BPH

Benign Prostatic Hyperplasia

Doddy M. Soebadi
LAB./SMF UROLOGI
F.K.UNAIR RSUD DR.SOETOMO

BPH - DMS 2005

Referensi:
Smiths General Urology
BPH: Sunaryo Hardjowijoto, AUP, 1999
Campbells Urology
BPH - DMS 2005

Anatomi prostat:
Kel.prostat: kel.seks asesorius pria
Normal sebesar buah kenari dikelilingi
kapsul fibrous dan mengelilingi uretra
Pada waktu ejakulasi memproduksi cairan prostat
yang bersama dengan produk dari testis,
ves.seminalis & kel.bulbo-uretral membentuk semen
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Anatomy
Anatomy of the
the prostate
prostate gland
gland
Prostatic
urethra

Prostate

Ejaculatory duct
openings

External urethral
sphincter

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Normal bladder and prostate

BPH is the most common
neoplasm in man
Pathological changes of this
disorder can be found in 50%
of men in their 5th decade and
in 90% of men in their ninth
decade
The aetiology of BPH is
multifactorial but there are
two essential prerequisites:
the presence of testes and
ageing

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Benign prostatic enlargement

The median lobe projects
into the base of the
bladder
The prostatic urethra
narrows
The bladder shows
trabeculation and
thickening of the wall

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Effects of Benign prostatic obstruction

Thickening of the bladder
wall
Recurrent haematuria
Bladder diverticulum
formation
Urinary tract infections
Bladder stone formation
Upper tract dilation
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BPH

Diketahui sejak 1500 S.M.

1000 tahun kemudian didiskusikan oleh
Hippocrates
Insidensi: 50% (klinis) pria 60-69 tahun, k.l.
100% pada umur 80 tahun (mikroskopik
sejak umur 35 tahun)

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Age-specific prevalence of BPH

A g e (y ear s)

20

40

70-7 9

60

57

60-6 9
27

40-4 9

9
0

100

80

100

80

42

50-5 9

80

69
51

27
20

40

60

Prevalence (%)
Cinical prevalence in the Baltimore Longitudinal Study of Ageing (based on history and
Physical examination, n = 1,057)

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Clinical prevalence in the Baltimore Longitudinal

BPH 2000 - DMS
Study of Ageing (based on rectal
examination, n= 1,057)

Patofisiologi BPH

Patogenesis
Simptomagenesis
Hiperplasia
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Patogenesis BPH
Syarat terjadinya BPH :
* Testis yg memproduksi
androgen
* Ketuaan ( ? )
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Theories for the cause of BPH

Theory

Cause

Effect

Dihydrotestosteron
hypothesis

5- reductase and
androgen receptors

Epithelial and stromal

hyperplasia

Oestrogen-testosteron
imbalance

Oestrogens
Testosteron

Stromal hyperplasia

Stromal-epithelial
interactions

Epidermal growth
Epithelial and stromal
factor/fibroblast
hyperplasia
growth factor
Transforming growth
factor

Reduced cell death

Oestrogens

Longevity of stroma
and epithelium

Stem cell theory

Stem cells

Proliferation of transit
cells

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Simptomagenesis
Prostatisme
Sindroma Prostatisme
LUTS
(lower urinary tract
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symptoms)

15

Fungsi unit Vesiko Urethral

1. Penyimpanan

(STORAGE)

2. Mengeluarkan urin periodik

(VOIDING)

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Fungsi Normal Unit V.U. tergantu

1. Morfologi Detrusor
2. Innervasi
3. Transmiter
* Acetylcholin
* ATP
4. Compliance buli-buli
5. Kontraksi yang dipertahankan
6. Tahanan sal.keluar buli-buli
* Elemen dinamik: saraf simpatik dg
reseptor alpha
* Elemen statik / mekanik
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BPH
LUTS keluhan obstruktif:
1.
2.
3.
4.
5.
6.
7.

Hesitansi
Pancaran lemah
Mengejan
Kencing lama
Terasa tak habis
Retensi urin
Overflow Incontinence (ischuria p
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BPH
LUTS keluhan iritatif

-1.Urgensi Urge incontinenc

-2.Frekuensi (pollakisuria)
-3.Nokturia
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International Prostate Symptom Score (I-PSS)

I-PSS

(International Prostate Symptom Score)

Dalam 1 bulan terakhir:

1. Terasa sisa kencing
0
1
2
3
4
2. Sering kencing
0
1
2
3
4
3. Terputus-putus
0
1
2
3
4
4. Tidak bisa menunda
0
1
2
3
4
5. Pancaran lemah
0
1
2
3
4
6. Mengejan
0
1
2
3
4
7. Kencing malam
0
1
2
3
4
Total
.
Total IPSS score: 0-7: ringan, 8-18 : sedang, 19-35 : berat

BPH
- DMS1999
2005
Doddy M.Soebadi,

5
5
5
5
5
5
5

20

Uroflowmetry
Unobstructed

Detrusor underactivity

Obstructed

Urethral stricture

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Provokator Retensi Urine Akuta

1. Minum alkohol

Stimulan simpatetik

Tonus Prostat &

otot polos bladder outlet
2.
3.
4.
5.

Bepergian jauh
Masukan cairan banyak
Konstipasi
Agen anti cholinergik
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DRE (digital rectal examination) = RT = CD

Size
Consistency:
smooth or elastic
/hard /nodule /tender
Mobility
Anatomical limits:
lateral /cranial /medial
sulcus
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PSA interpretation
PSA value

Interpretation

0.5 - 4 ng/ml
4 - 10 ng/ml
> 10 ng/ml

Normal
20% chance of Ca
50% chance of Ca

rise of > 20%/year

Refer for biopsy

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Uroflowmetry
Max.flow rate (ml/sec)

Interpretation

> 15 ml/sec

Normal

10 - 15 ml/sec

Mild obstructed

< 10 ml/sec

Obstructed

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TRUS (Transrectal ultrasound)

Accurate measurement of the prostate
Hypoechoic focus
Prostatic biopsy (if indicated)

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Diagnosa BPH
Anamnesa:
I-PSS

Pem.fisik:
buli-buli
CD / RT

Pem.tambahan:
lab: UL,DL,RFT,PSA
pencitraan: USG/BOF/TRUS/IVP
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Terapi BPH
I-PSS

Konservatif: observasi (watchful waiting)

Medikamentosa (Tx medik)
8 - 18
Pembedahan:
19 - 35

0- 7

terbuka
endoskopik: TURP, TUIP

Invasif minimal:
balloon dilatation
stent
microwave (thermotherapy)
radiofrequency
laser ablation

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Kontra-indikasi Tx medik BPH

Retensi urin (akut atau kronik)

Insufisiensi renal
Dilatasi traktus atas
Hematuria berulang
ISK berulang
Batu buli-buli / divertikel
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Terapi medik BPH

Alpha blocker
terazosin
prazosin
tamsulosin, dll

Supresi Androgen
5 alfa-reduktase inhibitor

Fitoterapi
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Morfometri BPH
Rasio of epithelium terhadap stroma:
epith : stroma = 21.6 - 50 % : 60 - 78 %
BPH simtomatik: proporsi stroma lebih
tinggi
Respons terhadap Tx:
predominan otot polos
predominan epithel
predominan fibrosis

: alpha blocker
: supresi androgen
: bedah

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Rasional penggunaan alpha blocker

Kontraksi otot polos prostat dimediasi oleh : stimulasi

simpatis reseptor alpha
Kontraksi otot polos (kapsul, adenoma, leher buli) :
merupakan 40% dari penyebab obstruksi saluran
keluar
Alpha blocker :
relaksasi otot polos prostat
mengurangi simtom
memperbaiki pancaran kencing

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Distribusi reseptor alpha

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Agen fitoterapi untuk BPH

Pygeum africanum (African plum)

Urtica spp. (stinging nettle)
Sabal serrulatum (Dwarf palm)
Serenoa repens B (American dwarf palm)
Cucurbita pepo (Pumpkin seed)
Populus tremula (Aspen)
Echinaceapurpurea (Purple coneflower)
Secale cerelea (Rye)
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Intervensi urologis di Surabaya

Balloon dilatation
Prostatic stent
Thermotherapy
TUIP (transurethral incision of the prostate)
TURP (transurethral resection of the p.)
Laser TURP
Open prostatectomy
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Efikasi vs. risiko terapi BPH

efikasi

OPEN
OPEN
PROSTATECTOMY
PROSTATECTOMY
TURP
TURP
TUNA
TUNA
THERMOTHERAPY
THERMOTHERAPY

5-ALPHA
5-ALPHA
REDUCTASE
REDUCTASE
INHIBITORS
INHIBITORS

ALPHA
ALPHABLOCKERS
BLOCKERS

PHYTOTHERAPY
PHYTOTHERAPY

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risiko

PROSTATIC
PROSTATICSTENT
STENT

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THERMOTHERAPY
THERMOTHERAPY

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