Benign Prostatic Hyperplasia

**Benign Prostatic HyperplasiaGeneralised disease of the prostate due to hormonal derangement which leads to enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms

BPHProposed EtiologiesCause not completely understoodReawakening of the urogenital sinus to proliferateChange in hormonal milieu with alterations in the testosterone/estrogen balanceInduction of prostatic growth factorsIncreased stem cells/decreased stromal cell deathAccumulation of dihydroxytestosterone, stimulation by estrogen and prostatic growth hormone actions

**BPH factsOccurs in 50% of men over 50 and in 80% of men over 80 have BPHBPH progresses differently in every individualMany men with BPH may have mild symptoms and may never need treatmentBPH does not predispose to the development of prostate cancer

**Benign Prostatic Hyperplasia

BPH PathophysiologyNormalBPHHypertrophied detrusor muscleObstructed urinary flowPROSTATEBLADDERURETHRAKirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

BPH PathophysiologySlow and insidious changes over timeComplex interactions between prostatic urethral resistance, intravesical pressure, detrussor functionality, neurologic integrity, and general physical health.Initial hypertrophydetrussor decompensation poor tonediverticula formationincreasing urine volumehydronephrosisupper tract dysfunction

**ComplicationsUrinary retentionUTISepsis secondary to UTIResidual urineCalculiRenal failureHematuriaHernias, hemorroids, bowel habit change

**Clinical manifestations

Voiding symptomsdecrease in the urinary streamStrainingDribbling at the end of urinationIntermittencyHesitancy Pain or burning during urinationFeeling of incomplete bladder emptying

**Clinical manifestationsIrritative symptomsurinary frequencyurgencydysuriabladder painnocturiaincontinencesymptoms associated with infection

Benign Prostatic Hyperplasia

Leading to symptom bother and worsened QOL

Other Relevant HistoryGU History (STD, trauma, surgery)Other disorders (eg. neurologic, diabetes)Medications (anti-cholinergics)Functional Status

**Diagnostic TestsHistory & ExaminationAbdominal/GU examFocused neuro examDigital rectal exam (DRE)Validated symptom questionnaire.Urinalysis Urine cultureBUN, Cr

Prostate specific antigen (PSA)Transrectal ultrasound biopsyUroflometryPostvoid residual

AUA Symptom Score SheetInternational prostate symptom score (IPSS) Name:Date:

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost alwaysYour scoreIncomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?012345FrequencyOver the past month, how often have you had to urinate again less than two hours after you finished urinating?012345IntermittencyOver the past month, how often have you found you stopped and started again several times when you urinated?012345UrgencyOver the last month, how difficult have you found it to postpone urination?012345Weak streamOver the past month, how often have you had a weak urinary stream?012345StrainingOver the past month, how often have you had to push or strain to begin urination?012345

None1 time2 times3 times4 times 5 times or moreYour scoreNocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?012345

Quality of life due to urinary symptomsDelightedPleasedMostly satisfiedMixed about equally satisfied and dissatisfiedMostly dissatisfiedUnhappyTerribleIf you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?0123456

**DRE

BPHDanger Signs on DRE

Firm to hard nodulesIrregularities, unequal lobesIndurationStony hard prostateAny palpable nodular abnormality suggests cancer and warrants investigation

Optional Evaluations and Diagnostic TestsUrine cytology in patients with:Predominance of irritative voiding symptoms.Smoking historyFlow rate and post-void residualNot necessary before medical therapy but should be considered in those undergoing invasive therapy or those with neurologic conditionsUpper tract evaluation if hematuria, increased creatinineCystoscopy

**PSAElevated levels of PSA 0 4 ng/mlProstatic pathologyCorrelates with tumor massSome men with prostate cancer have normal PSA levels

BPH SYMPTOMSDifferential DiagnosisUrethral strictureBladder neck contractureCarcinoma of the prostateCarcinoma of the bladderBladder calculiUrinary tract infection and prostatitisNeurogenic bladder

BPH TREATMENT INDICATIONSAbsolute vs Relative

Severe obstructionUrinary retentionSigns of upper tract dilatation and renal insufficiency

Moderate symptoms of prostatismRecurrent UTIsHematuriaQuality of life issues

Treatment OptionsMild to severe symptoms with little botherManage with watchful waiting.Risk of therapy outweighs the benefit of medical or surgical treatment

Moderate to severe symptoms with botherManagement options include watchful waiting, medical management and surgical treatment.

TherapyWatchful waiting and behavioral modificationMedical ManagementAlpha blockers5-alpha reductase inhibitorsCombination therapy Surgical ManagementOffice based therapyOR based therapyUrethral stents

Watchful Waiting and Behavioral Modificationis the preferred management technique in patients with mild symptoms and minimal bother

AUA score < 7,

1/3 improve on own.

Watchful Waiting and Behavioral ModificationDecrease caffeine, alcohol )diuretic effect(Avoid taking large amounts of fluid over a short period of timeVoid whenever the urge is present, every 2-3 hoursMaintain normal fluid intake, do not restrict fluidAvoid bladder irritants to include dairy products, artificial sweeteners, carbonated beveragesLimit nighttime fluid consumptionBPH symptoms can be variable, intermittent

Medical ManagementNutritional supplementsSaw PalmettoAlpha blockersDoxazosin (Cardura), Terazosin (Hytrin), Tamsulosin (Flomax), Alfuzosin (Uroxatral) 5-alpha reductase inhibitors Finasteride (Proscar), Dutasteride (Avodart)Combination therapyAlpha blocker and 5-alpha reductase inhibitor

BenefitsConvenientNo loss of work timeMinimal risk

DisadvantagesExpensiveDrug InteractionsMust be taken every dayManages the problem instead of fixing itmedicationnnnnnnn

**Medical ManagementAlpha adrenergic receptor blockers promote smooth muscle relaxation in the prostateRelaxation of the muscles facilitates urinary flowDoxazosin (Cardura), Terazosin (Hytrin), Tamsulosin (Flomax), Alfuzosin (Uroxatral)Side effects: postural hypotension, dizziness, fatigue,Other problems can occur when pt is also taking cardiac or other hypertensive drugs

Alpha-Adrenergic Blockers

Equal clinical effectivenessSlight differences in adverse event profileOrthostasis (lower in tamsulosin)Ejaculatory dysfunction (higher in tamsulosin)Decreased energy levelsNasal congestionIncrease in CHF risk with doxazosinMust titrate doxazosin and terazosin to effective levels

**Medical Management5 alpha reductase inhibitor ) finasteride: Proscar(Reduce size of prostate gland by up to 30 %Blocks the enzyme of 5 alpha reductase which is nec, for the conversion of testosterone to dihydroxytestostersoneRegression of hyperplastic growth Dont work immediatelySmall effect on symptom score and flow rates

5-Alpha Reductase Inhibitors

Agents are effective and appropriate treatment for patients with lower urinary tract symptoms and demonstrable enlargement of the prostate.

Average prostate size is 30 ccs. Original studies showed benefit only in men with prostate sizes greater than 50 ccs.

5-Alpha Reductase InhibitorsFinasteride (Proscar) and Dutasteride (Avodart) Less effective for relief of BPH symptoms than alpha blockersAdverse events includeDecreased libidoWorsened sexual function (erectile dysfunction)decrease volume of ejaculationBreast enlargement and tendernessReduces risk of urinary retention by 3%/year.PSA must be doubled if screening for prostate cancer

Combination TherapyConcomitant use of alpha blockers and 5-alpha reductase inhibitorsShould be reserved for patients who are at significant risk of progression and adverse outcomePoor surgical candidatePatient wants to avoid surgerySignificant cost associated with dual medications

**Medical ManagementHerbal therapy saw palmetto fruit use to improve urinary symptoms and urinary flowProblem with herbal therapy long term effectiveness

surgical treatment

Surgical ManagementOffice based therapies:Transurethral microwave therapy (TUMT)Transurethral needle ablation (TUNA)Therapies are effective or partially effective for relieving the symptoms of BPHSignificant side effects/complications associated with these treatments have prompted a FDA warning

Surgical ManagementOR based therapiesOpen simple prostatectomyTURPTransurethral incision of the prostateLaser photoselective vaporization of the prostate (green light laser PVP)Laser Prostatectomy

Surgical Management

Patients may select surgical treatment as initial therapy if moderate or severe bother is present.

Patients who have developed complications of BPH (i.e urinary retention, renal insufficiency, recurrent UTI) are best treated surgically.

New surgical treatment have not demonstrated better outcomes than TURP to date.

BPH TREATMENTSurgical

Indicated for AUA score >16 Transurethral Prostatectomy(TURP): 18% morbidity with .2% mortality. 80-90% improvement at 1 year but 60-75% at 5 years and 5% require repeat TURP.Transurethral Incision of Prostate (TUIP): less morbidity with similar efficacy indicated for smaller prostates.Open Prostatectomy: indicated for glands > 60 grams or when additional procedure needed for suprapubic/retropubic approaches

TURP Gold Standard of care for BPHn

the gold standard- TURPBenefitsWidely availableEffectiveLong lasting

DisadvantagesGreater risk of side effects and complications1-4 days hospital stay1-3 days catheter4-6 week recovery

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possible side effects ofGreater than 5% risk of:Irritative voiding symptomsBladder neck contractureUTIRisk of incontinence 1% Decline in erectile function 65% of retrograde ejaculationTUR syndrome (acute hyponatremia from free water absorption)HemorrhageBladder spasms

TURP

**Preoperative GoalsRestoration of urinary drainageTreatment of any urinary tract infectionUnderstanding of procedure, implications for sexual functioning and urinary control

**Preoperative careAntibiotics Allow pt to discuss concerns about surgery on sexual functioningProstatic surgery may result in retrograde ejaculation

**Postoperative GoalsNo complicationsRestoration of urinary controlComplete bladder emptyingSatisfying sexual expression

**Postoperative CareMonitoringContinuous irrigation & maintain catheter patencyBlood clots and hematuria are expected for the first 24-36 hoursAfter catheter is removed check for urinary retention and urinary stream

**TURPSphincter tone may be poor after catheter is removed. Kegal exercise pelvic muscle floor technique is encouraged. Starting and stopping the urinary stream is helpful.Stool softeners to avoid strainingSitting and walking for long periods should be avoided

**Discharge planningCatheter careManaging urinary incontinenceOral fluid intake 2,000-3,000 cc per dayObserve for s/s of urinary tract infectionPrevent constipationAvoid liftingNo driving or intercourse after surgery

**Surgical approaches for prostatectomyRetropubicMidline abd. incisionPerinealIncision between the scrotum and anusSuprapubicAbdominal incision

**ProstatectomyComplications: Bleeding Postoperative pain Risk for infection Erectile dysfunction

BPH TREATMENTNew ModalitiesMinimally invasive: (Prostatic Stents,TUNA,TUMT, HIFU,Water-induced Thermotherapy)Laser prostatectomy (VLAP,ILC,CLAP,TULIP,HoLRP)Electrovaporization (TUVP,TVRP)

Destroy prostate tissue with heatTissue is left in the body and is expelled over time (called sloughing)Transurethral Microwave Therapy (TUMT)Transurethral Needle Ablation (TUNA)Interstitial Laser Coagulation (ILC)Water Induced Thermotherapy (WIT)

heat therapiesnnnnnn

heat therapiesBenefitsOffice treatmentsLocal anesthesiaMinimally invasive Reduced risk of complications as compared to invasive surgical TURP DisadvantagesSome symptoms will persist for up to 3 monthsCannot predict who will respondMay require prolonged catheterizationnnnnnnn

possible side effects of Urinary Tract InfectionImpotenceIncontinence

heat therapiesnnn

Laser Photoselective Vaporization of the Prostate (Laser PVP)TURP-equivalent 7 year improvement in symptom score and urination parametersDecreased risk of bleeding and TUR syndrome, otherwise similar adverse effect profileMay be done on anti-coagulated patients

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Fig 1

*Medications address the desire we all have to find a cure to fix the problem. We all like a quick and easy solution.They can, however, become less effective over time.Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.

*Until recently, the only option we could offer patients for treatment of their symptoms was either an open abdominal surgical procedure, or a trans-urethral resection of the prostate.*****Medications address the desire we all have to find a cure to fix the problem. We all like a quick and easy solution.They can, however, become less effective over time.Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.

*Medications address the desire we all have to find a cure to fix the problem. We all like a quick and easy solution.They can, however, become less effective over time.Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.