Benign prostatic hyperplasia (BPH) is a common condition in aging men that involves enlargement of the prostate gland. It often causes bothersome lower urinary tract symptoms (LUTS) such as frequent urination and weak urine flow. BPH-LUTS refers to these urinary symptoms linked to an enlarged prostate. Treatment involves medications like alpha-blockers and 5-alpha-reductase inhibitors to shrink the prostate and relieve symptoms. For men with larger prostates or those where medications fail, surgery such as transurethral resection of the prostate (TURP) may be considered, though it carries risks like incontinence or sexual side effects.

1. BPH AND LUTS
Salman Bangash 2014-081

2. BPH-LUTS
• Benign prostatic hyperplasia is the histological pattern of the
prostate, characterized by proliferation of smooth muscle
and epithelial cells within the prostatic transition zone. This
may lead to prostatic enlargement.
• Lower urinary tract symptoms refer to storage and/or voiding
disturbances.
• BPH-LUTS refers to bothersome lower urinary tract symptoms
linked to the prostate.
• Not all men with BPH have LUTS and not all patients with LUTS
have BPH.

3. BPH
• It is considered a normal part of aging in men and is
hormonally dependent on testosterone and DHT
production.
• 50% of men develop BPH by age 60 years and 90% by
age 85 years.

4. BPH
• Patients with mild LUTS can be treated medically.
• TURP ( transurethral resection of the prostate ) is the
standard procedure for relieving bladder outlet
obstruction secondary to BPH.

5. PROSTATE
• It is a walnut sized gland and is a part of the male
reproductive system
• Located anterior to the rectum and distal to the urinary
bladder.
• It is connected directly with the penile urethra hence
it’s a conduit between the bladder and urethra.
• BPH originates in the Transition zone which surround the
urethra.

6. PROSTATE

7. PROSTATE
• Main function of the prostate is to secrete and alkaline
fluid that compromises 70% of the seminal volume.
• Secretions produce lubrication and nutrition for the
sperm.
• Alkaline fluid helps neutralize the acidic vaginal
environment.

8. RISK FACTORS
• Obesity
• Lack of physical activity
• Erectile dysfunction
• Increasing age
• Family history of BPH

9. EVALUATION OF PATIENTS
• Medical history
• Directed physical exam
• Urinalysis
• PSA testing
• Symptom assessment

10. MEDICAL HISTORY
• Nature and duration of symptoms
• Fluid intake – amount and types of fluid
• Sexual history
• Comorbid conditions
• Prior and current illness
• Prior surgery and trauma
• Current medications
• Any previous treatments.

11. CLINICAL
MANIFESTATIONS
• Urinary frequency
• Urgency
• Nocturia
• Hesitancy
• Incomplete emptying of bladder
• Straining
• Dribbling

12. SEXUAL HISTORY
• Sexual history is important because studies have
identified LUTS as an independent risk factor for erectile
dysfunction and ejaculatory dysfunction.

13. EXAMINATION
• DIGITAL RECTAL EXAM
--- Evaluate prostate for size, consistency, shape
and abnormalities suggestive of prostate
cancer (such as nodules or asymmetry)
• Assess suprapubic area to rule out bladder
distention
• Evaluate overall motor and sensory function of the
perineum and lower limbs

14. COMPLICATIONS
• Urinary retention
• Renal insufficiency
• Recurrent UTI
• Gross hematuria
• Bladder calculi
• Renal failure or Uremia

15. URINALYSIS
•Dipstick urinalysis should be performed in all BPH-LUTS
patients to rule out other diagnoses that may cause LUTS.
•Abnormal/borderline urinalysis results should be
repeated and/or followed with a urine culture

16. URINALYISIS
Urinalysis result Possible diagnosis
Hematuria
Kidney stones
Bladder cancer
Pyuria or nitrates
UTI
Urethral stricture
Proteinuria Underlying renal disease
Glucosuria diabetes

17. PSA TESTING
• BPH does not cause prostate cancer, however men at
risk of BPH are also at risk of developing prostate
cancer.
• It is a sensitive screening test for prostate volume.
• Men at age 50 who are expected to live at least 10
more year.
• 45 years in men who are at high risk ( African
American’s or close relative with prostate cancer )

18. ULTRASONOGRAPHY
• Help determine prostate and bladder size and degree
of hydronephrosis in patients with urinary retention.
• Transrectal ultrasonography is recommended in
selected patients to determine the dimensions and
volume of the prostrate.

19. CYSTOSCOPY
• It is indicated in patients whom a malignancy or foreign
body is suspected.

20. INTERNATIONAL PROSTATE
SYMPTOM SCORE
1-7 = mild 8-19 = moderate 20-35 = severe

21. AMERICAN UROLOGICAL
ASSOCIATION

22. TREATMENT FLOW CHART

23. MEDICAL THERAPY
• Alpha-blockers are a first-line option for men with
symptomatic bother who desire treatment
• 5ARI’s are an effective option for symptomatic patients
with demonstrable prostatic enlargement
• Combination alpha-blocker and 5-ARI therapy improves
symptom score and peak urinary flow vs. monotherapy;
appropriate for patients with LUTS associated with
prostatic enlargement
• A PDE5 inhibitor can be used once-daily in men with
moderate to severe symptoms and bother, to effectively
reduce symptoms of BPH-LUTS while maintaining sexual
function
• Phytotherapy is not recommended by the CUA

24. ALPHA BLOCKERS
• Selective antagonist of α1-adrenoceptors located in:
• Prostate
• Prostatic capsule
• Bladder base
• Bladder neck
• Prostatic urethra
• Help relax smooth muscle in the bladder neck and prostate;
allow urine to flow more freely
• Selective and non-selective alpha-blockers exist
• Non-selective alpha-blockers are not commonly used for BPH-
LUTS

25. ALPHA BLOCKERS
• First line options include
• Equal clinical effectiveness for LUTS secondary
to BPH
• Do not alter the natural progression of the
disease
• Choice of agent should depend on
comorbidities, side effect profile and tolerance
Selective :- Alfuzosin
Tamsulosin
Silodosin
Non selective: Doxazosin
Terazosin

26. SIDE EFFECTS
• Retrograde ejaculation
• Erectile dysfunction
• Asthenia •
• Dizziness
• Orthostatic hypotension
• Nasal congestion

27. 5-ALPHA REDUCTASE
INHIBITORS
• Indicated as first-line therapy for men with enlarged
prostates:
• Finasterideinhibits 5α-reductase Type 2 (prostate)
• Dutasterideinhibits 5α-reductase Type 1 AND 2 (liver, skin
and prostate)
• Blocks the conversion of testosterone to DHT (responsible for
prostate growth)
• Treatment with 5-ARIs reduce:
• Prostate size
• PSA
• Long-term risk of acute urinary retention
• Need for surgery

28. SIDE EFFECTS
• Reduced libido
• Erectile dysfunction
• Decreased ejaculate volume
• Breast tenderness

29. COMBINATION THERAPY
• Combined alpha-blocker and 5-ARI therapy is effective
for LUTS associated with prostatic enlargement
• Improves symptom score and peak urinary flow greater
than either monotherapy option
• Delays symptomatic disease progression
• Decreased risk of urinary retention and/or prostate
surgery

30. PDE5 INHIBITORS
• Promote smooth muscle relaxation.
• Improve LUTS.
• Improves quality of life.
• Effective in men with or without erectile dysfunction.
• Tadalafil is the only approved PDE5 inhibitor for BPH-
LUTS.

31. SIDE EFFECTS
• Headache
• Facial flushing
• Dyspepsia

32. TREATMENT RESPONSE
Drug class Time for symptom improvement
Alpha blockers 2-4 weeks
5 alpha reductase inhibitors Atleast 6 months
PDE5 inhibitors 4 weeks

33. CASE SCENARIOS
Case description Recommendation
Moderate – severe bother (PSA
1.3ng/ml)
Alpha blocker
Diabetes Alpha blocker
hypertension Alpha blocker
Erectile dysfunction Alpha blocker or PDE5
Enlarged prostate + PSA >
1.5ng/ml
5-ARI
Enlarged prostate + PSA >
1.5ng/ml + ED
5-ARI and/or PDE5
Bothersome sexual side effects
with α-blocker or 5-ARI PDE5

34. SURGICAL TREATMENT
• Renal insufficiency
• LUTS complications
• Patient requests surgical treatment
• Medication is ineffective
• Medication side effects are intolerable

35. PROSTATE SIZE
Very large ( 80-100g ) Large ( 30-80g ) Small ( <30g )
Open prostatectomy TURP TURP
Laser prostatectomy
-holium
-greenlight
Laser prostatectomy
-holium
-greenlight
Minimally Invasive
- TUMT
- TUNA

36. RISKS OF SURGERY
• Excessive bleeding requiring blood transfusion
• TUR syndrome
• Permanent sexual side effects:
• Retrograde ejaculation
• Erectile dysfunction (less common)
• Urinary tract infections
• Urinary incontinence
• Need for retreatment:
• Prostate regrowth
• Bladder/urethral strictures