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
BPH
Proposed 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 Pathophysiology
Normal BPH
Hypertrophied
detrusor muscle
Obstructed
urinary flow
PROSTATE
BLADDER
URETHRA
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 frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms 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
International prostate symptom score (IPSS)


Name: Date:


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

Frequency
Over 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

Intermittency
Over the past month, how often have you found you stopped and started again several
times when you urinated?
0 1 2 3 4 5

Urgency
Over the last month, how difficult have you found it to postpone urination?
0 1 2 3 4 5

Weak stream
Over the past month, how often have you had a weak urinary stream?
0 1 2 3 4 5

Straining
Over 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











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

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
BPH
Danger 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 SYMPTOMS
Differential 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
INDICATIONS
Absolute vs Relative

Severe obstruction
Urinary retention
Signs of upper tract
dilatation and renal
insufficiency

Moderate symptoms
of prostatism
Recurrent UTIs
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
Benefits
Convenient
No loss of work
time
Minimal risk

Disadvantages
Expensive
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 Management
5 alpha reductase inhibitor )finasteride :Proscar(
Reduce size of prostate gland 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
Dont work immediately
Small 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 ccs. Original studies
showed benefit only in men with prostate sizes
greater than 50 ccs.
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 TREATMENT
Surgical

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 ejaculation
TUR syndrome (acute hyponatremia from free
water absorption)
Hemorrhage
Bladder 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 TREATMENT
New 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 therapies
Benefits
Office treatments
Local anesthesia
Minimally invasive
Reduced risk of
complications as
compared to
invasive surgical
TURP
Disadvantages
Some symptoms will
persist for up to 3
months
Cannot predict who will
respond
May 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