Learning Objective

At the end of medical school, the medical student will be able to...

Benign Prostatic • Identify and name the major anatomic and histologic features of the prostate gland
• Identify the predominant location in the prostate where BPH develops and describe how
this fact relates to the symptoms and signs of BPH

Hyperplasia • Define BPH

Basuki B. Purnomo, Besut Daryanto, Kurnia Penta Seputra
Department of Urology
Medical Faculty Brawijaya University/RS Dr Saiful Anwar
MALANG
• Describe the distinctive epidemiological features and natural history of BPH
• List the symptoms and signs of BPH
• List the important components of the history when interviewing a patient with BPH
• List the important components of the physical exam of a patient with BPH
• Summarize the laboratory, radiologic, or urodynamic tests, if any, that should be ordered in
a patient with BPH
• List the indications for treatment of BPH
• List the medical and surgical treatment options for BPH.
• Describe when a patient with BPH should be referred to a urologist

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Prostate Pyramid Daftar Penyakit

UROLOGIST

GP

Lives with symptoms

Asymptomatic

Sumber: SKDI 2013

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 DAFTAR MASALAH KESEHATAN
INDIVIDU DAN MASYARAKAT Daftar Ketrampilan Klinis

Sumber: SKDI 2013

Sumber: SKDI 2013

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 Definition Prostate: Anatomical Zone
BPH: benign prostatic hyperplasia

BPE: benign prostatic enlargement

BPO: benign prostatic obstruction

BOO: bladder outlet obstruction

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 Histopathology: BPH Prostatic disease
Prostatic inflamation (prostatitis)

Benign prostatic Hyperplasia (BPH)

Prostatic carcinoma

Stromal

Glandular

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Mean urinary flow rates VS Age Prevalence
60 years 80 years

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 Etiology??? Conversion T to DHT in Prostatic Cell

Aging

Normal testis

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 Conversion of T to DHT Alpha adrenergic receptor

NADPH NADP

5α-reduktase

Testosteron Dihydrotestosteron

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 Static and Dynamic Component in
Prostatic Obstruction

Prostatic mass Smooth muscle tonus

(static component) (Dynamic component)
Voiding problems Voiding symptoms

Bladder aging
Storage problems Storage symptoms
Neuropathic

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 BPH: Complications BPH: Diagnose
Mandatory (highly recommended)
Urinary retention • History
• Physical examination and digital rectal examination
UTI • Urinalysis
Recommended
Bladder calculi •
•
PSA
Quantification of symptoms: IPSS and QoL
• RFT
Haematuria • Voiding diary
Optional
Renal impairment • Flow rates recording (uroflometry)
• Post voiding residual urine
Diverticulae •
•
Imaging
Pressure flow study
• Urethrocystoscopy*

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Quantification of symptoms Medical history
 IPSS and bother symptoms

 IPSS Nature and duration of reported GU tract symptoms

 0-7 : mildly symptomatic
Previous surgical procedure on GU tract
 8-19 : moderately symptomatic

 20-35: severely symptomatic General health issues, sexual function

Medication

Patient’s fitness status

(IAUI BPH Guidelines, 2003)

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 Physical Examination Urinalysis
Palpable bladder? Dipstick testing

DRE
Microscopic examination
• Prostate size, consistency
• Anal sphincter tone

To screen:
Neurological examination
• Hematuria
• Ambulatory status
• leukosituria
• Lower extremity neuromuscular function

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 Prostate Specific Antigen (PSA) Urethrocystoscopy

Predictor of the natural history of BPH, increasing PSA:

Maybe appropriate in men with a history of

• Future growth of the prostate
• Symptom and flow rate determination
• AUR • Microscopic or gross haematuria
• Bladder carcinoma
• Urethral stricture
25% men with BPH have PSA ≥ 4 ng/dL

Recommended at the time of surgical intervention (TUIP-TURP-Open

prostatectomy)
Most appropriate for patients < 70 years or natural life span > 10
years.

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 INITIAL ASSESSMENT
• Medical history
• Physical Examination, DRE

Treatment
• Urinalysis
• RFT
• PSA
•Voiding diary

IPSS and QoL

Watchful waiting
MILD (IPSS <7) ASSOCIATED WITH
MODERATE – SEVERE
Symptoms not bothersome • Suspicious DRE
Doesn’t want treatment
(IPSS 8-19) – IPSS (20-35) • PSA abnormal
• Hematuria

Medical therapies ADDITIONAL

• Pain
• Neurological abnormal
ASSESSMENT • Palpable bladder
• RFT abnormal
• Flowrates
• α adrenergic blocker, • PVR
• 5α reductase inhibitor, • USG

• phytotherapy
Discuss treatment option with the patient

Intervention therapies
Choose non invasive
Choose invasive treatment
treatment
• Minimally invasive therapies
• Surgical therapies
REFER TO
Watchfull waiting Medical Treatment
UROLOGIST

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 Watchful waiting Medical therapy

Moderate (IPSS 8-19) & severe symptoms (IPSS 20-35)

Mild-moderate symptom (IPSS<7)

Refused medical treatment Failure after watchful waiting

Altering modifiable factor such as:

• Concomitant drug
• Regulation of fluid intake especially in the evening
• Life style change (avoid sedentary life)
• Dietary advice (avoid excessive intake of alcohol, and highly seasoned or irritative
foods)

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 Medical Therapy Medical therapy of BPH: mechanism of action

Alpha adrenergic blocker 5 Alpha reductase inhibitor

Reducing smooth muscle tone (dynamic component): α adrenergic blocker
• Short acting: prazosin, afluzosin
• Long acting: doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component): 5α reductase inhibitor

• Finasteride
• Dutasteride (6-azasteroid )
• Phytotherapy

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 Medical Therapy Intervention therapy

First choice: α adrenergic blocker Minimally invasive therapy

• TUNA
Second choice: 5α reductase inhibitor • HIFU
• TUMT
• prostate weight >30 g
• Stent

Combination?? Surgical therapy

• TUIP
• TURP
• Open prostatectomy
• TUVP
• Laser

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 SUMMARY
The prostate is composed of several regions and zones: two zones of interest are the
peripheral zone, where most cancers arise, and the transition zone, where BPH arises.

The diagnosis of voiding dysfunction due to BPH is made based on both subjective and
objective findings on clinical evaluation.

Medical treatment of BPH involves treatment that relaxes the muscular stromal tissue of the
bladder neck and prostatic urethra (alpha-blockers) and reduction in the acinar-glandular
volume of the prostate through reduced DHT production (5-alpha-reductase inhibitors).

Indications for surgical intervention with BPH includes urinary retention, gross hematuria,
bladder stones, and urinary tract infection.

Serum PSA, a serine protease that liquefies the ejaculate, increases over time with both BPH
and prostate cancer, which makes it a difficult diagnostic marker for cancer alone.
TURP: Trans Urethral Resection of the Prostate

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