductase activity and androgen receptor number more. This causes the cells of the prostate in BPH is more sensitive to DHT thus more cell replication that occurs as compared with normal prostate.
b. Estrogen-testosterone imbalanceAt an older age, testosterone levels decline, while estrogen levels remain relative to the comparison between the estrogen: testosterone increases relative. Estrogen in the prostate play a role in proliferation of prostate gland cells by increasing the sensitivity of prostate cells to stimulation of androgen hormones, boost the number of androgen receptors, and reduce the amount of the death of prostate cells (apoptosis). The end result of all these circumstances are, although stimulation formation of new cells due to decreased testosterone stimulation, but prostate cells that have been there to have a longer life so that the mass of the prostate become larger.
c. Stromal-epithelial interactionsCunha prove that the differentiation and growth of prostate epithelial cells are indirectly controlled by stromal cells through a mediator (growth factor) specified. Once the stromal cells of the DHT-stimulated and estrogen, stromal cells synthesize a growth factor which in turn affects the stromal cells themselves are intrakrin or autocrine, as well as affect the epithelial cells in a paracrine. Stimulation caused the proliferation of epithelial cells and stromal cells.
d. Reduction in cell death of prostateApoptosis in prostate cells is a physiological mechanism to maintain homeostasis of the prostate gland. Condensation occurs on apoptosis and subsequent cell fragmentation of cells undergoing apoptosis will difagositosis by surrounding cells, and then degraded by lysosomal enzymes.On normal tissue, there is a balance between the rate of cell proliferation with cell death. In times of growth of the prostate to the adult prostate. Of the number of new prostate cells that die in a state of balance. Reduced number of prostate cells undergoing apoptosis causes prostate cell number as a whole be increased so that the mass accretion causes the prostate.Suspected androgen hormones play a role in inhibiting the apoptotic process because after castration, there is increased activity of the prostate gland cell death. Estrogens are thought to be able to extend the life of prostate cells, whereas the growth factor TGFβ plays a role in the process of apoptosis.
e. Stem cell theoryTo replace cells that have been maengalami apoptosis, has always formed the new cells. In the prostate gland is known a stem cell, which cell has the ability to proliferate so extensively. Life of these cells is highly dependent on the presence of androgen hormones, so if these hormone levels are declining as in castration, leads to apoptosis. Prosliferasi the cells in BPH postulated as ketidaktepatannya stem cell activity resulting in excessive production of stromal cells and epithelial cells.
IV. PathophysiologyProstate enlargement causes a narrowing of the lumen of prostatic urethra and blocks the flow of urine. This situation led to increased pressure intravesikal. To be able to mnegeluarkan urinary bladder must contract more forcefully against the prisoner's guan. This continuous contraction causes anatomic changes in bladder. Destrusor form of muscle hypertrophy, trabekulasi, selula formation, and diverticular sakula jar. Structural changes in the bladder, the patient felt as a grievance on the lower urinary tract or urinary tract symptoms (LUTS), known as prostastismus symptoms.Intravesikal high pressure continued throughout the jar is no exception to the mouth of the ureter. Pressure on both the estuary ureter can cause backflow of urine from the bladder into the ureter or vesico-ureteric reflux. This situation if it continues will result hidroureter, hydronephrosis, bahakan may eventually fall into kidney failure.Obstruction caused by benign prostatic hyperplasia is not only due to the presence of prostate mass that clogs the posterior urethra, but also due to the existing smooth muscle tone in the prostatic stroma, prostatic capsule, and the smooth muscle of the bladder neck. There polo muscles are innervated by sympathetic fibers originating from the nerve pudendus.BPH occurs on increasing the ratio of stroma to the epithelial component. If the normal prostate epithelium compared with stroma ratio is 2:1. But in BPH ratio increased to 4:1. This causes an increase in BPH prostate smooth muscle tone compared with normal prostate. In this case the mass of the prostate that causes static obstruction component, while the smooth muscle tone which is a dynamic kompoen as the cause of prostatic obstruction.
V. CLINICAL SYMPTOMS
Usually the symptoms of prostate enlargement known as the Lower Urinary Tract Symptoms (LUTS) are divided into irritating and obstructive symptoms.
Obtruksi prostate can cause urinary tract complaints and grievances outside the urinary tract.A. Complaints of lower urinary tractUsually the symptoms of BPH can be divided into irritating and obstructive symptoms. Obstructive symptoms caused by the narrowing of the pars prostatic uretara as urged by an enlarged prostate and the failure of the detrusor muscle to contract and be strong enough or long enough so that the intermittent contractions. Obstructive symptoms are weak jet, a sense of not lampias after micturition, if you want to have to wait long micturition (hesitancy), must be straining (straining), intermittent urination (intermittency) and time of micturition which eventually became elongated and retained urine due to overflow incontinence.Irritating symptoms caused by the emptying of the vesica urinaris incomplete at the time of micturition, or caused by hypersensitivity of the detrusor muscle due to an enlarged prostate causes stimulation of the vesica, so vesica often though not yet fully contracted irritating symptoms that is often micturition (frequency), woke up to micturition at night days (nocturia), feeling like a very urgent micturition (urgency), and pain during micturition (dysuria).
  

Internasional ProstateSymtom Score
In the last month
Never
<than once in 5 times
Less than half
sometimes (about 50%)
> than half
Almost always
Score
How often do you feel there is still finished urinating
0
1
2
3
4
5

How often do you have to go back, urinating within <2 hours after you finished urinating
0
1
2
3
4
5

How often do you find that your urine is lost - broken
0
1
2
3
4
5

How often do your urinary stream weak
0
1
2
3
4
5

How often do you have to strain to begin urination
0
1
2
3
4
5

How often do you have to get up to pee, since the start sleeping at night to wake up in the morning
0
1
2
3
4
5

Relative Issues on Quality of Life


Very pleased
Pleased
Satisfied
Satisfied and dissatisfied
Very dissatisfied
not happy
Very Bad
When you have to live the rest of life with a situation like this
0
1
2
3
4
5
6
  
Of the IPSS score can be grouped three degrees: Mild (score 0-7), moderate (8-19), weight (20-35)

SKOR MADSEN IVERSEN
Question
0
1
2
3
4
emission
Normal
Changes

Weak
Dripping
Straining to urinate
No

Yes


Will have to wait while urinating
No


Yes

Miksion discontinuous
No


Yes

The feeling of persistent residual urine
Unknown
Changes
residual urine
1 x retensi
> 1 x retensi
Inkontinensia


Yes


Difficulty to  delayed urination
No
Mild
Moderate
Severe

Urinating at night
0 - 1
2
3 – 4
> 4

Urine during the day
> 3 hour/x
Every 2 – 3 hour/x
Every 1 – 2 Hour/x
< 1 hour

                  Number of ratings: 0 = excellent, 1 = good, 2 = poor, 3 = less, 4 = poor, 5 = very bad.

Derajat
Gejala ringan
Gejala sedang
Gejala berat
IPSS
0 – 7
8 – 18
19 - 35
Madsen Inversen
0 -10
10 - 20
> 20
2. Symptoms of upper urinary tract
Complaints due to complications of prostate hyperplasia in the upper urinary tract obstruction in the form of symptoms, including back pain, a lump on his waist (which is a sign of hydronephrosis) or a fever that is a sign of infection or urosepsis.

3. Outside the urinary symptoms disaluran
Not infrequently patients present to physicians with complaints of inguinal hernia or hemorrhoids. Incidence of both diseases as frequent straining during micturition resulting in an increase in intraabdominal pressures.

VI. DIAGNOSIS
Diagnosis based on symptoms and physical examination. On physical examination may be obtained jar fully charged and palpable mass kistus supra symphysis area due to urinary retention. Sometimes the urine is obtained which is always dripping unnoticed by the patient that is a sign of incontinence paradoksa.
Performed digital rectal examination to feel / palpate the prostate gland. This examination can be known with an enlarged prostate, hard lumps (indicating cancer) and tenderness (indicating infection). Usually do blood tests to determine kidney function and for prostate cancer screening (measuring levels of prostate specific antigen or PSA).
VII. Examination supporta. LABORATORYUrine sediment examined for possible infection or inflammation of the urinary tract. Examination urine culture useful in finding a type of bacteria that cause infections and also to determine the sensitivity of bacteria to some antimicrobials tested.Renal physiology examined to look for possible complications of the upper urinary tract, while the blood sugar is intended to seek the possibility of diabetes mellitus that can cause neurological disorders in the bladder (neurogenic bladder). If it is suspected prostate malignancy need to be examined PSA tumor marker levels.
b. ImagingPlain abdominal useful for finding the existence of an opaque stones in the urinary tract. The presence of stone / kalkulosa prostate and may show a shadow-filled jar filled with urine, which showed signs of retained urine. Examination of PIV can describe it is:• Abnormalities in the kidneys and ureters be hidroureter or hydronephrosis.• Estimating the size of the prostate gland is shown by the presence of prostate indents (pendesakan ole jar of the prostate gland) or adjacent to the distal ureter is shaped like a hook or a hooked fish• Complications that occur in a jar that is the trabekulasi, diverticular or sakulasi jar.
However, examination of PIV is now not recommended for BPH. Transrektal ultrasound examination or TRUS, are intended to:• know or volume of the prostate gland• the possibility of malignant prostate enlargement• as guidance (instructions) to perform aspiration biopsy of prostate• determine the amount of residual urine• look for other abnormalities that may exist in a jar.Transabdominal ultrasound examination can detect the presence of hydronephrosis or renal damage caused by obstruction of the old BPH.Other checks that can be done is to check the degree of prostatic obstruction, can be estimated by measuring:• residual urine, the amount of residual urine after micturition. Residual urine can be calculated by means of catheterization after micturition or determined by ultrasound imaging after micturition.• Arc of urine or the flow rate can be calculated in a simple way is to calculate the amount of urine divided by the length of his last micturition (ml / sec) or with a tool that presents a graphical uroflometri emission of urine. A more thorough examination with the examination urodinamika. Uroflometri of micturition can be known a long time, long beam, the time required to reach maximum emission, and the volume of urine dikemihkan.



 
VIII. MANAGEMENTNot all patients need to undergo prostate hyperplasia medic action. Sometimes they complain of mild LUTS can heal itself without getting any treatment or only with the advice and consultation only. But among them there eventually requiring medical treatment or other medic action because the complaint is getting worse.
The goal of therapy is the patient's prostatic hyperplasia:• Improve the micturition complaints• Improve life kualita• Reduce obstruction infravesika• Restoring renal function in case of renal failure• Reduce the volume of residual urine after micturition• Preventing progression of the disease. In the complaint mild IPSS (0-7), Medsen inverson (0-10)  waiting watchfull. In the complaint moderate IPSS (8-18), Mendsen inverson (10-20)  Medical:o alpha adrenergic blockerso Inhibiting the enzyme 5-alpha-reductaseo Fitoterapi In the severe degree of IPSS (19-35), mendelsen inverson (> 20)  Conventional Surgical Therapy:o TURP (Transurethral Resection of the Prostate)o TUIP (Transurethral Insision of the Prostate)o Open Prostatektomyo Prostatektomy with laser
Waiting watchfullElection without the therapy is intended to BPH patients with IPSS scores below 7, the minor complaints that do not interfere with daily activities. Patients do not mendapaykan any therapy, were given an explanation on a matter which might aggravate the complaint. Misalanya do not consume alcohol or coffee after dinner, eat less food or beverages that irritate the bladder (coffee or chocolate), limit the use of influenza drugs containing phenylpropanolamine, eat less spicy and salty, do not hold urine for too long.Periodically required to control the patient's complaint asked whether the better, in addition to doing laboratory tests, residual urine, or uroflometri. If complaints of micturition increased ugly before, may need a lot of rethinking to select another therapy.
MedicalPurpose of medical treatment are:• Reduce esistensi prostate smooth muscle as a dynamic component to the cause of obstruction infravesika drugs alpha adrenergic inhibitor (alpha adrenergic blocker)• Reduce the volume of the prostate as a static component by lowering the levels of the hormone testosterone / dihydrotestosterone by inhibiting 5α-rduktase.
A. Adrenergic receptor-αCaine was the first reported use of α-adrenergic inhibitors as one of the BPH therapy. At that time used fenoksibenzamin, which is a non-selective alpha blockers who were able to improve the emission rate of micturition and reduce complaints of micturition. Unfortunately, these drugs are not favored by patients because it causes undesirable systemic complications, such as postural hypotension and other cardiovascular disorders.Discovery of the alpha adrenergic inhibitors can reduce systemic complications caused by the effects of inhibition of α2 fenoksibenzamin. Several classes of drugs are α1 adrenergic inhibitors prazosin given twice daily, terazosin, afluzosin, and deksazosin given once a day. This class of drugs has been reported to improve the rate of complaints of micturition and urine emission.Recently been found also type α1A adrenergic inhibitors, tamsulosin is highly effective against prostate smooth muscle. Reported that this drug can improve the emission micturition without effect on blood pressure, heart rate mapun.
2. 5 α-reductase inhibitorsThis drug works by inhibiting the formation of DHT from testosterone is catalyzed by the enzyme 5 α-reductase in prostate cells. Decreasing levels of DHT causes the protein synthesis and replication of cells of the prostate decreased.Reported that administration of 5 mg per day finasterid drug is given once after 6 months can cause a decrease in the prostate by 28%, this is correct and emission micturition micturition complaints.
PhytopharmacaSome extracts of certain herbs can be used to improve symptoms caused by prostatic obstruction. The mechanism is not known for sure. Fitoterapi possibility to work as an anti estrogen, anti-androgens, reducing levels of sex hormone binding globulin (SHBG), inhibition of basic fibroblast growth factor (bFGF, and epidermal growth factor (EGF), disrupt the metabolism of prostaglandins, anti-inflammatory effects, decrease outflow resistance, and improve prostate volume.Among the most widely marketed fitoterapi is pygeum africanum, Serenoa repens, Hypoxis rooperi, Radix Urtica, and much more.
OperationSurgery is directed at the prostate hyperplasia is caused certain complications, such as: urinary retention, urinary tract stones, hematuri, urinary tract infections, urinary tract abnormalities in the upper part, or complaints LUTS who showed no improvement after treatment medical. Surgery is performed open surgery or surgery transuretra endourology.
A. Open surgerySeveral kinds of techniques oprasi open prostatectomy is the method of Millin enucleation of the prostate gland that is done via the retropubic approach intravesical, suprapubic Freyer melelaui transvesika or transperineal approach. Open prostatectomy is the oldest action is still used today, most invasive and most efficient for the treatment of BPH. Dilakuakan Proatatektomi can open suprapubic approach transvesikal (Freyer) or infravesikal retropubic (Millin). Open prostatectomy is recommended for very large prostate (> 100 grams).Complications that can occur after open prostatectomy are urinary incontinence, impotence, retrograde ejaculation and bladder neck contractures. Improvement of clinical symptoms as much as 85% -100% and a mortality rate of as much as 2%.2. Surgery endourologyCurrently TURP action is the most widely oprasi done. Oprasi is more favored because it is not necessary incision in the abdominal skin, mole-mass more quickly, and gives results that are not much different than open oprasi. Tranuretra endourology surgery can be done by means of electric power TURP (Transurethral Resection of the Prostate) or by using laser energy. Oprasi of a resection of prostate (TURP), an incision (TUIP) or evaporation.
a. TURP (Prostate Resection Transuretra)Transuretra resection of the prostate gland performed by means of irrigation fluid (rinse) the area to be resected to remain light and are not covered by the blood. Fluid used is a solution of the non-ionic, dimakasudkan to prevent electrical conduction at oprasi. Liquids are often used and it's cheap is sterile H2O (distilled water).One of the disadvantages of its hypotonic distilled water adalaha so the liquid may enter the systemic circulation through blood vessels at the time of resection tgerbuka. H2O excess can cause symptoms of hyponatremia or water intoxication relative or known as TURP syndrome. This syndrome patients starting ditendai with anxiety, somnolence awareness, increased blood pressure and bradycardia. If not addressed, will experience edema Pasie brain that eventually fell into a coma and died. TURP syndrome is a mortality rate of 0.99%.To limit the incidence of TURP syndrome, the operator should limit themselves to not perform a resection of more than 1 hour. Besides, some operators put before sitostomi suprapubic resection, it is expected to reduce water absorption into the circulation sitemik.
At prostet hyperplasia is not so great, in the absence of medial lobe enlargement, and the young age of patients who required only incision of the prostate gland or TUIP (Transurethral Incision of the Prostate) or bladder neck incision or BNI (Bladder Neck Incision). Prior to this action should be excluded the possibility of carcinoma of the prostate by digital rectal, transrektal ultrasound examination and measurement of PSA levels. recommended size of the prostate is small (less than 30 cm 3), is found medial lobe enlargement, and not found any suspicion of prostate carcinoma.This technique was popularized by orandi in 1973, by mono or bilateral incision incision Colling a knife from the mouth of the ureter, bladder-neck to the verumontanum. Incision is deepened to the capsule of the prostate. The time needed faster, and fewer complications compared to TURP. TUIP able to improve the complaints due to BPH and improve Qmax although not as good as TURP.
b. Prostate ElektrovaporasiElektrovaporasi way TURP prostate is the same premises, except that this technique using a roller ball diathermy machine specific and strong enough, so as to mebuat vaporisasi prostate gland. This technique is safe, not much cause bleeding during the treatment period oprasi rumaha and shorter hospital. However, this technique is intended only to the prostate that is not too large (<50 grams) and need a longer time speeches.
c. Laser prostatectomy (Greenligth Laser)When compared with surgery, laser pemakaisan were fewer complications, can be done in a clinic, faster healing, and with approximately the same results. Unfortunately, these therapies require repeated therapy of 2% per year. The drawback is unable to obtain tissue for examination, often cause dysuria pasaca many surgeons that can last up to 2 months, not immediately after the operation spontaneous micturition and peak flow rate is lower than the post-TURP.3. Acts minimally invasivea. TermoterapiTermoterapi prostate gland is heating with microwaves at a frequency of 915-1296 MHz is emitted through the antenna is placed inside the urethra. By heating in excess of 440 C causes tissue destruction in the transitional zone of the prostate due to coagulation necrosis. This procedure is done without giving anesthesia poliklinis.Heat energy is emitted in conjunction with microwaves through a catheter that is attached didalm urethra. Magnitude and direction of beam energy is set through a computer so it can soften the prostate tissue that clogs the urethra. Morbidity is relatively low, it can be done without anesthesia and can be lived by a patient whose condition is not good if you have surgery. This method is recommended for a small prostate size.
b. TUNA (Tranurethral Needle Ablation of the Prostate)This technique of using radio frequencies which generate heat until it reaches 1000C, resulting in necrosis of prostate tissue. This system consists of TUNA catheter is connected to a generator that can generate radio frequency energy at 490 kHz. Kedalma urethral catheter through cystoscopy with topical anesthesia xylocain provision so that the needle is located at the tip of the catheter lies in the prostate gland. Patients often still complain hematuria, dysuria, urinary retention times, and epididymo-orchitis.
c. StentsProstatic stent mounted on the prostatic urethra to overcome the obstruction due to prostate enlargement. Intraluminal stent is placed between the bladder neck and verumontanum poksimal area so that urine can freely pass through the lumen of prostatic urethra. Stents can be placed temporarily or permanently. A temporary set for 6-36 months and are made of materials that are not absorbed and does not hold a tissue reaction. This tool is installed and removed by endoscopy again.Permanent stent is made of webbing of metal super alloy, nickel or titanium. In the long term this material will be covered by urotelium so if one day like to be removed should require general or regional anesthesia.Installation of the tool is intended for patients who may not have surgery because the risk of surgery is quite high. Often a stent can be detached from the posterior urethra insersinya in, or having enkurtasi. Unfortunately after this catheter, the patient still feels micturition complaints of irritating symptoms, urethral bleeding, bad taste or penis area.
d. HIFU (High intensity focused ultrasound)Heat energy is directed to cause necrosis of the prostate from the ultrasound waves from the transducer having a frequency of 0.5 to 10 piezokeramik MHz. energy emitted by devices placed on transrektal and focused onto the prostate gland. This technique requires general anesthesia. Clinical data showed improvement of clinical symptoms occur 50-60% and the average Qmax increased 40-50%. Treatment failure was recorded by 10% every year.
Although many modalities have been found to treat prostate enlargement, but to date therapies that provide the most satisfactory result is TURP.
Periodic controlEach BPH patients who have received treatment to control them regularly for disease progression. Schedule control depending on what action has been lived.Patients who only get control (waiting watchfull) control is recommended after 6 months, then annually to determine whether there is clinical improvement. Assessment carried out by a score of IPSS, uroflometri, and post-micturition residual urine.Patients treated with 5α reductase inhibitors, should be controlled at 12 weeks and 6 months to assess response to therapy. Then annually to assess changes in micturition symptoms. Patients who experience treatment 5α adrenergic inhibitors, should be assessed response to treatment after 6 weeks of the examination IPSS, residual urine uroflometri and post-micturition. If there is improvement in symptoms without complications showed significant, treatment can be continued. Further control is done after 6 months and then annually. Patients after receiving treatment and did not show collar Medical improvements should be considered when surgery or other therapeutic interventions.After surgery, patients should undergo control at least 6 weeks post oprasi to mengatuhi possibility of complications. Control then after 3 months to see the final result oprasi.Patients who received minimal invasive therapy, should undergo regular control in the long term, ie after 6 weeks, 3 months, 6 months and every year. In patients who have minimal invasive therapy, conducted an assessment of the score of micturition and urine culture investigation.
X. COMPLICATIONSIf the bladder becomes decompensated urinary retention will occur. Due to the continued production of urine in a jar when no longer able to hold urine so that intra vesicles increased pressure, can arise hidroureter, hidrnefrosis, and kidney failure. The process of accelerated kidney damage in case of infection.Because there is always residual urine sediment may form stones in the bladder. This stone can add to the complaints of irritation and cause hematuria. Stones can also cause cystitis and reflux can occur in case of pyelonephritis.At the time of micturition, so patients should straining over time can cause a hernia or hemorrhoids.



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