Benign Prostatic Hyperplasia

DR.Gehan Mohamed

Normal Prostate Anatomy

• Prostate weights ~20g

• Measures ~3 by 4 by 2 cm

• Apex = inferior portion of prostate, continuous with striated sphincter. Base = superior portion and continuous with bladder neck.

PROSTATE histology

Prostatic tissue is formed of two components :•fibromuscular tissue (30%)

•glandular epithelial cells (70%)

Normal histology of prostate: formed of glands and fibromuscular stroma

Normal histology of the prostate formed of glands and stroma glands: lined by two layers of cells which are inner cuboidal cells and outer basal cells stroma :fibro muscular stroma

Prostate zones

Central zone (CZ) •Cone shaped region that surround the ejaculatory ducts (extends from bladder base to the verumontanum) •Only 1-5% of prostate cancer from this region . Peripheral zone (PZ) •Posteriolateral prostate •Majority of prostatic glandular tissue •Origin of up to 70% of prostate adenocarcinoma

Transitional zone (TZ) •Surrounds the prostatic urethra •Commonest site for benign prostatic hyperplasia.

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What causes BPH?

BPH is part of the natural aging process, like getting gray hair or wearing glasses

BPH cannot be prevented

BPH can be treated

Half of all men over the age of 60 will develop an enlarged prostate.

By the time men reach their 70’s and 80’s, 80% will experience urinary symptomsBut only 25% of men aged 80 will be receiving BPH treatment

BPHProposed Etiologies

• 1-alterations in the testosterone/estrogen balance:enlarged prostate may be caused by lower levels of testosterone (male hormone) production in middle to old age. As men age, the levels of testosterone in their blood decreases, leaving a higher proportion of estrogen (female hormone), so a higher amount of estrogen within the prostate gland can increase activity that promotes cell growth.

• 2-Induction of prostatic growth factors.

• 3- Increased stem cells/decreased stromal cell death

Benign Prostatic Hypertrophy (BPH)—Pathophysiology

• Common in older men; varies from mild to severe

• Change is actually hyperplasia of prostate– Nodules form around urethra

• Not change to cancer prostate.• Rectal exams reveals enlarged gland• Incomplete emptying of bladder leads to

infections• Continued obstruction leads to distended

bladder, dilated ureters, renal damage– If significant, surgery required

What’s Lower Urinary Tract Symptoms secondary to prostatic urethra obstruction?

Abnormal Voiding (obstructive)

symptoms• Hesitancy• Weak stream• Straining to pass urine• Prolonged micturition• Feeling of incomplete

bladder emptying• Urinary retention

Storage (irritative orfilling) symptoms• Urgency:an increasingly

strong desire to void)• Frequency• Nocturia• Urge incontinence

LUTS is not specific to BPH – not everyone withLUTS is not specific to BPH – not everyone withLUTS has BPH and not everyone with BPH has LUTSLUTS has BPH and not everyone with BPH has LUTS

BPH—Signs and Symptoms

• Initial signs– Obstruction of urine flow

• Hesitancy : delay between trying to urinate and the flow actually beginning.

• dribbling • decreased force of urine stream• Incomplete bladder emptying

– Frequency,– nocturia : need to urinate at night – recurrent Urinary Tract Infections

BPH complications

• hypertrophy of the prostatedetrussor muscle of the bladder undergo hypertrophy to overcome the obstruction in the prostatic urethra. Later on decompensation occur .

• Increase pressure inside bladderdiverticula formationincreasing urine

retentionhydronephrosis renal failure.

Diverticula in bladder

Diagnosis of BPH• Symptom assessmentSymptom assessment

• Digital rectal examination(DRE)Digital rectal examination(DRE)–inaccurate for size but can detect shape and consistency

• Prostate Volume (PV) determination by ultrasonographyProstate Volume (PV) determination by ultrasonography

• Urodynamic analysisUrodynamic analysis

• Measurement of prostate-specific antigen (PSA) Measurement of prostate-specific antigen (PSA) –high correlation between PSA and PV,–men with larger prostates have higher PSA levels–PSA is a predictor of disease progression and screening tool for Cancer Prostate.–as PSA values tend to increase with increasing Prostatic Volume and increasing age, PSA may be used as a prognostic marker for BPH.

BPH : show marked hyperplasia in the number of prostatic glands

When should BPH be treated?

BPH needs to be treated ONLy IF:

Symptoms are severe enough to bother the patient and affect his quality of life

Complications related to BPH

Medication :α blockers - relax the smooth muscle of

prostate and provide a larger urethral opening

Surgical approaches

1- Transurethral resection of the prostate (TURP) 2- Open simple prostatectomy

Treatment options

Indication of surgical intervention

• Acute urinary retention • Gross hematuria• Frequent urinary tract infection (UTI)• Vesical stone • BPH related hydronephrosis or renal

function deterioration• Obstruction

Differential Diagnosisof BPH(i.e from other causes of

urinary obstruction)

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