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Benign
Prostatic Hyperplasia(BPH)
Mohsen Amjadi MD.Head of Urology Department
ENDOUROLOGISTamjadizm@yahoo.com
TBZMED
Farzin Soleimanzadeh MD. Fellow of Europen Board of Urology
Reconstructive Urologistfarzinsoleimanzade@gmail.com
TBZMED
Benign Prostatic Hyperplasia
What is BPH?
BPH
• Introduction
• Anatomy
• Pathogenesis
• Assessment
• Treatment
• Questions
Terminology
• Benign Prostatic Hyperplasia• BPH
• Pathological Dx
• Benign Prostatic Enlargement• BPE
• Clinical Dx
• Bladder Outflow Obstruction• BOO
• Urodynamic Dx
Anatomy of Prostate
Anatomy of Prostate
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Secretes part of semen
which carries sperm
Secretions are
responsible for
liquification of semen
Physiology of prostate
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Prevalence of BPH by Age
Half of all men over the age of 60 will
develop an enlarged prostate.
By the time men reach their 70’s and 80’s,
80% will experience urinary symptoms.
But only 25% of men aged 80 will be
receiving BPH treatment
Prevalence of BPH
Risk Factors.
• Age
• Testosterone
• Hereditary
• Obesity
• Diabetes
• Dyslipidaemia
Regulation of cell growth in the
prostate in BPH
DHT-androgen
receptor complex
Growth
factors
Unbalanced
DHT
T
5AR (1 and 2)
Serum testosterone (T)
Prostate
cell
Increased
Cell growth
Cell death
Serum Dihydrotestosterone
(DHT)
what causes BPH?
BPH is part of the natural
aging process, like getting
gray hair or wearing glasses
BPH cannot be prevented
BPH can be treated
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what causes these symptoms?
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symptoms
Lower Urinary Tract
Symptoms
LUTS
What’s LUTS?Voiding (obstructive)
symptoms
• Hesitancy
• Weak stream
• Straining to pass
urine
• Prolonged
micturition
• Feeling of
incomplete
bladder emptying
• Urinary retention
Storage (irritative or
filling) symptoms
• Urgency
• Frequency
• Nocturia
• Urge
incontinence
common symptoms
Frequent and urgent
need to urinate,
especially at night
Dribbling or leaking
after urination
Intermittent or weak
stream
Straining to urinate
Pain or burning
during urination
Feeling that the
bladder never
completely emptiesn
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nn
What’s LUTS?
LUTS is not specific to BPH
not everyone with LUTS has BPHand
not everyone with BPH has LUTS
LUTS BOO
BPE
Bladder Outflow Obstruction
Lower Urinary Tract Symptoms
Benign Prostatic Enlargement
1. Hald T et al. Proceedings of the 4th International Consultation on Benign Prostatic Hyperplasia, Paris, 1997. SCI, 1993, 129-178.
Hald Diagram
ignoring the symptoms...
Risk of bladder and
kidney damage
Impact on quality of life
...will not make them go away!
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History : co-morbidity
• Other causes of symptoms
– Polyuria
– Heart failure
– Diabetes
– Diuretics
– UTI
– Urethral stricture
– Bladder carcinoma (TCC)
– Phimosis
Urinary Retention
• Acute
• Painful
• Normal renal function
• Precipitating event
– UTI
– Fluid overload
– Constipation
– Medication
Chronic
n Painless
n Impaired renal function
n Large residual volume
Watch Video
Investigations : routine
• Frequency volume chart (Voiding diary)
• Glucose
• Creatinine & Electrolytes
• PSA
• IPSS
• Urinary flow rate (uroflowmetry)
• Post-void residual urine
Examination
• Palpable bladder
• DRE• Smoothly enlarged prostate
• Estimate size (normal 25-30mls)
• Non tender
• Constipation
• Hypertension
• Peripheral edema
• Renal impairment
AUA Symptom Index Scoring
SCORE INTERPRETATION
0-7 Mild
8-19 Moderate
20-35 Severe
when should BPH be treated?
BPH needs to be treated ONLY In case of:
Symptoms severe enough to bother and affect patients’ quality of life
Frequent urinary tract infections
Hydronephrosis
Bladder decompansation
choosing the right treatment
Consider risks, benefits
and effectiveness of each
treatment
Consider outcome and
lifestyle needs
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Treatment Options
“Watchful waiting”
Medication
Heat therapies
Surgical approaches
Invasive “open” procedures
Less-invasive modalities (TUR, Laser,…)
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“watchful waiting”
With mild symptoms, condition should be
monitored by physician 1 - 2 times yearly
Doctor may offer suggestions
that help reduce symptoms- Avoid caffeine and alcohol
- Avoid decongestants and antihistamines
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Medication
First line of defense against bothersome urinary symptoms
Manage the condition - don’t fix it
Two major types:
Relaxants - relax the prostate and provide a larger urethral opening (Terazosin, Tamsulosin)
Shrinking the prostate gland(Finasteride, Dutasteride)
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Distribution of 1-Adrenergic Receptors
Reminder: Adrenergic Receptor Blockers
1-Adrenergic Blockers: Summary
• All currently available 1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy
• They are all well tolerated; however, the adverse event spectrum differs between the agents
– Terazosin and doxazosin induce more dizziness, fatigue,
and asthenia
– Tamsulosin induces more ejaculatory disturbances
• None of the 1-blockers alter urodynamic parameters, prostate volume or serum PSA
• None have been shown to alter the natural history of the disease or prevent AUR / Surgery
5-Reductase Inhibitor: Rationale• Prostatic differentiation & growth depend on androgenic
stimulation
• Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by
5-reductase enzyme
• 5-reductase inhibitor: deprive the prostate of its
testosterone support
• 5-reductase enzyme:
Type I: skin & liver
Type II: stromal & basal cells of prostate, seminal vesicle,
epididymis
Kirby RS et al. Br J Urol. 1992;70:65-72
Tammela TLJ et al. J Urol. 1993;149:342-344
possible side effects of
• Impotence
• Dizziness
• Headaches
• Fatigue
• Loss of sexual drive
medication
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Destroy prostate tissue with heat
Tissue is left in the body and is expelled
over time (called sloughing)
Transurethral Microwave Therapy (TUMT)
Transurethral Needle Ablation (TUNA®)
Interstitial Laser Coagulation (ILC)
Water Induced Thermotherapy (WIT)
Heat Therapies
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surgical treatment
Indication of surgical intervention
• Acute urinary retention
• Gross hematuria
• Frequent UTI
• Vesical stone
• BPH related hydronephrosis or renal function deterioration
• Obstruction
• Patient’s preference
Because the tissue is removed
and not left in the body
n
n
RESULTS ARE
IMMEDIATE
strong urine flow
relief of urinary symptoms
The “gold standard”- TURP
Benefits
Widely available
Effective
Long lasting
Disadvantages
Greater risk of side effects and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery
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TURP
“Gold Standard” of care for BPH
Uses an electrical “knife” to surgically cut
and remove excess prostate tissue
Effective in relieving symptoms and
restoring urine flow
(transurethral resection of the prostate)
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Complication of TURP
• Immediate complication
bleeding
capsular perforation with fluid extravasation
TUR syndrome
• Late complication
urethral stricture
bladder neck contracture (BNC)
retrograde ejaculation
impotence (5-10%)
incontinence (0.1%)
Vaporization of the Prostate
Using Heat or Laser
Enlarged Prostate
Urethra is open
Normal urine flow is
restored
Urethra is obstructed
Urine flow blocked
After therapy
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Need a Catheter?
Many patients do not require a catheter
If one is required, it is usually removed in
less than 24 hours
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Open Simple Prostatectomy
• “Too large prostate” -- >100 gm
• Combined with bladder diverticulum or
vesical stone surgery
Suprapubic or retropubic method
Conclusions• B.P.E. is a common condition with many more men suffering
symptoms than present to the medical profession.
• Signs and symptoms vary in their character and severity.
• All patients should have standard assessment in the form of history, examination and investigations with specialised investigations being reserved for complicated or equivocal cases.
• Medical and surgical treatment options are available and these should be discussed with the patient prior to commencement.
• Surgery remains the gold standard in the form of TURP
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