Ipertrofia prostatica benigna

L’ipertrofia prostatica benigna è nota anche con l’acronimo italiano IPB (Iperplasia prostatica benigna) o quello inglese BPH (benign prostatic Hiperplasia). In maniera inopportuna viene definita anche adenoma della prostata BEP (benign elargement prostate). Si tratta di una tra le patologie benigne più comuni nell’uomo.

Questa condizione patologica si contraddistingue per un aumento di volume della ghiandola prostatica.

Il suo sviluppo è legato ad un fisiologico invecchiamento dell’organismo, nonché da una lenta e graduale trasformazione dell’assetto ormonale del sistema endocrino sessuale.

L’IPB presenta una bassa incidenza negli uomini con età inferiore ai 40 anni. In questo caso, la percentuale si attesta intorno all’8%. Aumenta, invece, in maniera progressiva con il trascorrere degli anni. Negli uomini over 60, infatti, si attesta in percentuali superiori al 50.

Il tasso di mortalità relativo all’Ipertrofia prostatica benigna è basso: si parla, infatti, di uno 0,35 su 100.000. Va sottolineato, comunque, che, se non monitorata, può far evidenziare un aggravamento progressivo, con un conseguente peggioramento dello stato di benessere del paziente.
 

Cause

La prostata, conosciuta anche come ghiandola prostatica, è una ghiandola che appartiene dell'apparato genitale maschile. Il suo compito principale è quello di produrre ed emettere il liquido prostatico, una delle componenti dello sperma, che contiene gli elementi utili per nutrire e veicolare gli spermatozoi.

Nel corso degli anni, il processo di invecchiamento provoca un calo relativo della produzione di testosterone. Ciò comporta, di conseguenza, una maggiore attività della componente estrogenica endogena, che determina un aumento dello stimolo della crescita della componente centrale fibro-muscolare della prostata da cui genera l’IPB.

In virtù della sua localizzazione anatomica, la ghiandola riveste, dunque, un ruolo strategico nel processo di svuotamento delle vie urinarie. Questo perché, mediante la prostata, passa l’uretra, ovvero il canale attraverso cui decorrono le urine ed il liquido seminale.

Si intuisce facilmente che, qualsivoglia processo evolutivo, benigno o maligno che sia, ostacola la zona centrale della prostata. Tale processo, inoltre, è responsabile di malattie che interessano le vie escretrici, in particolare la vescica.

Il ruolo evolutivo dell’Ipertrofia prostatica benigna è decisivo sui sintomi delle vie urinarie (LUTS), così come anche sul benessere di un individuo.

Sintomi

Il graduale aumento di volume della porzione centrale della prostata, responsabile della genesi dell’ipertrofia prostatica benigna, comporta un restringimento lento e progressivo dell’uretra prostatica (si tratta della parte della ghiandola che comincia con l'orifizio uretrale interno della vescica, per terminare all'apice del pene, corrispondentemente all'orifizio uretrale esterno).

Il primo elemento sintomatologico, generalmente ravvisabile è, quasi sempre, la diminuzione del calibro e del getto urinario. Di frequente, si associa anche a difficoltà nel cominciare la minzione.
La sintomatologia, poi, potrebbe essere completata da altri segni, quali:
 

• bisogno di urinare più frequentemente del normale;
• il bisogno di urinare di notte, ovvero la nicturia;
• la necessità di urinare, talvolta con perdita involontaria di qualche goccia di urina. In tal caso si parla di urgenza minzionale;
• una minzione a più tempi, definita intermittente;
• la sensazione di non aver svuotato completamente la vescica;
• difficoltà a cominciare la minzione, sebbene la presenza di un forte stimolo;
• dopo aver urinato, il paziente nota la fuoriuscita di alcune gocce di urina. Si parla, in tal caso, di gocciolamento post-minzionale.

Nelle situazioni più gravi, può manifestarsi anche una completa incapacità ad urinare (ritenzione urinaria). In questi casi, è fondamentale ricorrere al catetere per lo svuotamento.
 

Diagnosi

Per eseguire una diagnosi di ipertrofia prostatica, attualmente i cardini sono rappresentati da tre step in particolare, ovvero:
 

• un’anamnesi scrupolosa. Si tratta di un aspetto importante, perché può mostrare patologie parallele (endocrinologiche, dismetaboliche e cardiovascolari);
• l’IPSS (International Prostate Symptom Score), ovvero un questionario valutativo, che, mediante un punteggio, analizza l’importanza dei sintomi urinari sulla qualità di vita;
• l’esame obiettivo, che prevede l’esplorazione rettale, nota anche come DRE digital rectal eploration.

Esistono, poi, ulteriori esami opzionali, preziosi per la diagnosi. Essi sono:
 

• esame urine e urinocoltura con ev ABG;
• esami ematochimici della funzionalità renale (azotemia, creatinina, acido urico, elettroliti, emocromo completo);
• l’uroflussimetria e, eventualmente, l’esame urodinamico;
• al tempo stesso, nell'ambito della visita, allo scopo di ottenere una corretta valutazione clinica, viene richiesto l’esame ematochimico del PSA (antigene prostatico specifico). I valori di tale esame devono essere interpretati, in modo da valutare la coesistenza di una neoplasia prostatica;
• l’ecografia prostatica transrettale, che ha l’obiettivo di valutare il volume prostatico, qualora l’esplorazione rettale abbia dato esiti sospetti, e, soprattutto, ai fini di un eventuale intervento chirurgico.

Rischi

Una possibile evoluzione dell'ipertrofia prostatica benigna, laddove non trattata, il più delle volte, può comportare delle complicazioni. Si tratta di complicanze correlate a uno svuotamento incompleto della vescica, nonché al ristagno urinario in vescica (ovvero la ritenzione urinaria). Tra le complicazioni più comuni, possiamo elencare:
 

• infezioni urinarie ricorrenti;
• ematurie (ovvero presenza di globuli rossi nelle urine) frequenti e recidivanti;
• litiasi vescicale o comunemente note come calcolosi vescicale. Questa condizione patologica vescicale è legata ad una ritenzione urinaria reiterata nel tempo. Essa provoca un addensamento urinario di minerali urinari nel fondo vescicale, che è all’origine della formazione dei calcoli. Questa condizione comporta sanguinamento (ematuria), dolore e infezioni urinarie;
• insufficienza renale cronica, data da una ritenzione urinaria cronica che, provocando un aumento della pressione idrostatica intra-vescicale, determina una dilatazione delle vie urinarie alte (idronefrosi), con compromissione irreversibile della filtrazione dell'emuntorio renale;
• compromissione della funzionalità vescicale, secondaria ad un eccesivo iper-lavoro della muscolatura detrusoriale. Questa situazione è legata all'ostruzione dell'adenoma prostatico, a livello dell'uretra prostatica, comportando una pressione idrostatica endovescicale che cresce in maniera progressiva, definendo una lenta e graduale perdita di forza contrattile ed elastica. Ne consegue ipocontrattilità e ritenzione urinaria.

Cure e Trattamenti

Non tutti i soggetti affetti da ipertrofia prostatica benigna devono obbligatoriamente essere sottoposti a una specifica terapia, poiché possono rientrare in un protocollo definito di vigile sorveglianza. Ovviamente, questo è possibile solo in seguito a un monitoraggio clinico e strumentale.

Per quanto riguarda la terapia medica, questa annovera:
 

• farmaci chimici o di sintesi (Inibitori delle 5 alfa reduttasi, Alfa-litici), che comprendono le seguenti molecole: Finasteride e Dutasteride. Tali farmaci presentano un meccanismo d’azione similare e sono i soli capaci di bloccare l’evoluzione dell’IPB;
• gli alfa litici sono la classe di farmaci di sintesi. Si tratta di medicinali particolarmente utilizzati per il trattamento dell’ipertrofia prostatica benigna e comprendono le seguenti molecole: AlfuzosinaI, Tamsulosina, terazosina; Silodosina. Il loro processo di azione si realizza mediante il rilassamento della muscolatura liscia del collo vescicale.

Entrambi i farmaci possono presentare effetti collaterali. Questi possono variare dal deficit erettile, nel caso degli inibitori della 5 alfa reduttasi, fino all’ipotensione arteriosa e eiaculazione retrograda, nel caso degli alfa litici.

Ci sono poi i farmaci naturali, conosciuti anche come fitofarmaci. Si tratta di medicinali che hanno una derivazione vegetale. Tra questi, quelli maggiormente utilizzati sono la serenoa repens, il pygeum africanum, l’ortica dioica e i semi di zucca. Tali sostanze operano in maniera analoga ai farmaci chimici. La loro modalità di azione include:
 

• inibizione delle 5 alfa reduttasi;
• rilassamento del collo vescicale;
• azione antiproliferativa sulle cellule prostatiche.

Nei casi in cui non c’è alcuna scelta di tipo terapeutico, l’unica soluzione è rappresentata dal ricorso al trattamento chirurgico. In quel caso, ci troviamo di fronte alla rimozione della porzione ostruente, adenomatosa della prostata. Si tratta di un intervento che può essere eseguito sia mediante un’incisione addominale o intervento di chirurgia open, ma anche tramite l’introduzione di uno specifico strumento chiamato “resettore endoscopico” attraverso l’uretra.

Altri interventi, invece, possono essere di chirurgia endoscopica o di endo-urologia, tra i quali è possibile annoverare:
 

• incisione trans-uretrale della prostata (TUIP);
• resezione trans-uretrale della prostata (TURP);
• vaporizzazione laser della prostata (PVP);
• prostatectomia trans-uretrale mediante laser al tullio (TULEP);
• enucleazione laser olmio adenoma della prostata (HOLEP).

Per quanto concerne i trattamenti chirurgici open o a cielo aperto, possiamo trovare, come abbiamo visto in precedenza, l’asportazione chirurgica dell’adenoma prostatico (ATV).

 
N.B.: L’articolo in questione, scritto in maniera semplice ed essenziale, si pone l’obiettivo di fornire elementi di conoscenza, che possono essere utili al fine di essere d’aiuto ad un lettore o paziente, nel comprendere e/o rendersi edotto su una delle patologie benigne più comuni nell’uomo adulto.
 

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