Benign Prostatic Hyperplasia

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
 Terminology

BPH BPE BPO

Histologic Enlargement due Urodynamically
diagnosis to benign growth proven BOO
(can be without (static/dynamic
obstruction) components)

BPH = benign prostatic hyperplasia; BPE = benign prostatic enlargement; BPO =

benign
1.2prostatic obstruction; BOO = bladder outlet obstruction
A Modern View of BPH
Clinical, Anatomic, and Pathophysiologic Changes
 BPH = Benign Prostatic
Hyperplasia All Men
>50 y
 Histologic: stromoglandular
hyperplasia1
 May be associated with Histologic
BPH
 Clinical: presence of BPE
bothersome LUTS2 Enlargement

 Anatomic: enlargement of
the gland (BPE = Benign
Prostatic Enlargement)2
 Pathophysiologic:
compression of urethra and `
BOO LUTS/
compromise of urinary flow Obstruction

(BOO = Bladder Bother

Outlet Obstruction)2

1. American Urological Association Research and Education Inc. BPH Guidelines 2003.
2. Nordling J et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd;
2001:107166.
 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
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
Benign Prostatic Hyperplasia
 BPH Pathophysiology
Normal BPH

BLADDER

Hypertrophied
detrusor muscle
PROSTATE

URETHRA Obstructed
urinary flow

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 hypertrophydetrussor decompensation
poor tonediverticula formationincreasing urine
volumehydronephrosisupper tract dysfunction
Complications
 Urinary retention
 UTI
 Sepsis secondary to UTI
 Residual urine
 Calculi
 Renal failure
 Hematuria
 Hernias, hemorroids, bowel habit change
 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
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
 Symptoms attributable to lower urinary
tract dysfunction
 storage (irritative) symptoms
 emptying (obstructive) symptoms
 may be associated with BPH, BPE, and BPO, but
not exclusive to these
Other Relevant History
 GU History (STD, trauma, surgery)
 Other disorders (eg. neurologic,
diabetes)
 Medications (anti-cholinergics)
 Functional Status
 Diagnostic Tests
 History & Examination  Prostate specific
Abdominal/GU exam

antigen (PSA)
 Focused neuro exam
 Digital rectal exam (DRE)  Transrectal
 Validated symptom
ultrasound – biopsy
questionnaire.  Uroflometry
 Urinalysis  Postvoid residual
 Urine culture
 BUN, Cr
 AUA Symptom Score Sheet
More
Less Less
About than
than 1 than Almost Your
Not at all half the half
time half the always score
time the
in 5 time
time

Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your 0 1 2 3 4 5
bladder completely after you finish urinating?

Frequency
Over the past month, how often have you had to urinate again less than two hours 0 1 2 3 4 5
after you finished urinating?

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

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

5 times Your
None 1 time 2 times 3 times 4 times
or more score

Nocturia
Over the past month, many times did you most typically get up to urinate from the 0 1 2 3 4 5
time you went to bed until the time you got up in the morning?

Quality of life due to urinary symptoms Mixed – about equally Mostly

Delighted Pleased Mostly satisfied Unhappy Terrible
satisfied and dissatisfied dissatisfied

If you were to spend the rest of your life with your

urinary condition the way it is now, how would you 0 1 2 3 4 5 6
feel about that?

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.
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
PSA
 Elevated levels of PSA
 0 – 4 ng/ml
 Prostatic pathology
 Correlates with tumor mass
 Some men with prostate cancer have
normal PSA levels
PSA… It’s not just for cancer
 Serine protease produced by epithelial
cells
 Dissolves semen coagulum
 Most bound to antiproteases ACT
 Increased with-
 Malignancy
 Hyperplasia
 Infection/Inflammation
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
 Initial Evaluation
 Detailed medical history
 Physical exam
 including DRE and neurologic exam
 Urinalysis
 Serum creatinine no longer mandatory
 PSA*
 Symptom assessment (AUA-SS)

PSA = prostate-specific antigen

*Per physician’s clinical judgment
AUA BPH Guidelines 2003
 Evaluation (Part 1)
Initial evaluation
• History
• DRE & focused exam
• Urinalysis
• PSA1

Objective Symptom Assessment

Mild Moderate to severe

IPSS7 IPSS8

Offer treatment
alternatives

Watchful Medical Minimally invasive

Surgery
waiting therapy therapies

Cystoscopy, if important in
planning operative approach
1Optional
in AHCPR Guidelines;
Recommended by International Consensus Committee Clinical Practice Guideline, Number 8.
AHCPR Publication No. 94-0582.
 Evaluation (Part 2)
Initial evaluation
• History
• DRE & focused exam
• Urinalysis
• PSA1

Objective Symptom Assessment

Moderate to severe Presence of:

IPSS8 • Refractory retention
Any of the following
Additional clearly 2° BPH:
diagnostic tests • Recurrent or persistent
gross hematuria
•Flow rate test1 • Bladder stones
•Residual urine1 • Renal insufficiency
•Pressure-flow2

Compatible Not compatible

with obstruction with obstruction Surgery
Non-BPH problems
1Optional in AHCPR Guidelines;
identified and treated
Recommended by International Consensus Committee
2Optional in both AHCPR and International Consensus recommendations
 Goals of Therapy for BPH
BPH Treatment Success measured by:
 ↓ symptoms (IPSS/AUA)
 ↓ bother (bother score) and ↑ QOL
 ↓ prostate size or arrest further growth
 ↑Increase in peak flow rate / Relieve obstruction
 Prevention of long-term outcomes/complications

 Acceptable adverse events profile

US Agency for Health Care Policy and Research. AHCPR publication 94-0582; O’Leary MP. Urology. 2000;56(suppl 5A):7-11.
BPH TREATMENT INDICATIONS
Absolute vs Relative

 Severe obstruction  Moderate symptoms

 Urinary retention of prostatism
 Signs of upper tract  Recurrent UTI’s
dilatation and renal  Hematuria
insufficiency  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,

 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
medication
Benefits Disadvantages
 Convenient  Expensive
 No loss of work  Drug Interactions
time 
Must be taken every day
 Minimal risk 
Manages the problem
instead of fixing it
 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
 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
 Don’t 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 cc’s. Original studies

showed benefit only in men with prostate sizes
greater than 50 cc’s.
 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
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 Disadvantages
 Widely available  Greater risk of side
effects and complications
 Effective
 1-4 days hospital stay
 Long lasting
 1-3 days catheter
 4-6 week recovery
 possible side effects of
TURP
 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
Preoperative Goals
 Restoration of urinary drainage
 Treatment of any urinary tract infection
 Understanding of procedure,
implications for sexual functioning and
urinary control
Preoperative care
 Antibiotics
 Allow pt to discuss concerns about
surgery on sexual functioning
 Prostatic surgery may result in
retrograde ejaculation
Postoperative Goals
 No complications
 Restoration of urinary control
 Complete bladder emptying
 Satisfying sexual expression
 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
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
 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
 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

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BPH TREATMENT
New Modalities
 Minimally invasive: (Prostatic
Stents,TUNA,TUMT, HIFU,Water-
induced Thermotherapy)
 Laser prostatectomy
(VLAP,ILC,CLAP,TULIP,HoLRP)
 Electrovaporization (TUVP,TVRP)
heat therapies
 Destroy prostate tissue with heat
 Tissueis 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
Benefits Disadvantages
 Office treatments  Some symptoms will
 Local anesthesia persist for up to 3
months
 Minimally invasive
 Cannot predict who will
 Reduced risk of
respond
complications as
compared to
 May require prolonged
invasive surgical catheterization
“TURP”
possible side effects of
heat therapies
 Urinary Tract Infection

 Impotence

 Incontinence
 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