This document discusses the management of benign prostatic hyperplasia (BPH). It begins with the anatomy and blood supply of the prostate gland. It then describes BPH, including the pathology and common lower urinary tract symptoms. Diagnosis involves medical history, physical exam including digital rectal exam and tests like PSA, ultrasound and urodynamic studies. Treatment options discussed include watchful waiting, pharmacological treatments like alpha blockers and 5-alpha reductase inhibitors, and surgical options ranging from minimally invasive procedures like transurethral resection of the prostate to more invasive open prostatectomy. Complications of treatments like TURP are also reviewed.

1. MANAGEMENT OF BPH
Moderator : Dr M Talukdar
Associate Professor
Presenter : Dr Monitosh Paul
2nd yr PGT

2. Anatomy of Prostate
• It is an accessory gland of male
reproductive system
• Average weight 20gms
• Capsules:
1. True capsule- condensation of
peripheral part of gland &
2. False Capsule- derived from pelvic
fascia
• Lobes:
5 lobes; 1anterior, posterior, 2 lateral lobes
and 1 median lobe

3. Zonal Anatomy of Prostate (McNeal Classification)
• Transition Zone  median lobe
• Central Zone │
• Peripheral Zone│posterior & lateral lobes
• Anterior fibromuscular stroma  anterior lobe

5. Blood Supply of Prostate
• Arterial Supply
From Inferior vesical artery prostatic
artery divides into two main
branches:
 Urethral artery- supply urethra,
periurethral glands, transition zone
 Capsular artery
• Venous drainage to periprostatic
plexus(Santorini’s plexus ) 
Internal iliac vein

6. Benign Hyperplasia of Prostate (BPH)
• BPH is benign enlargement of prostate which
involves increase in number of cells in both
glandular epithelium and connective tissue stroma
• It commonly develops from periurethral transition
zone
• Theories: Hormonal(disturbance in androgen and
estrogen ratio), neoplastic theory
(fibromyoadenoma)

7. Pathology:
• BPH involves median and lateral lobes or one of them
• Median lobe enlarges into bladder
• Lateral lobe enlargement causes narrowing of urethra
causing obstruction
• Initially there is trabeculations and sacculation
formation in bladder and later diverticula formation
• Enlarged prostate compresses prostatic venous plexus
causing congestion , vesical piles leading to
haematuria
• Backpressure hydroureter and hydronephrosis
• Chronic pyelonephritis
• Obstructive uropathy with renal failure

8. Lower Urinary Tract Symptoms (LUTS):
• Storage Symptoms(Irritative Symptoms) :
frequency (m/c), urgency, incontinence, nocturia, pain
• Voiding Symptoms( Obstructive Symptoms) :
weak stream, hesitancy, urinary retention
Post mictural LUTS: incomplete emptying and post void dribbling
Bladder Outlet Obstruction: Voiding symptoms along with postmictural LUTS

9. Management of BPH
Diagnosis:
Medical History:
• History of hematuria, uti, urinary retention
• History of diabetes, nervous system disease, urethral stricture disease
• Medications like: anticholinergics and α sympathomimetic drugs
Signs and Symptoms:
Two scoring systems are:
1. American Urological Association Symptom Scoring Index( AUA SS Score)
0-7 = mild 8-19 = moderate 20-35 = severe
2. International Prostate Symptom Score (IPSS)

12. Examination:
• Physical Examination
-Abdominal Examination- Supra pubic bulge with tenderness
- Examination of external Genitalia(abnormality, discharge)
- Digital Rectal Examination
• Urinalysis: routine, microscopy, culture
• Kidney Function tests
• Serum Prostate Specific Antigen
• Ultrasonography KUB

13. Additional Diagnostic investigations:
• Urethrocystogram
• Urodynamic and Pressure/flow study
flowmetry bladder pressure
>15-20ml/sec- normal >80 cm H2O - high
10-15ml/sec –equivocal 60-80 cm H2O - equivocal
<10ml/sec – BOO <60cm H2O - normal
• Urethro-cystoscopy
• TRUS & biopsy
(if elevated PSA or suspicious DRE)

14. Treatment:
• Watchful Waiting
• Pharmacological treatment
• Surgical treatment

15. Watchful waiting
• In patients with mild symptoms
• Regular follow ups
• Patients with moderate symptoms who are not bothered by their symptoms

16. Medical Management
• Non selective alpha 1 antagonists
a) short acting: Prazosin, Alfuzosin
b) long acting: Terazosin, Doxazosin
• Selective alpha 1 A antagonists
Tamsulosin, Silodosin
• 5- alpha reductase inhibitors
Finasteride, Dutasteride
• Miscellaneous
PDE 5 inhibitor – Tadalafil
GnRH agonists – Naferelin acetate, Leuprolide

17. Alpha 1 blockers
• Relaxation of both bladder neck and prostatic
smooth muscle, thus decreasing pressure in the
bladder and urethra improve the urinary flow
• Improve the obstructive symptoms than irritative
symptoms
• Drugs are- Prazosin, Terazosin, Doxazosin,
Alfuzosin, Tamsulosin, Silodosin
5 alpha reductase inhibitors
• In prostate, testosterone converted to dihydroxy
testosterone ( DHT ) by 5 alpha reductase enzyme.
• DHT increases the growth in prostate
• Drugs:
Finasteride, Dutasteride

18. Surgical Management
INVASIVE
Open prostatectomy
Endoscopic
-Transurethral resection of prostate
(TURP)
-Transurethral incision of prostate (TUIP)
MINIMALLY INVASIVE
- Transurethral electro vaporizations (TUEV)
- Transurethral microwave thermotherapy
(TUMT)
- Transurethral needle ablation (TUNA)
- Laser ablation
- High intensity focused ultrasound
- Transurethral ethanol ablation
- Water induced thermotherapy

19. Indication of Surgical Intervention
(1) acute urinary retention;
(2) recurrent or persistent UTIs;
(3) significant symptoms from bladder outlet obstruction not responsive to
medical therapy;
(4) recurrent gross hematuria of prostatic origin;
(5) pathophysiologic changes of the kidneys, ureters, or bladder secondary to
prostatic obstruction; and
(6) bladder calculi secondary to obstruction.

20. Open Prostatectomy
Indications:
• Patients with symptomatic bladder outlet obstruction due to
BPH and markedly enlarged prostate gland
• Patients with a concomitant bladder condition, such as bladder
diverticulum or large bladder calculi
• Patient who cannot be placed in the dorsal lithotomy position for
TURP

21. Different approaches of Open Prostatectomy:
1. Freyer’s Suprapubic Transvesical Prostatectomy
2. Millin’s Retropubic Prostatectomy
3. Young’s Perineal Prostatectomy

22. Minimally Invasive & Endoscopic management of BPH
• Transurethral resection of Prostate(TURP)
• Transurethral Needle Ablation of Prostate(TUNA)
• Transurethral Microwave Therapy(TUMT)
• Lasers
• Transurethral Vaporization of Prostate
• Transurethral Incision of Prostate(TUIP)
• Intraprostatic Stents
• PKVP(TUVis) (plasma kinetic vaporization) and TURis(transurethral resection in saline)

23. Transurethral Resection of Prostate(TURP)
• It is Gold standard for surgical management of BPH
• Resection done from proximal to distal
• If large middle lobe, then it is done first

24. Stages of TURP
1st stage: Resect bladder neck(superiorly to inferiorly) 12 to 3
O’clock
2nd stage: resect lateral & median lobes( superiorly to inferiorly)
3rd stage: resect apical lobes (inferiorly to superiorly)

26. Complications of TURP
1. Hemorrhage
2. Clot Retention
3. TURP Syndrome
4. Incontinence
5. Retrograde Ejaculation (m/c)
6. Re-operation 5-15%
7. Strictures (m/c bladder neck)

27. TURP Syndrome
- Occurs within 4-6 hrs of surgery
- Primarily due to dilutional hyponatremia
- Features: confusion, disorientation, nausea, vomiting
- Management:
S. Na <120mmol/L → 3% NaCl (not >8-10mEq/L/day)
S. Na>120 mmol/L → fluid restriction

28. Transurethral radiofrequency needle ablation of
prostate (TUNA)
• Low-level radiofrequency is transmitted to the
prostate via transurethral needle delivery system
• The resultant heat causes localized necrosis of the
prostate.

29. Laser Therapy:
Mechanism of action
• Ablation
• Resection
• Vaporization
Types of Laser used:
• Nd:YAG
• KTP(Potassium Titanyl Phosphate)
• Ho:YAG laser
• Diode Laser

30. Novel approaches:
• Gene therapy
• COX-2/ LOX-5 inhibitors
• Vit D3 analogue
• Antibody dendrimer conjugates
• Oxytocin antagonists
• Radio nucleotide therapy
• NX-1207 (pro-apoptotic)

31. THANK YOU