Benign

Prostatic Hyperplasia(BPH)

Mohsen Amjadi MD.Head of Urology Department

ENDOUROLOGISTamjadizm@yahoo.com

TBZMED

Farzin Soleimanzadeh MD. Fellow of Europen Board of Urology

Reconstructive Urologistfarzinsoleimanzade@gmail.com

TBZMED

Benign Prostatic Hyperplasia

What is BPH?

BPH

• Introduction

• Anatomy

• Pathogenesis

• Assessment

• Treatment

• Questions

Terminology

• Benign Prostatic Hyperplasia• BPH

• Pathological Dx

• Benign Prostatic Enlargement• BPE

• Clinical Dx

• Bladder Outflow Obstruction• BOO

• Urodynamic Dx

Anatomy of Prostate

Anatomy of Prostate

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Secretes part of semen

which carries sperm

Secretions are

responsible for

liquification of semen

Physiology of prostate

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Prevalence of BPH by Age

Half of all men over the age of 60 will

develop an enlarged prostate.

By the time men reach their 70’s and 80’s,

80% will experience urinary symptoms.

But only 25% of men aged 80 will be

receiving BPH treatment

Prevalence of BPH

Risk Factors.

• Age

• Testosterone

• Hereditary

• Obesity

• Diabetes

• Dyslipidaemia

Regulation of cell growth in the

prostate in BPH

DHT-androgen

receptor complex

Growth

factors

Unbalanced

DHT

T

5AR (1 and 2)

Serum testosterone (T)

Prostate

cell

Increased

Cell growth

Cell death

Serum Dihydrotestosterone

(DHT)

what causes BPH?

BPH is part of the natural

aging process, like getting

gray hair or wearing glasses

BPH cannot be prevented

BPH can be treated

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what causes these symptoms?

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symptoms

Lower Urinary Tract

Symptoms

LUTS

What’s LUTS?Voiding (obstructive)

symptoms

• Hesitancy

• Weak stream

• Straining to pass

urine

• Prolonged

micturition

• Feeling of

incomplete

bladder emptying

• Urinary retention

Storage (irritative or

filling) symptoms

• Urgency

• Frequency

• Nocturia

• Urge

incontinence

common symptoms

Frequent and urgent

need to urinate,

especially at night

Dribbling or leaking

after urination

Intermittent or weak

stream

Straining to urinate

Pain or burning

during urination

Feeling that the

bladder never

completely emptiesn

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What’s LUTS?

LUTS is not specific to BPH

not everyone with LUTS has BPHand

not everyone with BPH has LUTS

LUTS BOO

BPE

Bladder Outflow Obstruction

Lower Urinary Tract Symptoms

Benign Prostatic Enlargement

1. Hald T et al. Proceedings of the 4th International Consultation on Benign Prostatic Hyperplasia, Paris, 1997. SCI, 1993, 129-178.

Hald Diagram

ignoring the symptoms...

Risk of bladder and

kidney damage

Impact on quality of life

...will not make them go away!

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History : co-morbidity

• Other causes of symptoms

– Polyuria

– Heart failure

– Diabetes

– Diuretics

– UTI

– Urethral stricture

– Bladder carcinoma (TCC)

– Phimosis

Urinary Retention

• Acute

• Painful

• Normal renal function

• Precipitating event

– UTI

– Fluid overload

– Constipation

– Medication

Chronic

n Painless

n Impaired renal function

n Large residual volume

Watch Video

Investigations : routine

• Frequency volume chart (Voiding diary)

• Glucose

• Creatinine & Electrolytes

• PSA

• IPSS

• Urinary flow rate (uroflowmetry)

• Post-void residual urine

Examination

• Palpable bladder

• DRE• Smoothly enlarged prostate

• Estimate size (normal 25-30mls)

• Non tender

• Constipation

• Hypertension

• Peripheral edema

• Renal impairment

AUA Symptom Index Scoring

SCORE INTERPRETATION

0-7 Mild

8-19 Moderate

20-35 Severe

when should BPH be treated?

BPH needs to be treated ONLY In case of:

Symptoms severe enough to bother and affect patients’ quality of life

Frequent urinary tract infections

Hydronephrosis

Bladder decompansation

choosing the right treatment

Consider risks, benefits

and effectiveness of each

treatment

Consider outcome and

lifestyle needs

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Treatment Options

“Watchful waiting”

Medication

Heat therapies

Surgical approaches

Invasive “open” procedures

Less-invasive modalities (TUR, Laser,…)

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“watchful waiting”

With mild symptoms, condition should be

monitored by physician 1 - 2 times yearly

Doctor may offer suggestions

that help reduce symptoms- Avoid caffeine and alcohol

- Avoid decongestants and antihistamines

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Medication

First line of defense against bothersome urinary symptoms

Manage the condition - don’t fix it

Two major types:

Relaxants - relax the prostate and provide a larger urethral opening (Terazosin, Tamsulosin)

Shrinking the prostate gland(Finasteride, Dutasteride)

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Distribution of 1-Adrenergic Receptors

Reminder: Adrenergic Receptor Blockers

1-Adrenergic Blockers: Summary

• All currently available 1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy

• They are all well tolerated; however, the adverse event spectrum differs between the agents

– Terazosin and doxazosin induce more dizziness, fatigue,

and asthenia

– Tamsulosin induces more ejaculatory disturbances

• None of the 1-blockers alter urodynamic parameters, prostate volume or serum PSA

• None have been shown to alter the natural history of the disease or prevent AUR / Surgery

5-Reductase Inhibitor: Rationale• Prostatic differentiation & growth depend on androgenic

stimulation

• Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by

5-reductase enzyme

• 5-reductase inhibitor: deprive the prostate of its

testosterone support

• 5-reductase enzyme:

Type I: skin & liver

Type II: stromal & basal cells of prostate, seminal vesicle,

epididymis

Kirby RS et al. Br J Urol. 1992;70:65-72

Tammela TLJ et al. J Urol. 1993;149:342-344

possible side effects of

• Impotence

• Dizziness

• Headaches

• Fatigue

• Loss of sexual drive

medication

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Destroy prostate tissue with heat

Tissue 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 Therapies

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surgical treatment

Indication of surgical intervention

• Acute urinary retention

• Gross hematuria

• Frequent UTI

• Vesical stone

• BPH related hydronephrosis or renal function deterioration

• Obstruction

• Patient’s preference

Because the tissue is removed

and not left in the body

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RESULTS ARE

IMMEDIATE

strong urine flow

relief of urinary symptoms

The “gold standard”- TURP

Benefits

Widely available

Effective

Long lasting

Disadvantages

Greater risk of side effects and complications

1-4 days hospital stay

1-3 days catheter

4-6 week recovery

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TURP

“Gold Standard” of care for BPH

Uses an electrical “knife” to surgically cut

and remove excess prostate tissue

Effective in relieving symptoms and

restoring urine flow

(transurethral resection of the prostate)

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Complication of TURP

• Immediate complication

bleeding

capsular perforation with fluid extravasation

TUR syndrome

• Late complication

urethral stricture

bladder neck contracture (BNC)

retrograde ejaculation

impotence (5-10%)

incontinence (0.1%)

Vaporization of the Prostate

Using Heat or Laser

Enlarged Prostate

Urethra is open

Normal urine flow is

restored

Urethra is obstructed

Urine flow blocked

After therapy

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Need a Catheter?

Many patients do not require a catheter

If one is required, it is usually removed in

less than 24 hours

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Open Simple Prostatectomy

• “Too large prostate” -- >100 gm

• Combined with bladder diverticulum or

vesical stone surgery

Suprapubic or retropubic method

Conclusions• B.P.E. is a common condition with many more men suffering

symptoms than present to the medical profession.

• Signs and symptoms vary in their character and severity.

• All patients should have standard assessment in the form of history, examination and investigations with specialised investigations being reserved for complicated or equivocal cases.

• Medical and surgical treatment options are available and these should be discussed with the patient prior to commencement.

• Surgery remains the gold standard in the form of TURP