BPH (benign prostatic hyperplasia)

A. DEFINITIONS

BPH is the enlargement or prostate hypertropi. Enlarged prostate gland, extends forwards to the bladder and obstruct urinary outflow, can cause hydronefrosis and hydroureter. The term benign prostate Hipertropi not really accurate because it is not enlarged prostate gland or prostate hipertropi, but periuretra glands undergoing hiperplasian (the cells multiply. Prostatic glands themselves will become flattened and pressed called surgical capsule. So in the literature on benign hyperplasia of the prostate gland or prostate adenoma, but was hipertropi common prostate.

B. AETIOLOGY

Cause of benign prostate Hipertropi not known for certain. Prostate is the organ that depends on the endocrine and can also be considered an invitation (counter part). Therefore, the etiology is considered to be due to the absence of endocrine balance. However, according to Hidayat Syamsu and Wim De Jong in 1998 the aetiology of BPH are:

v The periuretral hyperplasia caused by changes in the balance of testosterone and estrogen.o endocrine imbalance.

Factor v age / old age.

v Unknown / not known for certain.

C. ANATOMY PHYSIOLOGY

Prostate gland is a gland fibro muscular Bledder circular proximal neck and the urethra. Prostate gland weight in adults approximately 20 grams with an average size: - Length, width 3.4 cm-4.4 cm Thickness 2.6 cm. In embryological terdiro of 5 lobur: - 1 lobe medius anterior lobe of fruit 1 fruit 1 fruit posterior lobe-lateral lobe 2 lobe development buahSelama medius, the anterior lobe and posterior lobe will be called lobes medius cypress. In cross-section medius lobes sometimes do not seem as too small and it looks homogeneous lobe gray, with small cysts filled with fluid such as milk, the cyst is called the prostate gland. In cross-section of the posterior urethra in the prostate gland consists of:

- Capsules anatomical

- Network stroma consisting of fibrous tissue and muscular tissue, glands network, divided into 3 groups of parts:

o The outside is gland is

o The center is called sub-mucosal glands, this layer also called zone adenomatus

o In the vicinity of the urethra called periuretral gland

The third channel from the glands together with the channel from vesika seminal ducts united to form communist ejakulatoris which culminated into the urethra. In adolescent males had palpable prostate on rectal plug, whereas in adults Oran slightly palpable and the parents are usually easy to cross teraba.Sedangkan bumps in the process hiperplasi prostate, prostate tissue is still good. Added elements glands produce reddish yellow color, soft and konsisitensi clear boundary with prostate tissue is pushed into the white-gray ash and solid. If the bulge is pressed out liquid like susu.Apabila growing network of projections fibromuskuler gray, solid and fluid, so the limit is not clear. This bulge can press so that the urethra from the lateral slit-like urethral lumen. Sometimes this assertion can also cover the urethral lumen, but the glandular tissue fibrosis who urged gradual contraction of the prostate and vesika can cause inflammation.

D. PATHOPHYSIOLOGY

According to Hidayat syamsu and Wim De Jong in 1998 is this disorder usually occurs after middle age due to hormonal changes. Least in part to the formation of enlarged prostate adenoma spread. Progressive adenoma enlargement or suppress the urge to normal prostate tissue to produce a true capsule surgical capsule. This surgical capsule and adenoma restrain expansion tends to grow into the lumennya, which limit the passage of urine. Finally, increased emphasis is needed to empty the bladder. Muskulus fibers destrusor respond hipertropi, which produces biological trabekulasi in some cases kemih.Pada if obsruksi out too great, there dekompensasi bladder becomes flasid structures, dilated and able to contract effectively. Because there is the urine, so there is an increase of infection and bladder stones. Increased back pressure can cause progressive hidronefrosis.Retensi for water, sodium, and urea can cause edema great. This edema respond quickly with catheter drainage. Post operative diuresis may occur in patients with edema and hydronephrosis following great obstruksinya removed. At first the water, elekrolit, urine and weight increase diuresis solutlainya this, finally a progressive loss of fluid can damage the kidneys ability to concentrate and retain water and sodium and fluid loss due to excessive elekrolit can cause Mansjoer hipovelemia.Menurut Arif in 2000 of prostate enlargement occurred in slowly on Urinary tract, occur slowly. In the early stages of prostate enlargement occurred, causing physiological changes that cause the prostate urethral resistance, vesika neck and detrusor contraction cope with more result kuat.Sebagai detrusor fibers will become thicker and protrusion of the fibers into the mucosa detrusor jar will be seen as a block - block tampai (trabekulasi). When viewed from the vesika with sitoskopi, vesika mucosa could break out among the detrusor fibers, forming a mucosal bulge called small if and when the big sakula called diverkel. Detrusor thickening phase is the phase when the compensation will be ongoing detrusor tired and eventually will have dekompensasi and no longer able to contraction, resulting in total urinary retention continues to hydronephrosis and urinary tract dysfunction over

E. PATHWAY

Urethral obstruction of urine accumulation VU dlm Surgery / destrusorSpasme muscle prostatektomiKompensasi muscle muscles spincterMerangsang nociseptorHipotalamusDekompensasi urine destrusorPotensi urinTek intravesikalRefluk to ginjalTek ureter & kidney meningkatGagal ginjalRetensi urinPort de insisiResiko dysfunction mikroorganismekateterisasiLuka Entree seksualNyeriResti infeksiResiko vol cairanResiko lack of bleeding: risk of shock hipovolemikHilangnya pattern tbhPerub function eliminasiKurang ttg information penyakitnyaKurang pengetahuanHyperplasia periuretralUsia lanjutKetidakseimbangan endokrinBPH

F. CLINICAL MANIFESTATIONS

Although benign prostate Hipertropi always occur in the elderly, but not always accompanied by clinical symptoms, this occurs because of two things: 1. Narrowing of the urethra which causes difficulties berkemih2. Retention of urine in the bladder causes the bladder dilatation, hypertrophy of the bladder and cystitis.Adapun symptoms and signs that appear in patients with benign prostate hypertrophy: a. Urinb retention. Lack of or weak emission kencingc. Puasd not Miksi. Increased urinary frequency, especially at night (nocturia) e. At night miksi must mengejanf. Hot, pain, or around the time miksi (dysuria) g. Abdominal mass bawahh part. Hematuriai. Urgency (the urgent impulse and suddenly to remove urine) j. Difficulty starting and ending miksik. Renall colic. Turunm weight. AnemiaKadang-sometimes without a known cause, the patient was not able to urinate should be issued with a catheter. Because urine is always filled in the bladder, it is easy to occur cystitis and kidney damage membranes.

G. DIAGNOSTIC EXAMINATION

In patients Hipertropi generally benign prostate examination:

1. LaboratoriumMeliputi urea (BUN), creatinine, elekrolit, sensitivity tests and urine cultures

2. RadiologisIntravena pylografi, BNO, sistogram, Retrograde, ultrasound, CT Scanning, cystoscopy, abdominal plain. Indications sistogram retrogras done if bad kidney function, ultrasound can be performed trans-abdominal or trans-rectal (TRUS = trans rectal Ultra Sonography), in addition to knowing the ultra sonography of prostate enlargement can also determine the volume of jar, urine and mengukut remaining other pathological conditions such as difertikel, tumors and stones (Syamsuhidayat and Wim De Jong, 1997).

3. Retro prostatectomy PubisPembuatan lower abdominal incision, but the bladder is not opened, just pull and adematous prostate tissue through the incision made on the anterior capsule of the prostate.

4. That is Parineal prostatectomy with prostate gland surgically removed via the perineum.

H. COMPLICATIONS

Complications that can occur in the prostate is hipertropi. Chronic retention can cause vesiko-ureteric reflux, hidroureter, hydronephrosis, failed ginjal.b. The process accelerated kidney damage in case of infection at the time miksic. Hernia / hemoroidd. Because there is always the rest of the formation of urine, causing batue. Hematuriaf. Cystitis and Pyelonephritis

I. TREATMENT
Drugs

   1. Alpha 1-blocker
      Example doxazosin, prazosin, tamsulosin and terazosin.
      These drugs cause relaxation (relaxation) the muscles of the bladder, so people more easily micturition.
   2. Finasterid
      Finasterid causing reduced levels of the hormone that reduces the size of prostate prostate.
      These drugs also cause increased urine flow rate and reduce symptoms. But it takes about 3-6 months until the occurrence of significant improvement.
      Side effects of Finasterid is reduced sexual desire and impotence.
   3. Other Drugs
      For the treatment of chronic prostatitis, which often accompanies BPH, was given antibiotics.

Surgery
Surgery is usually performed on patients who have:
- Incontinence uri
- Haematuria (blood in urine)
- Retensio uri (stuck in the urine in the bladder)
- Recurrent urinary tract infections.
Selection of surgical procedure usually depends on the weight of symptoms and the size and shape of the prostate gland.

   1. TURP (trans-urethral resection of the prostate)
      TURP is a surgical BPH is the most frequently performed.
      Endoscope is inserted through the penis (urethra). The advantage of TURP is not made the cut to reduce the risk of infection.
      88% of patients who undergo TURP experience improvement that lasted 10-15 years. Impotence occurs in 13.6% patients and 1% of patients experienced incontinence uri.

      Trans-urethral resection of the prostate

   2. TUIP (trans-urethral incision of the prostate)
      TUIP like TURP, but is usually performed on patients who have a relatively small prostate.
      In prostate tissue made a small incision to widen the hole in the urethra and bladder hole, resulting in improved urine flow rate and decreased symptoms.
      Complications that may occur are bleeding, infection, narrowing of the urethra and impotence.

   3. Open prostatectomy.
      An incision can be made in the abdomen (the structure behind the pubic bone / retropubic and above the pubic bone / suprapubic) or in the perineum (pelvic floor including the scrotum to the anal area). Through the perineal approach currently used jarangn because the incidence of impotence after surgery to reach 50%.
      This surgery usually requires time and patients should be treated for 5-10 days.
      Complications that may occur is impotence (16-32%, depending on the surgical approach) and incontinence uri (less than 1%).

Other treatment effectiveness is still in the research hyperthermia, laser therapy, and prostatic stents.

# If the degree of blockage is minimal, could be the actions as follows: Take a hot bath
# As soon as micturition micturition desire to appear
# Doing sexual activity (ejaculation) as usual
# Avoid alcohol
# Menhindari excessive fluid intake (especially at night)
# To reduce nocturia, fluid intake should be cut a few hours before bedtime
# Patients with BPH should avoid the use of cold and sinus medicines that are sold freely, a decongestant because it can improve the symptoms of BPH.

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Furunkulosis, skin diseases due to bacteria infection

Are you or your child's skin is often exposed to disease due to allergies or infection? Do you reply that skin disease is not the same kind or medicine. So be careful to treat your skin disease with drugs that are often found in the market, one-of your skin disease becomes worse. This review is about one skin disease caused by infection, which is very often found in people, especially in children. Furunkolosis name, is one form than pyoderma. At the Dermatology and Gender, University of Indonesia Faculty of Medicine, the incident ranks third most, and are closely related to socio-economic condition.
Furunkolosis can cause fatal complications. One of them is the furunkel malignant furunkel arising in the triangle area bounded by the upper lip and the lateral edge of the eye, because it may spread to the intra-cranial. Another problem is the spread of bacteria can occur in a more extensive or more so that it can also occur cellulitis or bakterimia. And if hygiene or poor patients suffering diebetes militus, furunkel become frequent relapses. The following will be presented of the causes, pathogenesis, to management.
 

Regarding understanding of this disease  

Pyoderma is a skin disease caused by Staphylococcus and Streptococcus, or by both. Furunkel is inflammation of the hair follicle and surrounding tissue, caused by Staphylococcus aureus. Furunkelnya If more than one is called furunkolosis.

Endemic
Pyoderma is a common disease in the community. At the Dermatology and Gender, University of Indonesia Faculty of Medicine, the incident took third place, and are closely related to socio-economic condition.
Furunkel more often in the summer, because a lot of sweating. In terms of age onsetnya can occur in children and young people. More frequency in boys.
 

Etiology / Causes
Etiologinya mostly by Staphylococcus aureus, the cells are spherical or Gram-positive coccus that the four pairs and groups. Staphylococcus aureus is a form of positive koagulase, this is what distinguishes it from other species, and is a major pathogen for humans. On the negative Staphylococcus is koagulase human normal flora. Staphylococci produce catalase which distinguishes it from streptococcus.
 

Predisposing factors that influence the emergence of this disease
Actually, the influence to the occurrence of pyoderma, especially furunkel or furunkolosis there are three factors that host factors, agents, and the environment.
Host factors

   1. bad hygiene
   2. diabetes militus
   3. obesity
   4. hyper IgE syndrome
   5. Chronic Carier S. aureus (nose)
   6. kemotaktik interference
   7. no underlying diseases such as HIV
   8. as a complication of dermatitis atopy, ekscoriasi, or pedikulosis scabies (a skin or lesions on the skin can also incomplete due to frequent scratching or rubbing)
Agent: usually S. aureus
Environment

   1. environment clean, dirty or ugly
   2. hot climate  

  

Pathophysiology, Pathogenesis, Pathology
Many things affect a person until the occurrence of pyoderma include host factors, agents, and the environment as has been described above in which the imbalance between the three factors. Staphylococcus contain polysaccharides and proteins that are antigens which are important substances in the cell wall structure. Peptidoglycan, a polysaccharide polymer containing subunit-subunit is strung, is eksoskeleton rigid cell wall. Peptidoglycan was destroyed by strong acid or lysozyme. This is important in infection potogenitas: This substance causes monocytes to interleukin-1 (endogenous pyrogen) and antibody opsonik, and this substance is also a chemical attractants (kemotraktan) for Polymorphonuclear leukocytes, endotoxin has a similar activity, activate komplement.
Pathology is the prototype lesion furunkel staphylococcus or other local abscess. S. groups aureus, which lives in the hair follicles causing tissue necrosis. Produced and Koagulase around mengkoagulasi fibrin within the lesion and lymph channels, resulting in the formation of a wall that limits preses and reinforced by the accumulation of inflammatory cells and tissue fibrosis. In the middle of the lesion, there was necrotic tissue melting (aided by slow type hypersensitivity) and abscesses that lead to the smallest lifetimes, after flowing out of necrotic tissue, cavity gradually filled with granulation tissue and eventually recovered.
 

Clinical picture
Bacteria enter the hair follicles causing folliculitis and perifolikulitis, appears as a red node and very painful. In severe conditions can be accompanied by symptoms of fever, malaise, etc.. After 2-4 days there is a process and formed an abscess supurasi this was known by the fluctuations. At the center of the lesion is yellowish spots that are necrotic tissue, and is called the eye sores (core). If the abscess broke the core of necrotic tissue will be out. Special treatment is the malignant furunkel ie furunkel arising in the triangle area bounded by the upper lip and the lateral edge of the eye, because it may spread to the intra-cranial. Another problem is the spread of bacteria can occur in a more extensive or more so that it can also occur cellulitis or bakterimia. And if hygiene or poor patients suffering diebetes militus, furunkel become frequent relapses. Predileksi this disease is usually in areas such as facial hair, back, head, armpits, buttocks and ekstrimitas, and especially in the area that a lot of rubbing.
Efloresensi, early lesions of small infiltrates, enlarged to form a cone-shaped eritematosa nodules, pain, there are core (eye ulcers), and then softened into an abscess, rupture, formed ulcers. 

  

How to diagnose it.
Furunkel or furunkolosis diagnosis can be established most clinically considering the typical clinical picture of early lesions of small infiltrates, enlarged to form conical eritematosa nodules, pain, there are core (eye ulcers), and then softened into an abscess, rupture, ulcers formed. But for better enforce the terms of the diagnosis:

   1. anamnesis: arise boils or painful lumps and no eyes.
   2. physical examination, especially erythema efloresensi conical nodules, and there are core ditengahnya
   3. investigation: painting Gram, culture and sensitivity tests
 

Differential diagnosis
Furunkolosis diagnosis was folliculitis and karbunkel. Between furunkolosis and folliculitis can be distinguished in terms of folliculitis efloresensinya if the macula of eritematus, papul, pustules, there is no core and the surrounding tissue is not inflamed. Between furunkolosis with karbunkel, can be distinguished in terms similar to efloresensinya only furunkel bigger and his eyes more than a single boil. And usually common in people with DM.
 

Complications
Here are a few complications furunkel:

   1. furunkel malignan: namely furunkel arising in the triangle area bounded by the upper lip and the lateral edge of the eye, because it may extend into the intra-cranial venous facialis and anguular emissary veins and also in that they have not spread to the valve so that later cavernosus sinus could be meningitis.
   2. cellulitis can occur if furunkel become deeper and widespread.
   3. bakterimia and haematogenous: bacteria in the blood can about heart valves, joints, spine, long bones, visceral organs, especially kidneys
   4. Repeated furunkel, this is caused by a bad higine
 

About Management / Treatment
As for management to furunkelatau furunkolosisi are as follows:

   1. Topical
Given topical ointment containing basitrasin and neomycin, fusidat acid, sodium-containing fusidat or mupirosin. In the event of ulcer or lesion was performed eksudatif open with a solution compresses permanganas kalikus 1 / 5000, 0.1% solution rivanol or povidin iodine 5% -10%.

   1. Systemic
Given systemic antibiotics, such as
Koksasilin 3 x 500 mg per oral / day for 5-7 days or
Sefadroksil 2 x 500 mg peroral / day for 10-14 days
If allergic to penicillin are given erythromycin
In malignant furunkel given intramuscular sefotaksim 1 gram per 8 hours for 10 days.
 

Prognosis
Generally good. Provided getting adequate treatment and causative factor is eliminated, and the prognosis becomes poor if complications occur. 

  

This paper Source: 

1. Djuanda, A. Ilmu Penyakit Kulit dan Kelamin, edisi keempat, Fakultas Kedokteran Universitas Indonesia, Jakarta, 2005, p. 110-112 , 379-381 

2. Duarsa, W., Pindha, S., Bratiartha, Adiguna, S., Wardhana, Darmada, Wiraguna, Nusantara, A. Pedoman Diagnosis dan Terapi Penyakit Kulit dan Kelamin Rumah Sakit Umum Pusat Denpasar, Fakultas Kedokteran Udayana, Denpasar, 2007, p. 27-28

3. Freeberg, I.M., Elsen, A.Z., Wolff, K. Fitzpatrieks Dermatology in General Med, 6 ^th ed, McGraw Hill, 2003, vol 2 p. 1856-1863.

4. Fitzpatrieks Color atlas and Synopsis of Clinical Dermatologg, 5 ^th ed, McGraw Hill, 2003, p. 595-597

5. Katzung, B.G. Basic & Clinical Pharmacology, 9 ^th ed, McGraw Hill, 2004, p. 801-806

6. Siregar, R.S. Atlas Berwarna Saripati Penyakit Kulit, edisi kedua, EGC, Jakarta, 2004, p. 80-81, 84-87

7. Jawetz, dkk., Mikrobiologi Kedokteran. Edisi 20, EGC , 1996. 

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