BENIGN PROSTATIC

HYPERPLASIA

BY
OGWANG SAMUEL
BCM/3326/153/DU
4 T H /2/2020
OUTLINE OF PRESENTATION
Anatomy
Definition
Etiology
Epidemiology of BPH
Pathophysiology
Clinical features
complications
Investigations
Management
Anatomy of the Prostate
Gross anatomy
It is a fibro muscular glandular organ that surrounds the prostatic urethra and is
surrounded by a fibrous capsule.
It is about 3 cm long and lies between the neck of the bladder above and the
urogenital diaphragm below ,it is 7-16 grams
It is somewhat conical with a base, which lies against the bladder neck above,
and an apex which lies against the urogenital diaphragm below.
 STRUCTURE

The prostate is divided into five lobes and 4 zones.

i. The anterior lobe lies in front of the urethra and is devoid of glandular tissue.
ii. The middle lobe is the wedge of gland situated between the urethra and the
ejaculatory ducts. Its upper surface is related to the trigone of the bladder; it is
rich in glands.
iii. The posterior lobe is situated behind the urethra and below the ejaculatory
ducts and also contains glandular tissue.
iv. The right and left lateral lobes lie on either side of the urethra ,the lateral lobes
contain many glands.
Histology
It is also divided into the peripheral zone (PZ), approx. 70%. Most carcinoma arises from here
a central zone (CZ), surrounds the ejaculatory ducts 20%
There is a transitional zone (TZ) surrounds the proximal prostatic urethra.- 50%. Most benign
prostatic hyperplasia (BPH) arises
Anterior fibromuscular stoma – no glandular tissue - 5 %
Smooth muscle cells are found throughout the prostate but, in the upper part of the prostate and
bladder neck, there is a separate sphincter muscle that sub serves a sexual function, closing
during ejaculation
The distal striated urethral sphincter muscle is found at the junction of the prostate and the
membranous urethra; it is horseshoe shaped with the bulk lying anteriorly and is quite distinct
from the muscle of the pelvic floor
Function
The prostate produces a thin, milky fluid containing citric acid and acid
phosphatase that is added to the seminal fluid at the time of ejaculation.
The smooth muscle, which surrounds the glands, squeezes the secretion into
the prostatic urethra. The prostatic secretion is alkaline and helps neutralize the
acidity in the vagina
Definition:

The definition of BPH is diverse

Microscopic BPH
Histological evidence of cellular proliferation
Macroscopic BPH
Enlargement of the prostate due to microscopic BPH
Clinical BPH
LUTS, bladder dysfunction, hematuria and UTI resulting from macroscopic BPH.
ETIOLOGY
Histopathologically, BPH is characterized by an increased number of epithelial and
stromal cells in the transitional zone of the prostate.
This increase in number of cells is attributed to increased proliferation or impaired
apoptosis causing cellular accumulation
There are several factors affecting these 2 processes:
- Androgens.
- Androgen receptors
- Dihydrotestosterone and 5α- reductase
- Estrogens
Epidemiology
Occurs in men over 50 years of age; by the age of 60 years,50% of men have
histological evidence of BPH
Little evidence of BPH in males younger than 30.
Incidence :Men 40-64 20% Men age > 65 40%
Prevalence increases rapidly in the 4th decade of life
Is a common cause of significant lower urinary tract symptoms in men and is the
most common cause of bladder outflow obstruction(BOO) in men > 70 years of
age
PATHOPHYSIOLOGY
PROSTATE HYPERPLASIA

BOO --------- OTHER CAUSES OF BOO ( Bladder outflow obstruction)

DETRUSOR RESPONSE -----CAN ALSO BE IMPAIRED IN NEUROGENIC DISEASE AND PRIMARY

BLADDER DISEASES

LUTS
PATHOPHYSIOLOGY
Prostatic hyperplasia increases urethral resistance.
Elevated detrusor pressure leads to bladder dysfunction.
Bladder response to obstruction.
- changes associated with detrusor instability/ decreased compliance.
- changes associated with decreased detrusor contractility.
CLINICAL FEATURES
Symptoms (LUTS) can be ‘obstructive/voiding’ or ‘irritative/ storage’
Obstructive/voiding symptoms include;
• Hesitancy
• Poor flow (weak stream)-unimproved by straining
• Intermittent stream
• Dribbling(including after micturition);
• Sensation of poor bladder emptying
• Straining
SYMPTOMS CONT’D

Irritative/storage symptoms include;

Frequency
Nocturia
Urgency
Urge incontinence
Nocturnal incontinence (enuresis)

Other symptoms may include; haematuria, erectile dysfunction.

SIGNS

A digital rectal examination (DRE)-increased size, firm, nodular gland. Normal

anal sphincter tone.
Examination of external genitalia to exclude meatal stenosis or palpable urethral
mass
Focused neurologic exam to rule out neurologic problems.
Per abdomen- distended palpable bladder, enlarged kidneys.
COMPLICATIONS OF BPH
Acute urinary retention
Hematuria (gross)
Urinary tract infections (recurrent)
Bladder calculi
Detrusor failure (bladder decompensation)
Urinary incontinence
Renal insufficiency/ failure.
INVESTIGATIONS
Urinalysis –to rule-out UTI and haematuria
Urine culture
Serum creatinine, BUN and electrolytes levels-exclude renal insufficiency
Serum prostate-specific antigen (PSA)
Imaging studies- ultrasonography (transrectal, abdominal) , iv pyelography.
CBC
Specialist investigations
Reasons
◦ Objective assessment of symptoms
◦ Diagnostic precision
◦ Ranking of treatment options
◦ Prediction of treatment outcome
◦ Patient assurance & explanation

They include;
◦ Cystoscopy
◦ Uroflowmetry
◦ Biopsy
◦ Bladder pressure studies
ASSESSMENT OF SYMPTOMS
•A validated questionnaire using International Prostate Symptom Scale(IPSS).
•Completion gives total score of 35
1 – 7 mild
8 – 19 moderate
20 – 35 severe
•Response to the quality of life questionnaire strong predictor on whether
intervention is necessary.
QUESTIONS
In last month how often have you
1. Had sensation of not emptying bladder completely?
2. Had urge to urinate < 2 hours after previously finished?
3. Found you stopped and started again several times?
4. Found it difficult to postpone urination?
5. Had a weak stream (compared to when aged 30)?
6. Had to push or strain to begin urination?
7. How many times did you get out of bed per night to urinate?
SCORING SYSTEM
◦ Ask 7 questions. Answers on scale 0 – 5 depending on severity of symptoms
◦ For first 6 questions scores are
◦ Not at all =0
◦ < 1 in 5 =1
◦ < half the time= 2
◦ About half the time = 3
◦ > half the time =4
◦ Almost always = 5
◦ Q7
◦ Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5
Quality of life
•If you were to spend the rest of your life with your urinary condition the way it is
now, how would you feel about that?
– Delighted 0
– Pleased 1
– Mostly satisfied 2
– Mixed feelings 3
– Mostly dissatisfied 4
– Terrible 5
TREATMENT
Can be medical or surgical
Medical therapy
Clinically significant outcomes are obtained with fewer, less serious, & reversible
side effects.
The patient should have symptoms that are bothersome & negatively affect
quality of life.
Examples
Adrenergic blockers; clinical BPH is in part caused by BOO w/c
is mediated by alpha-one(α1) adrenoceptors .e.g
Prazosin,terazosin etc
Androgen suppression;dev’pt of BPH is an androgen-
dependent process & therefore androgen suppression would
cause regression of prostate.e.g; GnRH analogues-leuprolide,
progestational agents- megestrol,anti-androgens-flutamide,
& 5α -reductase inhibitors-Finasteride
Following careful assessment, the following questions should be answered:
Have they failed a preliminary trial of medical therapy? They are then referred by
their general practitioner to the urologist.
Is BOO present? In many cases, the findings of significant symptoms (assessed by
symptom scoring)
How severe are the symptoms and what are the risks of doing nothing? Severe
symptoms and a large residual volume of urine will usually require treatment
Is the man fit for operative treatment?
What treatments are available, what are the outcomes and do the side-effects
justify treatment?
Open prostatectomy
Retropubic –enucleation of the hyperplastic prostate adenoma thru’ a direct
incision of the anterior prostatic capsule. There is excellent exposure of the
prostate hence complete removal
Suprapubic (Transvesical)- consists of the enucleation of the hyperplastic
prostatic adenoma thru’ an extraperitoneal incision of the lower anterior
bladder wall. It allows direct visualization of the bladder neck & mucosa.
Indications

Acute Urinary Retention

Persistent or recurrent UTIs
Gross hematuria
Bladder calculi
Severe symptoms unresponsive to medical therapy
Renal insufficiency
 When to consider an open
prostatectomy
i. When the obstructive tissue is estimated to weigh more than 75mg.
ii. If sizable bladder diverticula justify removal.
iii. Large bladder calculi that are not amenable to easy transurethral
fragmentation.
iv. When a man presents with ankylosis of the hip or other orthopedic
conditions, preventing proper positioning for TURP.
v. In men with recurrent or complex urethral conditions, such as urethral
strictures or previous hypospadias repair, to avoid the urethra trauma
associated with TURP.
Contraindications
A small fibrous gland
Presence of prostate cancer
Previous prostatectomy
Complications of open prostatectomy
Hemorrhage
Urinary extravasation-incomplete closure of the prostatic capsulotomy or
cystotomy.
Urgency or urge incontinence (weeks-months)
Erectile dysfunction
Retrograde ejaculation (80-90%)
Bladder neck contracture
Late urologic complications like acute cystitis, acute epididymitis.
Common non-urologic complications
DVT
Pulmonary embolus (PE)
Myocardial infarction
Cerebral vascular event
Their incidence is less than 1%.
References
Bailey & Love –short practice of surgery 25th edition.
THANKS FOR LISTENING