BPH

Benign prostatic hyperplasia

BPH

*BPH is the most common benign tumor in men.

*Its age related disease.
For Pathology mean cellular proliferation of stromal and epithelial elements of prostate
For Radiologist mean an enlarged prostate > 30cm
For Urologist represent collection of lower urinary tract symptoms (LUTs) that develop in male population in
association with aging and prostatic enlargement
Pathology.
The prostate composed of
-stroma (smooth muscle & fibrous tissue) and
-epithelium.
BPH can arise from any one of them or in combination
Etiology. BPH need both age +androgen to developed
Increase in cell number
Epithelial and stromal proliferation.
Impaired programmed cell death (apoptosis)
Proposed factors that play role in aetiology include
Androgens
Estrogens
Stromal-epithelial interactions
Growth factors
Neurotransmitters
Genetic(autosomal dominant) family history usually effect younger age group
Anatomically




the prostate had 3 zones
-peripheral (70%) commonest site for Ca,
-central (25%) around ejaculatory duct, &
-transitional (5%) periurethral.
BPH uniformly originate from the transitional zone & as the nodule enlarge compress the outer zones of the prostate resulting in surgical capsule.
Pathophysiology
Increase urethral pressure lead to bladder wall hypertrophy so
First : the changes that lead to decrease compliance
causing frequency and urgency

Second :changes associated with decreased contractility causing decrease force of urinary stream,hestancy,intermittency and increase resudial volume





Clinical features :-
Either obstructive or irritative.
obstructive symptoms
-hesitancy,
-decrease force & caliber of stream,
-sensation of incomplete bladder emptying,
-double voiding
-straining to urinate, & post void dribbling
Irritative symptoms
Urgency, Frequency, & Nocturia.
* The amount of post void residual urine is extremely variable in sequential evaluation of same patient.
DRE,
used to determine the size, consistency of the prostate
-a smooth firm usually BPH while
-induration signify the possibility of Ca & need further evaluation.
-retention may occur usually precipitated by prostatic infection or infarction, ingestion of diuretic, anticholenergic, antidepressant
Symptom not related to prostatic size
Investigation
GUE, infection & hematuria.
Renal function : b.urea & s.creatinine.
PSA : is optional .prostatic tumor marker
Imaging : IVU &U/S is some time recommended.
Cystoscopy. Used to choose surgical approach when surgery is indicated.


D.Dx.
Obstructive condition of lower tract like
-urethral stricture,
-bladder neck contracture,
-bladder stone, &
-Ca prostate.
irritative
-UTI,
-CIS, &
-neurogenic bladder

Treatment Options

Watchful waiting
Medication
Surgical approaches
TURP
Invasive open procedures
Minimal invasive
A-Watchful waiting
Idea is Only 5%of BPH patients will develop retention
Mild symptoms with not very active life style
Follow up every 3-6 months
Offer suggestions that reduce symptoms
Like avoid caffeine , night time excessive fluid and decongestant,antihistamine anticholinergic
B-Medical therapy.
1-Alpha blocker:
The human prostate & bladder neck contain alph-1a receptors.
Alpha blocker lead to smooth muscle relaxation & dilatation of bladder neck.
Alpha blocker either nonselective act on alpha like phenoxybenzamine
Selective which either
short acting e.g prazosin or,
long acting e.g terazosin & doxazosin .
These need dose titration to decrease their side effect


side effect include
-orthostatic hypotension,
-dizziness,
-tiredness,
-retrograde ejaculation,
-rhinitis, &
-headach .
Highly selective act on alpha 1a receptors like
tamsolusin and Silodosin in both no need for dose titration because it had fewer side effect.mostly causing retrograde ejaculation ,not effect blood pressure.

2- 5-alpa reductase inhibitor

Finasteride and dutasteride are 5 alpha reductase inhibitors that block the conversion of testosterone to dihydrotestosteron. This drug act on epithelial component (adenoma) of the prostate reduce the size of the gland
(20% reduction of weight in 6 months).

side effect

-decrease libido &
-reduce PSA level to 50% complicating cancer detection.
B-Surgical management.
Absolutetely Indicated in
1-refractory retention (after at least 1 trial of catheter removal),
2-recurrent UTI due to PBH
3-recurrent gross hematuria, due to PBH
4-bladder stone,
5-renal insufficiency
6-bladder diverticulum
7- failure of medical treatment (medication not improving the quality of life)
*provide these are from BPH.
1-TURP (transurethral resection of the prostate)
-resection of the prostate endoscopically into small pieces which removed by bladder wash.
-Used in 95% of BPH.
complications. Immediate
-Bleeding
-Capsular perforation with fluid extravasation
-Infaction
-TURP syndrom
TURP syndrome : resulting from hypervolemic hyponatremic state due to absorption of hypotonic irrigating solution.
Manifested by nausea, vomiting, confusion, hypertension, bradycardia,& visual disturbance
Late complication
Urethral stricture
Bladder neck contracture
Retrograde ejaculation
Impotence
Incontinence


2-open simple prostatectomy.

Indicated when TURP not performed due to

1- large prostate >100g.
2- concomitant bladder pathology like stone or diverticulum, &
3- when dorsal lithotomy positioning is not possible.
Its either transvesical or retropubic
3-minimal invasiae therapy.
1- laser therapy,
2- electrovaporization of the prostate,
3- transurethral needle ablation,
4- high intensity focused ultrasound,
5- intraurethral stent,
6- balloon dilation of the prostate