Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that is common in aging men. BPH occurs when the prostate gland grows larger and squeezes the urethra, causing problems with urination. Symptoms include difficulty starting or stopping urination and frequent urination, especially at night. Treatment options depend on symptom severity and include medications to shrink the prostate or relieve symptoms, minimally invasive procedures such as transurethral resection of the prostate, and surgery for severe cases. Potential complications of treatment include retrograde ejaculation and temporary difficulty urinating.

1. Benign Prostatic Hyperplasia
(BPH)
Nodular Hyperplasia; Glandular & Stromal Hyperplasia
W. P. Rivindu H. Wickramanayake
Group no. 04a
5th Year 1st Semester – 2019 April
Tbilisi State Medical University, Georgia

4. Cause
Age related change (present in most men >60 years)
No increased risk of cancer

5. BPH occurs in almost all men as they age.
About half of all men older than 75 have some
symptoms.
It is probably a normal part of the aging
process In men
- caused by changes in hormone
balance and in cell growth.
Epidemiology

6. Age 40 years and older
Family history of BPH
Obesity,
Cardiovascular diseases,
Type 2 diabetes
Sedentary Lifestyle
Erectile dysfunction
Risk Factors

7. Pathogenesis
• Related to increased dihydrotestosterone (DHT)
DHT made from testosterone by 5alpha-reductase in
stromal cells
DHT acts on androgen receptors on stromal and epithelial
cells resulting in hyperplastic nodules
Trabecula  Hydronephrosis

8. Clinical Features
Presentation based on pinching of urethra
Decreased caliber and force of the stream
Problems starting(hesitancy) and stopping urine stream; post-
void dribbling
Impaired bladder emptying
- high risk of infection and hydronephrosis
Urinary retention
Incontinence
Nocturia; polyuria / Dysuria
Hypertrophy of bladder wall muscle
- increased risk for bladder diverticula
Microscopic hematuria maybe present

10. Complications
 Urinary tract infection
 Urinary bladder trabeculation and
 Diverticula formation
 Hydronephrosis and
 Renal failure (rare)
Cellulose
Trabeculae

11. Labs
 Slightly increased prostate
specific antigen (PSA) -
made by prostatic glands
and it liquefies semen
(still <10 ng/ml)
 Levels increase with
enlarged prostate. -
elevated PSA levels can
also be secondary to
infection, surgery or
Prostate cancer.

12. Grossly;
 An enlarged Prostate with well-demarcated
nodules in the Transition and Central
(periurethral) zones,
 which often results in slit-like compression of
the prostatic urethra.
Microscopically;
 Lesion shows Glandular and Stromal
hyperplasia resulting in the
characteristic prostate enlargement.
corpora amylacea.

13.  Digital rectal exam (DRE)
 Urinalysis (to help rule out an
infection)
 Blood test. (it can indicate
kidney problems)
 Neurological exam - can help
identify causes of urinary
problems other than BPH
Diagnosis And Tests

14. To help confirm an enlarged prostate
and to rule out other conditions:
Post-void residual volume test
- measuring if bladder emptying is complete. > by the
use of ultrasound or by insertion of a catheter into the bladder after
urination to measure how much urine is left in the bladder.
 24-hour voiding diary
- a record of the frequency and amount of urine >
especially helpful if more than one-third of daily urinary
output occurs at night.
Urinary flow test
- urinating into a receptacle connnected to a machine >
measures the strength and amount of urine flow as it determines if it
gets worse over time

15. In a more complex condition:
 Urodynamic and pressure flow studies
- to measure bladder pressure and to determine how well the bladder muscles are
working
> A catheter is threaded through the urethra into the bladder where water
(or air) is injected slowly into the bladder.
 Transrectal ultrasound
- insertion of ultrasound probe into your rectum to measure and evaluate the
prostate.
 Prostate biopsy - to rule out a prostate cancer
> needles are inserted guided by transrectal ultrasound to take tissue
samples (biopsies) of the prostate.
 Cystoscopy - to visualize the bladder and urethra
> a lighted, flexible cystoscope is inserted into your urethra, a local anesthetic
is given before this test.
 Intravenous pyelogram or CT urogram
- to detect urinary tract stones, tumors, or blockages above the bladder
> a tracer is injected into a vein. X-rays or CT scans are then taken of the
kidneys, bladder and the tubes that connect the kidneys to the bladder (ureters).

16.  Minimally invasive or surgical therapy might be recommended for
patients with:
- moderate to severe symptoms
- Medication that failed to relieve symptoms
- urinary tract obstruction, bladder stones, hematuria or
kidney problems
 Minimally invasive or surgical therapy might not be an option for patients
with:
- untreated urinary tract infection
- Urethral stricture disease
- A history of prostate radiation therapy or urinary tract
surgery
- A neurological disorder, such as Parkinson's disease or
multiple sclerosis
Management

17.  TURP - Transurethral resection of the prostate
> A lighted scope is inserted into the urethra, and removes all but the outer part of the
prostate
- relieves symptoms quickly
> post-TURP, the patient might temporarily need a catheter to drain the bladder,
> the patient is advised to do only light activity until healed.
Types of minimally invasive or surgical therapy:
 TUIP - Transurethral Incision Of The Prostate
> A lighted scope is inserted into the urethra, and makes one or two small cuts in the
prostate gland making urine to pass through the urethra easily.
> an option for small or moderately enlarged prostate gland, especially for patients with
health problems that make other surgeries too risky.
 TUMI - Transurethral Microwave ThermoTherapy
> a special electrode is inserted through the urethra into the prostate area.
> the inner portion of the enlarged prostate glands are destroyed and shrink by the
microwave energy from the electrode. This eases the urine flow.
- generally suggested only on small prostates in special circumstances
> re-treatment might be necessary.

18. TUNA - Transurethral Needle Ablation
- an outpatient procedure
> a scope is passed into urethra, needles are placed into the prostate gland, radio
pass through the needles
> excess prostate tissues blocking the flow of urine are heated and destroyed.
- a good choice for patient that bleeds easily or have certain other health problems.
- It might only partially relieve symptoms
- it might take some time before results are noticed
 Prostate Lift - an experimental transurethral procedure
> to increase the flow of urine, compression of the sides of the prostate through the
use of special tags are done.
 Embolization - an experimental procedure
- selectively blocking the blood supply to or from the prostate causing the prostate to
decrease in size
 Open or Robot-assisted Prostatectomy
- an incision in the lower abdomen is performed to remove tissue of the prostate
- generally for patients with a very large prostate, bladder damage or other complicating
factors.
- requires a hospital confinement for a short period
- the patient might be at risk of needing a blood transfusion.

19. Laser Therapy - use of high-energy laser
- destroys or removes overgrown prostate tissue
- generally relieves symptoms right away
- has a lower risk of side effects than does non-laser surgery
- for men who did not have other prostate procedures because they take
thinning medications.
(a) Ablative procedures - it vaporizes obstructive prostate tissue thus increasing urine flow
- Examples: photoselective vaporization of the prostate (PVP) holmium laser ablation of the
prostate (HoLAP).
- causes irritating urinary symptoms post-surgery resection procedure might be done if
(rare case)
(b) Enucleative procedures - Prevents tissue regrowth
- Removal of all the prostate tissue that blocks urine flow
- Similar to open prostatectomy
- removed tissue can be examined for prostate can
- Example: holmium laser enucleation of the prostate (HoLEP)

20. For mild to moderate symptoms BPH:
Medication
Alpha blockers
- to relax bladder neck muscles and muscle fibers in the prostate making urination easier
- alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), silodosin (Rapaflo)
- works quickly in men with relatively small prostates
- Side effects: > dizziness > Retrograde Ejaculation (semen goes back into the bladder instead
of out the tip of the penis, it is harmless)
 5-alpha reductase inhibitors
- to shrink prostate by preventing hormonal changes that cause prostate growth
- finasteride (Proscar) dutasteride (Avodart)
- might take up to six months to be effective
- Side effect: retrograde ejaculation.
 Combination drug therapy - alpha blocker and 5-alpha reductase inhibitor is
given at the same time if either medication alone isn't effective.
 Tadalafil (Cialis) - Studies suggest that this medication can also treat prostate
enlargement and is generally prescribed to men who also experience erectile dysfunction.

21. a. Retrograde Ejaculation
(semen goes back into the bladder
instead of out the tip of the penis)
b. Temporary difficulty with
urination - Urinary tract infection
c. Bleeding
d. Erectile dysfunction
e. Urinary Incontinence (loss of
bladder control)
- a very rare case
 Possible complications depending on the type of
prostate procedure:

22. References ;
 Robbins Pathology – 10th Edition
 Pathoma Lecture Notes – 2017
 Board Review System – Pathology – 5th Edition
 https://library.med.utah.edu/WebPath/MALEH
TML/MALEIDX.html
 Reference: Staff, M. C. (2014) ‘Benign prostatic
hyperplasia (BPH) Treatments and drugs’.
MayoClinic. Available at:
http://www.mayoclinic.org/diseases-
conditions/benign-prostatic-
hyperplasia/basics/treatment/con- 20030812