Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia or BPH, also referred to as prostate gland enlargement is one of the most significant medical conditions among elderly men. It is a serious condition which proactively leads to other complications such as urinary tract infections and prostate gland functional abnormalities. The prostate gland is a two-lobed walnut shaped gland often associated with sperm mobilization. The growth of the prostate gland is directly related to age. The exact mechanism or the cause of this condition is not well determined. However, many studies indicate that the hormonal imbalance as the age increases in a man is responsible for the enlargement of the prostate gland. This refers to the excessive production of estrogen and decrease in the male sex hormone testosterone.

Clinical manifestations of BPH

The symptoms of Benign Prostatic Hyperplasia (BPH) worsen with age. The most common clinical symptom is repeated urination episodes. Often patients either complain of frequent urination, urinary urge or even difficulty in passing urine if there is an associated infection. These symptoms occur because of the inability of the tissues to make space for the enlarged or hypertrophic prostate gland. This lays pressure on the urethra to stimulate the process of urination frequently. Many patients complain of Nocturia. In addition to these symptoms, patients also suffer renal stones and reduced kidney function.

Diagnosis and Management of Benign Prostatic Hyperplasia

BPH is diagnosed based on various urological criteria. The American Urological Association recommends a score system. In most cases patients are examined to identify the presence of malignancy in the prostate region and hence test such as prostate specific antigen (PSA) is recommended along with cytological study of the prostate gland. Important parameters such as post-void residual volume, uroflowmetry, urinary pressure studies are conducted. Along with these diagnostic parameters, kidney function test is done to rule out other associated complications.

BPH can also transmit as a genetic disorder in some cases. The high risk groups are generally obese or suffer diabetes and hypertension. Along with these, other factors such as alcoholism, drug abuse and erectile dysfunction can lead to BPH.

Treatment of Benign Prostatic Hyperplasia

BPH patients are often kept under surveillance to avoid medical emergencies. The drugs administered for this condition reduce blood pressure and facilitate smooth muscle relaxation of the prostate gland thereby regulating urine flow. The drugs used are predominantly alpha blockers such as alfuzosin, terazosin and anticholinergics.

PSA blood test

The Prostate Specific Antigen (PSA) test enables the medical practitioner to detect prostate cancer at an early stage. prostate Specific Antigen (PSA) is a protein produced in small amounts in the cells of the prostate gland. A PSA blood test helps to determine whether stage of prostate cancer is advanced enough to perform a biopsy of the prostate gland or not. When the prostate gland enlarges, PSA level in the blood tends to rise. This is indicative of cancer or benign non-cancerous conditions. PSA is called biological marker or tumor. As men age, both benign prostate conditions and prostate cancer become more frequent. The most common benign prostate conditions are prostatitis which is inflammation of the prostate, and benign prostatic hyperplasia - BPH which refers to the enlargement of the prostate.

BPH - Benign Prostatic Hyperplasia is not usually dangerous by itself. Any strain on the bladder owing to urine retention can lead to complications like bladder/kidney damage, kidney stones, Urinary tract infection (UTI) or incontinence. The etiology of BPH is still not clear while most agree that the metabolism of testosterone can partially exacerbate BPH. A part of the secreted testosterone ends up as DHT - Dihydrotestosterone which may accentuate other conditions other than BPH - like male pattern baldness.

When the PSA test is combined with rectal examination, 90% of prostate cancers can be detected. In the U.S., the American Cancer Society recommends PSA blood test at least once a year to avoid the risk of prostate cancer.

The PSA test has been called the 'male PAP test'. The normal range for a PSA blood test is between 0 - 4 ng/ml (nanograms per milliliter). A PSA level of 4 - 10 ng/ml is considered slightly elevated. Levels between 10 -20 ng/ml are considered moderately elevated. Anything about 20 ng/ml is considered highly elevated. Although the higher the PSA level, the higher the risk of cancer, one abnormal PSA test result does not necessarily mean it is cancer that is present, as various other factors may cause PSA levels to fluctuate.

The PSA test is a radioimmunoassay. In a diagnostic laboratory, the patient's blood sample is exposed to the antibody against PSA. That moment the amount of antigen (PSA) can be measured. It should be borne in mind that a man who is undergoing hormone therapy for prostate cancer may have a low PSA test reading during or immediately after the treatment. The low level may not be a true measurement of PSA in the patient's body. It is essential that such patients brief the doctor who may probably advise him to wait a few months after hormone treatment before having a PSA test done.

PSA test does not help a man with fast-growing tumors or aggressive cancer. It helps only in detection of small tumor and slow growing tumors which are unlikely to threaten a man's life. PSA test also cannot detect cancers spreading to the other parts of the body beforehand. There is a fear of false positives test results in PSA testing. Sometimes PSA level could be elevated but that does not necessarily mean cancer is present. A fear of false negative test result can also occur in PSA testing. That is the PSA test result will show negative even if prostate cancer is actually present in the patient. PSA blood test is often followed by other diagnostic tests such as ultrasound, x rays and cystoscopy to determine the presence of cancer or any other problem in the prostate.

CBCT Scan

CBCT, also known as C-arm CT, Cone Beam Volume CT or flat panel CY is a medical imaging technique, like a conventional CT scan. It provides fast and accurate visualization of bony anatomical structures in three dimensions. It is essentially X-ray computed Tomography where the X rays are divergent, forming a cone. Unlike traditional dental x-rays that are flat images, CBCT scan can provide multiple images of the teeth, soft tissues, bone and nerve pathways. The image quality is better due to reduced scatter radiation. These images help compile exact 3D images of various angles of the face and jaw. It also allows the dentist to zoom into specific maxillofacial structures with alternate angles for clearer evaluation.

CBCT applications

CBCT is important in planning and diagnosis in implant dentistry and interventional radiology among other things. In dentistry, it is used in oral surgery, endodontics and orthodontics.

CBCT is an important tool in image-guided radiation therapy for patient positioning and verification. Nearly 600 distinct images can be captured by rotating the CBCT scanner around the patient's head. In interventional radiology, a single 200 degree rotation over the region of interest provides volumetric data. The scanning software collects the data and reconstructs it, producing a digital volume composed of three dimensional voxels of anatomical data that can be manipulated and visualized with specialized software.

CBCT offers invaluable information in planning and assessment of surgical implants. A dental cone beam scan is the preferred method for pre surgical assessment of dental implant sites. Since CBCT is a 3D rendition, there are several structures that can be viewed with this facility, which are not available with conventional 2D radiology. CBCT offers an undistorted view of the dentition. That is why it is used for accurately visualizing both erupted and non erupted teeth. It is also used in tooth root orientation and anomalous structures.

Use of CBCT in Interventional Radiology (IR)

The scanner is mounted on a C arm in the IR suite offering real time imaging. Since this can be done on a stationary patient, it eliminates the time spent to transfer a patient from the Angiography suite to a conventional computed Tomography scanner. It also facilitates many applications of CBCT during IR procedures. Both primary and supplementary form of imaging can be done with CBCT. For fluoroscopy and soft tissues, it can be very helpful during complex procedures to reduce patient's radiation exposure.

Clinical applications of CBCT

In hepatocellular carcinoma, CBCT contrast confirms that the proper artery is selected to deliver the therapy. For benign prostatic hypertrophy BPH, CBCT provides soft tissue details needed to visualize prostatic enhancement, identify duplicated prostatic arteries and avoid non target embolization. During abscess drainage, CBCT confirms needle tip location after placement under ultrasound and confirms drain placement by revealing contrast injection into the desired location.

For adenoma adrenal vein sampling, contrast enhanced CBCT shows perfusion of the adrenal gland to confirm catheter placement for obtaining a satisfactory sample. During stent placement, CBCT improves the visualization of intracranial and extracranial stents. CBCT guides needle placement and allows diagnostic accuracy, sensitivity and specificity in lung nodules. After correction of vascular anomalies, CBCT sensitively detects small infarcts in tissue during the procedure to prevent further shunting.

Risks

Although it is a compact, faster and safer version of the regular CT, dental CBCT delivers more radiation than conventional dental X rays. Even properly shielded CBCT exposes patients to radiation many times more than 2D digital dental x rays. However, improved outcomes at lowered cost and time saving, reduced morbidity and reduced need for exploratory procedures and other such benefits of CBCT continue to make it popular with practitioners.