BENIGN PROSTATE

ENLARGEMENT
DR. MUNGUTI
ANATOMY
DEFINITION
• BPH - Progressive benign enlargement of the prostate gland resulting
from an increase in the number and size of epithelial cells and stromal
tissue

• Non cancerous increase in size of the prostate gland which involves

hyperplasia of prostatic stromal and epithelial cell resulting in
formation of large fairly discrete nodules in transitional zone of
prostate, which push on and narrow the urethra resulting in an
increase resistance to flow of urine from the bladder
EPIDEMIOLOGY
• Incidence increases with age
• 70% of men aged between 60 and 69 years
• 80% of men >80 years age
RISK FACTORS
• Non modifiable risk factors
• Race: increased prevalence among black men and at a younger age.
• Genetic susceptibility: - familial BPH – younger and larger prostate sizes
• Hormonal levels: age-related increase in the serum estrogen-androgen ratio is
associated with an increase in the estrogen-androgen ratio in prostatic tissue,
especially in the stroma
Modifiable risk factors
• Obesity and metabolic syndrome
• Low levels of physical activity
• Alcohol consumption
• Dietary: low vegetable/fruit intake, high animal fat and saturated fatty acids
PATHOPHYSIOLOGY
• Elevated androgen levels within prostate cause increased proliferation
of epithelial and stromal tissues
• Local and systemic inflammatory process also contribute to prostate
hyperplasia
• Stromal hyperplasia driven by Androgen receptor – DHT activity
• Estradiol role in BPH – estrogen levels increase in men with age.
• Hyperplasia usually occurs in the transition zone of the prostate
• may cause obstruction at the vesical neck/prostatic urethra.
• Size of prostate does not correlate with obstructive symptoms.
• Prostatic smooth muscle:
• stimulation of the adrenergic nervous system clearly results in a dynamic
increase in prostatic urethral resistance.
• Mediated by α1A adrenergic receptors.
• Adrenergic hyperactivity also contribute to LUTs.
BLADDER RESPONSE TO BPH
• BPH increases urethral resistance resulting in compensatory changes in
bladder function:
• Detrussor instability/decreased compliance
• Elevated detrusor pressure required to maintain urine flow
• Lead to altered storage symptoms: frequency, nocturia, urgency
• Decreased detrusor contractility
• Decreased urine stream, hesitancy, intermittency, increased residual volume
• Smooth muscle hypertrophy
• Adaptive response to increased intravesical pressures
• Bladder outlet obstruction
• Obstructive uropathy
• Voiding symptoms
HISTORY
Presenting complaints -LUTS
• Storage/irritative symptoms:
• frequency, nocturia, urgency, incontinence
• Voiding symptoms:
• reduced force of urine stream, hesitancy, intermittency, post micturition dribbling.
• dysuria
• Incomplete voiding
• Stasis of urine predispose to urinary tract infections
• Hematuria
• constipation
• History of
• urethral trauma, urethritis, or urethral instrumentation – RF for urethral stricture
• Gross hematuria
• pain
• Underlying neurologic disease
• Co morbid conditions: DM, Heart failure
• Cigarette smoking
• Medication:
• impair bladder contractility (eg, anticholinergic agents)
• increase outflow resistance (eg, sympathomimetic agents)
• diuretics for hypertension or congestive heart failure
• Systemic signs and symptoms
DIFFERENTIALS
• The diagnosis of lower urinary tract symptoms (LUTS)/benign
prostatic hyperplasia (BPH) is established by the presence of storage,
voiding, and/or irritative urinary symptoms in the absence of
history, examination or laboratory findings suggesting of non-BPH
causes of LUTS
PHYSICAL EXAMINATION
• General examination
• Functional status
• Abdominal/Groin/Pelvic examination

• Digital rectal examination

• Prostate size
• Tenderness
• Nodularity
• Asymmetry
• Sphincter tone
• Neurological examination
IPSS SCORE
COMPLICATIONS
• Acute urinary retention
• Urinary tract nfections
• Renal calculi
• Hydronephrosis
• Pyelonephrosis
• Detrussor dysfunction/instability
• Renal dysfunction secondary to obstructive uropathy
INVESTIGATIONS
• Urine
• Urinalysis: identify pyuria, glucosuria, proteinuria, ketonuria, or bacteruria
• Serological
• Full haemogram
• Renal function tests
• PSA
IMAGING
• KUB Ultrasound
• Obstructive uropathy
• Pre/post void residual volume
• Prostate imaging
• Prostatic Ultrasound – Trans-rectal ultrasound
• CT/MRI
• cystourethroscopy
• considered in men with a history suggestive of a urethral stricture or bladder
neck contracture
• Dynamic testing/uroflowmetry
MANAGEMENT
• Acute presentation
• Acute urine retention
• Urethral catheterization
• Suprapubic catheterization
MANAGEMENT - GENERAL
• Treatment depends on severity of symptoms and general health
condition
• Lifestyle modifications
• Limiting fluid intake before bedtime or prior to travel
• Limiting intake of mild diuretics (eg, caffeine, alcohol)
• Limiting intake of bladder irritants (eg, highly seasoned or irritative foods)
• Avoiding constipation
• Increasing activity, including regular strenuous exercise
• Weight control
MEDICAL MANAGEMENT
• Pharmacological treatment
• Alpha1 adrenergic blockers
• Firstline/agent of choice
• Prazosin, alfuzosin, tamsulosin, terazosin, doxazosin
• SE: anejaculation, hypotension
• 5 alpha reductase inhibitors (lock peripheral conversion of testosterone to DHT)
• Useful in large prostates >35 g
• Symptom relief after 6 -12 months
• SE: suppress serum PSA level
• ẞ adrenergic agonist/anticholinergics
• For patients with detrusor overactivity manifesting as frequency, urgency, incontinence
• Lifestyle modifications along with medical treatment.
• Trial without catheter (TWOC)
SURGICAL MANAGEMENT
• Indications:
• moderate-to-severe voiding symptoms
• Patients with AUR who fail two or more voiding trials
• An elevated or increasing post-void residual urine volume (PVR)
• Recurrent urinary tract infection (UTI)
• Recurrent gross hematuria
• Recurrent bladder stones
• Bilateral hydronephrosis with renal functional impairment
SURGICAL MANAGEMENT
• Minimally invasive techniques
• Transurethral microwave thermotherapy
• Transurethral needle ablation
• Laser prostatectomy
• Interstitial laser coagulation
• photovaporization
• Invasive
• Transurethral
• Transurethral resection of the prostate (TURP)
• Transurethral incision of prostate (TUIP)
• Transurethral vaporization of prostate (TUVP)
• Open
• Suprapubic prostatectomy
• Perineal prostatectomy
• Retropubic prostatectomy
POST SURGICAL COMPLICATIONS
• Immediate
• Hemorrhage
• Spasms
• Infection
• TURP syndrome
• Delayed
• Bladder neck stenosis
• Retrograde ejaculation
• incontinence