The management of BPH

1. BENIGN PROSTATIC HYPERPLASIA
Presentation & Mgt
Medical students lecture series
By
Dr Ogwuche E. I MBBS,FWACS
Professor of Urology, BSU, Makurdi
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ogwuche E.I

2. introduction
• BPH is the most common benign tumor in men, and its
incidence is age-related.
• The prevalence of histologic BPH in autopsy studies rises
from approximately 20% in men aged 41-50, to 50% in men
aged 51-60, and to over 90% in men older than 80.
• Although clinical evidence of disease occurs less
commonly, symptoms of prostatic obstruction are also age-
related.
• At age 55, approximately 25% of men report obstructive
voiding symptoms. At age 75, 50% of men complain of a
decrease in the force and caliber of their urinary stream.
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3. • Risk factors for the development of BPH are
poorly understood. Some studies have
suggested a genetic predisposition, and some
have noted racial differences. Approximately
50% of men under the age of 60 who undergo
surgery for BPH may have a heritable form of
the disease. This form is most likely an
autosomal dominant trait, and first-degree
male relatives of such patients carry an
increased relative risk of approximately 4-fold.
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4. Anatomy
• Location
• Relations
• Zones
• lobes
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5. Prostatic zonal anatomy
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6. ogwuche E.I
BPH
• ≥40yrs—increased growth
• Only 1 in 10 in 50yrs have symptoms
• Size vs symptoms
• Microscopic, macroscopic, clinical BPH
• Obstruction may result from
- static or dynamic components
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7. ogwuche E.I
BPH: Pathology
• testosterone →dihydrotestoterone → BPH
• Periurethral glands
• fibromyoadenoma
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8. ogwuche E.I
BPH: Aetiology
• Age- increased growth with age
• Testes (testosterone)
• Increased 5-alpha reductase activity
• Positive family hx
• Genetic
• Oestrogen imbalance
• Growth factors
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9. ogwuche E.I
BPH: effects-1
• Urethra-narrow, lengthened,
tortous,outflow rersistance
• Bladder- hypertrophy, cellules
sacculation, trabeculation,
diverticulum, atony, residual
urine, retention, ca
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10. ogwuche E.I
BPH: effects-2
• Ureter-hydroureter,
kinking
• Kidney-hydronephrosis,
renal failure
• General- stasis,
infection, calculi, ca
• Size vs obstruction
• Median lobe ball valve
effect
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11. ogwuche E.I
BPH: symptoms
• Frequency, Nocturia
• Difficulty with micturition-hesitancy,poor
stream, terminal dribbling
• Urgency
• Retention- acute, chronic
• Incontinence
• Haematuria
• Recurrent UTI
• Fxs of renal failure-
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12. ogwuche E.I
BPH-
• LUTO= lower urinary tract obstruction
• LUTO- irritative and obstructive symptoms
• IPSS - 3 irritative symptoms
- 4 obstructive symptoms
QOL due to urinary symptoms
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13. 3/21/2024 13
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14. ogwuche E.I
BPH: signs
• General
• anaemia,
oedema,dehydration,
↑BP,
• CVS, RS
• Full bladder
• Urethra-r/o stricture
• Hernial orifices
• DRE
• bimanual
• neurologic
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15. ogwuche E.I
BPH: complications
• Retention
• UTI
• Diverticula
• Hydroureter, hydronephronesis
• Calculus
• Haematuria
• Renal failure
• Effects on QOL e.g. sleep, recreation, erectile
function etc
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16. ogwuche E.I
BPH: Investigations
• diagnosis
urethrocystoscopy urethral cath-
r/o stricture
• extent urine m/c/s,
urea, electrolytes & creatinine,
(gfr), pcv
ultrasound- kub (+ pvr)
intravenous urogram? ipss,
peak urine flow rate( n=≥ 20ml/s),observe
• baseline- gxm blood, urinalysis,hiv, hbsag,ecg, chest x-ray,
psa
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17. ogwuche E.I
BPH: Differentials
• Urethral stricture
• Ca prostate
• Bladder neck obstruction
• Ca bladder
• Bladder calculus
• neurogenic bladder
• DM, Depression
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18. ogwuche E.I
BPH; Mx- Watchful waiting
• Pts with minimal symptoms(IPSS<8, QOL-not
bothered)
• Follow up- IPSS, DRE, PSA,PFR,PVR,USS
• Contraindication- complication
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19. ogwuche E.I
Medical treatment
• Alpha blockers-phenoxybenzamin,prazosin,
doxazosin, tamsulosin, alfuzocin, terazosin
• 5-alpha reductase inhibitors – finasteride,
dutesteride (avodart)
Testosterone→Dihydrotestosterone by 5αR
• Combinations- alpha blockers +finasteride
• Plant extracts
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20. ogwuche E.I
BPH-Mx Retention
• Acute -Catheter-urethral
-suprapubic puncture????
-duration of cath
• Chronic –Assess renal function-u/e/cr, uss, ivu
-good renal function-surgery next list
-poor fxn-continous drainage
-correct fluid/electrolytes,acidosis, anaemia
-antibiotic cover
- change catheter 2wkly
-prostatectomy when normal
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21. ogwuche E.I
PRE-OP PREP
• Catheter drainage if in retention. No need if
none
• Prophylactic antibiotics
• Correct fluid/elec, anaemia,uraemia,nutrition
• Screen to exclude pulmonary, cardiac dss, DM.
ie do CXR, Echo, RFTs, urinalysis, FBS
• Other Ix-GXM, urine mcs,HIV,HbsAg etc
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22. ogwuche E.I
Figure 32.28 Traditional surgical approaches for the treatment of benign prostatic hypertrophy. [From Grayhack JT, Sadlowski RW. Results of surgical treatment of benign prostatic hyperplasia. In:
Grayhack JT, Wilson JD, Scherbendke MJ, eds. Benign prostatic hyperplasia, NIMADD workshops proceedings, Feb 20–21, 1975. US Department of Health, Education and Welfare pub no (NIH) 76-
1113, 1976, with permission.]
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23. ogwuche E.I
PROSTATECTOMY-Methods
• Preliminary cystoscopy
• Transvesical
• Retropubic
• Transperineal
• Transurethral TURP(gold
standard)
• TURis
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24. ogwuche E.I
Prostate
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25. ogwuche E.I
Prostatectomy-complications 1
• Haemorrhage
• Clot retention
• Urinary infection
• Persistent vesicocutaneous fistula
• Wound infection
• Incontinence of urine
• epididymoorchitis
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26. ogwuche E.I
Prostatectomy-complications 2
• Impotence
• Infertility from retrograde ejaculation
• Urethral stricture
• Bladder neck stenosis
• Damage to ureters
• Osteitis pubis
• TURP SYNDROME-
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27. ogwuche E.I
Minimally invasive methods-1
• Ballon dilatation
• High intensity focused ultrasound(HIFU)
• Trasurethral needle ablation(TUNA)
• Microwave treatment
• Stents
• Transurethral incision of prostate
• Laser prostatectomy
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28. ogwuche E.I
BPH: Conclusion
• Common affliction amongst men
• Presents with LUTS
• DRE important in assessment
• Can be managed by watching waiting,
drugs,open prostatectomy or minimally
invasive means
• Haemorrghage and clot retention are major
early post-op complx
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