Interventional Radiologist

Northwell Health Physician Partners

Vice Chairman- Department of Radiology

Long Island Jewish Medical Center

Associate Professor

Hofstra Northwell School of Medicine

Attending Physician

Departments of Radiology, Surgery and Urology

The ABCs of BPH

David Siegel, M.D., FSIR

• Speakers Bureau: St. Jude Medical

The prostate is a compound tubuloalveolar exocrine gland of the male mammalian reproductive system

Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen

Benign Prostatic Hyperplasia

is a nonmalignant enlargement

of the prostate gland caused by

cellular hyperplasia of both

glandular and stromal

elements that leads to

troublesome lower urinary

tract symptoms (LUTS) in

some men

• Nearly 20 million US men have BPH

• 12 million require therapy

• Annual US cost is > 3 billion dollars

• >40% of men over 50 have the condition >80% after 80

columnar arrangement of cells

corpora amylacea in gland lumens

BPH= “nodular prostatic hyperplasia”

nodule filled with enlarged glands

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

Didhydrotestosterone (DHT) is synthesized in the prostate from circulating testosterone by 5α-reductase. This enzyme is localized principally in the stromal cells; hence, these cells are the main site for the synthesis of DHT

DHT binds to nuclear androgen receptors and signals the transcription of growth factors that are mitogenic to the epithelial and stromal cells

BPH occurs when men generally have elevated estrogen levels and relatively reduced free testosterone levels

Estrogens may render cells more susceptible to the action of DHT

Age

Hereditary(genetic)/Race

Blacks

Hispanics

Lifestyle

Obesity

No Association with Smoking or Exercise

Kristal, Alan R., Kathryn B. Arnold, Jeannette M. Schenk, Marian L. Neuhouser, Noel Weiss, Phyllis Goodman, Colleen M. Antvelink, David F. Penson, and Ian M. Thompson. “Race/Ethnicity, Obesity, Health Related Behaviors and the Risk of Symptomatic Benign Prostatic Hyperplasia: Results From the Prostate Cancer Prevention Trial.” The Journal of Urology 177, no. 4 (April 2007): 1395–1400. doi:10.1016/j.juro.2006.11.065.

ANATOMY

Zones & Lobes

Normal BPH

Hypertrophied

detrusor muscle

Obstructed

urinary flow

PROSTATE

BLADDER

URETHRA

Slow and insidious changes over time

Complex interactions between prostatic urethral resistance, intravesical pressure, detrussor functionality, neurologic integrity, and general physical health.

Microscopic BPH

Smooth Muscle

Hyperplasia

Prostatic

EnlargementBladder Outlet

Obstruction

LUTS

Severity of LUTS does not necessarily correlate with prostate size

15

Voiding/Obstructive symptoms:

Hesitancy

Intermittency

Incomplete voiding

Weak urinary stream

Straining to pass urine

Prolonged micturition

Terminal dribbling

Storage/ Irritative symptoms:

Frequency of urination

Nocturia

Urgency (compelling need to void that can not be deferred)

Burning

Urge incontinence

Prostatitis

Neurogenic bladder

Drugs

Polyuria

Dietary

Constipation

Psychological

Urethral stricture

Bladder neck contracture

Carcinoma of the prostate

Carcinoma of the bladder

Bladder calculi

Urinary tract infection

18

History & Examination Abdominal/GU exam

Focused neuro exam

Digital rectal exam (DRE)

Validated symptom questionnaire

Urinalysis

Urine culture

BUN, Cr

Prostate specific antigen (PSA)

Uroflometry

Prostate MRI

_________________

Post-void residual

Urodynamics

Transrectal ultrasound

Prostate Biopsy

Elevated levels of PSA

0 – 4 ng/ml (? 2.5 or 3ng/ml)

Prostatic pathology

Some men with prostate cancer have normal PSA levels

Firm to hard nodules

Irregularities

Unequal lobes

Induration

Stony hard prostate

Mild (score 0-7)

Moderate (score 8-19)

Severe (score 20-35)

Interventional Radiologist

Northwell Health Physician Partners

Vice Chairman- Department of Radiology

Long Island Jewish Medical Center

Associate Professor

Hofstra Northwell School of Medicine

Attending Physician

Departments of Radiology, Surgery and Urology

The ABCs of BPH