STUDY ON ESTIMATION OF SERUM PROSTATE SPECIFIC ANTIGEN LEVEL AND PROSTATE VOLUME WITH TRANS-ABDOMINAL ULTRASONOGRAPHY FINDING IN BENIGN PROSTATE HYPERTROPHY AT TERTIARY CARE HOSPITAL : A CROSS SECTIONAL DESCRIPTIVE STUDY

1* Chandra Prakash Gaire Introduc on The periurethral and transi on zones of the prosta c gland develop benign prosta c hyperplasia and represent an inevitable phenomenon for the ageing male popula on. Prosta c specific an gen, is a serine protease, level rises in the blood if the barrier between the lining epithelium and the blood stream is damaged. Benign prosta c hyperplasia, prosta c carcinoma and prosta s are three common diseases where PSA in the serum is raised. Prostate volume also increases according to age, which can be es mated by trans-abdominal ultrasonography. Objec ve The aim of the study is to es mate the PSA level in blood and its rela onship with prostate volume in benign prosta c hyperplasia pa ents. Methodology It is a descrip ve cross-sec onal study which was carried out st st between a periods of 1 April 2018 to 31 March 2019 at Birat Medical College Teaching Hospital. All the pa ents diagnosed with benign prostate hyperplasia at the department of urology were included in the study. Blood samples of pa ents were analyzed for Prostate specific an gen level es ma on by chemiluminescence immunosorbent assay. Prosta c volume of the pa ents was measured by Transabdominal ultrasound technique. Data were entered and analyzed in Microso Excel. Result A total of 68 pa ents were diagnosed with benign prostate hyperplasia. The mean age of the pa ents was 61.8±12.3 years. The maximum number 23 of pa ents with BPH was there in age group 51-60. The maximum no of pa ents 38 were having their PSA level between the range of 4.0-10.0 ng/ml. The maximum no of pa ents 28 was having Prostate volume in the range of 40-60 gm. The maximum number of pa ents 31 was having diabetes mellitus as a co-morbid associa on. The maximum mean PSA level and prostate volume in the pa ents were observed in age group >80 years, which was 20.1±8.6 ng/ml and >80 gm respec vely. Conclusion The prostate specific an gen level and prostate volume both increase in advance age group of pa ents suffering with benign prostate hyperplasia.


Methodology
It is a descrip ve cross-sec onal study which was carried out st st between a periods of 1 April 2018 to 31 March 2019 at Birat Medical College Teaching Hospital. All the pa ents diagnosed with benign prostate hyperplasia at the department of urology were included in the study. Blood samples of pa ents were analyzed for Prostate specific an gen level es ma on by chemiluminescence immunosorbent assay. Prosta c volume of the pa ents was measured by Transabdominal ultrasound technique. Data were entered and analyzed in Microso Excel.

Result
A total of 68 pa ents were diagnosed with benign prostate hyperplasia. The mean age of the pa ents was 61.8±12.3 years. The maximum number 23 of pa ents with BPH was there in age group 51-60. The maximum no of pa ents 38 were having their PSA level between the range of 4.0-10.0 ng/ml. The maximum no of pa ents 28 was having Prostate volume in the range of 40-60 gm. The maximum number of pa ents 31 was having diabetes mellitus as a co-morbid associa on. The maximum mean PSA level and prostate volume in the pa ents were observed in age group >80 years, which was 20.1±8.6 ng/ml and >80 gm respec vely.

Conclusion
The prostate specific an gen level and prostate volume both increase in advance age group of pa ents suffering with benign prostate hyperplasia.

INTRODUCTION
Benign prosta c hyperplasia arises in the periurethral and transi on zones of the prosta c gland and represents an inevitable phenomenon for the ageing male popula on. Prostate is fibro-musculo-glandular organ which is located around the neck of the urinary bladder. Prosta c enlargement that may due to any cause may give rise to 1 bladder outlet obstruc on. Benign prosta c hyperplasia (BPH) is a progressive condi on characterized by prostate enlargement accompanied by lower urinary tract symptoms. An es mated 75% of men >50 years of age have symptoms arising from benign prosta c hyperplasia, and 20-30% of men reaching 80 years of age require surgical 2 interven on for the management of BPH. Prostate is a male specific organ and the rate of clinical symptoms due to obstruc on of the bladder neck goes up as the age rises due 3 to increase in prosta c volume. BPH affects both glandular epithelium and connec ve ssue stroma to variable degrees in which adenosis, epitheliosis and stromal 4 prolifera on are seen in differing propor ons. A serine protease enzyme, i.e. PSA having the molecular weight 33 kDa, produced by the prostate epithelium and periurethral glands in male.PSA is normally formed as a proenzyme, secreted primarily by the secretory acinar cells that line the prostate and are secreted into the lumen. PSA is the enzyme that is responsible for liquefac on of semen 5 within a few minutes a er it has clo ed. Serum PSA eleva ons occur as a result of disrup on of normal prosta c architecture that allows PSA to diffuse into prosta c ssue and gain access to the circula on. PSA levels in the blood go up if the barrier between the lining epithelium and the blood stream is damaged. PSA is a prosta c specific but it does not specify 6 the type of the disease. This can occur in the se ng of prostate disease and prostate manipula on. Benign prosta c hyperplasia, prosta c carcinoma and prosta s are three common diseases where PSA in the serum is 7 raised. During the course of different prosta c diseases including benign prosta c hyperplasia, prostate volume (PV) varies widely throughout individual's life me. The development of highly specialized ultrasound equipment has allowed the applica on of this imaging technique in the diagnosis, treatment and follows up of prosta c disease, par cularly BPH. Transabdominal ultrasound measurement of prostate volume is consistent and correlated to transrectal prostate volume when the bladder volume is less than 400ml. In normal person, the serum concentra on of PSA is propor onal to the volume of prosta c epithelium, but the release of PSA from BPH is three fold that from the normal prostate. Therefore, the ra onale of present piece of work aimed to es mate serum PSA level and its rela onship with volume of prostate, es mated by trans-abdominal ultrasonography in BPH pa ents. Par cipants with chronic kidney or liver disease / because chronic liver and Kidney disease may influence prostate disease. Blood sample of the pa ents was collected for the es ma on of prostate specific an gen level. 5 ml of venous blood was drawn and collected in the vial. Serum part was separated by centrifuging vial at room temperature. PSA was es mated by chemi luminescence immunosorbent assay (CLIA), a solid phase two-site immunoassay. Transabdominal ultrasound was used to measure prosta c volume at Radiology Department. Pa ents with minimal bladder volume of 100 to 200 ml were subjected to USG for near 8 correct es ma on of prostate volume by USG. Data were entered and calcula ons were done in Microso Excel, point es mate at 95% Confidence Interval was calculated along with frequency and propor on for binary data.

RESULTS
A total of 68 pa ents were enrolled for this study. The mean age of the pa ents was 61.8±12.3 years. Age of the pa ents varied between ranges of 42 to 87 years. The number of pa ents diagnosed with BPH in different age groups is men oned in Table 1. The maximum number (23) of pa ents with BPH was there in age group 51-60. The es mated PSA level was categorized in four groups and the maximum no of pa ents 38 were having their PSA level between the range of 4.0-10.0 ng/ml. Few pa ents 5 were having their PSA level below than 4.0 ng/ml as shown in Table 2.    Table 4: Co-morbidi es of pa ents All pa ents were diagnosed for BPH by subjec ng them to transabdominal ultrasound. The volume of prostate is shown in Table 3. The maximum no of pa ents 28 was having Prostate volume in the range of 40-60 gm as shown in Table 3. All the pa ents with BPH were evaluated for their co-morbid condi ons and it was noted that maximum pa ents 31 were having diabetes mellitus as shown in Table 4. The minimum number of pa ents 3 was having COPD as associated condi on.
The elevated mean value of PSA level of the pa ents in the age group of 40-50 years showed 8.4±3.1 ng/ml, whereas the elevated mean PSA level of the pa ents in the 51-60 year age group showed 12.6±4.8 ng/ml. The age group of 61-70 & 71-80 years had 15.3±7.7 ng/ml and 17.7±8.6 ng/ml as the elevated mean PSA level respec vely. The mean PSA level of >80 years of pa ents was 20.1±8.6 ng/ml as shown in Figure  1. Similarly, the mean prostate volume of pa ents of >80 years was found >80gm, which was higher than other age groups of pa ents as shown in figure 2.

DISCUSSION
Benign prostate hypertrophy is most common benign tumour in men, and its incidence is age related. The maximum cases of BPH were recorded in age group 51-60 in this study. One of the study demonstrated that the percentage of male with enlargement of prostate increases from 20% at 40 years of age to 70% by age 60 and 90% by eighth decade 9 of life. In this study the PSA level showed significant correla on with both pa ent age and weight of the prostate gland (P < 0.05), Similarly the weight of the gland was also significantly correlated with the age of the pa ent (P<0.05)In the present study, age group of the pa ent varied from 42 to 87 years with the mean age 61.8±12.3 years, 10 where as in the study done by Hirachand et al, age group of the pa ent was 46-88 years with the mean age of 68 years which is similar to the study done by , Lakhey M, Banerjee B RajasundaramRwith the mean age 65.55, 67.61, 69.7 [11][12][13] years. Prosta c Specific An gen is produced only by the lining cells of prosta c acini and prosta c ssue. Since it is produced only by prostate, it is considered as the serum marker for Prosta c carcinoma. Unfortunately PSA is specific for prostate but not for the prosta c disease. Its concentra on was also found to increase in BPH, PIN and Prosta s. Epithelial cells of all types of prosta c ssue, benign and malignant produce PSA. Prosta c lesions are more common in the elderly age group, BPH more common than carcinoma of prostate. Prostate specific an gen level is raised in both the neoplas c and non-neoplas c lesions of prostate. The peri urethral glands produce extra prosta c PSA, which is measurable in urine but cannot be detected in serum in women and in men. The liquifica on of the ejaculate, done 14 by PSA, increases the mo lity of sperms PSA level has got prognos c value too in diagnosed pa ents. PSA is accurate and precise noninvasive biomarker and its diagnos c significance is well documented. In this study, 38 pa ents were having their PSA range between 4-10 ng/ml, 18 pa ents with PSA 10.1-20 ng/ml, 7 pa ents with PSA >20 ng/ml and 5 pa ents with PSA <4 ng/ml. In the study done 15 by Kamaleshwaran et al,94.87% of the total BPH pa ent have a serum PSA level less than 10 ng/ml, whereas in the another study done by Hirachand et al, 73.43% had a serum PSA level less than 7 ng/ml. All pa ents were diagnosed for BPH by subjec ng them to transabdominal ultrasound. The maximum no of pa ents 28 was having Prostate volume in the range of 40-60 gm in the present study. In a study, it was observed that 46.7% pa ents had prosta c volume of 40-59 gm, 60% had 60-79 gm and 13.3% had >80 gm. 16 The gold standard triad for diagnosing prostate disease comprised of Prostate specific an gen (PSA) level es ma on in blood and Transrectal ultrasonography. We have analyzed the level of PSA among the pa ents of different age group. The age group of 61-70 & 71-80 years had 15.3±7.7 ng/ml and 17.7±8.6 ng/ml as the elevated mean PSA level respec vely. The mean PSA level of >80 years of pa ents was 20.1±8.6 ng/ml. The mean PSA value of 49.8±6.0 ng/ml has been reported in one study, which was carried out in Chinese men suffering with prostate 17 cancer. Similarly, in another study carried in eastern Nepal, it was observed that the highest PSA value was upto The age-specific PSA reference range reflects the associa on between PSA and age. As men's age increases, the value of their serum PSA also increases. This is because of the enlarged prostate and increased leakage of the prosta c epithelium. It seems to be due to the subclinical inflamma on or microscopic foci of cellular atypia. In this present study, we observed that the higher age group had more level of elevated mean PSA than lower age group. Similarly, prostate volume was also found to be higher in higher age group of pa ents.

CONCLUSION
The present study revealed that mean PSA and prostate volume increased with advance age in BPH pa ents. BPH was more associated with pa ents suffering with Diabetes mellitus.

RECOMMENDATION
Prostate specific an gen level es ma on in blood and measurement of prosta c volume by trans-abdominal ultrasonography are really very helpful in diagnosing the various patho-physiology related with prostate gland. Timely diagnosis followed with accurate treatment yields with be er prognosis and disease management. PSA has been recommended test in guidelines of the American cancer society since 1993 for annual check-up of men aged 50 years or above and has resulted in early diagnosis and treatment. Hence the es ma on of PSA level in serum can be used as a diagnos c tool for screening prostate disease. So, a well regulated awareness program through NGOs or Health department may be ini ated so that various diseases related with prostate may be reduced among males.

LIMITATIONS OF THE STUDY
Low sample size.