In the ambulatory of  Somesan Clinic the specialized consultations are offered by doctor Vincze Bela, urologist.

Urology is the surgical specialty where we diagnose and treat affections of the urinary tract for male and female patients, and also affections of the reproductive apparatus for male patients. The professionals in the urology field are called urologists and are trained to diagnose, treat and manage patients with urologic affections. The organs that form the urology field are: kidneys, ureteras, urinary bladder, uretra and male reproductive organs (testicles, epidydim, seminal seminal vesicles, prostate and penis). Urology combines medical management problems )for example: non-surgical), like infections or the urinary tract and prostate benign hyperplasia, and surgical problems, like surgical treatment of cancer, correction of congenital abnormalities and urinary incontinence.

Urology has a tight bond , and sometimes is overlaped with the areas of oncology, nephrology, gynecology, andrology, pediatric surgery, gastroenterology and endocrinology..

Endourology is the Urology branch that is responsible for minimally invasive surgical procedures. Unlike open surgery, endourology is made with the help of small cameras and instruments that are being introduces in the urinary tract. Traditionally, transurethral surgery was the base stone of Endourology. Through the urethra we reach the urinary tract. This allows a prostate surgical intervention, urothelium tumor surgery, lithiasis and simple procedures or ureteral and urethra surgery.

Laparoscopy is  branch that quickly evolves in Urology, and has replaced some open surgical procedures.

Urologic oncology studies the surgical treatment of genitourinary malignant diseases like cancer of prostate , suprarenal glands, urinary bladder, kidneys, ureters, testicles and penis.

Neurourology studies the control of the genitourinary system, and the control of conditions that provoke abnormal urination due to defective functioning of nervous system. Neurologic diseases and disorders, like spinal cord lesions, multiple sclerosis and Parkinson disease can disrupt the function of inferior urinary tract and lead to conditions like urinary incontinence, detrusor hyperactivity and urinary retention.

Andrology is concentrated over the male reproductive system. Its main concern is male infertility, erectile dysfunction and ejaculation problems. Because the sexuality in male sex is mostly controlled by hormones, andrology is overlapped with endocrinology. Surgeries in this field include fertilization procedures, vasectomies, and penis prosthesis implants. Female urology is a branch that diagnoses and treats urinary incontinence, hyperactive bladder and prolapsed pelvic organs . 

 PROSTATE ADENOMA

Prostate adenoma, the main cause of urinary disorders (dysuria), is mentioned in Egyptian papyruses in aprox. 1500 b.c and recognized by Hypocrates 1000 years later.

The first modifications of prostate pathology appear around the age of 35, being represented by microscopic stromal nodules, developed around the periurethral glands. The BPH incidence in which they appear, and the clinical manifestations increases with age; so, between 60 and 69 years old, 51% of men have these lesions that need a form of treatment.

If around the age of 50 it is considered that aprox. a third of men have a specific prostate adenoma symptomatology, around the age of 70, aprox. half have this suffering and over 90% of men with the age of over 85 have a prostate adenoma symptomatology.

In spite the increased incidence, the disease is under diagnosed. In Romania, according to statistics, there are aprox. 200.000 men under treatment, but the number of patients might exceed 900.000. Men have the tendency to go to the doctor only when the symptoms become hard to bare and affect their daily life. In fact, every man with the age of over 50 should make a periodic urology control, every year, not just because in an early stage the disease is treated easily, but because the results are better .

ETIOLOGY

The etiology (BPH) is incompletely clarified. There are more hypothesis that try to explain the adenomyomatosis development of the prostate, frequently related to aging.

The hormonal role of androgens and estrogens n inducing prostate adenoma is complex and incomplete. It is known that orchiectomy  (castration) made before puberty prevents the development of prostate adenoma. It is appreciated that androgen hormones are necessary for initiating, inducing prostate hyperplasia, but not for maintaining it.

CLINICAL MANIFESTATION

     Clinically, prostate adenoma evolves in 3 stages:

I.                  prostatism stage;

II.                Incomplete urine retention without bladder distention;

III.             Incomplete urine retention with bladder distention.

I. Prostatism stage is characterized through premonitory manifestations. Nocturnal  pollakiuria, dysuria, diminished force of the urinary flow mark the affection's debut. There are 4 clinical forms after the predominance and intensity of some of the pathologic manifestations:

a). Moderate nocturnal pollakiuria (2-3 urination), diminished urinary flow, prolonged urination;

b).Exacerbation of nocturnal pollakiuria (4-5-6 urination);

c).Clinical suffering is dominated by dysuria;

d).In prostatism stage, away from the mentioned symptoms we can observe: the sensation of a foreign body in the rectum, nocturnal erection and pollution.

II. Incomplete retention without distention is characterized by the apparition of bladder residue and diurnal pollakiuria;

III.Incomplet retention with bladder distention . In this stage, the bladder residual volume crosses 300 ml, arriving and crossing the anatomic capacity of the gallbladder.

URINARY MANIFESTATIONS 

Pollakiuria and dysuria accentuate day and night. In the hypogastric area exam, the bladder globe is palpated. Urine, if not infected, has a pale aspect, due to the concentration power loss of the kidney.

 GENERAL MANIFESTATIONS

A pale color is observed, thirst, sometimes edema of the inferior limbs, apathy, sleepiness, lack of appetite, nausea, vomit, dry skin. The urea has high values, over 100 mg/dl, plasma creatinine highly elevated. Cardio-vascular manifestations are frequent, they can be systematized in: ischemic cardiomyopathy , arterial hypertension, cardiac failure.

In conclusion, the clinical prostate adenoma in divided in 2 sign and symptom groups: irritative and obstructive.

The evolution of a prostate adenoma can be burdened by many complications:

1.     bladder lithiasis ;

2.     macroscopic hematuria;

3.     infections: cystitis, pyelonephritis, orchiepididymitis;

4.     Pseudo-incontinence;

5.     complete urine retention;

6.     ureterohydronephrosis- vesicoureteral reflux.

Bladder lithiasis– appears as a consequence of the bladder stasis or urinary infection. Urination is painful and frequent. The pain radiates in the glans and has an effort provoked character.

     2.   Macroscopic hematuria– is not a frequent sign in the evolution of a prostate adenoma. The hematuria with prostate origin is usually initial, , reduced quantitative, but can also by abundant. Total hematuria must be considered as a complication.

3. Infectious complications :

-          acute and chronic cystitis  ;

-         acute and chronic pyelonephritis;

-         acute orchiepididymitis;

-        acute and chronic adenomitis .

The adenoma infection (adenomitis) is manifested acute or chronic: fever, frissons, pain and perineal heaviness sensation with glans radiation, distention that accentuates and leads to complete urine retention.

4.      Pseudo-incontinence - is met in patients with incomplete urine retention with bladder distention. False incontinence is due to urination from over full. This is nocturnal, at first, and then diurnal.

5.      Complete urine retention – may appear suddenly or may be preceded by dysuria accentuation. Food excess, alcohol ingestion, cold weather, sedative medication, rachidian or general anesthesia are factors that can lead to complete urine retention. The patient is agitated, has hypogastric pain, rectal and bladder tenesmus, but can not urinate .

6.    Ureterohydronephrosis –vesicoureteral reflux – appears after long periods of incomplete adenomatous obstruction, with bladder distention and then ureterohydronephrosis, so the distention of the entire urinary apparatus. In the clinical exam we find general signs of uremia, associated with bladder globe, soft and big kidneys, bilaterally sensible. Often, the patients feel lumbar pain during urination.

BPH TREATMENT

As a consequence of the fact that prostate adenoma does not have a progressive invariable evolution of the symptomatology, the planning of surgical intervention or of other form of treatment, for every patient is variable and depends, in the same time, of the severity of the symptomatology and the presence of complications.

It is estimated, in relation with the actual surgical intervention percentage, that aprox. 30-40% of men in their 40s will get to a prostate adenoma intervention, with the condition that they will live until the age of 80.

The absolute indications for prostate adenoma treatment include:

          -severe obstructive symtomatology;

          -incomplete retention with bladder residue>50 ml;

          -ureterohydronephrosis- superior urinary apparatus dilatation;

          -renal insufficiency consecutive to prostate obstruction;

          -complete urine retention.

Relative indications for treating prostate adenoma are represented, mainly, by:

- relative prostatism symptomatology;

- persistent, relapsed urinary infections;

- macroscopic hematuria.

The biggest part of the urologists, and patients also, prefer an early treatment, to ameliorate the symptoms, the quality of life and to avoid sequelae.

Until recently, surgical treatment was considered the most important and in the same time, the sole therapeutic mean. We see, in the last decade, a true and sustained offensive of the non surgical methods, medicines or minimally invasive methods.