Prostate hyperplasia .

1. BENIGN PROSTATIC
HYPERPLASIA
Presented by ROLL NO.- 75 & 76

2. Anatomy
 Embryology
 Develops around 12th week of
intra uterine life .
 Primitive buds from urethra
form glandular tissue .
 Surrounding mesenchyme
forms the fibromuscular
stroma .
• Developmentally prostate has
5 lobes- anterior ,posterior ,
middle and 2 lateral lobes.

3. • Enlargement of middle lobe / median lobe in BPH is
responsible for urethral obstruction. It enlarges upwards
into the bladder .
In BPH glands of inner adenomatous zone hypertrophies –
leads to obstruction.
Carcinoma occurs in outer non- adenomatous zone ( posterior
lobe ).

4. Zones of prostate
Based on McNeal’s zonal anatomy – 5 zones have been identified
1. Central zone
2. Periurethral glandular tissue
3. Transitional zone
4. Peripheral zone
5. Anterior fibromuscular stroma

5. Structural anatomy-
verumontanum
Prostatic urethra is
surrounded by
fibroadenomatous gland
Urethral glands open into
prostatic urethra .
These submucosal glands
are responsible for BPH .
When prostate enlarges it
compresses the outer
zone resulting in false
capsule .

6. BPH- DEFINITION:
• Non cancerous increase in size of prostate gland
which involves hyperplasia of prostatic stromal &
epithelial cell resulting in formation of large fairy
discrete nodule in transitional zone of prostate
,which push on and narrow the urethra resulting
in an increase resistance to flow of urine from the
bladder.’’

8. INCIDENCE:
• Occurs in men over 50 years of age; by the
age of 60 years, 50% of men have histological
evidence of BPH
• Common cause of significant lower urinary
tract symptoms in men and is the most
common cause of bladder outflow
obstruction in men > 70 years of age

9. AETIOLOGY:
• Serum testosterone levels slowly but
significantly decrease with advancing age;
however, levels of oestrogenic steroids are
not decreased equally.
• According to this theory, the prostate
enlarges because of increased oestrogenic
effects. That the secretion of intermediate
peptide growth factors plays a part in the
development of BPH

10. PATHOLOGY:
• BPH affects both glandular epithelium and connective
tissue
• Typically affects the submucous group of glands in the
transitional zone, forming a nodular enlargement.
Eventually, this overgrowth compresses the PZ glands into a
false capsule and causes the appearance of the typical
‘lateral’ lobes.
• When BPH affects the subcervical CZ glands, a ‘middle’ lobe
develops that projects up into the bladder within the
internal sphincter.
• Sometimes, both lateral lobes also project into the bladder,
so that, when viewed from within, the sides and back of
the internal urinary meatus are surrounded by an
intravesical prostatic collar

12. EFFECTS OF BENIGN PROSTATIC HYPERPLASIA
Pathophysiologically, BOO may be caused in part by increased
smooth muscle tone, which is under the control of α-adrenergic
agonists

13. ANATOMICALLY: EFFECTS
• Urethra- The prostatic urethra is lengthened, sometimes to twice
its normal length, but it is not narrowed anatomically. The normal
posterior curve may be so exaggerated that it requires a curved
catheter to negotiate it. When only one lateral lobe is enlarged,
distortion of the prostatic urethra occurs.
• Bladder- If BPH causes BOO, the musculature of the bladder
hypertrophies to overcome the obstruction and appears
trabeculations / fasciculations .
• Between the fasciculations , depressed area called sacculations.
• Sacculi are thin as pressure increasee, herniation occurs outside,
resulting in diverticuli.

14. • Ureter & Kidney- bilateral hydronephrosis and bilateral
hydroureter are the end result of BPH , may result in renal
failure .

15. CLINICAL FEATURES:
• FREQUENCY , URGENCY & HESITANCY- TRIAD OF BPH.
BPH
IRRITATIVE
SYMPTOM
FREQUENCY
URGENCY
NOCTURIA
OBSTRUCTIVE
SYMPTOM
POOR STREAM
INTERMITTENCY
STRAINING
SENSE OF INCOMPLETE
EMPTYING
MNEMONIC: FUN PISS

16. • FREQUENCY: Present in daytime followed by night (5-10 times) it is
due to ineffective emptying of bladder , results in residual urine in
bladder and precipitate cystitis.
• URGENCY: Vesical introversion of the sensitive mucus membrane of
the prostatic urethra within the bladder. This causes the internal
sphincter to stretch and prevents contraction. Resulting in a few
drops of urine trickling down the posterior urethra , causing an
urgent desire to pass urine (urgency)
• HESITANCY :Hesitation to pass urine because obstruction makes it
ineffective.
• HEMATURIA (rare): Due to congestion of
the prostatic venous plexuses resulting
in hyperemia and hematuria.

17. • ACUTE RETENTION OF URINE: Sometime first symptom of BOO. This
occurs due to postponement of micturition ,following alcohol or
drugs like mydriatics.
• CHRONIC RETENTION: In patients in whom the residual volume is >
250 ml or so, the tension in the bladder wall increases owing to the
combination of a large volume of residual urine and increased
resting and filling bladder pressures (a condition known as high-
pressure chronic retention).
• The increased intramural tension results in functional obstruction of
the upper urinary tract with the development of bilateral
hydronephrosis.

18. COMPLICATIONS -
• STONES: 8 times more common
• DIVERTICULI
• RENAL FAILURE
• RECURRENT UTI : Most common cause of surgical
intervention.

19. DIAGNOSIS OF BPH:
• DIGITAL RECTAL EXAMINATION: Enlarged lateral lobes can be
easily felt. Rectal mucosa is free and firm .
• In an enlarged prostate , in case of carcinoma prostate , the
mucosa of the rectum cannot be moved, if there is infiltration into
rectum.
• GRADING OF PROSTATE ( Roger Barnes grading )
I. Prostatic lobes protrude minimally into the rectal lumen by 1-2
cm and median sulcus is palpable.
II. Prostatic lobes protrude 2-3 cm into the rectal lumen and the
median sulcus is obliterated.
III. Prostatic lobes protrude 3-4 cm into the rectal lumen.
IV. Prostatic lobes protrude >4 cm & most of the rectal lumen is
filled by the projecting prostatic lobes .

20. INVESTIGATIONS:
• ESSENTIAL investigations
■ Urine analysis by dipstick for blood, glucose and protein
■ Urine culture for infection
■ Serum creatinine
■ Urinary flow rate and residual volume measurement
• ADDITIONAL investigations
■ PSA if indicated
■ Pressure–flow studies

21. • BLOOD UREA & CREATININE : Raised level indicate renal failure
• UROFLOWMETRY: The person is asked to void urine from their full
bladder into the flowmeter . The flow rate is assessed.
PEAK FLOW RATE –
Normal peak flow rate : > 15 ml/sec
Doubtful peak obstruction : 10-15 ml/sec
Definite peak obstruction : < 10 ml/sec
Thus , the degree of bladder outlet obstruction can be secured by
uroflowmetry.
• ULTRASONOGRAM : To assess the size and weight of the prostate ,
assess the residual urine , and look for hydroureteronephrosis &
bladder wall changes.

23. •URODYNAMIC STUDIES:
They should be performed on the following patients:
• men with suspected neuropathy (Parkinson’s disease,
dementia, longstanding diabetes, previous strokes,
multiple sclerosis);
• men with a dominant history of irritative symptoms and
men with lifelong urgency and frequency;
• men with a doubtful history and those with flow rates in
the near normal range (~ or > 15 ml s–1);
• men with invalid flow rate measurements (because of
low voided volumes)

25. TREATMENT:
MEDICAL
Alpha
adrenergic
blockers
5-alpha
reductase
inhibitor
SURGICAL
Transurethral
resection of
prostate
Transvesical
suprapubic
prostatectomy
Perineal
prostatectomy

26. MEDICAL TREATMENT:
• ALPHA- ADRENERGIC BLOCKERS : inhibit the contraction of smooth
muscle that is found in the prostate and relax the internal sphincter
for better bladder drainage .
Given as monotherapy when the prostate is <40g as measured by
ultrasound.
Eg : TAMSULOSIN (Most selective) , TERAZOSIN , ALFAZOSIN.
Latest drug : SILODOSIN 4-8 mg once nightly.
• 5-ALPHA REDUCTASE INHIBITOR : which inhibit the conversion of
testosterone to DHT, the most active form of androgen.
Eg: FINASTERIDE ACETATE 5mg daily for 6 months . Helps in
preventing hyperplasia of prostate. Given in case of large prostates .
Other drug: DUTASTERIDE 0.5mg once daily for 6-12 months.

27. SURGICAL TREATMENT:
INDICATIONS
• 1 Acute retention : in fit men with no other cause for
retention (drugs, constipation, recent operation, etc.)
(accounts for 25% of prostatectomies)
• 2 Chronic retention and renal impairment: a residual
urine of 200 ml or more, a raised blood urea,
hydroureter or hydronephrosis demonstrated on
urography and uraemic manifestations (accounts for 15%
of prostatectomies).
• 3 Complications of bladder outflow obstruction: stone,
infection and diverticulum formation.

28. • 4 Haemorrhage: occasionally, venous bleeding from a
ruptured vein overlying the prostate will require
prostatectomy to be performed.
• 5 Elective prostatectomy for severe symptoms: this
accounts for about 60% of prostatectomies. Increasing
difficulty in micturition, with considerable frequency day
and night, delay in starting and a poor stream are the
usual symptoms for which prostatectomy is advised.
CONTD

29. TRANSURETHRAL RESECTION OF
PROSTATE (TURP):
• GOLD STANDARD method of surgery.
• A rectoscope is passed through the urethra , and under vision with
constant irrigation with water or 1.5 percent glycerine , prostate is
resected into multiple pieces and removed.
• Haemostasis is obtained by cauterization.
COMPLICATIONS OF TURP:
• TURP Syndrome : nausea , confusion, vomiting , visual disturbances.
• Retrograde ejaculation (15%)
• Impotence (5-10%)
• Incontinence (<1%)
• Bladder neck contracture.

30. TRANSVESICAL SUPRAPUBIC
PROSTATECTOMY(FRAYERS)
• EXTRAPERITONEAL APPROACH: bladder is opened , prostate is
enucleated with a finger & bleeding is controlled by inflating the
foleys bulb with 30-50 ml of air and by ligatures.
• Bladder is drained by a Malecots catheter , which is wider than foleys
catheter , it can drain potential bleeding in the bladder.
• During the process, prostatic urethra is also avulsed.
• After about 7-10 days a tract develop along the length of foley
catheter , heals by granulation and fibrosis , form a future prostatic
urethra.

31. This method is now restricted to glands >100g in weight
associated with calculus. And in orthopaedic condition like
ankylosis of hip ( difficulty in positioning)
DISADVANTAGES:
• Blind resection
• Increased risk of haemorrhage
• Stricture of prostatic urethra.

32. RETROPUBIC PROSTATECTOMY
• Performed by an extraperitoneal approach without
opening the bladder by pushing the bladder to one side
and excising the prostate .
NEWER TREATMENTS:
• Holmium:YAG laser: for >100g prostate patients.
• Intraurethral stents: who are grossly unfit for surgery.

33. COMPLICATIONS : AFTER TREATMENT
• Haemorrhage Water intoxication (fluid
excess)
• Sepsis Osteitis pubis
• Incontinence Cardiovascular
• Retrograde ejaculation
• Impotence Myocardial infarction
• Stricture Pulmonary atelectasis
Pneumonia
CCF
DVT
local General

34. COUNSELLING OF PATIENTS
• Retrograde ejaculation - 65% of men after
prostatectomy.
• Erectile impotence- This occurs in about 5% of
men.
• The risk of reoperation- After TURP, this is
about 15% after 8–10 years.