Benign prostate hyperplasia

Div. of Urology, Dept. Surgery

Medical Faculty,

University of Sumatera Utara

Ref :

• Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd

ed, 2001ed, 2001

• Smith’s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15th

ed, 2000

Definition

• Regional nodular growth of varying combinations of glandular and stromal proliferation that occurs in almost all menproliferation that occurs in almost all menwho have testes and who live long enough

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

• Common non-neoplastic lesion.

• Involves peri urethral zone.

• BPH is common as men age.• BPH is common as men age.

• 25% by 50y, but 90% By 80y..!

• About 10% are symptomatic.

Prevalence

The Most Frequent Benign Tumor in Men

• 70 % of men above 60 years.*

• 90 % of men above 80 years.**• 90 % of men above 80 years.**

• 30 – 40 % of men above 70 years

• Indonesia : The Second after Stone Disease in

Urology Clinic ***

* Berry SJ et all J Urol 1984 ;132:474-79

** Carter HB , Coffey DS. Prostate 1990;16 : 39-48

*** Rahardjo D,Birowo P,Pakasi LSMed . J of Ind 1999 ; 8(4) : 260 - 63

Impact of ageing population

• With life expectancy approaching 80 years in many countries � 88% chance developing histological BPH

• � in life expectancy � significantly � the • � in life expectancy � significantly � the number of men affected by BPH

• The number of men presenting with BPH symptoms will � ± 45% in the next 10 years and � further in the following decade

Prevalence of histological BPH with age

48%

77%

87%92%

60

80

100

Prevalence (%)Prevalence (%)

11%

29%

48%

0

20

40

60

31–40 41–50 51–60 61–70 71–80 80+

Berry SJ et al. J Urol 1984; 132: 474–9Berry SJ et al. J Urol 1984; 132: 474–9

Anatomy

• N weight about 20 g

• Classification of Lowsley : 5 lobes : anterior, posterior, median, right lateral, left lateral

• According to Mc Neal : • According to Mc Neal :

- peripheral zone

- central zone

- transitional zone

- an anterior segment

- a preprostatic sphincter zone

Causes

- Many theories

- The actual cause still not clear

- Factors are known to be important:

1. Male sex

2. Aging

3. Testosterone

4. Growth Factors (EGF, FGF, IGF II)

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*

Prostate growth

Increased urethral resistance

Decompensation

Flow ↓

Bladder emptying ↓,

hesitancy, intermittency

Mechanism

• Hormonal imbalance with ageing.

• Estrogen sensitive peri-urethral glands.

• Accumulation of DHT in the prostate and its

growth-promoting androgenic effect

• Some Drugs (Finasteride) inhibit DHT �

diminishes prostatic enlargement.

Morphology

• Microscopically, nodular prostatic hyperplasia

consists of nodules of glands and intervening

stroma. (Mostly glands)stroma. (Mostly glands)

• The glands variably sized, with larger glands

have more prominent papillary infoldings.

• Nodular hyperplasia is NOT a precursor to

carcinoma.

Symptoms LUTS

• Weaker, smaller

stream

• Hesitancy

• Intermittent /

• Nocturia

• Frequency

• Urgency

• dysuria• Intermittent /

interrupted flow

• Feeling of incomplete

emptying or retention

• Terminal dribbling

• dysuria

• Symptoms may

worsen with alcohol

and caffeine, cold

remedies

How to Assess the Patient?

Diagnosis

• Anamnesis

Cardinal symptoms:

Weak StreamWeak Stream

Frequency

Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

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

5

Gejala Tidak Pernah < 20 % < 50 %

2 3

=50% > 50 % Hampir Selalu

0 1 2 3 4

4 5

0 1 2 3 4 5

0 1

BPH SYMPTOM SCORE / IPSS

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

0 1 2 3 4 5

5

4 5

0 1

0 1 2 3

1 2 3

2 3 4

4 5

Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4 5kali, =5

0

IPSS (International Prostate

Symptom Score ).

0 – 7 : Mild

8 - 19 : Moderate8 - 19 : Moderate

20 – 35 : Severe

≤ 7 : Watchful & Waiting

≥ 7 : Medical treatment

Diagnosis

Physical

examination :

Prostate :

1. Size

DRE 2. Nodule

3. Consistency

4. Tenderness

DRE

Diagnosis

Uroflowmetry Qmax

Voided volumeVoided volume

Residual urine TAUS

Catheter

Uroflowmetry

Lab test

• Blood Count

• Serum Electrolyte

• Serum Creatinine• Serum Creatinine

• Serum PSA

• Urine :

Proteinuria

Sediment

Culture

IMAGING

• TRUS

• Transabdominal Ultrasound

• With Indication :• With Indication :

IVP

Cystography

CT-Scan

MRI

Trans Rectal Ultra Sonography :

• Volumometry

• Identification of hypoechoic lesions

• Calcification

• Periprostatic vein

� Urethral stricture

� Bladder neck contracture

Differential diagnosis

� Bladder neck contracture

� Small bladder stone

� Locally advanced prostate ca

� Poor bladder contractility

Effects of benign prostatic obstruction

• Irreversible bladder changes

• Thickening of the bladder wall

• Recurrent haematuria

• Bladder diverticulum formation

• Repeat urinary tract infections• 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 • 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 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• Medical therapies

• Intervention therapies• Minimally invasive therapies

• Surgical therapies

Watchful waiting

Altering modifiable factor such as:

– Concomitant drug

– Regulation of fluid intake especially in the evening

– Life style change (avoid sedentary life)– Life style change (avoid sedentary life)

– Dietary advice (avoid excessive intake of alcohol, and

highly seasoned or irritative foods)

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• Flow > 5 ml/s

• Residual urine < 100 ml

• No hard nodule

• PSA < 4 ng/dl

Medical therapy

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

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

• Reducing prostatic mass (static component):5α redutase inhibitor (finasteride, epristeride)5α 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 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 adrenergic stimuli � relaxation of the smooth muscle cell:

– intra urethral pressure ↓

– Improvement of urine flow

Sintesis Protein

Transkripsi DNA

Hipotalamus

LHRHLHRH

ACTHACTH

Rationale of 5Alpha reductase inhibitor

Reseptor Inti

+

Transkripsi DNA

T DHT

5-α reductase

DHT

Invasive Treatment for BPH

Absolute indication:

• Chronic Retention

• With Hematuria

• Concomitant Bladder stone• 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)• HIFU (High Intensity Focused Ultrasound)• TUMT (Trans Urethral Microwave Theraphy)• Laser

– Stent

• Surgical therapy• TUIP (Trans Urethral Incision of the Prostate)• TURP (Trans Urethral Resection of Prostate)• Open prostatectomy• TUVP (Transurethral Vaporization of the Prostat)• Laser

Invasive Treatment for BPH

• TURP (gold standard)

• Laser resection (Hol YAG Laser)

TURP

JARINGAN PROSTAT

TUIP