Benign prostate hyperplasia

Dr. Syah Mirsya Warli, SpUDiv. of Urology, Dept. Surgery

Medical Faculty, University of Sumatera Utara

2009

الرحمن الله الرحمن بسم الله بسمالرحيمالرحيم

Ref :

• Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd ed, 2001

• Smith’s General Urology (Tanagho & McAninch eds), Lange Medical Books, 17th ed, 2008

Definition

• Regional nodular growth of varying combinations of glandular and stromal proliferation that occurs in almost all men who 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.

• 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.**• 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 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

11%

29%

48%

77%87%

92%

0

20

40

60

80

100

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

Prevalence (%)Prevalence (%)

Anatomy

• N 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

Causes

- Many theories- The actual cause still not clear- Factors are known to be important:

1. Male sex2. Aging3. Testosterone4. 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.

Symptoms LUTS

• Weaker, smaller stream

• Hesitancy• Intermittent /

interrupted flow• Feeling of

incomplete emptying or retention

• Terminal dribbling

• Nocturia• Frequency• Urgency• dysuria• Symptoms may

worsen with alcohol and caffeine, cold remedies

How to Assess the Patient?

Diagnosis

• Anamnesis Cardinal symptoms:Weak StreamFrequencyNocturia

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 Kencing3.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 Kencing5.PANCARAN KENCING YANG LEMAH Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah6. MENGEDAN SAAT KENCING Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing7.KENCING DI MALAM HARI Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk Kencing

Gejala Tidak Pernah < 20 % < 50 % =50% > 50 % Hampir Selalu

0 1 2 3 4 5

0 1 2 3

0 1 2 3

2 3

4 5

4 5

0 1

0 1

4 5

4 5

1 2 3

2 3

BPH SYMPTOM SCORE (by :AUA)

4 5

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

0

.• IPSS (International Prostate

Scoring System ). 0 – 7 : Mild 8 - 19 : Moderate 20 – 35 : Severe

7 : Watchful & Waiting

7 : Medical treatment

Diagnosis

Physical examination:DRE

Prostate:1. Size2. Nodule3. Consistenc

y 4. Tendernes

s

DRE

Diagnosis

Uroflowmetry QmaxVoided volume

Residual urine

TAUSCatheter

Diagnostic for BPH

• Uroflowmetry :

Lab test

• Blood Count• Serum Electrolyte• Serum Creatinine• Serum PSA• Urine :

Proteinuria Sediment Culture

IMAGING

• TRUS• Transabdominal Ultrasound• With Indication :

IVP Cystography CT-Scan MRI

Trans Rectal Ultra Sonography :• Volumometry• Identification of hypoechoic lesions• Calcification• Periprostatic vein

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

Differential diagnosis

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

Altering modifiable factor such as:– Concomitant drug– Regulation of fluid intake especially in the evening– 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• 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) 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:– intra urethral pressure – Improvement of urine flow

Sintesis Protein

Reseptor Inti+

Transkripsi DNA

T DHT

5-α reductase

Hipotalamus

LHRHLHRH

ACTHACTH

DHT

Rationale of 5Alpha reductase inhibitor

Invasive Treatment for BPH

Absolute indication:• Chronic Retention• With Hematuria• Concomitant Bladder stone• Intractable UTI• Deteriorating kidney functionRelative 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• 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 standar)• Laser resection (Hol Yag Laser)

TURP

JARINGAN PROSTAT

TUIP

Ref :

• Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd ed, 2001

• Smith’s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15th ed, 2000

• The most common cancer in men• 2nd most common cause of cancer

related death after lung ca• The choice of th/ for localized

disease must be based on many factors :

- grade & stage - personal preference - age - performance status

• Prostate tumors are generally androgen sensitive and advanced disease is most often treated by single or combined androgen ablation

Etiology

• Risk factor : - age > 50 - family history - ethnic origin African American

>> - androgens - diet (>> animal fat) - environmental exposure - insulin-like growth factors

pathology

• Benign cystadenoma• Prostatic intraepithelial neoplasia (PIN) - high grade (2 & 3) 30 – 40% chance of developing prostat Ca need repeat

biopsies• Malignant - conventional adenocarcinoma - transitional cell carcinoma - sarcoma - metastatic tumour - hematologic malignancies

Conventional adenocarcinoma (small acinar carcinoma)

• Vast majority (95 – 97%) is adenoCa from acinar epith

• Majority lesion in peripheral zone, 20 – 25% from the transitional zone

• Classically discovered after TURP

Patterns of spread

• Direct extension into the seminal vesicles & extracapsularly through the periprostatic nerve routes

• Direct extension into the rectum is uncommon

• Ureteral obstruction 10 – 35%

• Lymphatic spread is not uncommon

hypogastric, obturator, external iliac, presacral, common iliac

• 90% distant metastate osseous• Visceral meta (lung, liver, adrenal)

less common

Grading & Staging

• Gleason grade based on the degree of glandular diff and growth pattern

• Mostofi grade based on the degree of nuclear irregularity. The lesion are graded as well, moderately and poorly differentiated

• Staging systems The American Joint Committee on Cancer , modified TNM system

Signs & symptoms

• A prostatic nodule or induration of the gland hallmark sign

• Consist of : - symptom of bladder outflow obstruction - symptom resulting from local extension - symptom from distant metastase (bone pain, low back pain, weight loss)

diagnosis

• Digital rectal examination (DRE) any palpable irregularity 50% chance

• TRUS very sensitive but non specific• Serum marker PSA• Prostate needle biopsy• Bone scan• CT & MRI

DRE findings that may indicate cancer :

• Asymmetry of the gland• A nodule within one lobe of the gland• Induration of part or all of the prostate• Lack of mobility due to adhesion to

surrounding tissue• Palpable seminal vesicles

Treatment for localized disease

• Radical or complete prostatectomy• Radiation th/ : - external beam radiation th/ - interstitial brachyth/

• Follow up after treatment for localized disease - serum PSA single most important

parameter

Treatment for advanced disease

• Prostate Ca is an androgen-sensitive tumor• Methods of androgen ablation : bilateral simple orchiectomy diethylstilbesterol DHT receptor blockade (flutamide,

bicalutamide LHRH agonist (leuprolide) aminoglutethimide ketoconazole

• Castration - easily accomplished, relatively

inexpensive, well-tolerated, almost free of complication - side effects : vasomotor instability, loss of libido, ED

• LHRH agonist - long term effects of bone mineralization - as effective as castration with similar side effects, administered subcutaneously

• Antiandrogens - act by blocking DHT receptor - not as effective as castration or LHRH th/ - do not lower the serum testosterone

level do not cause impotence or decreased

libido - side effects : diarrhea & liver function

abN

wr09