a departmental presentation

1. PRINCIPLES OF MANAGEMENT
OF BENIGN PROSTATIC
HYPERPLASIA
BY DR E.S ENAMINE
27/4/2011

2. OUTLINE
INTRODUCTION
ANATOMY
EPIDEMIOLOGY/NATURAL HISTORY
PATHOPHYSIOLOGY
CLINICAL FEATURE
DIAGNOSIS
INVESTIGATION
TREATMENT
COMPLICATIONS

3. • BPH is the proliferation of the epithelial and
stromal element of the prostate evidenced by
enlargement of the gland as detected by DRE/
TRUS.
• Subdivided into 3;
 Histological BPH
 Macroscopic BPH
 Clinical BPH.

4. RELEVANT ANATOMY
• Divided into 4 glandular zones and 1 non-
glandular zone:
• Peripheral zone (PZ).
-70% of CAP originate here.
-largest anatomical subdivision.
-contains 70-75% of normal prostatic glandular
tissue
-no contribution to BPH.

5. • Central zone (CZ); 25% of normal glandular tissue
-10% of CAP originate here.
• Transition zone (TZ); 5% of normal glandular
tissue.
-lies adjacent to prostatic urethra.
-site of BPH.
-expands to compress the outer PZ to form the
false capsule.
• Preprostatic zone; 1% of normal gland.
-smallest and most complex.
-sphincteric function prevents reflux ejaculation.

7. EPIDEMIOLOGY.
• One of the most common disease of the
elderly male.
• Prevalence is age dependent.
-initial devt usu after 40yrs.
-By 60, prev is >50%
-By 85, it is as high as 90%.

8. NATURAL HISTORY
• Symptoms worsen in 55% of patients.
• Remain stable in 30%, improve in 15%.
• Prostate size incr. at a rate of 0.6ml/yr.
 Factors associated with increased risk of
progression include:
Age, symptom severity, prostate vol.,PSA.
Change in size and force of stream,sensation of
incomplete voiding, enlarged prostate on DRE.

9. PATHOPHYSIOLOGY
• The devt of the histological BPH, requires age and
androgens.
• Dihydrotestosterone (DHT) is the specific angdrogen
mediating prostate growth.
• Testosterone is converted to DHT by 5-alpha reductase
enz.
• Others GF involved are IGF, EGF etc.
• Obstruction to urine flow is due to static component
from the bulk of glandular and fibromuscular tissue.
• Dynamic component is due to contraction of smooth
muscle mediated by alpha 1a adrenoceptors.

10. CLINICAL FEATURES
• IRRITATIVE SYMPTOMS:
-frequency, urgency, nocturia.
• OBSTRUCTIVE:
-poor stream, incomplete bladder emptying.
-straining on micturition.
-intermittency, hesitancy.
-urine retention (acute/chronic)

11. • Others:
-haematuria.
-recurrent UTI
- AKI and CKD.

12. GUIDELINES FOR DIAGNOSIS
• 3 questions:
 Do you wake up at night?
Do you have problem of urine flow?
Is your bladder bothersome?
• If ‘yes’ , IPSS score should be done.
• General exam
• UGS
• DRE

13. INVESTIGATIONS
• Urinalysis/MCS.
• FBC+ESR, E&U/Cr
• PSA: age specific. However if abnormal, then
-PSA velocity- a rise >0.75ng/ml/yr suggests CAP.
-PSA density- (PSA/prostatic vol.) results
>0.15ng/ml suggests CAP.
PSAD is aimed at differentiating rise in PSA due to
BPH from CAP.

14. CAP is usually a 10-fold rise in PSAD.
-Free and Total PSA- the proportion of free to
total PSA maybe evaluated as % free PSA.
- Total PSA= free PSA + bound PSA.
• for an elevated PSA >10ng/ml, the chances of
prostate cancer being present may be further
evaluated based on % free PSA and need for
biopsy.

15. PERCENT FREE PSA PROBABILITY OF CANCER
0 - 10 56%
10-15 28%
15-20 20%
20-25 16%
>25 8%

16. • Prostatic biopsy.
INDICATIONS:
Abnormal DRE
Elevated PSA >10ng/ml
Free PSA percent < 20.
• Urine flow rate, post void residual urine,
Pressure flow Urodynamics.
Indicated in patients with moderate to severe
symptoms IPSS 8-20 where decisions have to
be taken on modalities of treatment.

17. • URINE FLOW RATE.
-Peak Flow Rate (PFR) >15ml/s = normal.
10-15ml/s = equivocal
<10ml/s suggests BOO.
• POST VOID RESIDUAL VOLUME.
-measured by transabd USS.
value >200ml indicate need for surgery.

18. • Urethrocystoscopy. Indicated prior to surgery
to select the correct operative modalities.
• Imaging of upper tract:
- IVU
-Abdominal USS
• TRUS and TRUS-guided biopsy.
• Colour doppler imaging of the prostate.

19. TREATMENT
MODALTIES INCLUDE:
• Waitful watching
• Medical therapy
• Minimally invasive Rx
• Surgery.

20. • WATCHFUL WAITING:
• Offer to pts with IPSS < or =8 who are not
bothered by their symptoms.
• Involves regular assessment of IPSS, PSA, PFR,
PVR.
• Contraindications: AUR, chronic retention,
recurrent UTI, dilatation of upper tracts.

21. • MEDICAL THERAPY:
• Indicated for pts with IPSS <19 with bothersome
symptoms but no complication after exclusion of
CAP.
 Androgen suppression;
i. 5-alpha reductase inhibitors- finesteride,
episteride.
reduces prostate vol by 20%
reduces PSA value by 50%.
ii. Flutamide-an androgen receptor antagonist.
has no effect on IPSS, PFR and bothersome
symptoms

22. Alpha adrenergic blockers;
- e.g Tamsulosin.
Combination therapy.
-5 alpha reductase inhibitor+ alpha 1 blocker
shrinks the prostate by 25% in a year and 20%
improvement of symptoms.
Phytotherapy.
Various plant extract shave been used to treat
BPH empirically though without clinical and
safety value proven scientifically.

23. • They include:
 pygeum africannum (African plum)
 serenoa repens B (American dwarf palm)
 sabal serrulatum (Dwarf palm)
 urtica spp (stinging nettle)
 hypoxis roopers (South African grass)
 cucurbitapepo (pumpkin seed)

24. • MINIMALLY INVASIVE TREATMENT.
• indicated in pts with IPSS 8-19
• Pts unfit for major surgery-pulmonary
dxs, liver dxs, MI etc.
• CONTRAINDICATIONS:
• Recurrent episodes of haematuria
• Bladder stone due to BPH
• Upper tract dilatation
• Recurrent UTI
• Renal insufficiency.

25. • OPTIONS:
High intensity focused ultrasound (HIFU)
Transurethral vapourisation of prostate
Transurethral laser therapy (TULIP)
Intra-urethral stents
Transurethral needle ablation of prostate
(TUNA)
Transurethral balloon dilatation.

26. SURGERY
OPTIONS
OPEN PROSTATECTOMY
TRANSURETHRAL RESECTION OF PROSTATE
TRANSURETHRAL INCISION OF PROSTATE
INDICATIONS
IPSS 19-35
Moderate to severe Bothersome symptoms
which are not Relieved By medical Rx/minimally
invasive Rx

27. TUIP
• Suitable For small Prostate with tight Bladder
Neck and No middle lobe Enlargement
• Incision made using a Collins Knife Below the
ureteric orifice and carried thru to the Bladder
neck
• Post op PFR-18mls/sec
• Incidence of Retrograde Ejaculation is 10%
• 10% of Px will Relapse and will Require TURP

28. TURP
• Done using a Resectoscope
• Used to Remove the Obstructing tissue in all
but the most enormous tissue,thereby carving
a passage way from the bladder
• Hospital stay is short

29. • Little Risk of DVT/Pulmonary Embolism
• Performed by specialist Urologist
• 80% of Px improve after TURP with reduction
in IPSS, improve PFR from 8 -18 mls/sec in
85% of Px.
• Likelihood of re-operation for BPH in 5yrs is
3.4%

30. Indications for TURP
• Prostate <60g.
• LUTS not responding to change in
lifestyle/medical therapy
• Recurrent acute urinary retention.
• Renal impairment due to BOO
• Recurrent hematuria due to BPH
• Small bladder stones due to BPH.

31. Complications of TURP
• Hemorrhage; primary and secondary.
• Urinary incontinence; maybe due to pre
existing detrusor instability +/- sphincter
weakness. Stress incontinence maybe due to
sphincter damage

32. • Retrograde Ejaculation; usually during
ejaculation there is reflex closure of the
internal sphincter when semen enters the
prostatic urethra.
• Urethral stricture; common sites--- ext
urethral meatus, bladder neck and
penoscrotal jxn.
0ccurs 4-10 months post surgery.

33. Trans urethral Resection Syndrome
Arises from infusion of large vol of Hypotonic
irrigating sol during the Procedure e.g glycine
Manifest as confusion,seizures,visual
disturbance,bradycardia.
Central to this syndrome is dilutional
Hyponatremia.
Can be prevented thus;limit Resection time,

34. • Avoid aggressive resection near the the
capsule
• Use a continous irrigating cystoscope-this
provides low pressure irrigation

35. OPEN PROSTATECTOMY
• Two types
 Retropubic
 Transvesical
• Indications
Prostate gland 70-100g
Bladder diverticulum
Large Hard ca stone
Marked ankylosis of the Hip preventing
lithotomy position

36. • It is the most effective method of treating
BOO due to BPH
• PFR inceasesto>20mls/s,symptoms improve
markedly.
• Likelyhood of px requiring further surgery is
0.4%,compaared to TURP 3.4%
• Complication rate 31.7% compared to TURP
16.1%

37. COMPLICATIONS
• Haemorrhage-Follows inadequate haemostas
• Clot Retention,folows severe bleed and
inadequate nursing care
• UTI
• Epididymo-orchitis-Arise from retrograde spread
of infxn from prostatic fossa along the vas to the
Epididymis
• Erectile Dysfxn-carvenosal nerve controlling
erection may be destroyed during prostatectomy
• Damage to the ureters

38. • Retrograde ejaculation-bladder neck is
removed in prostatectomy
• Infertility
• Incontinence of urine-Due to mech effect of
the urethral catheter on the int sphincter of
the bladder neck
• DVT

39. REFERENCES
• Badoe E.A,Archampong E.Q et al. (Eds) the
prostate;3rd Edn. Ghana Publishing
Corporation;2000; 47,850-866.
• Bailey and love 25th Ed pg 1344-1353
• Surgical Oncology contemporary principle and
practice;Kirby .i.Baid,John .m. Daly
• Campbell walsh urology 9th Ed,WB
Saunders,sect viii,chap 46;pg223-226
• American Urology Association

40. • Oxford Hand Book of Urology 1st Ed

41. • THANK YOU FOR YOUR TIME