BPH - Introduction

1. BENIGN PROSTATIC
ENLARGEMENT (BEP)
Dr. Hemanta Pun
MCh Urology Resident
Ist year

2. LEARNING OBJECTIVE
• Epidemiology and Pathophysiology
• Differential Diagnosis
• Workup

3. DEFINITIONS
• BPH: “Benign Prostatic Hyperplasia”
- term used (and reserved) for the typical histological pattern, which defines the disease.
• ..LUTS now constitute the main focus, rather than the former emphasis on Benign Prostatic Hyperplasia
(BPH). The term BPH is now regarded as inappropriate as it is Benign Prostatic Obstruction (BPO).
• Bladder outlet obstruction (BOO) : generic term for obstruction during voiding and is characterized by
increasing detrusor pressure and reduced urine flow rate
• Benign prostatic obstruction (BPO) : form of BOO and may be diagnosed when the cause of outlet
obstruction is known to be BPE.

4. • ..Detrusor overactivity (DO) : urodynamic observation characterised by involuntary detrusor
contractions during the filling phase which may be spontaneous or provoked.
• Detrusor overactivity is usually associated with overactive bladder syndrome characterised by
urinary urgency, with or without urinary incontinence, usually with increased daytime
frequency and nocturia, if there is no proven infection or other obvious pathology.
• Detrusor underactivity (DU) (during voiding): characterised by decreased detrusor voiding
pressure leading to a reduced urine flow rate.
• Detrusor underactivity causes underactive bladder syndrome which is characterised by
voiding symptoms similar to those caused by BPO.

5. EPIDEMIOLOGY
• Incidence age-related
• Autopsy studies, BPH prevalence:
• 20% men in their 40s
• 90% men over 80

6. PATHOPHYSIOLOGY
• ..Two ingredients for BPH
• Androgens (dihydrotestosterone): castration shrinks established BPH,
improves symptoms
• Aging (aging prostate more androgen-sensitive)
• ..Prostate: stromal + epithelial tissues
• BPH from either alone or in combination
• ..Stroma has abundant adrenergic innervation
• Increased tone  increased resistance to urine flow through prostatic urethra

7. DIAGNOSTIC EVALUATION
1. CLINICAL ASSESSMENT:
2 main objectives:
• to identify the differential diagnoses, since the origin of male LUTS is
multifactorial
• to define the clinical profile (including the risk of disease progression) of men
with LUTS in order to provide appropriate care.
2. INVESTIGATIONS:
• Tests are useful for diagnosis, monitoring, assessing the risk of disease
progression, treatment planning, and the prediction of treatment outcomes.

8. PATIENT HISTORY
• Aims to identify the potential causes and relevant comorbidities, including
medical and neurological diseases. In addition, current medication, lifestyle
habits, emotional and psychological factors must be reviewed.
• ..Symptoms: Obstructive & Irritative
1. Obstructive
• Increased resistance to flow
• Neck of bladder, prostatic urethra
• Static and dynamic components
2. Irritative
• From bladder’s response to flow resistance
• Hypertrophy + collagen deposition
• Detrusor instability, less passive compliance

9. SYMPTOMS IN BPH – “LUTS”
Obstructive (Voiding) symptoms Irritative (Storage) symptoms
Intermittency Frequency
Poor flow of urine Urgency
Straining Nocturia
Sense of Incomplete voiding
Hesitancy
Post void dribbling

10. Frequency volume charts and bladder diaries :
• Frequency volume chart (FVC) : Recording of volume and time of each void by the patient.
• Bladder diary : Inclusion of additional information such as fluid intake, use of pads, activities during
recording, or which grades of symptom severity and bladder sensation.
• Parameters that can be derived from the FVC and bladder diary include:
• day-time and night-time voiding frequency, total voided volume, the fraction of urine production during
the night (nocturnal polyuria index) and volume of individual voids.
• The FVC/bladder diary is particularly relevant in nocturia, where it underpins the categorization of
underlying mechanism(s). The use of FVCs may cause a ‘bladder training effect’ and influence the frequency
of nocturnal voids.
• The duration of the FVC/bladder diary needs to be long enough (>3 days)to avoid sampling errors, but short
enough to avoid non-compliance.
• The ICIQ-Bladder diary (ICIQ-BD) is the only diary that has undergone full validation.

12. COMPLICATIONS
• Hematuria
• UTI
• Urinary retention
• Acute retention of urine : defined as a painful, palpable or percussible
bladder, when the patient is unable to pass any urine
• Chronic retention of urine : is defined as a non-painful bladder, which
remains palpable or percussible after the patient has passed urine. Such
patients may be incontinent.
• Features of Renal failure (Uremia)

13. DIFFERENTIAL DIAGNOSIS
• Prostate cancer
• Bladder cancer
• Bladder stone
• UTI (also BPH complication)
• Urethral stricture (trauma, instrumentation, urethritis)
• Contracture of bladder neck (instrumentation)
• Neurogenic bladder (CVA, MS, trauma, DM)

15. PHYSICAL EXAMINATION
• Important step in the basic workup of every patient complaining of LUTS, and should not be neglected
• Focus on the suprapubic area, the external genitalia, the perineum and lower limbs should be performed.
1. Suprapubic examination: to R/O overdistended, palpable, or percussable bladder
2. Penis : to R/O Urethral discharge (s/o urethritis) , meatal stenosis, phimosis and penile cancer.
• ventral side of the penis should be palpated to search for palpable urethral masses (indirect sign of
strictures).
3. Scrotum and the testicles: look for signs of orchiepididymitis
4. Testicular size along with other secondary male sex characteristics (e.g., body hair, pattern of hair loss)
may be useful to detect a low testosterone level, which could be a/w central obesity and metabolic
alterations –s/o “Metabolic syndrome”.
• Indeed, the association between metabolic alterations and BPE has been widely demonstrated; as
such, LUTS patients with elevated BMI and signs suggestive for metabolic syndrome may benefit
from lifestyle changing involving dietary interventions (Gratzke et al., 2015)
5. Lower limb : motor/sensory functions of the perineum; to rule out neurologic alterations.

16. DRE (Digital Rectal Examination) and Prostate
volume size evaluation
• ..simplest way to assess prostate volume, but the correlation to prostate volume is poor.
• ..DRE – size, consistency, tenderness
• BPH usually results in a smooth, firm, elastic enlargement of the prostate.
• Induration or nodule : must alert the physician to the possibility of cancer and the need for further evaluation ---
prostate-specific antigen (PSA), transrectal ultrasound (TRUS), consideration of prostate magnetic resonance imaging
(MRI), and biopsy.
• Transrectal ultrasound (TRUS) is more accurate in determining prostate volume than DRE.
• Underestimation of prostate volume by DRE increases with increasing TRUS volume, particularly where the volume is > 30
mL

17. • Abdomen – palpation, percussion
• Enlarged bladder?
• Normal = well below umbilicus
• Neurological
• Perineal sensation
• Sphincter tone
• Anal wink
• Bulbocavernosus reflex

18. INVESTIGATIONS

19. LAB TESTS : 1. URINALYSIS
1. Dipstick test
2. Urine RME
• presence of pyuria and a positive nitrite test on urinalysis s/o underlying UTI (which could be
responsible for reported patient symptoms).
• presence of gross hematuria should prompt the physician to exclude the presence of bladder
cancer
• proteinuria, glucosuria, and ketonuria detected by urinalysis could be considered a sign of
diabetes mellitus, potentially correlated with LUTS.
3. Urine cytology
• always requested in men with severe storage symptoms and dysuria, especially if they have a
smoking history.

20. 2. PROSTATE SPECIFIC ANTIGEN (PSA)
• ..Aim:
1. Risk assessment ---- R/O Prostate cancer
2. Estimate Prostate volume
3. Predict BPH-related outcomes
• Caution should be paid in patients treated with 5α-reductase inhibitors (5ARIs),
given that serum PSA level is reduced by 40% to 50% after 12 months of
treatment (Guess et al., 1993).
• Failure to establish a baseline (pretreatment) PSA level may complicate the
interpretation of future PSA assessments.

21. PSA & Probability of Ca prostate
• PSA, compared with DRE alone, certainly increases the ability to detect prostate cancer, but
because there is much overlap between levels seen in BPH and prostate cancer, its use remains
controversial.
• Serum PSA trends over time (PSA velocity), measurement of free versus complexed PSA, PSA
density, and new markers such as PCA3 and p2PSA may help to improve PSA testing specificity in
men with BPH.
• Current clinical guidelines suggest :
• Measurement of PSA if a diagnosis of PCa will change LUTS management, (excluding, for
instance, those men with a life expectancy of less than 10 years).
• Potential benefits and harms of using serum PSA testing to diagnose PCa in men with LUTS
should be discussed with the patient.

22. PSA & prediction of Prostate volume
• PSA has a good predictive value for assessing prostate volume, with areas under
the curve (AUC) of 0.76-0.78 for various prostate volume thresholds (30 mL, 40
mL, and 50 mL).
• To achieve a specificity of 70%, while maintaining a sensitivity between 65-70%,
approximate age-specific criteria for detecting men with prostate glands
exceeding 40 mL are PSA > 1.6 ng/mL, > 2.0 ng/mL, and > 2.3 ng/mL, for men
with BPH in their 50s, 60s, and 70s, respectively.
• Both PSA forms were found to predict transrectal ultrasound (TRUS)-measured PV
to within ± 20% in > 90% of the cases.

23. PSA and BPH related outcomes
• Serum PSA is a stronger predictor of prostate growth than prostate volume.
• As per PLESS study, PSA level correctly predicted changes in terms of LUTS, QoL, and maximum urinary flow
rate (Qmax).
• Baseline serum PSA predicted the risk of acute urinary retention (AUR) and BPO-related surgery.
• Patients with BPO seem to have a higher PSA level and larger prostate volumes.
• PPV of PSA for the detection of BPO was recently shown to be 68%.
• Elevated free PSA levels could predict clinical BPH, independent of total PSA levels

25. 3. RENAL FUNCTION ASSESSMENT
• ..Parameters:
• Serum Creatinine
• Estimated GFR (eGFR)
• Prevalence of Renal insufficiency in BPO:
• An elevated serum creatinine level was found in 11% of patients presenting for LUTS (Gerber et al., 1997). .
• In the Medical Therapy of Prostatic Symptoms (MTOPS) trial, less than 1% of men with LUTS experienced kidney
failure over a period of 4 years (McConnell et al., 2003).
• Decreased peak flow rate (Qmax) along with a history of hypertension and/or diabetes was associated with chronic
kidney disease in men with LUTS (Hong et al., 2010).
• Qmax significantly correlated with estimated glomerular filtration rate in middle-aged men with moderate-to-severe LUTS,
whereas PV, postvoid residual (PVR) volume, and IPSS did not (Lee et al., 2013).
• Patients with renal insufficiency are at an increased risk of developing post-operative complications

26. • The assessment of renal function based on serum creatinine level or estimated
glomerular filtration rate is not routinely suggested in patients with LUTS (Gratzke
et al., 2015; McVary et al., 2011).
• AUA guidelines no longer recommend a routine renal function assessment
• EAU guidelines suggest assessment of serum creatinine level if renal impairment
is suspected on the basis of medical history or when surgical treatment is
considered.

27. INSTRUMENTAL INV… : 1. PVRU
• PVRU (Post-voidal Residual urine) volume : defined as the volume (mL) of urine left in the bladder at the end
of micturition.
• Currently, no standardized definition for a normal PVR volume.
• In clinical practice, (Asimakopoulos et al., 2016)
• PVR volume of less than 30 mL is usually considered nonsignificant
• PVR volume persistently greater than 50 mL could be regarded as important.
• PVR > 10-20% of MCC (Max Cystometric capacity) --- significant
• Significant chronic PVR volume has been widely defined as a volume more than 300 mL
• Of clinical relevance, there is a large within-subject variability in the PVR volume assessment [reported in
66% of cases when three measurements were done on the same day (Birch et al., 1988)].

28. Assessment of PVRU
• Modalities: transabdominal US, bladder scan or catheterisation.
• Guideline for the correct assessment of PVR volume (As per ICS Urodynamics Committee; 2014
stating that (level of evidence 3):
1. The interval between voiding and PVR volume measurement should be of short duration.
2. Although transurethral catheterization is considered the gold standard to assess PVR
volume, it could be associated with patient discomfort and the risk for UTIs and urinary tract
trauma.
3. The ultrasound bladder volume measurement should be used to assess PVR volume and can
be performed with either a real-time transabdominal ultrasound scanner or a portable
bladder scanner.

29. • Post-void residual is not necessarily associated with BOO, since high PVR volumes can be a
consequence of obstruction and/or poor detrusor function (DU).
• Using a PVR threshold of 50 mL, the diagnostic accuracy of PVR measurement has a PPV of
63% and a negative predictive value (NPV) of 52% for the prediction of BOO.
• Implications of high PVRU:
• Not a contraindication to watchful waiting (WW) or medical therapy (PVR volume did not
correlate with the need for BPH-related surgery).
• may indicate a poor response to treatment and especially to WW.
• In both the MTOPS and ALTESS studies, a high baseline PVR was associated with an increased
risk of symptom progression
• Monitoring of changes in PVR over time may allow for identification of patients at risk of AUR
(particularly in pts using Antimuscarinic meds). ---- [Level 3 evidence]
• Due to large test-retest variability and lack of outcome studies, no PVR threshold for treatment
decision has yet been established; this is a research priority.

30. In conclusion, PVR volume assessment is suggested both during basic
workup and during the follow-up of patients with LUTS. Men with
significant PVR volume should be monitored closely if they elect to
have nonsurgical therapy.

31. 2. UROFLOWMETRY
• Basic noninvasive urodynamic test providing an objective and quantitative
indication of the integration of bladder function and outlet.
• Based on the electronic recording of the free urinary flow rate throughout
the course of micturition…
• Key parameters : Qmax and flow pattern
• ..Pre-requisite: voided volume > 150 mL.
• As Qmax is prone to within-subject variation, it is useful to repeat
uroflowmetry measurements, especially if the voided volume is < 150
mL, or Qmax or flow pattern is abnormal

32. Normal value
1. Max flow rate (Qmax) >15ml/sec
[<10 ml/sec ---s/o Obstructive pattern]
[10-15 ml/sec --- Equivocal]
2. Flow time 30 sec
3. Shape “Bell-shaped” curve
4. Voided volume Should be >150ml
• Diagnostic accuracy for detecting BOO varies considerably and is substantially
influenced by threshold values.
• Threshold Qmax of 10 mL/s : specificity 70%, PPV 70%, sensitivity of 47% .
• Threshold Qmax of 15 mL/s : Specificity 38%, PPV 67% and sensitivity 82%.
• As per EAU, 10 mL/s cutoff threshold value to define BOO was associated with a
positive predictive value of 74.3% and a negative predictive value of 68% (Malde
et al., 2017).
• Uroflowmetry alone is unsuitable to detect and properly quantify BOO

33. • Causes of Low Qmax:
1. BOO
2. Poor detrusor function
3. Under-filled bladder
• Therefore, it is limited as a diagnostic test as it is unable to discriminate between
the underlying mechanisms. Specificity can be improved by repeated flow rate
testing.
• Uroflowmetry can be used for monitoring treatment outcomes and correlating
symptoms with objective findings.

34. 3. URODYNAMICS
• Aim:
1. Explore the functional mechanisms of LUTS
2. To identify risk factors for adverse outcomes
3. To provide information for shared decision-making.
[Most terms and conditions (e.g. DO, low compliance, BOO/BPO, DUA) are defined by urodynamic investigation].
• 2 types:
1. Invasive urodynamic test: involves the use of catheters or transducers inserted into the bladder and/or other body cavities.
• gold standard for the assessment of LUTS pathophysiology and it is used to identify DO, DUA, low bladder compliance, and BOO.
• 2 distinct evaluations investigating the storage and voiding phase of micturition: the filling cystometry and the pressure-flow study (PFS).
2. Noninvasive urodynamic tests : performed without the use of catheters (e.g., uroflowmetry, PVR volume, penile compression–release test, penile cuff).
• Videourodynamics:..
• use of synchronous radiographic imaging and filling the bladder with contrast medium while cystometry and a PFS are performed.
• additional anatomic information by showing the presence of eventual alteration of the bladder profile (diverticula, trabeculation), of vesicoureteral reflux,
or of alterations of the pelvic floor activity.
• No clear recommendation is currently provided regarding the use of videourodynamics (Abrams et al., 2013; Gratzke et al., 2015).

35. Filling Cystometry
• AIM:
1. Assessment of the storage phase.
2. In patients with LUTS, detection of involuntary detrusor contractions, which
may identify DO. [Up to 61% of them showed DO on filling cystometry. Age
and obstruction degree were significantly associated with DO (Thomas et al.,
2005b)].
• Diagnosis of DO : useful to identify patients who may benefit from the use of
anticholinergic drugs either alone or in combination with other treatments
• Procedure:
• continuous fluid filling of the bladder through a transurethral catheter, with a
concomitant measurement of intravesical and abdominal pressure and the
display of the detrusor pressure (Rosier et al., 2017).
• Patients are instructed before the test on how to report sensations: during the
filling phase, parameters such as first sensation of filling, first desire to void,
and strong desire to void are recorded.

36. Pressure-Flow study (PFS)
• defined as the measurement of the intravesical and abdominal pressure while
uroflowmetry is performed with a transurethral catheter in place.
• AIM:…
1. Allows assessment of the voiding phase.
2. Evaluation of detrusor pressure and flow rate allows the diagnosis of
either BOO (characterized by impaired flow rate along with an increased
detrusor pressure) or DUA (characterized by the impairment of both flow
rate and detrusor pressure). ---[prevalence of DUA in men with LUTS is
11-40%]
3. Identify DO (In men with LUTS attributed to BPO; DO was present in 61%
and independently associated with BOO grade and ageing).

37. • Both EAU and AUA guidelines do not routinely suggest the use of urodynamic
tests to assess men with LUTS (Gratzke et al., 2015; McVary et al., 2011).
• …Indications of PFS (suggested before invasive treatments):
1. Patients with previously unsuccessful invasive treatments for LUTS
2. Patients who cannot void more than 150 mL
3. Patients with PVR volume greater than 300 mL
4. Patients older than 80 years of age with predominantly voiding LUTS
5. Patients younger than 50 years of age with predominantly voiding LUTS
6. PFS may be performed in patients with a Qmax greater than 10 mL/s before
surgical treatment is considered (Abrams et al., 2013).
7. Should be considered for men with suspected underlying neurologic
conditions or with a history of pelvic surgery.

39. IMAGING.. 1. Upper Tract Imaging
• Routine assessment of the upper tract with ultrasonography is not recommended in patients with
LUTS (Gratzke et al., 2015; McVary et al., 2011).
• Men with LUTS are not at increased risk for upper tract malignancy or other abnormalities
when compared to the overall population
• Indications of Upper tract Imaging:
1. patients with LUTS combined with an elevated serum creatinine level
2. LUTS with large PVR volumes
3. History of hematuria, UTI, urolithiasis
4. H/O prior urinary tract surgery

40. 2. Imaging of prostate
• Modalities:
1. Transabdominal US
2. TRUS (superior to transabdominal PV measurement)
3. Computed tomography (CT)
4. Magnetic resonance imaging (MRI)..
• Aim:
1. Estimation of Prostate volume (PV)
2. Estimation of Intravesical Prostatic Protrusion (IVPP)

41. Estimation of PV
• Prostate volume predicts symptom progression and the risk of complications.
• Indications:
1. Prior to surgery
• Selection of surgical intervention (Open prostatectomy/TURP/TUIP/ other MIT)..
• Assessment of median lobe may also guide treatment choice since medial lobe presence
can be a contraindication for some minimally invasive treatments (eg UROLIFT)..
2. Prior to initiating 5-ARIs..

42. Estimation of IVPP
• Distance from the tip of the protruding prostate to the base at the circumference of the bladder
• Assessment : suprapubic ultrasound imaging in the sagittal plane
• IPP can differ according to the bladder volume, and should be estimated with a volume of 100 to 200 mL of urine in
the bladder (Yuen et al., 2002).
• Grading of IVPP: I: <5mm II: 5-10mm III: >10mm
• Use:
1. ..Noninvasive tool for the diagnosis of BOO (Gratzke et al., 2015).
• With cut-off value of 10 mm (high grade IPP), sensitivity and specificity of IPP for the detection of BOO : 67.8%
and 74.8%, respectively, with PPV 73.8% and a NPV 69.3%.
• .. no clear recommendation for using IPP as a noninvasive alternative to PFS to diagnose BOO.
2. High IPP grade (>10 mm) is associated with a higher probability of medical treatment over time (Lieber et al., 2009)
3. Good overall accuracy in predicting the outcome of a trial without catheter (TWOC) after AUR (Mariappan et al.,
2007)

43. 3. Imaging of Bladder
• Provides 2 additional parameters that are useful for the detection of BOO.
1. Bladder wall thickness (BWT)
2. Detrussor wall thickness (DWT)
1. BWT:
• …entire diameter of the bladder wall measured from the hyperechogenic mucosa and hyperechogenic
adventitia.
• Sensitivity of 82.7% and specificity of 92.6% for a BWT threshold of 2 mm (Malde et al., 2017).
2. DWT:
• distance between the hypoechogenic detrusor sandwiched between the hyperechogenic mucosa and
hyperechogenic adventitia
• The accuracy of both measures in detecting BOO is higher than that of Qmax, PVR volume, PV, or symptom
severity (Malde et al., 2017).
• ..However, No recommendation for the use of BWT/ DWT for the diagnosis of BOO.

44. 4. CYSTOURETHROGRAM (MCUG & RGU)
• Not recommended in the routine diagnostic work-up of men with LUTS.
• MCUG: useful for the detection of vesico-ureteral reflux, bladder diverticula, or urethral pathologies.
• Retrograde urethrography (RGU) : useful for the evaluation of suspected urethral strictures.

45. CYSTOURETHROSCOPY
• Importance: provides info regarding
1. Morphology of the prostate and bladder neck
2. Detection of detrusor trabeculation at the level of the bladder wall
3. Presence of diverticula
4. ..Selection of surgical treatment
• Cystourethroscopy is neither useful for the diagnosis of BOO nor to determine the need for treatment.
• poor correlation between BOO and cystourethroscopy findings has been widely reported.
• up to 15% of patients with BOO showed a normal bladder wall, and up to 8% had severe trabeculation and no evidence of BOO.
• Indications:..
1. gross hematuria
2. history of bladder cancer
3. History of recurrent UTIs
4. H/O urethral injury (to rule out urethral stenosis)
5. H/O previous surgery of the prostate or urethra
6. ..Marked obstructive symptoms in the setting of relative minimal prostate enlargement

46. OTHER NON-INVASIVE TESTS..
1. External condom catheter test & Penile cuff test (PCT):
• allow the measurement of detrusor pressure without the use of a urethral catheter, by
assessing the equal urine pressure along the urethra (in the penile cuff) or at the external
meatus (using an external condom catheter)
• In PCT, the pressure needed to stop the flow of urine represents the bladder isovolumetric
pressure, and is detected by a cuff placed around the penis (Griffiths et al., 2002).
• sensitivity of 88% and a specificity of 70% in detecting BOO (Malde et al., 2017).
2. Doppler ultrasound Imaging :
• identification of arterial blood flow within the bladder wall
• measure the reduction in detrusor blood flow associated with detrusor hypertrophy and BOO.
• Calculates detrusor resistive index (RI) as the average of the RIs measured from three different
sites in the bladder wall
• PPV of 95% and a negative predictive value of 57% have been reported in detecting BOO, with
an RI greater than 0.05 (Belenky et al., 2003).

47. 3. Near-infrared spectroscopy (NIRS)
• based on the use of the infrared spectrum to monitor changes in the concentration of chromophores
(oxyhemoglobin and deoxyhemoglobin) as a consequence of changes in detrusor oxygenation and
hemodynamics, which usually occur with BOO during both the storage phase and voiding phase of the
bladder.
• high diagnostic accuracy, with a median sensitivity of 85.7% and a specificity of 87.5% (Malde et al.,
2017)…

49. THANK YOU