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1. Benign Prostatic
Hyperplasia

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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

3. BPH
Proposed 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

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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

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Benign Prostatic
Hyperplasia

6. BPH Pathophysiology
Normal BPH
Hypertrophied
detrusor muscle
Obstructed
urinary flow
PROSTATE
BLADDER
URETHRA
Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

7. 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

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Complications
 Urinary retention
 UTI
 Sepsis secondary to UTI
 Residual urine
 Calculi
 Renal failure
 Hematuria
 Hernias, hemorroids, bowel habit change

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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

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Clinical manifestations
 Irritative symptoms
urinary frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection

11. Benign Prostatic Hyperplasia
• Leading to “symptom bother” and
worsened QOL

12. Other Relevant History
 GU History (STD, trauma, surgery)
 Other disorders (eg. neurologic,
diabetes)
 Medications (anti-cholinergics)
 Functional Status

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Diagnostic Tests
 History & Examination
 Abdominal/GU exam
 Focused neuro exam
 Digital rectal exam (DRE)
 Validated symptom
questionnaire.
 Urinalysis
 Urine culture
 BUN, Cr
 Prostate specific
antigen (PSA)
 Transrectal
ultrasound – biopsy
 Uroflometry
 Postvoid residual

14. AUA Symptom Score Sheet
Not at all
Less
than 1
time
in 5
Less
than
half the
time
About half
the time
More
than
half
the
time
Almost
always
Your
score
Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your
bladder completely after you finish urinating?
0 1 2 3 4 5
Frequency
Over the past month, how often have you had to urinate again less than two hours after
you finished urinating?
0 1 2 3 4 5
Intermittency
Over the past month, how often have you found you stopped and started again several
times when you urinated?
0 1 2 3 4 5
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
None 1 time 2 times 3 times 4 times
5 times
or more
Your
score
Nocturia
Over the past month, many times did you most typically get up to urinate from the
time you went to bed until the time you got up in the morning?
0 1 2 3 4 5
Quality of life due to urinary symptoms
Delighted Pleased Mostly satisfied
Mixed – about equally
satisfied and dissatisfied
Mostly
dissatisfied
Unhappy Terrible
If you were to spend the rest of your life with your
urinary condition the way it is now, how would you
feel about that?
0 1 2 3 4 5 6
Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

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DRE

16. 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

17. 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

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PSA
 Elevated levels of PSA
 0 – 4 ng/ml

Prostatic pathology
 Correlates with tumor mass
 Some men with prostate cancer have
normal PSA levels

20. 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

21. BPH TREATMENT
INDICATIONS
Absolute vs Relative
 Severe obstruction
 Urinary retention
 Signs of upper tract
dilatation and renal
insufficiency
 Moderate symptoms
of prostatism
 Recurrent UTI’s
 Hematuria
 Quality of life issues

22. 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.

23. 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

24. Watchful Waiting and Behavioral
Modification
 “is the preferred management technique in
patients with mild symptoms and minimal bother”
 AUA score < 7,
 1/3 improve on own.

25. 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

26. 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

27. Benefits
Convenient
No loss of work
time
Minimal risk
Disadvantages
Expensive
Drug Interactions
Must be taken every day
Manages the problem
instead of fixing it
medication
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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

29. 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

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Medical Management
5 alpha reductase inhibitor ) finasteride: Proscar(
 Reduce size of prostate gland by up to 30 %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 immediatelyDon’t work immediately
 Small effect on symptom score and flow ratesSmall effect on symptom score and flow rates

31. 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.

32. 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

33. 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
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Patient wants to avoid surgery

Significant cost associated with dual
medications

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Medical Management
 Herbal therapy –
saw palmetto fruit –
use to improve
urinary symptoms
and urinary flow
 Problem with herbal
therapy – long term
effectiveness

35. surgical treatment

36. 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

37. 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

38. 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.

39. 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

40. TURP
“Gold Standard” of care for BPH

41. the “gold standard”- TURP
Benefits
Widely available
Effective
Long lasting
Disadvantages
Greater risk of side
effects and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery
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42. possible side effects of
Greater than 5% risk of:
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Irritative voiding symptoms
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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
TURP

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Preoperative Goals
 Restoration of urinary drainage
 Treatment of any urinary tract infection
 Understanding of procedure,
implications for sexual functioning and
urinary control

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Preoperative care
 Antibiotics
 Allow pt to discuss concerns about
surgery on sexual functioning
 Prostatic surgery may result in
retrograde ejaculation

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Postoperative Goals
 No complications
 Restoration of urinary control
 Complete bladder emptying
 Satisfying sexual expression

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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

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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

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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

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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

51. BPH TREATMENT
New Modalities
 Minimally invasive: (Prostatic
Stents,TUNA,TUMT, HIFU,Water-
induced Thermotherapy)
 Laser prostatectomy
(VLAP,ILC,CLAP,TULIP,HoLRP)
 Electrovaporization (TUVP,TVRP)

52. Destroy prostate tissue with heat
Tissue is 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
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53. heat therapies
Benefits
Office treatments
Local anesthesia
Minimally invasive
Reduced risk of
complications as
compared to
invasive surgical
“TURP”
Disadvantages
Some symptoms will
persist for up to 3
months
Cannot predict who will
respond
May require prolonged
catheterization
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54. possible side effects of
Urinary Tract Infection
Impotence
Incontinence
heat therapies
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55. 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