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Prostatic Congestion Associated with Benign Prostatic Hyperplasia (BPH)

E. Bierhoff, J. Vogel, W. Vahlensieck

Prostatic congestion is a combination of a temporary or permanent stasis of secretions together with edematous changes in the prostatic tissue. Oftentimes this is combined with hyperemia, in particular of the very vascularized peripheral and subcapsular parts of the prostate (11,14). In cases of prostatic congestion, the tissue and expressed prostatic secretions do not show evidence of inflammation (5,14). This serves as an important differential diagnostic sign to rule out prostatitis since the clinical picture of prostatitis and prostatic congestion are often completely identical. Because of the different therapeutic measures, however, it is important to distinguish between the two disease entities (e.g., antibiotic treatment in cases of inflammatory prostatitis) (4,11,14).

Prostatic congestion is mainly seen in younger patients between the ages of 20 and 40 years. Because of the typical symptoms, it was labelled earlier as congestive prostatitis or ,vegetative adnexitis" (5,14). It may also be seen as congestion associated with other prostatic diseases, such as in cases of acute or chronic prostatitis or in the context of benign prostatic hyperplasia (4,11,14). The incidence and severity of associated prostatic congestion in cases of BPH are the topic of this study.

Material and Methods

The 282 prostate tissue samples collected from patients with the clinical diagnosis of BPH between 1988-1990 in the Department of Urology of the Rheinische Friedrich-Wilhelms University and Medical School, Bonn, Germany form the basis for this study. Of these samples, 105 TURP specimens and 8 specimens from open suprapubic prostatectomies were studied; these did not show any inflammatory changes and were therefore considered as bland, benign prostatic hyperplasia. In these cases, therefore, the prostatitis oftentimes associated with BPH was ruled out as a possible cause for the congestion. Ten TURP's had been performed on patients because of recurrent benign prostatic hyperplasia in men who had already been operated on before for BPH.

The tissue fixed in 4 % formalin was embedded in paraffin and stained with Haematoxylin-Eosin. Significant dilation of the glandular acini with or without demonstrable stasis of secretion, and flattening of the glandular epithelial cells were judged as evidence of congestion. Dilation and hyperemia of the periglandular and subcapsular veins, edematous changes in the fibromuscular stroma (in particular in the periglandular and perivascular areas), and the isolated dissociation of smooth muscular and fibrous cell formations caused by edema were considered as evidence of congestion in the fibromuscular stroma of the gland. The severity of the associated congestion was semi-quantitatively judged as mild (+) (=single glandular group with congestive changes and stromal areas per field at a 25 fold magnification), moderate (++) (=several groups of glandular acini and stromal areas with congestive changes per field at 25-fold magnification), and severe (+++) (equals large confluent congestive changes of glandular and stromal tissue components per field at 25-fold magnification). The evaluation of the slides was performed by two blinded investigators according to the predetemined criteria. The correlation between the two investigators was 94%.

Figs. 1a and 1b Histological findings of congestive changes associated with BPH in glandular tissue.

Fig. 1a Significant dilation of the glandular lumina (Haematoxylin-Eosin stain, 25-fold).
Fig. 1b Flattening of the glandular epithelium and retention of secretion in the glandular lumina (Haematoxylin-Eosin, 100-fold).

Results

The average age of the patients from whom the material was obtained at surgery was 66.5 years, and the mean weight of the removed prostatic tissue was 21.7 grams. In the examined specimen, mild congestion was found in 47.7%, moderate congestion was found in 46.4 %, and in 5.9 % severe congestion of glandular and stromal parts were found. The determination of the severity was based on the more severely affected tissue component. In 60 % of the specimens - in particular in the specimens with mild congestive changes - the congestive changes were found equally common in the glandular and in the stromal tissue components. In 10.5 % of the cases, the congestion was predominantly in the glandular parts, while in 29.5% it was predominantly found in the stromal tissue component. The latter was particularly evident in moderate or severe cases of congestion. In the group of patients who had undergone open suprapubic prostatectomy and had a large amount of tissue removed, predominantly moderate and severe cases of congestion were found.

Figs. 2a and 2b Histological findings of prostatic congestion associated with BPH in the stromal tissue component.

Fig. 2a Dilation and hyperemia of veins as well as perivascular stroma edema (Haematoxylin-Eosin, 100-fold).
Fig. 2b Periglandular stroma with dissociation of smooth muscle and fibrous cell clusters caused by edema.

Discussion

In patients with the clinical symptom complex of acute, recurrent, or chronic prostatitis, no adequate clinical or morphological inflammatory correlate is found in the prostate tissue in about one-half of the cases (2,9). These cases have been summarized under the term ,vegetative urogenital syndrome" or in anglo-american terminology as prostatodynia (3,4,6,7,13,15). In the group of patients with prostatodynia, some are found with dysfunctions of the pelvic sympathetic nervus plexus and resulting detrusor or smooth muscle sphincter dyssynergia (1), spastic myalgia of the pelvic floor muscles (6, 10, 12), the dome of the bladder and the prostatic urethra (8), prostatic neuroses, or anogenital syndrome (9,11).

Furthermore, in this group of patients with prostatitis-like symptoms, patients are found regularly who have an edematous or elastic and often tender digital rectal examination of their prostate (11, 14). Based on the idea of a temporary or long-lasting increased fluid accumulation in prostatic tissue, this has led to the term prostatic congestion. The clinical findings justify only in exceptional cases further invasive diagnostic tests such as biopsies or prostatic resection. Therefore, the underlying morphological correlate has only become known through individual cases (5, 14).

The morphological correlate of prostatic congestion is a stasis of secretions in the lumina of the glandular acini which varies in intensity and may lead to the formation of so-called corpora amylacea. These are often found in combination with a significant dilation of lumina and flattening of the cylindrical glandular epithelium. Furthermore, edematous changes are found in the fibromuscular stroma as well as hyperemia of the peripheral subcapsular venus plexus. Aside from small groups of individual, in particular periglandular-located round cells, no evidence is usually found for acute or chronic inflammatory changes (4,5,15). Both prostatic tissue compartments, the glandular and the stromal parts, can be similarly affected by the congestive changes, or a more glandular or a more stromal predominance of the congestive changes may be found (4).

Based on these criteria, the present study demonstrates that in all cases of benign prostatic hyperplasia, congestive changes are present. These are predominantly of mild and moderate severity. Therefore, prostatic congestion is an obligatory phenomenon universally associated with BPH.

The cause for the development of prostatic congestion might be mechanical compression and blockage of ducts draining the glandular acini and veins. To what extent other causes such as vegetative functional disturbances, stress, increased sensitivity to cold, nervousness, the lack of physical exercise, subvesical obstruction caused by urethral strictures, blockage of venous drainage in the pelvic area, and spasms of the pelvic floor muscles play a role in the etiology of prostatic congestion, is clinically very difficult to determine (4,5,11,14,15).

At least in those cases examined in this particular study in which moderate or severe congestion was found in association with BPH, a worsening of the clinical symptoms, and the development of prostatitis-like symptoms due to the congestive changes are very likely (11). Consequently, the therapeutic strategy for BPH might be enhanced by the addition of drugs aimed at reversing 13 these congestive changes (decongestants).

Summary

In all cases of benign prostatic hyperplasia (BPH) even without histological proof of associated prostatitis, evidence for a congestion is found in the form of secretions in the glandular acini and / or edematous changes in the prostatic stroma. In our own studies conducted on 282 prostate tissue specimens, we distinguished between mild, moderate, and severe congestive changes. Predominantly, mild and moderate forms of congestion were found. At least the moderate or severe changes might influence the voiding dysfunction associated with BPH, and consequently, decongestants might improve micturition in such cases.

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