Benign prostate hyperplasia

Moro abdul malik

Outline
• introduction
• brief anatomy
• Definition
• Epidemiology
• Aetiology /pathophysiology
• Clinical evaluation :history/ physical exam/investigation
• Management
• Complication
Introduction

• Benign prostatic hyperplasia (BPH) is a common condition

encountered in aging men and a common cause of lower urinary

tract symptoms. Histological prevalence of BPH is common, and

disease progression is associated with bladder outflow
obstruction, this may present clinically in both the emergency
surgical and outpatient clinical settings
Brief anatomy
Definitions related to BPH

• Benign prostatic hyperplasia (BPH) refers to the non-malignant

growth or hyperplasia of prostate tissue and is a common cause
of lower urinary tract symptoms in men.

• BPE:) describes the increased size of the gland (usually

secondary to BPH)

• BOO: bladder outlet obstruction as a result of BPE

Epidemiology
• Age is a significant predictor of both development of BPH and
subsequent LUTS, with 50% of men over the age of 50 shown to
have evidence of BPH and the association with the development
of LUTS shown to increase with age in a linear fashion
• BPH is a common problem affecting the quality of life of approximately
1/3 of men older than 50 .it is histologically present in up to 90% of
men over the age of 85.world wide about 30million men have
symptoms of BPH
• The prevalence is similar in all races however African Americans have
a more severe and progressive symptoms ,possibly due to higher
androgen levels .
Aetiolgy/pathophysiolgy
• The aetiology of BPH is thought to due to an altered equilibrium
between cell proliferation and apoptosis .the aetiological factors are
complex .prostatic enlargement depends on the potent androgen
DHT from the metabolism of testosterone by type II 5-alpha-
reductase in the prostate. DHT acts locally and binds to androgen
receptors the prostate ,potentially leading to BPH.
• Other factors in the aetiology include ,metabolic
syndrome,hyperinsulinemia,norepinephrine ,angiotensin II,insulin like
growth factors
• Studies have shown that there is a large number of alpha-adrenergic
receptors located in the smooth muscle of the stroma and capsule as
well as the bladder neck. stimulation of these receptors causes an
increase in smooth muscle tone which worsens the symptoms of
BPH(LUTS)
• BPH is microscopically characterized by a hyperplastic process, this
may result in restriction of the flow of urine from the bladder >
manifestation of symptoms
Clinical presnetation
LUTS can be grouped into :
Storage/irritative symptoms
• Urinary frequency
• Nocturia
• Urinary urgency
• Voiding/obstructive symptoms
• Hesitency
• Straining
• Weak stream,intermittency,dribbling,incomplete bladder emptying ,retention
• The clinician must rule out other conditions that can present with LUTS
• DM
• Ca prostate
• UTIs
 Cauda equina syndrome (can present with acute retention)
 Prostatitis
 Neurogenic bladder (can be secondary to Parkinson's, Multiple sclerosis, etc.)
 Urinary tract stones (bladder stones)
 Urethral stricture
Physical exam and evaluation

• A general exam should be performed first (anemia,edema ,

BP,hydration),
• IPSS
• the examination should include abdominal examination (looking for
a palpable bladder/loin pain) and examination of external genitalia
(meatal stenosis or phimosis). The examination should then conclude
with a digital rectal examination making a note in particular of the
size, shape (how many lobes), and consistency
(smooth/hard/nodular) of the prostate (BPH is characterized by a
smoothly enlarged prostate).
investigations
Urinalysis
• Appearance,Dipstick,Urine microscopy,Urine culture/ sensitivity(MSU)
Prostate specific antigen (normal value=0-4.0ng/ml)
Blood tests
• Fbc,RFT-serum creatinine ,BUE,blood urea and electrolytes
Ultrasound,CT/MRI urogram,retrograde urethro-cystography
Cystoscopy/urethroscopy
Biopsy
Treatment / management
Men with BPH may present acutely with urinary retention at the
ER, a transurethral catheter should be passed to relieve the
retention or a suprapubic catheterization if the transurethral
approach fails (in the absence of contraindications)

Treatment modalities include

Watchful waiting
Medical therapy
surgery
Watchful waiting
• Patients are adequately assessed to rule out malignancy. usually
offered to patients with an IPSS < 8 who are not troubled by
symptoms of BPH
• lifestyle advice. Examples include weight loss, reducing caffeine
intake or reducing fluid intake in the evening, and avoiding
constipation are given to patients.
• 3 monthly reassessment
• Contraindicated if there is
• Acute/chronic retention 2.recurrent UTIs,haematuria,signs of renal
impairment.
Medical treatment
Both static and dynamic components contribute to the
pathophysiology of BPH. Medical therapy aims to address both of
these components. For those with IPSS<19
1.Alpha-blockers=blocks alpha-adrenergic receptors in the
stromal smooth muscles of the prostate>smooth muscle
relaxation and improving urine flow
• Tamsulosin (400mcg once daily)
• Alfuzosin (10mg once daily)
• 5 alpha-reductase inhibitors:addresses the static component by
prevention the conversion of testosterone to DHT causing the
shrinkage of the prostate by about 25%. It takes about 6 months
for effects to be seen
• finasteride (5mg once daily) ##loss of libido and erectile
dysfuction are some adverse effects.
• dutasteride
• Anticholinergics detrusor muscle stability (solifenacin, tolterodine, and
oxybutynin)

• Phosphodiesterase-5 enzyme inhibitors; mediate smooth muscles

relaxation in the lower urinary tract (tadalafil)

• Alpha blocker+ a 5 alpha-reductase inhibitor= combination therapy

Surgery
• Guidelines for the indications for surgery in BPH as outlined by the European Association of Urology
(EAU) are as follows:[
 Refractory urinary retention
 Recurrent urinary infections
 Haematuria refractory to medical treatment (other causes excluded)
 Renal insufficiency
 Bladder stones
 Increased post-void residual
• High-pressure chronic retention (absolute indication
TURP

• Transurethral resection surgery focuses on debulking the

prostate to produce an adequate channel for urine to flow. This
is achieved using diathermy to produce a high-frequency
current that allows the cutting of tissue. By resecting all
obstructing prostatic tissue, an adequate channel can be created
to allow urine to flow. Bipolar diathermy has largely replaced
monopolar diathermy techniques for TURP, with increased
benefits such as resection in saline and reduced risk of "TUR
syndrome
HOLEP(Holmium laser enucleation of the
prostate)

• Previously, open prostatectomy allowed adenoma to be

removed or enucleated off its capsule. This can now be achieved
with laser enucleation, referred to as HoLEP (Holmium laser
enucleation of the prostate). Meta-analysis has shown improved
Qmax (flow rate), reduction in post-void residual, and IPSS
compared to TURP.
• Benefits include a lower transfusion rate with no increase in
complications compared to TURP. However, limitations include
specialized equipment required making it less readily available
Urolift

• Tissue-sparing approaches, such as Urolift, have also been

developed. This can help minimize the risk of bleeding in co-
morbid patients and the associated risks of more invasive
surgery (such as anesthesia risk, prolonged surgery time, etc.).
By compressing prostate lobes, the channel can be widened in
the prostatic urethra, improving LUTS. Studies have shown
benefits, including the possibility of day-case surgery, preserved
sexual function, and improved symptom scores (IPSS), and flow
rates (QMax
Other surgical options
• Intra urethral stents
• High intensity focused ultrasound(HIFU)
• Trans urethral vaporization of the prostate
• Trans urethral needle ablation (TUNA)
• Trans urethral laser therapy
• Transurethral balloon dilatation
• Open simple prostatectomy
Common Complications of BPH
 Urinary retention
 Chronic retention
 Urinary tract infection (due to incomplete emptying)
 Haematuria
 Bladder calculi
BOO > reflux of urine into the ureters and kidney> renal impairment
Thank you