BENIGN PROSTATE HYPERPLASIA

Div. of Urology, Dept. Surgery Medical Faculty, University of Sumatera Utara

REFERENCES

DEFINITION
BPH is : Enlargement of the prostate gland from the progressive hyperplasia of stromal and glandular prostatic cells Pathologic process that contributes to, but is not the sole cause of, lower urinary tract symptoms (LUTS) in aging men
Urol Clin N Am 35 (2007) 109115 Campbell-Walsh Urology, 9th ed.2007

TERMINOLOGY
BPH (Benign Prostatic Hyperplasia) histopathologic
diagnosis BPE (Benign Prostatic Enlargement) anatomic diagnosis BOO (Bladder Outlet Obstruction) anatomic diagnosis BPO (Benign Prostatic Obstruction) BOO caused by BPE LUTS (Lower Urinary Tract Symptoms) clinical manifestation of lower urinary tract obstruction

INTRODUCTION
Most common benign tumor in men Age related in life expectancy significantly the number of men

affected by BPH
BPH is said to be a stromal disease, but it remains unclear whether the initiating events occur in the stomal compartment, the epithelial compartment, or both

ANATOMY
Normal weight about 20 g

Classification of Lowsley : 5 lobes : anterior, posterior, median, right lateral, left lateral
According to Mc Neal : - peripheral zone - central zone - transitional zone - an anterior segment - a preprostatic sphincter zone

PREVALENCE

20 % of men 40 - 50 years 50 % of men 50 - 60 years > 90 % of men older than 80 years The Most Frequent Benign Tumor in Men

PREVALENCE OF HISTOLOGICAL BPH WITH AGE

Prevalence (%)

100
80 60 40 20 0 11% 29% 48% 77%

87%

92%

3140

4150

5160

6170

7180

80+

Berry SJ et al. J Urol 1984; 132: 4749

All Men > 40 yrs BPH

Storage Total 51.3%

BPE

Storage Total 51.3%

LUTS BO O

ETIOLOGY
Multifactorial and endocrine controlled (Androgens, estrogens, stromalepithelial interactions, growth

factors, and neurotransmitters may

play a role ) BUT not completely understood

THEORIES FOR THE CAUSE OF BPH

Theory
Dihydrotestosteron hypothesis Oestrogentestosteron imbalance Stromal-epithelial interactions

Cause
5- reductase and androgen receptors
Oestrogens Testosteron

Effect
Epithelial and stromal hyperplasia Stromal hyperplasia

Reduced cell death

Epithelial and Epidermal growth stromal factor/fibroblast hyperplasia growth factor Transforming growth factor Longevity of stroma and epithelium Oestrogens
Stem cells Proliferation of transit

Stem cell theory

MORPHOLOGY
Microscopically, nodular prostatic hyperplasia consists of nodules of glands and intervening stroma (mostly glands)

The glands variably sized, with larger glands have

more prominent papillary infoldings

Nodular hyperplasia is NOT a precursor to carcinoma

PATHOPHYSIOLOGY
1. Pathogenesis hyperplasia 2. Symptoms disorders ( Voiding

phase or storage phase )

PATHOPHYSIOLOGY
Nodular hyperplasia of glands and stroma Normal 20 to 30 50 to 100 gm Press upon the prostatic urethra Obstruction - difficulty on urination Dysuria, retention, dribbling, nocturia

Infections, hydronephrosis, renal failure

Not a premalignant condition

PATHOPHYSIOLOGY
Prostate growth Increased urethral resistance

Decompensation
Flow Bladder emptying , hesitancy, intermittency, etc

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Static component

Dynamic component

LUTS

STATIC COMPONENT

Prostate mass (volume)

Urethral closure pressure

DYNAMIC COMPONENT
Bladder pressure Prostate smooth muscle tone: in stroma capsule bladder neck

LUTS ARE A CONSTELLATION OF STORAGE AND VOIDING SYMPTOMS

Storage Voiding Post-micturition

Urgency Frequency Nocturia Urgency incontinence Other incontinence

Hesitancy Poor flow Intermittency Straining Terminal dribble

Post-void dribble Sense of incomplete emptying

Prevalence of LUTS in Men

Percentage of men in the general male population who report at least 1 symptom representative of a particular type of LUTS

Voiding Total 25.7%

Postmicturition Total 16.9%

Storage Total 51.3%

Irwin DE et al. Eur Urol. 2006;50:13061315

How to Assess the Patient?

RECOMMENDED INVESTIGATIONS
Clinical history
Physical examination Validated symptom score, e.g IPSS Laboratory Uroflowmetry Imaging

1. CLINICAL HISTORY
Obstructive :
Hesitancy Poor flow Intermittency Straining Terminal dribble

Irritative :
Urgency Frequency Nocturia Urgency incontinence Other incontinence

2. PHYSICAL EXAMINATION
DRE :
Size Consistency : smooth or elastic/hard Nodule/ tender Mobility Anatomical limits: Lateral/ cranial/ medial sulcus
DRE is recommended in the evaluation of men with LUTS

DRE

3. VALIDATED SYMPTOM SCORE

IPSS (International Prostate Scoring System ).

: : : : : Mild Moderate Severe Watchful & Waiting Medical treatment

07 8 - 19 20 35 7 7

BPH SYMPTOM SCORE Gejala

1. KENCING TIDAK LAMPIAS Dalam sebulan ini berapa sering anda merasakan sensasi tidak lampias saat kencing (terasa belum habis) ? 2. Sering Kencing Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam 2 jam setelah anda Kencing 3.KENCING TERPUTUS PUTUS Dalam sebulan ini berapa sering kencing anda terhenti sejenak, lalu mulai lagi ( Terputus putus) 4.TIDAK DAPAT MENUNDA KENCING Dalam Sebulan ini Berapa sering anda merasa kesulitan untuk menunda Kencing 5.PANCARAN KENCING YANG LEMAH Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah 6. MENGEDAN SAAT KENCING Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing 7.KENCING DI MALAM HARI Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk Kencing

(by :AUA)
< 50 % 2 =50% 3 > 50 % Hampir Selalu 4 5

Tidak Pernah < 20 % 0 1

0 0

1 1

2 2

3 3

4 4

5 5 5kali, =5

Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4

4. LAB TEST

Blood Count Serum Electrolyte Serum Creatinine Serum PSA Urine : Proteinuria Sediment Culture

5. UROFLOWMETRY

Uroflowmetry

Qmax Voided volume

Residual urine TAUS Catheter

DIAGNOSTIC FOR BPH

Uroflowmetry :

UROFLOWMETRY

5. IMAGING
TRUS ( Transrectal ultrasound ) Transabdominal Ultrasound With Indication : IVP Cystography CT-Scan MRI

Trans Rectal Ultra Sonography :

Volumometry Identification of hypoechoic lesions Calcification Periprostatic vein

Differential diagnosis
l l l

l
l

Urethral stricture Bladder neck contracture Small bladder stone Locally advanced prostate ca Poor bladder contractility

Differential Diagnosis
Bladder Detrusor overactivity Impaired detrusor contractility Sensory urgency Sphincteric incontinence Polyuria/nocturnal polyuria Medications Antihistamines Antidepressants

EFFECTS OF BENIGN PROSTATIC OBSTRUCTION

Irreversible bladder changes Thickening of the bladder wall Recurrent haematuria Bladder diverticulum formation Repeat urinary tract infections Bladder stone formation Upper tract dilatation Renal impairment

COMPLICATIONS

Increased risk of UTI due to urinary retention Calculi due to alkalinization of residual urine Hematuria due to overstretched blood vessels Pyelonephritis Renal failure

INDICATION FOR TREATMENT

Absolute or near absolute : - refractory or repeated urinary retention - azotemia due to BPH - recurrent gross hematuria - recurrent or residual infection due to BPH - bladder calculi - large residual urine - overflow incontinence - large bladder diverticula due to BPH

TREATMENT

Watchful waiting
Medical therapies Intervention therapies
Minimally

invasive therapies Surgical therapies

WATCHFUL WAITING
Component: Education ( about the patients condition ) Reassurance ( cancer is not a cause ) Periodic monitoring Lifestyle advice ( alcohol, caffein etc ) Evaluation/ monitoring : after 6 months/ 1 year IPSS, uroflowmetry, post-void residual urine volume

MEDICAL THERAPY
I.P.S.S. > 7 Flow > 5 ml/s Residual urine < 100 ml No hard nodule PSA < 4 ng/dl

MEDICAL THERAPY

Reducing smooth muscle tone (dynamic component) : -1 adrenergic blocker

Short acting : prazosin, afluzosin Long acting : doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):

5 redutase inhibitor (finasteride, epristeride) estrogen aromatase inhibitor LHRH agonist / antagonist GF inhibitor antiandrogens

Unknown
phytotherapy

ADRENERGIC STIMULI

Alpha adrenergic stimuli increases tonus of smooth muscle cell in the trigonum, bladder neck and prostate Location of alpha receptor:

Bladder Trigonum Prostate gland

MODE OF ACTION ALPHA BLOCKING AGENT

Alpha adrenergic blocking agent blocks adrenergic stimuli relaxation of the smooth muscle cell:
urethral pressure Improvement of urine flow
intra

RECOMMENDATIONS
-blockers should be offered to men with moderate to severe LUTS 5-reductase inhibitors should be offered to men who have moderate to severe LUTS and an enlarged prostate. 5-reductase inhibitors can prevent disease progression with regard to acute urinary retention and need for surgery The Guidelines committee is unable to make specific recommendations about phytotherapy of male LUTS because of the heterogeneity of the products and the methodological problems associated with meta analyses
EAU guideline 2010

INVASIVE TREATMENT FOR BPH

Absolute indication: Chronic Retention With Hematuria Concomitant Bladder stone Intractable UTI Deteriorating kidney function Relative indication: Huge PVR due to obstruction or low Qmax Refuse medical treatment Failure in medical treatment

INTERVENTION THERAPY

Minimally invasive therapy

Thermotherapy
TUNA (Trans Urethral Needle Ablation) HIFU (High Intensity Focused Ultrasound) TUMT (Trans Urethral Microwave Theraphy) Laser

Stent
TUIP (Trans Urethral Incision of the Prostate) TURP (Trans Urethral Resection of Prostate) GOLD STANDARD Open prostatectomy TUVP (Transurethral Vaporization of the Prostat) Laser

Surgical therapy

TURP

JARINGAN PROSTAT

TUIP