BPH

• Benign prostatic hyperplasia (BPH)


  The most common benign tumor in men, characterized by cellular proliferation of the stromal and epithelial elements of the prostate

  
• BPH (to the pathologist)


  A microscopic diagnosis characterized by cellular proliferation of the stromal and epithelial elements of the prostate

  
• BPH (to the radiologist)


  The diagnosis is made on the basis of an enlarged prostate either on ultrasound or with three-dimensional diagnostic imaging studies of the male pelvis

  
• BPH (to the practicing urologist)


  Represents a constellation of signs and lower urinary tract symptoms (LUTS) that develop in the male population in association with aging and prostatic enlargement

  
• BPH (to the patient)


  The patient is typically concerned about the impact of BPH on quality of life rather than the presence of cellular proliferation, prostatic enlargement, or elevated voiding pressures
• Hyperplasia


  In a given organ, the number of cells, and thus the volume of the organ, is dependent upon the equilibrium between cell proliferation and cell death
• Prostatic capsule


  One of the unique features of the human prostate, playing an important role in the development of LUTS

  
• The size of the prostate does not correlate with the degree of obstruction

  
• Lobar anatomy of BPH


  • Unilobar BPH: Median lobe enlargement
  • Bilobar BPH: Lateral lobe enlargement (kissing BPH)
  • Trilobar BPH
  • Anterior fibromusclar enlargement: small BPH
• Narrowing and elongation of prostatic urethra by enlarged prostate

  
• BPH


  A histological diagnosis that doesn't necessarily imply benign prostatic enlargement (BPE) or lower urinary tract symptoms (LUTS) or bladder outlet obstruction (BOO)

  
• Lower urinary tract symptoms (LUTS)


  Indicate all lower urinary tract symptoms that result from either bladder dysfunction or response of the bladder to a pathology in the prostate or urethra that causes bladder outlet obstruction

  
• Symptoms of BPH


  • Obstructive symptoms (emptying): hesitancy, decreased force and caliber of stream, sensation of incomplete bladder emptying, double voiding, straining to urinate, and post-void dribbling
  • Irritative symptoms (storage): urgency, frequency, nocturia, urge incontinence and nocturnal incontinence

  
• International Prostate Symptom Score (IPSS)


  • Recommended as the symptom scoring system to be used for the baseline assessment of symptom severity in men presenting with LUTS
  • Consists of 7 symptoms, 4 obstructive and 3 irritative, each one scored from 0-5 points according to severity
  • 0-8 mild, 9-19 moderate, 20-35 severe IPSS

  
• Physical examination findings in BPH


  • Examine the abdomen for distended bladder, inguinal hernia and palpable kidneys
  • Examine the genitalia for meatal stenosis, urethral stricture or epididymitis
  • Digital rectal examination (DRE): BPH usually results in a smooth lobulated, rubbery firm, elastic enlargement of the prostate with exaggerated median sulcus
  • Induration (hard nodules) detected on DRE must alert the physician to the possibility of cancer and the need for further evaluation
  • Neurological examination to exclude focal pathology that may cause LUTS

  
• Consequences of BPH


  • No symptoms, no BOO
  • No symptoms, but urodynamic evidence of BOO
  • Lower urinary tract symptoms, no evidence of BOO
  • Lower urinary tract symptoms and BOO
  • Others (acute/chronic retention, haematuria, urinary infection and stone formation)

  
• Essential laboratory investigations for BPH


  • Urinalysis to exclude infection or hematuria
  • Urine culture for infection
  • Serum creatinine measurement to assess renal function
  • Serum PSA (optional, but most physicians will include it in the initial evaluation)
• Serum PSA


  Compared with DRE alone, certainly increases the ability to detect prostate cancer
• Additional laboratory investigations for BPH


  • Measurement of flow rate (uroflowmetry)
  • Determination of post-void residual urine (by catheter or ultrasound)

  
• Imaging for BPH


  • Upper-tract imaging (intravenous pyelogram or renal ultrasound): recommended only in the presence of concomitant urinary tract disease or complications from BPH
  • Cystoscopy: not recommended to determine the need for treatment, but may assist in choosing the surgical approach in patients opting for invasive therapy

  
• Additional tests for BPH


  • Urodynamic tests: reserved for patients with suspected neurologic disease, dominant irritative symptoms or those who have failed prostate surgery
  • Pressure flow studies (cystometrogram): considered optional

  
• Differential diagnosis of BPH


  • Other obstructive conditions of the lower urinary tract: urethral stricture, bladder neck contracture, bladder stone, prostate cancer
  • Urinary tract infection
  • Neurogenic bladder disorders

  
• After patients have been evaluated, they should be informed of the various therapeutic options for BPH
• Men with presumptive BPH


  • Must be evaluated for urethral stricture, bladder neck contracture, bladder stone, and CaP
• Alpha-1-adrenoreceptors


  Found in the human prostate and bladder base, and mediate the contractile response of the prostate and bladder neck

  
• Alpha-blockers


  • Result in both objective and subjective degrees of improvement in the symptoms and signs of BPH in some patients
  • Can be classified according to their receptor selectivity as well as their half-life

  
• Selective blockade of the alpha-1a receptors


  Results in fewer systemic side effects (orthostatic hypotension, dizziness, tiredness, rhinitis, and headache), thus obviating the need for dose titration

  
• Finasteride


  • A 5-alpha-reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone
  • Affects the epithelial component of the prostate, resulting in a reduction in the size of the gland and improvement in symptoms
  • Requires 6 months of therapy to see maximum effects
  • Symptomatic improvement is seen only in men with enlarged prostates (>40 cm3)
• Dutasteride


  • Differs from finasteride as it inhibits both isoenzymes of 5-alpha-reductase
  • Similar to finasteride, it reduces serum prostatic specific antigen and total prostate Size
• Combination therapy


  The reduction in risk associated with combination therapy (risk reduction) was significantly greater than that associated with alpha-blocker or finasteride alone
• Phytotherapy


  The use of plants or plant extracts for medicinal purposes in BPH
• Flutamide


  An orally administered nonsteroidal antiandrogen that inhibits the binding of androgen to its receptor
• Cetrorelix


  The only gonadotropin-releasing hormone antagonist that has been investigated for BPH

  
• Atamestane


  A highly selective aromatase inhibitor that lowers both serum and intraprostatic levels of estradiol and estrone

  
• Anti-cholinergics


  Decrease irritative symptoms
• Absolute surgical indications for BPH


  • Refractory urinary retention
  • Recurrent urinary tract infection
  • Recurrent gross hematuria
  • Bladder stones
  • Renal insufficiency
  • Large bladder diverticula

  
• Transurethral resection of the prostate (TURP)


  The gold standard surgical approach

  
• Open prostatectomy


  Indicated when the prostate is too large (>80g) to be removed endoscopically, or when there is concomitant bladder diverticulum or big bladder stone, or if dorsal lithotomy positioning is not possible, or in the presence of inguinal hernia

  
• Surgical approaches for open prostatectomy


  • Transvesical (The Freyer operation)
  • Retropubic (Millin operation)
  • Perineal (Young operation)
• Local complications of prostatectomy


  • Hemorrhage
  • Sepsis and SSI
  • Bladder and prostatic capsule perforation
  • Incontinence
  • Retrograde ejaculation
  • Impotence
  • Urethral stricture
  • Bladder neck contracture
  • Reoperation