BENIGN PROSTATIC HYPERPLASIA
(BPH)
Dr. khader hassouneh .
• BPH is defined by
– by an increased number of epithelial & stromal cells in the
transition zones and periurethral area of the prostate and
thus correctly referred to as hyperplasia and not hypertrophy .
• Is a common cause of lower urinary tract symptoms
(LUTS)- (older term prostatism )in men .
PROSTATE ZONES:
BPH
• BPH is the most common benign disease in
older men
• The prevalence of BPH is related to age
– 8 % in men 50 s.
– 90 % in men older than 80 years.
• BPH is a progressive disease characterized by
prostate enlargement, which might
subsequently determine the onset of lower
urinary symptoms (LUTS).
• Histologic changes of prostatic enlargement
are evident in 50% of men by the age of 60 y,
Although not all patients have “luts”.
• half of men with prostatic enlargement
develop LUTS .
• Norm Prostate size .
20g\ML\cubic CM 4.4x3.4x2.6cm (W x l x A-P)
• Prostatic functions:
-perm nutrition.
- seminal anticoagulation.
• prostate classification is
often referred to the “3
lobes” of the prostate,
namely, the median and
the 2 lateral lobes.
Etiology of BPH:
1. aging (decreased apoptotic activity) :
Increase of prostatic cell number is related to an
imbalance in cell proliferation & cell death (apoptosis).
2 .Hormonal imbalance:
Prostate is mainly composed by androgen dependent
tissue, Serum testosterone levels decrease gradually with
aging ; oestrogen remains constant . Increasing estrogen
–to –androgen ratios , According to this theory, the
prostate enlargement is since of increased estrogenic
effects.
3. Recently, the role of Chronic inflammation .
Pathology:
• BPH is characterized by an increased number of epithelial
& stromal cells in the transition zones and periurethral
area of the prostate.
The main hormone acting on the prostate is
Testosterone, which is secreted by the Leydig cells of the testes.
Testosterone is converted to DHT by the enzyme 5a-reductase ,
which is found in high concentration in prostate.
DHT has five times the potency of testosteron Castration
results in the regression of established BPH and
improvement in urinary symptoms.
Pathology:
As BPH nodules in the transition zone
transition
enlarge, they compress the outer
zones of the prostate, resulting in the
formation of a surgical capsule.
Central
• This boundary separates the transition zone from the peripheral zone
and serves as a cleavage plane for open enucleation of the prostate
during open simple prostatectomies
Pathophysiology :
• can be subdivided into
the static & the dynamic component.
static component
Mediated by the volume effect of
BPH. intrusion into the urethral lumen leading to a
(bladder outlet obstruction) BOO and LUTS.
The dynamic component
• A1-adrenoceptor-mediated prostatic smooth
muscle contraction.
• Smooth muscle accounts for 40% of the
hyperplastic prostate.
• This effect is the rationale for A-adrenoceptor
blocker treatment for symptomatic BPH.
Effects of BPH ON :
Bladder.
• BOO causes thickening of the wall of the bladder, the
musculature of the bladder hypertrophies to overcome
the obstruction and called trabeculae (cystoscopy). If
left untreated, mucosal herniation between detrusor
muscle bundles ensues, causing diverticula formation.
• Significant BPH is associated with increased blood flow,
and the resultant veins at the base of the bladder are
liable to rupture to cause haematuria.
Cystogram cystoscopy
Presentation and Symptoms :
1. No symptoms (silent prostate)
[Link] urinary tract symptoms (LUTS)
- These have been subdivided into irritative (storage) & obstructive
(voiding) symptoms.
- Irritative symptoms have the most impact on the patient's quality of life.
3. Urine retention acute or chronic.
4. Hematuria .
5. UTI.
6. vesical stone.
7. bilateral hydronephrosis and renal failure.
Lower urinary tract symptoms LUTS:
• storage
[Link].
[Link].
3. urgency (urge incontinence).
• voiding
[Link] stream .
[Link] stream – stops and starts.
[Link] .
4. sensation of incomplete bladder emptying.
[Link]
[Link] dribbling
Acute urine retention(AUR):
AUR as a painful, palpable, or percussible bladder
when the patient is unable to pass any urine.
Patients are typically catheterized and then undergo a
trial without catheter (TWOC) when ? while taking an
α-blocker.
• A successful TWOC with an α-blocker reduces the
chance of needing prostate surgery.
• If the trial of voiding fails, the patient should be
considered for surgical intervention.
Assessment of Symptoms:
• To quantitate the severity of symptoms, a symptom-scoring system is
used called :
• International Prostate Symptom Score (IPSS) or AUA Symptom Score
.
• The IPSS is an 8-question tool (7 symptom questions + 1 quality of
life question) designed to be completed by the patients.
We ask patients to quantify the severity of their complaints on a scale
of 0–5. Thus, the score can range from 0 to 35.
A symptom score of 0–7 is mild,
8–19 is moderate ,&
20–35 is severe
The IPSS assessment should include an assessment of quality of life, which is a
reflection of the degree of ‘bother’ caused by a patient’s symptoms.
Sign :
DRE is performed in all patients.
DRE:
The size & consistency of the prostate & to assess
anal tone, faecal impaction.
BPH usually is a smooth, firm, elastic enlargement of
the prostate.
CA stony hard.
Investigations of men with BPH\LUTS:
Essential investigations:
1.A urinalysis to exclude infection or hematuria.
2. Renal function tests
S. Creatinine & B. urea
(renal insufficiency may be observed in 10% of BPH)
3. Prostatic specific antigen (PSA).
4. Ultrasound assess prostatic size, PVR, kidneys.
5. Urinary flow rate (flowmetry) .
ADDITIONAL TESTS:
– urodynamic study are reserved for patients with
suspected neurologic disease.
Differential Diagnosis:
• Urethral stricture
• CaP (may be detected by abnormalities on
the DRE or an elevated PSA).
• Neurologic disease, stroke, diabetes mellitus.
Modality of therapy:
1. watchful waiting.
2. Pharmacological therapy:
a) alpha blocker.
b) 5 alpha reductase inhibitor.
c) combination therapy.
d) 5 PDI.
3. phytotherapy.
4. Surgery .
TURP, TUIP, HOLEP, OPEN surgery .
Conservative treatment= Watchful waiting :
Is suitable in men with mild symptoms .
It includes education, re-assurance:
• Fluid restriction especially before bedtime.
• Avoidance of caffeinated beverages.
• Avoidance of some drugs (e.g., diuretics).
• treatment of constipation.
Surgery :
• Men should be offered TURP.
• Men with smaller prostates (<30 g) should be
offered transurethral incision of the prostate.
TUIP.
• Open prostatectomy should be offered to men
with prostates >80 g only.
Counselling men undergoing prostatectomy:
1. Retrograde ejaculation:
This occurs in about 65% of men after
prostatectomy.
2. Erectile dysfunction :
This occurs in about 5% of men.
3. Incontinence .
4. Bladder neck contracture.
5. bleeding.
Operative treatment:
[Link] Transurethral resection of the prostate
TURP is most suitable for prostates < 80 cc.
2. Open prostatectomy:
– Transvesical prostatectomy.
– Retropubic prostatectomy (Millin).
• When the prostate is too large to be removed
endoscopically, an open enucleation is necessary.
Prostate glands > 80 g.
• Open prostatectomy may also be initiated when
concomitant bladder stone is present.
LASER Therapy:
Laser Vaporization Enucleation HOLEP
( holmium laser enucleation of prostate) .
Laser Advantages :
(1) minimal blood loss.
(2) ability to treat patients receiving anticoagulation therapy.
Disadvantages:
(1) more irritative voiding complaints.
(2) High cost .
LASER:
Complications of BPH:
• UTI.
• Urine retention.
• Vesical stones.
• Hematuria .
• urinary incontinence.
• upper urinary tract deterioration with renal
insufficiency.
Note :
• The severity of urinary symptoms do not
correlate with prostate size.
• Small prostates can cause severe symptoms.
• Large prostates can be asymptomatic.
