This document provides information on benign prostatic hyperplasia (BPH): - It describes the anatomy and zones of the prostate gland and discusses theories on the causes of BPH related to hormone levels and aging. - The pathology, clinical features, investigations, management options including medications, minimally invasive procedures, and surgeries for BPH are summarized. Surgical options include transurethral resection of the prostate (TURP) and newer laser procedures. - Complications of treatments like TURP are noted. Indications for medical versus surgical management are provided.

1. BENIGN PROSTATIC
HYPERPLASIA
DR MUHAMMED MUNEER M .MS
GENERAL SURGERY
SGMC & RF
TRIVANDRUM
KERALA

2. Sagittal View of the Prostate
Rectum
Seminal vesicle
Denonvillier's
fascia
Deep transverse
perineal muscle
Puboprostatic
ligament
Plexus of
Santorini
Anterior
lobe Posterior lobe
Middle
lobe
Pubic bone
Penis and
Urethra
Base of
prostate
Apex of prostate

3. SAGITAL SECTION OF THE PROSTATE GLANDSAGITAL SECTION OF THE PROSTATE GLAND
Seminal
Vesicle
Central Zone
Bladder
Peri-urethral
zone
Anterior Zone
Fibro-muscular
Peripheral
Zone
Transition
Zone
Urethra

5. Peripheral Zone

6. THEORIES
• It is an involuntary hyperplasia due to disturbance
of ratio of circulating androgen and estrogen.
 Hypothalamus-pulsatile release of LHRH----
release of LH from anterior pituitary stimulate
leydig cells of testis -release testosterone -
reaches prostate- releases 5 alpha reductase of
prostate - convert TS to DHT for its effect.
 DHT is 5 times more potent than TS.
 90% of TS from testis ,10% TS from adrenal cortex
 With age TS level drops slowly. But fall of oestrogen
level is not equal . So enlarges through intermediate
peptide growth factor.

7. BPH
• BPH arises from submucosal glands of periurethral
transitional zone with stromal proliferation and
adenosis. It eventually compresses the peripheral
zone and enlarges as lateral lobe.
• BPH arising from subcervical glands of central zone
enlarges as middle lobe projecting up into the
bladder with in the internal spincter
• Most common benign internal neoplasm of the adult
male.
• BPH due to hyperplasia and hypertrophy with
increased glandular and stromal elements of the
prostate in varying amounts

8. PATHOLOGY
• BPH involves adenomatous zone of prostate, ie
submucosal glands .(TZ)
• Median lobe enlarges in to the bladder
• Lateral lobe narrow the urethra causing obstuction
• Urethra above the verumontanum gets elongated and
narrowed
• Bladder initially takes the pressure burden causing
trabeculations, sacculations and later diverticula
formation.

9. CYSTOSCOPIC PROSTATIC OBSTRUCTION

10. SONOGRAPHY OF BPH

11. • Enlarged prostate compress the prostatic venous
plexus causing congestion ,called as vesical piles
leading to hematuria.
• Back pressure causes hydroureter and
hydronephrosis
• Secondary ascending infection can cause acute or
chronic pyelonephritis.
• It can even cause severe obstruction can lead to
obstructive uropathy with renal failure

12. CLINICAL FEATURES
• The enlarged gland contribute to the overall lower urinary
tract symptoms (LUTS) complex via two routes:
• (1) direct bladder outlet obstruction (BOO) from enlarged
tissue (static component)
• (2) from increased smooth muscle tone and resistance within
the enlarged gland (dynamic component).
• Voiding symptoms have often been attributed to the physical
presence of BOO.
• Detrusor overactivity is thought to be a contributor to the
storage symptoms seen in LUTS

13. LUTS
SYMPTOMS OF
VOIDING
• Hesitancy
• Poor flow not
improving by
straining
• Dribbling even after
micturition
• Intermittent stream-
stops and starts
• Sensation of poor
bladder emptying
• Episodes of near
retention
SYMPTOMS OF
STORAGE
• Frequency
• Nocturia
• Urgency
• Urge incontinence
• Nocturnal
incontinence

14. CONSEQUENCES OF BPH
• No symptoms , no BOO
• No symptoms ,but urodynamic evidence of BOO
• LUTS, no e/o BOO
• LUTS and BOO
• Others (a/c , c/c retention, hematuria,UTI,, stone formation.)
• LUTS assessed by means of scoring systems,which give a semi
objective measure of severity.
• The AUA-SI and the International Prostate Symptom Score (I-
PSS) are nearly identical, short questionnaires are used to
assess the severity of:-
• 3 storage symptoms (frequency, nocturia, urgency) and
• 4voiding symptoms- (feeling of incomplete emptying,
intermittency, straining, and a weak stream).

15. IPSS SCORE
• Mild- IPSS <7 FLOW RATE >15 RV < 100
• MODERATE -IPSS 7-20 FLOW RATE <I5 ml rv <200
• Sever IIPSS >20 FLOW RATE < 10 RV > 20O
ml

16. • The term "benign prostatic hyperplasia" is reserved for the
histological pattern it describes.
• Benign prostatic enlargement is used when there is gland
enlargement and is usually a presumptive diagnosis based on
the size of the prostate.
• Benign prostatic obstruction (BPO) is used when obstruction
has been proven by pressure flow studies, or is highly suspected
from flow rates and if the gland is enlarged.
• Bladder outlet obstruction (BOO) is the generic term for all
forms of obstruction to the bladder outlet (e.g., urethral
stricture) including BPO.

17. BOO
• BLADDER OUTLOW OBSTRUCTiON
• This is a urodynamic concept based on combination of law of
flow rates in presence of high voiding pressure.
• Urodynamically proven BOO
• BPH
• Bladder neck stenosis
• Bladder neck hypertropy
• Prostrate cancer
• Urethral strictures
• Functional obstruction due to neuropathic
condition(DM,Parkinson’s disease, disseminated
sclerosis,Alzheimer’s , Stroke)

18. ∙ Little correlation with volume and degree of symptomatology
Degree of BOO does not necessarily correlate to the severity of LUTS
Long term effect of BOO
Bladder may decompensate so that detrusor contraction become
progressively less efficient and residual urine develops.
Bladder may become more irritable during filling with decrease in
functional capacity, partly by detrusor over activity.

19. INVESTIGATIONS
• Urine Microsopy and C/S
• Blood urea serum creatine, serum electrolytes
• Cystoscopy
• Prostate specific antigen
• Acid phosphatase
• USG - Look for residual urine, volume
• Urodynamics
 Urine Flow rate > 15ml / sec is normal
 10-15ml is equivocal
 < 10 ml is low
 Voiding pressure < 60 cm of water is normal
 60-80 ml is equivocal
 > 80 is high
 Normal peak urine flow rate is > 15 ml/sec., for a voided volume
more than 200ml. In obstruction it is < 10 ml/ sec

20. • No symptoms specific for early prostatic cancer
• Presenting symptoms are therefore those of BPH
• BX of prostate should be performed in those with abnl DRE or
PSA ABOVE Age specific reference range.

21. • Trans-rectal US (TRUS) is useful to find out nodules/ possibility
of carcinoma prostate. It is not done routinely.
• IVU- to see kidney function

22. PSA
• Prostate specific antigen
• Single chain glycoprotein of 240 AA residue and 4 CHO side
chain
• Physiological roole in lysis of seminal coagulam
• prostate specific, but not cancer specific
• In addition to ca pro , it can elevated in
• increasing age,
• A/c urinary retention
• CathetArisation
• After TURP,
• PROSTATE BX
• PROSTATITIS

23. PROBLEM WITH PSA
• Men with prostate cancer may have a normal PSA
• Men with BPH or other benign condition may have a raised psa
• Age specific PSA
• 40- 49YR OLD -- <2.5 ng/ml
• 50- 59 yr - < 3.5
• 60- 69 <4.5
• 70- 79 < 6.5 ng/ml
• Free : total PSA ratio ( < 0.15 strongly suggests posssibility of
carcinoma prostate)

24. MANAGEMENT
• Basic management of BPH/LUTS classifies diagnostic
tests as either recommended or optional.
• A "recommended test" should be performed on every
patient during the initial evaluation whereas an
"optional test" is a test of proven value in the
evaluation of select patients.
• If the initial evaluation demonstrates the presence of
LUTS associated with results of a digital rectal exam
(DRE) suggesting prostate cancer, hematuria,
abnormal prostate-specific antigen (PSA) levels,
recurrent infection, palpable bladder, history/risk of
urethral stricture, and/or a neurological disease
raising the likelihood of a primary bladder disorder,
the patient should be referred to a urologist for
appropriate evaluation before advising treatment

25. CONTD
• presence of LUTS ,with or without some degree of
nonsuspicious prostate enlargement, if the symptoms are not
significant or if the patient does not want treatment, no further
evaluation is recommended.
• In patients with significant symptoms, it is now recognized that
LUTS has a number of causes that may occur singly or in
combination. Among the most important are BPO, overactive
bladder, and nocturnal polyuria.
• Discuss the benefits and risks
• Treatment Options:
 watchful waiting,
 medical,
 surgical,
 minimally invasive surgical treatments.

26. MEDICAL MANAGEMENT
• In drug therapy, if there are coexisting BOO and overactive
bladder symptoms –combination of alpha-blocker and
anticholinergic therapy.
• If BOO symptoms predominate, alpha-adrenergic blocking agents
are the first treatment of choice for LUTS due to BPH.
• when the prostate is enlarged as assessed by PSA levels,
transrectal ultrasound (TRUS) or on DRE, alpha-blockers alone,
5-ARIs alone, and/or combination alpha-blocker and 5-ARI
therapy have shown the most efficacy,

27. • storage symptoms predominate in an overactive
bladder due to idiopathic detrusor overactivity.
• The treatment options of lifestyle intervention (fluid
intake alteration), behavioral modification and
pharmacotherapy (anticholinergic drugs) should be
discussed with the patient.

28. DRUGS USED IN BPH
• Medical Therapies
Alpha-Blockers
- Alfuzosin, Doxazosin, Tamsulosin, Terazosin, Silodosin*
• Inhibits smooth muscle contraction of prostate, they reduce bladder
neck resistance so as to improve the urine flow
• 5- Alpha-reductase inhibitors (5-ARIs)
- Dutasteride, Finasteride
• Inhibits conversion of TS to DHT, effective in palpable enlarged
prostate . Decrease actual volume of prostate with maximal efect
seen by 6 months
• This class of drugs also alter serum PSA level(reduce to 50%),must
be kept in mind with regard s to prostate cancer screening
• Combination Therapy
- Alpha blocker and 5-alpha-reductase inhibitor
- Alpha blocker and anticholinergics
• Anticholinergic Agents

29. INDICATION FOR SURGERY
Severe obstruction based on
 urodynamic data .. <10 ml/sec
 recurrent hematuria
 Recurrent infection ,
 urinary tract anatomic deterioration from obstruction
 Chronic retention of urine with residual urine more than 100-250
ml
 Accute retention with no other cause for retention, accounts for
25% of prostatectomy.
 Complication of BOO- stones in diverticula

30. SURGERY
• Minimally Invasive Therapies
- Transurethral needle ablation (TUNA)
- Transurethral microwave thermotherapy (TUMT)
• Surgical Therapies
- Transurethral resection of the prostate (TURP)
- Open prostatectomy
retropubic ((millin)
transvesical
perineal prostatectomy(young)
- Transurethral holmium laser ablation of the prostate (HoLAP)
- Transurethral holmium laser enucleation of the prostate (HoLEP)
- Holmium laser resection of the prostate (HoLRP)
- Photoselective vaporization of the prostate (PVP)
- Transurethral incision of the prostate (TUIP)
- Transurethral vaporization of the prostate (TUVP)

31. PROSTATE RESECTOSCOPE AND TURP

32. TURP
• Using cystoscope with fluid like 1.5% isotonic glycine irrigating
continuously, enlarged prostate is identified and resected using
a loop with hand control
• Resection is done using high frequency diathermy current,
above the level of verumontanum.
• After surgery continuous bladder irrigation using three way
foley’s catheter
• Antibiotic should be given and catheter is removed within 72
hours.

33. COMPLICATIONS OF TURP
• Water intoxication with CCF- TURP syndrome
• Hyponatraemia
• Haemorrahage / hematuria(3%)
• Infection (15-20%)
• Incontinence
• Perferation of bladder/ Prostatic capsule
• Stricture urethra
• Retrograde ejaculation(65%)
• Recurrence(15% after 8-10yr)
• Erectile dysfunction(5%)

34. BENEFITS OF TURP
• No suprapubic incision
• Most common and popular method
• Done using resectoscope
• Faster recovery and early discharge.

35. HISTOLOGY OF
BENIGN PROSTATIC HYPERPLASIA

36. CYSTOGRAPHY OF BLADDER BASE ELEVATION
INDICATING BPH

37. INTRA-PROSTATIC STENT

38. INTERSTITIAL LASER COAGULATION

39. HYPERTHERMIA OF BPH

40. TRANSURETHRAL DILATATION OF PROSTATE

41. • a large variety of MITs exist for bph who fails drug
therapy , but for most patients the gold standard
surgical proceedure remains TURP

42. THANK YOU

43. TUNA-INDICATIONS
• BPH/BOO
• Lateral lobe enlargement
• Prostate volume <60gms
• Median lobe not ideal, but can be Rx
• Bladder neck hypertrophy not ideal candidate

44. TUMT- METHOD OF ACTION
• Apoptosis induced by moderate thermal energy for longer period of
time
• Hemorrhagic necrosis induced by higher thermal energy over shorter
time