55章良性前列腺增生課件

2023/6/4TheFirstHospitalofXinxiangMedicalCollege1良性前列腺增生

BenignProstaticHyperplasia,BPH2023/6/4TheFirstHospitalofXinxiangMedicalCollege2前列腺的位置2023/6/4TheFirstHospitalofXinxiangMedicalCollege3概述BPH又稱為前列腺肥大(ProstateEnlargement)BPH是指腺上皮細胞的增多，而非細胞的肥大BPH是老年男性常見疾病北方地區(qū)的發(fā)病率高于南方通常前列腺從35～40歲開始增生，50歲出現(xiàn)癥狀，60歲需要進行有效的治療2023/6/4TheFirstHospitalofXinxiangMedicalCollege4病因前列腺發(fā)育依賴于功能性睪丸的存在“雙氫睪酮(DHT)”學說(70年Wilson提出)

基質(zhì)與上皮的相互作用性激素與基質(zhì)-上皮間的相互作用雙氫睪酮學說示意圖2023/6/4TheFirstHospitalofXinxiangMedicalCollege5病理通常將前列腺分為移行帶(尿道周圍腺體、占5%)、外周帶、中央帶增生的部分主要是尿道周圍腺體增生的腺體壓迫外周帶成為外科包膜增生結(jié)節(jié)：基質(zhì)型、腺泡型、混合型2023/6/4TheFirstHospitalofXinxiangMedicalCollege6病理增生使前列腺段尿道彎曲、伸長、狹窄，導致膀胱出口（BOO）梗阻梗阻代償期：膀胱逼尿肌肥厚梗阻失代償期：充溢性尿失禁、上尿路積水擴張、代謝產(chǎn)物潴留、尿毒癥增生的程度與梗阻程度不一定成正比2023/6/4TheFirstHospitalofXinxiangMedicalCollege7臨床表現(xiàn)尿頻：最早出現(xiàn)的癥狀排尿困難：最重要的癥狀尿潴留：梗阻加重的表現(xiàn)其他：血尿、感染、結(jié)石、腎積水、疝、痔等(實物標本)BPHBOOLUTS2023/6/4TheFirstHospitalofXinxiangMedicalCollege8國際前列腺癥狀評分(I-PSS)過去1個月癥狀無1/5<1/2約1/2>1/2總是1.尿不盡感0123452.間隔≤2h0123453.間斷排尿0123454.憋尿困難0123455.尿線變細0123456.排尿費力0123457.夜尿次數(shù)012345I-PSS：Score(0～35)2023/6/4TheFirstHospitalofXinxiangMedicalCollege9I-PSSMeans0-7分輕度增生8-19分中度增生20-35分重度增生2023/6/4TheFirstHospitalofXinxiangMedicalCollege10生活質(zhì)量評分患者認為其現(xiàn)在的排尿狀況非常好好滿意半數(shù)滿意多數(shù)不滿不滿意很痛苦評分0123456生活質(zhì)量評分：L(0～6)2023/6/4TheFirstHospitalofXinxiangMedicalCollege11診斷50歲以上男性，進行性排尿困難直腸指診(DigitalRectalExam,DRE)觸及增生前列腺Ⅰ°增生：雞蛋大?、颉阍錾壶喌按笮、蟆阍錾葫Z蛋大小客觀指標：殘余尿、尿流率、PSA測定膀胱鏡檢或B超檢查：直接測定前列腺大小2023/6/4TheFirstHospitalofXinxiangMedicalCollege12鑒別診斷膀胱頸纖維化(膀胱頸攣縮)：慢性炎癥所致，發(fā)病年齡較輕前列腺癌：前列腺堅硬，表面不平，PSA膀胱癌：指膀胱頸附近的膀胱癌，膀胱鏡檢可以鑒別神經(jīng)原性膀胱尿道功能障礙：有神經(jīng)系統(tǒng)損害的病史和體征尿道狹窄：有尿道損傷、感染病史2023/6/4TheFirstHospitalofXinxiangMedicalCollege13治療目的：緩解增生腺體所致的膀胱出口梗阻膀胱出口梗阻(BOO)的原因：增生腺體擠壓尿道所致的機械性梗阻增生腺體平滑肌張力所致的動力性梗阻治療方法：很多2023/6/4TheFirstHospitalofXinxiangMedicalCollege14藥物治療α-受體阻滯劑：降低前列腺平滑肌張力非選擇性α-受體阻滯劑：酚卞明選擇性α1-受體阻滯劑：Hytrin(高特靈)高選擇性α1a-受體阻滯劑：哈樂5α-還原酶抑制劑：Proscar(保列治)—阻止睪酮轉(zhuǎn)變?yōu)镈HT，長期服用可使前列腺體積縮小花粉類制劑：舍尼通等2023/6/4TheFirstHospitalofXinxiangMedicalCollege15手術治療適應癥：殘余尿量大于50ml曾經(jīng)出現(xiàn)過急性尿潴留大量出血或反復肉眼血尿病人迫切要求，身體狀況能耐受手術手術方法：恥骨上前列腺增生腺體摘除術恥骨后……摘除術經(jīng)會陰……摘除術經(jīng)尿道前列腺電切或電汽化術2023/6/4TheFirstHospitalofXinxiangMedicalCollege16經(jīng)尿道增生腺體切除術目前，在全世界范圍內(nèi)，這種治療方法被公認為治療BPH的“金標準”(GoldStandard)2023/6/4TheFirstHospitalofXinxiangMedicalCollege172023/6/4TheFirstHospitalofXinxiangMedicalCollege182023/6/4TheFirstHospitalofXinxiangMedicalCollege19經(jīng)尿道增生腺體切除術2023/6/4TheFirstHospitalofXinxiangMedicalCollege20前列腺電汽化術TUVP

TransurethralVaporizationoftheProstate

2023/6/4TheFirstHospitalofXinxiangMedicalCollege21前列腺電切除術TURP

TransurethralResectionoftheProstate

2023/6/4TheFirstHospitalofXinxiangMedicalCollege22電切除的前列腺碎片2023/6/4TheFirstHospitalofXinxiangMedicalCollege23前列腺鈥激光切除術2023/6/4TheFirstHospitalofXinxiangMedicalCollege24LaserAblationoftheProstate

2023/6/4TheFirstHospitalofXinxiangMedicalCollege25前列腺兩側(cè)葉、中葉增生合并膀胱結(jié)石2023/6/4TheFirstHospitalofXinxiangMedicalCollege26TreatmentofBPHPlaceboWatchfulwaitingPharmacotherapyAlpha-blockers5alphareductaseinhibitorsPhytotherapySurgeryTURPTUVPTU