BENIGN PROSTATIC HYPERPLASIA (BPH): Urological Aspects

Dr. Taha Abo-Almagd Associate Professor and Consultant Department of Urology

Learning objectives
Zonal anatomy of the prostate Pathophysiology and complications of BPH Symptoms and signs of BPH Evaluation of BPH Treatment of BPH

Dr. Taha Abo-Almagd

Content of the lecture

Anatomical aspects Incidence and Epidemiology of BPH Pathology Pathophysiology Symptoms and signs Investigations Treatment
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Anatomy of Prostate

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Gross appearance of hyperplastic prostatic tissue obstructing the prostatic urethra forming lobes.
A, Isolated middle lobe enlargement. B, Isolated lateral lobe enlargement. C, Lateral and middle lobe enlargement. D, Posterior commissural hyperplasia (median bar).
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BPH uniformly originates in the transition zone.

Zonal anatomy of the prostate

(J. E. McNeal , Am J Surg Pathol 1988;12:619-633).

The transition zone surrounds the urethra proximal to the ejaculatory ducts. The central zone surrounds the ejaculatory ducts and projects under the bladder base. The peripheral zone constitutes the bulk of the apical, posterior, and lateral aspects of the prostate. The anterior fibromuscular stroma extends from the bladder neck to the striated urethral sphincter.

 The prostate is composed of both: stromal and epithelial elements Each, either alone or in combination, can give rise to hyperplasia and the symptoms associated with BPH The stroma is composed of smooth muscle and collagen, rich in adrenergic nerve supply The level of autonomic stimulation sets a tone to the prostatic urethra Each element may be targeted in medical management schemes
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Incidence and Epidemiology of BPH

BPH is the most common benign tumor in men, and its incidence is age related. The prevalence of histologic BPH in autopsy studies:
4150: 20% 51-60: 50% Above 80: > 90%

Clinical BPH is also age related:

At age 55: At age 75: 25% 50%
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Risk factors
Risk factors for the development of BPH are poorly understood. Some studies have suggested a genetic predisposition, and some have noted racial differences. Approximately 50% of men under the age of 60 who undergo surgery for BPH may have a heritable form of the disease. This form is most likely an autosomal dominant trait, and firstdegree male relatives of such patients carry an increased relative risk of approximately fourfold.
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Etiology
The etiology of BPH is not completely understood. Multifactorial and endocrine controlled. Observations and clinical studies in men have clearly demonstrated that BPH is under endocrine control. Castration results in the regression of established BPH and improvement in urinary symptoms. Additional investigations have demonstrated a positive correlation between levels of free testosterone and estrogen and the volume of BPH.
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Pathology
BPH is truly a hyperplastic process (increase in cell number). Microscopic evaluation reveals a nodular growth pattern that is composed of varying amounts of stroma and epithelium. Stroma is composed of varying amounts of collagen and smooth muscle. The differential representation of histologic components of BPH may explain the potential responsiveness to medical therapy.
Alpha-blocker therapy may result in excellent responses in patients with BPH that has a significant component of smooth muscle. 5-alpha-reductase inhibitors might give better results in patients with BPH predominantly composed of epithelium. Patients with significant components of collagen in the stroma may not respond to either form of medical therapy.

Unfortunately, responsiveness to a specific therapy is not reliably predictable.

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Pathophysiology
Symptoms of BPH are related to either:
obstructive component of the prostate or secondary response of the bladder to outlet resistance.

The obstructive component can be subdivided into:

Mechanical obstruction. Dynamic obstruction.

Mechanical obstruction may result from intrusion into the urethral lumen or bladder neck, leading to a higher bladder outlet resistance. The dynamic component results from the effect of smooth muscle fibers (regulated by alpha adrenergic innervation) and collagen.
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Pathophysiology
Secondary response of the bladder to the increased outlet resistance: Bladder outlet obstruction leads to:
detrusor muscle hypertrophy, hyperplasia and collagen deposition.

Grossly, detrusor muscle bundles are thickened and seen as:

Trabeculations Diverticula (mucosal herniations between detrusor muscle bundles , composed of only mucosa and serosa)

Resulting: irritative voiding symptoms (see below).

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SYMPTOMS Lower Urinary Tract Symptoms (LUTS)

Obstructive Symptoms Irritative Symptoms
Hesitancy Weak stream Interrupted stream Need to strain Post void dribbling Prolonged voiding time Sense of incomplete void Double void AUR frequency Nocturia Urgency Urge incontinence

Dysuria: painful urination

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SIGNS
DRE (Digital rectal examination). Focused neurologic examination. Size and consistency of the prostate are noted. BPH usually results in a smooth, firm, elastic enlargement of the prostate. Induration must alert the physician to possibility of cancer and the need for further evaluation (ie, prostate-specific antigen [PSA], transrectal ultrasound [TRUS], and biopsy). Prostate size does not correlate with severity of symptoms or degree of obstruction.

LABORATORY FINDINGS
Urinalysis to exclude infection or hematuria. Serum creatinine measurement to assess renal function:
Renal insufficiency may be observed in 10% of patients with LUTS and warrants upper-tract imaging. Patients with renal insufficiency are at an increased risk of developing postoperative complications following surgical intervention for BPH.

Serum prostate specific antigen (PSA):

increases the ability to detect prostate cancer. there is much overlap between levels seen in BPH and cancer. Normal is 0 4 ng/ ml
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IMAGING
Upper-tract imaging (intravenous pyelogram or renal ultrasound) is recommended only in presence of concomitant urinary tract disease or complications from BPH:
hematuria, urinary tract infection, renal insufficiency (U/S), history of stone disease.

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Urodynamic Studies
Measurement of
flow rate, post-void residual urine, pressure-flow studies are considered optional.

Cystometrograms and detailed urodynamic profiles are reserved for patients with suspected neurologic disease or those who have failed prostate surgery.
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Cystoscopy
Cystoscopy is not recommended to determine the need for treatment. May assist in choosing the surgical approach in patients opting for invasive therapy.

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Differential Diagnosis
Other obstructive conditions of the lower urinary tract:
urethral stricture bladder neck contracture bladder stone prostate cancer A history of previous urethral instrumentation, urethritis, or trauma should be elucidated to exclude urethral stricture or bladder neck contracture. Hematuria and pain are commonly associated with bladder stones. Prostate cancer may be detected by abnormalities on the DRE or an elevated PSA.

Urinary tract infections, which can mimic the irritative symptoms of BPH, can be readily identified by urinalysis and culture; however, urinary tract infections can also be a complication of BPH. Bladder cancer, especially carcinoma in situ, (irritative voiding symptoms): urinalysis usually shows evidence of hematuria. Neurogenic bladder disorders: history of neurologic disease, stroke, diabetes mellitus, or back injury and simultaneous alterations in bowel function (constipation) may be present. In addition, examination may show diminished perineal or lower extremity sensation or alterations in rectal sphincter tone or the bulbocavernosus reflex.

TREATMENT
WATCHFUL WAITING MEDICAL THERAPY

CONVENTIONAL SURGICAL THERAPY

MINIMALLY INVASIVE THERAPY

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TREATMENT:

WATCHFUL WAITING

For mild symptoms watchful waiting only is advised.

The risk of progression or complications is uncertain. However, in men with symptomatic BPH, it is clear that progression is not inevitable some men undergo spontaneous improvement or resolution of their symptoms.

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TREATMENT:

Medical Treatment

Alpha-blockers 5-Alpha-reductase inhibitors Combination Therapy Phytotherapy

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Medical Treatment:

Alpha-blockers

The human prostate and bladder base contains alpha-1adrenoreceptors, and the prostate shows a contractile response to corresponding agonists. The level of autonomic stimulation thus sets a tone to the prostatic urethra. Use of alpha-blocker therapy decreases this tone, resulting in a decrease in outlet resistance. Alpha-blockade has been shown to result in both objective and subjective degrees of improvement in the symptoms and signs of BPH in some patients. Identification of subtypes of alpha-1-receptors (alpha-1a receptors) , which are localized in the prostate and bladder neck, and selective blockade of them results in fewer systemic side effects (orthostatic hypotension, dizziness, tiredness, rhinitis, and headache).
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Medical Treatment:

5-Alpha-reductase inhibitors

Block the conversion of testosterone to dihydrotestosterone. This drug affects the epithelial component of the prostate, resulting in a reduction in the size of the gland and improvement in symptoms. Six months of therapy are required to see the maximum effects on prostate size (20% reduction) and symptomatic improvement. Symptomatic improvement is better seen in men with enlarged prostates (>30 ml). Side effects include decreased libido, decreased ejaculate volume, and impotence. Serum PSA is reduced by approximately 50% in patients being treated with 5-Alpha-reductase inhibitors
Dr. Taha Abo-Almagd

TREATMENT: CONVENTIONAL SURGICAL

THERAPY

Absolute surgical indications include: Refractory urinary retention (failing at least one attempt at catheter removal) Recurrent urinary tract infection Recurrent gross hematuria Bladder stones Renal insufficiency Large bladder diverticula with narrow neck
Dr. Taha Abo-Almagd

TREATMENT: CONVENTIONAL SURGICAL

THERAPY

Transurethral resection of the prostate (TURP) 90% of simple prostatectomies Complications of TURP include bleeding, perforation of the prostate capsule with extravasation, and if severe, TUR syndrome. Late complications: retrograde ejaculation, impotence, incontinence, urethral stricture or bladder neck contracture, Transurethral incision of the prostate moderate to severe symptoms and a small prostate This procedure is more rapid and less morbid than TURP Open simple prostatectomy (Enucleation) When the prostate is too large to be removed endoscopically (usually >100 g). Large bladder stone Large bladder diverticula Dr. Taha Abo-Almagd

TREATMENT: MINIMALLY

INVASIVE THERAPY

Laser Therapy Transurethral electro-vaporization of the prostate Hyperthermia Transurethral needle ablation of the prostate (TUNA) High-intensity focused ultrasound Prostatic Stents
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Independent learning from textbooks

Toronto Notes 2010 Smiths General Urology
Seventeenth Edition (2008) Editors:
Emil A. Tanagho, MD Jack W. McAninch, MD, FACS

a LANGE medical book

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Independent learning from the Internet

http://emedicine.medscape.com/article/4373 59-overview

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Self- Assessment
1. BPH uniformly originates in :
a) b) c) d) e) The peripheral zone The central zone The transition zone The central and transition zones Any of the above zones
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Self- Assessment
2. Absolute surgical indications include all of the followings EXCEPT:
a) b) c) d) e) Refractory urinary retention Recurrent urinary tract infection Recurrent gross hematuria Renal insufficiency Any bladder diverticula
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Self- Assessment
3. Treatment options of BPH include all of the followings EXCEPT:
a) b) c) d) e) Alpha-blockers 5-alpha reductase inhibitors Radical prostatectomy Transurethral resection of the prostate Watchful waiting
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Thank You