cp2 - urology - bph
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BENIGN PROSTATIC HYPERPLASIA (BPH):
Urological Aspects
Dr. Taha Abo-Almagd
Associate Professor and Consultant
Department of Urology
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Learning objectives
Zonal anatomy of the prostate
Pathophysiology and complications of BPH
Symptoms and signs of BPH Evaluation of BPH
Treatment of BPH
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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 ofhyperplastic prostatic tissueobstructing the prostaticurethra forming lobes.
A, Isolated middle lobeenlargement.
B, Isolated lateral lobeenlargement.
C, Lateral and middle lobe
enlargement.
D, Posterior commissuralhyperplasia (median bar).
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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.
BPH uniformlyoriginates in the
transition zone.
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The prostate is composed of both:
stromal and epithelial elements
Each, either alone or in combination, can give riseto 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 tothe prostatic urethra
Each element may be targeted in medicalmanagement schemes
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Incidence and Epidemiology of BPH
BPH is the most common benign tumor in men, and itsincidence 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: 25%
At age 75: 50%
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Risk factors
Risk factors for the development of BPH arepoorly understood.
Some studies have suggested a geneticpredisposition, and some have noted racialdifferences.
Approximately 50% of men under the age of 60who undergo surgery for BPH may have aheritable form of the disease. This form is most
likely an autosomal dominant trait, and first-degree male relatives of such patients carry anincreased 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 apositive 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 iscomposed 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 BPHmay 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 intrusioninto 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 adrenergicinnervation) and collagen.
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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).
Pathophysiology
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Lower Urinary Tract Symptoms (LUTS)
Irritative Symptoms
frequency
Nocturia
Urgency
Urge incontinence
Dysuria: painful urination
Obstructive Symptoms
Hesitancy
Weak stream
Interrupted stream
Need to strain
Post void dribbling
Prolonged voiding time Sense of incomplete void
Double void
AUR
SYMPTOMS
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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, elasticenlargement of the prostate.
Induration must alert the physician to possibility ofcancerand the need for further evaluation (ie,prostate-specific antigen [PSA], transrectal ultrasound[TRUS], and biopsy).
Prostate size does not correlate withseverity of symptoms or degree of
obstruction.
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LABORATORY FINDINGS
Urinalysis to exclude infection or hematuria.
Serum creatinine measurement to assess renalfunction: Renal insufficiency may be observed in 10% of
patients with LUTS and warrants upper-tract imaging.
Patients with renal insufficiency are at an increasedrisk of developing postoperative complicationsfollowing 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 onlyin
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 withsuspected neurologic disease or those whohave 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 inpatients 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 shouldbe 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 tractinfections 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 bowelfunction (constipation) may be present. In addition, examination may show
diminished perineal or lower extremity sensation or alterations in rectalsphincter tone or the bulbocavernosus reflex.
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TREATMENT
WATCHFUL WAITING
MEDICAL THERAPY
CONVENTIONAL SURGICAL THERAPY
MINIMALLY INVASIVE THERAPY
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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 orresolution of their symptoms.
TREATMENT: WATCHFUL WAITING
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Alpha-blockers
5-Alpha-reductase inhibitors
Combination Therapy Phytotherapy
TREATMENT: Medical Treatment
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The human prostate and bladder base contains alpha-1-adrenoreceptors, and the prostate shows a contractileresponse to corresponding agonists.
The level of autonomic stimulation thus sets a tone to theprostatic 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 symptomsand signs of BPH in some patients.
Identification of subtypes of alpha-1-receptors (alpha-1a
receptors) , which are localized in the prostate and bladderneck, and selective blockade of them results in fewersystemic side effects (orthostatic hypotension, dizziness,tiredness, rhinitis, and headache).
Medical Treatment: Alpha-blockers
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Block the conversion of testosterone to
dihydrotestosterone. This drug affects the epithelial component of the
prostate, resulting in a reduction in the size of thegland and improvement in symptoms.
Six months of therapy are required to see the
maximum effects on prostate size (20% reduction) andsymptomatic improvement.
Symptomatic improvement is better seen in men withenlarged prostates (>30 ml).
Side effects include decreased libido, decreasedejaculate volume, and impotence.
Serum PSA is reduced by approximately 50% in patientsbeing treated with 5-Alpha-reductase inhibitors
Medical Treatment: 5-Alpha-reductase inhibitors
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Absolute surgical indications include:
Refractory urinary retention (failing at least oneattempt at catheter removal)
Recurrent urinary tract infection
Recurrent gross hematuria
Bladder stones
Renal insufficiency
Large bladder diverticula with narrow neck
TREATMENT: CONVENTIONAL SURGICAL THERAPY
CONVENTIONAL SURGICAL THERAPY
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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 smallprostate
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
TREATMENT: CONVENTIONAL SURGICAL THERAPY
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Laser Therapy
Transurethral electro-vaporization of the prostate
Hyperthermia Transurethral needle ablation of the prostate
(TUNA)
High-intensity focused ultrasound Prostatic Stents
TREATMENT: MINIMALLY INVASIVE THERAPY
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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 theInternet
http://emedicine.medscape.com/article/4373
59-overview
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Self- Assessment
1. BPH uniformly originates in :
a) The peripheral zone
b) The central zone
c) The transition zone
d) The central and transition zones
e) Any of the above zones
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Self- Assessment
2. Absolute surgical indications include all of
the followings EXCEPT:
a) Refractory urinary retention
b) Recurrent urinary tract infection
c) Recurrent gross hematuria
d) Renal insufficiency
e) Any bladder diverticula
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Self- Assessment
3. Treatment options of BPH include all of the
followings EXCEPT:
a) Alpha-blockers
b) 5-alpha reductase inhibitors
c) Radical prostatectomyd) Transurethral resection of the prostate
e) Watchful waiting
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Thank You
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