Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia

Generalised disease of the prostate due to hormonal derangement which leads to enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms

BPHProposed Etiologies

Cause not completely understood Reawakening of the urogenital sinus to proliferate Change in hormonal milieu with alterations in the

testosterone/estrogen balance Induction of prostatic growth factors Increased stem cells/decreased stromal cell death Accumulation of dihydroxytestosterone, stimulation

by estrogen and prostatic growth hormone actions

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BPH facts Occurs in 50% of men over 50 and in

80% of men over 80 have BPH BPH progresses differently in every

individual Many men with BPH may have mild

symptoms and may never need treatment

BPH does not predispose to the development of prostate cancer

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Benign Prostatic Hyperplasia

BPH PathophysiologyBPH PathophysiologyNormalNormal BPHBPH

Hypertrophied detrusor muscleHypertrophied detrusor muscle

Obstructed urinary flowObstructed urinary flow

PROSTATEPROSTATE

BLADDERBLADDER

URETHRAURETHRA

Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

BPH Pathophysiology

Slow and insidious changes over time Complex interactions between prostatic urethral

resistance, intravesical pressure, detrussor functionality, neurologic integrity, and general physical health.

Initial hypertrophydetrussor decompensation poor tonediverticula formationincreasing urine volumehydronephrosisupper tract dysfunction

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Complications Urinary retention UTI Sepsis secondary to UTI Residual urine Calculi Renal failure Hematuria Hernias, hemorroids, bowel habit change

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Clinical manifestations Voiding symptoms

decrease in the urinary stream

Straining

Dribbling at the end of urination

Intermittency

Hesitancy

Pain or burning during urination

Feeling of incomplete bladder emptying

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Clinical manifestations Irritative symptoms

urinary frequencyurgencydysuriabladder painnocturiaincontinencesymptoms associated with infection

Benign Prostatic Hyperplasia

• Leading to “symptom bother” and worsened QOL

Other Relevant History

GU History (STD, trauma, surgery) Other disorders (eg. neurologic,

diabetes) Medications (anti-cholinergics) Functional Status

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Diagnostic Tests History & Examination

Abdominal/GU exam Focused neuro exam

Digital rectal exam (DRE)

Validated symptom questionnaire.

Urinalysis Urine culture BUN, Cr

Prostate specific antigen (PSA)

Transrectal ultrasound – biopsy

Uroflometry Postvoid residual

AUA Symptom Score Sheet

Not at all

Less than 1 time in 5

Less than

half the time

About half the time

More than half the

time

Almost always

Your score

Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

0 1 2 3 4 5  

FrequencyOver the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5  

IntermittencyOver the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5  

UrgencyOver the last month, how difficult have you found it to postpone urination?

0 1 2 3 4 5  

Weak streamOver the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5  

StrainingOver the past month, how often have you had to push or strain to begin urination?

0 1 2 3 4 5  

  

None 1 time 2 times 3 times 4 times 5 times or more

Your score

Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

0 1 2 3 4 5  

Quality of life due to urinary symptoms Delighted Pleased Mostly satisfied

Mixed – about equally satisfied and dissatisfied

Mostly dissatisfied

Unhappy Terrible

If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?

0 1 2 3 4 5 6

 

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

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DRE

BPHDanger Signs on DRE

Firm to hard nodules Irregularities, unequal lobes Induration Stony hard prostate Any palpable nodular abnormality

suggests cancer and warrants investigation

Optional Evaluations and Diagnostic Tests

Urine cytology in patients with: Predominance of irritative voiding symptoms. Smoking history

Flow rate and post-void residual Not necessary before medical therapy but

should be considered in those undergoing invasive therapy or those with neurologic conditions

Upper tract evaluation if hematuria, increased creatinine

Cystoscopy

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PSA Elevated levels of PSA

0 – 4 ng/ml Prostatic pathology

Correlates with tumor mass Some men with prostate cancer

have normal PSA levels

BPH SYMPTOMSDifferential Diagnosis Urethral stricture Bladder neck contracture Carcinoma of the prostate Carcinoma of the bladder Bladder calculi Urinary tract infection and prostatitis Neurogenic bladder

BPH TREATMENT INDICATIONSAbsolute vs Relative

Severe obstruction

Urinary retention Signs of upper

tract dilatation and renal insufficiency

Moderate symptoms of prostatism

Recurrent UTI’s Hematuria Quality of life

issues

Treatment Options

Mild to severe symptoms with little “bother” Manage with watchful waiting.

Risk of therapy outweighs the benefit of medical or surgical treatment

Moderate to severe symptoms with bother Management options include watchful

waiting, medical management and surgical treatment.

Therapy

Watchful waiting and behavioral modification

Medical Management Alpha blockers 5-alpha reductase inhibitors Combination therapy

Surgical Management Office based therapy OR based therapy

Urethral stents

Watchful Waiting and Behavioral Modification

“is the preferred management technique in patients with mild symptoms and minimal bother”

AUA score < 7,

1/3 improve on own.

Watchful Waiting and Behavioral Modification

Decrease caffeine, alcohol )diuretic effect( Avoid taking large amounts of fluid over a short

period of time Void whenever the urge is present, every 2-3

hours Maintain normal fluid intake, do not restrict fluid Avoid bladder irritants to include dairy products,

artificial sweeteners, carbonated beverages Limit nighttime fluid consumption BPH symptoms can be variable, intermittent

Medical Management

• Nutritional supplements– Saw Palmetto

• Alpha blockers– Doxazosin (Cardura), Terazosin (Hytrin),

Tamsulosin (Flomax), Alfuzosin (Uroxatral) • 5-alpha reductase inhibitors

– Finasteride (Proscar), Dutasteride (Avodart)

• Combination therapy– Alpha blocker and 5-alpha reductase

inhibitor

BenefitsConvenient

No loss of work time

Minimal risk

DisadvantagesExpensive

Drug Interactions

Must be taken every day

Manages the problem instead of fixing it

medication

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Medical Management

Alpha adrenergic receptor blockers promote smooth muscle relaxation in the prostate Relaxation of the muscles facilitates urinary flow Doxazosin (Cardura), Terazosin (Hytrin),

Tamsulosin (Flomax), Alfuzosin (Uroxatral) Side effects: postural hypotension, dizziness,

fatigue, Other problems can occur when pt is also taking

cardiac or other hypertensive drugs

Alpha-Adrenergic Blockers Equal clinical effectiveness Slight differences in adverse event

profile Orthostasis (lower in tamsulosin) Ejaculatory dysfunction (higher in

tamsulosin) Decreased energy levels Nasal congestion Increase in CHF risk with doxazosin

Must titrate doxazosin and terazosin to effective levels

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Medical Management5 alpha reductase inhibitor ) finasteride: Proscar( Reduce size of prostate gland by up to 30 %by up to 30 % Blocks the enzyme of 5 alpha reductase which

is nec, for the conversion of testosterone to dihydroxytestostersone

Regression of hyperplastic growth Don’t work immediatelyDon’t work immediately Small effect on symptom score and flow ratesSmall effect on symptom score and flow rates

5-Alpha Reductase Inhibitors

Agents are effective and appropriate treatment for patients with lower urinary tract symptoms and demonstrable enlargement of the prostate.

Average prostate size is 30 cc’s. Original studies showed benefit only in men with prostate sizes greater than 50 cc’s.

5-Alpha Reductase Inhibitors

Finasteride (Proscar) and Dutasteride (Avodart) Less effective for relief of BPH symptoms

than alpha blockers Adverse events include

Decreased libido Worsened sexual function (erectile dysfunction) decrease volume of ejaculation Breast enlargement and tenderness

Reduces risk of urinary retention by 3%/year. PSA must be doubled if screening for prostate

cancer

Combination Therapy

Concomitant use of alpha blockers and 5-alpha reductase inhibitors Should be reserved for patients

who are at significant risk of progression and adverse outcome

Poor surgical candidate Patient wants to avoid surgery Significant cost associated with dual

medications

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Medical Management Herbal therapy –

saw palmetto fruit – use to improve urinary symptoms and urinary flow

Problem with herbal therapy – long term effectiveness

surgical treatment

Surgical Management

Office based therapies: Transurethral microwave therapy (TUMT) Transurethral needle ablation (TUNA)

Therapies are effective or partially effective for relieving the symptoms of BPH Significant side effects/complications associated with these treatments have prompted a FDA warning

Surgical Management

OR based therapies Open simple prostatectomy TURP Transurethral incision of the prostate Laser photoselective vaporization of

the prostate (green light laser PVP) Laser Prostatectomy

Surgical Management

Patients may select surgical treatment as initial therapy if moderate or severe bother is present.

Patients who have developed complications of BPH (i.e urinary retention, renal insufficiency, recurrent UTI) are best treated surgically.

New surgical treatment have not demonstrated better outcomes than TURP to date.

BPH TREATMENTSurgical

Indicated for AUA score >16 Transurethral Prostatectomy(TURP): 18%

morbidity with .2% mortality. 80-90% improvement at 1 year but 60-75% at 5 years and 5% require repeat TURP.

Transurethral Incision of Prostate (TUIP): less morbidity with similar efficacy indicated for smaller prostates.

Open Prostatectomy: indicated for glands > 60 grams or when additional procedure needed for suprapubic/retropubic approaches

TURP

“Gold Standard” of care for BPH

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

possible side effects of

Greater than 5% risk of: Irritative voiding symptoms Bladder neck contracture UTI

Risk of incontinence 1% Decline in erectile function 65% of retrograde ejaculationTUR syndrome (acute hyponatremia from free water absorption)HemorrhageBladder spasms

TURP

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Preoperative Goals Restoration of urinary drainage Treatment of any urinary tract

infection Understanding of procedure,

implications for sexual functioning and urinary control

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Preoperative care Antibiotics Allow pt to discuss concerns about

surgery on sexual functioning Prostatic surgery may result in

retrograde ejaculation

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Postoperative Goals No complications Restoration of urinary control Complete bladder emptying Satisfying sexual expression

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Postoperative Care Monitoring Continuous irrigation & maintain

catheter patency Blood clots and hematuria are expected

for the first 24-36 hours After catheter is removed – check for

urinary retention and urinary stream

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TURP Sphincter tone may be poor after

catheter is removed. Kegal exercise pelvic muscle floor technique is encouraged. Starting and stopping the urinary stream is helpful.

Stool softeners to avoid straining Sitting and walking for long periods

should be avoided

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Discharge planning Catheter care Managing urinary incontinence Oral fluid intake – 2,000-3,000 cc per day Observe for s/s of urinary tract infection Prevent constipation Avoid lifting No driving or intercourse after surgery

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Surgical approaches for prostatectomy Retropubic

Midline abd. incision

Perineal Incision between

the scrotum and anus

Suprapubic Abdominal incision

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Prostatectomy

Complications: Bleeding Postoperative pain Risk for infection Erectile dysfunction

BPH TREATMENTNew Modalities Minimally invasive: (Prostatic

Stents,TUNA,TUMT, HIFU,Water-induced Thermotherapy)

Laser prostatectomy (VLAP,ILC,CLAP,TULIP,HoLRP)

Electrovaporization (TUVP,TVRP)

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

heat therapiesBenefitsOffice treatmentsLocal anesthesiaMinimally invasive

Reduced risk of complications as compared to invasive surgical “TURP”

DisadvantagesSome symptoms will persist for up to 3 monthsCannot predict who will respondMay require prolonged catheterization

possible side effects of

Urinary Tract Infection

Impotence

Incontinence

heat therapies

Laser Photoselective Vaporization of the Prostate (Laser PVP)

TURP-equivalent 7 year improvement in symptom score and urination parameters

Decreased risk of bleeding and TUR syndrome, otherwise similar adverse effect profile

May be done on anti-coagulated patients