This document discusses benign prostatic hyperplasia (BPH) and its management. It begins by defining BPH as a benign enlargement of the prostate gland that commonly occurs in aging men. It then covers the anatomy and histology of the prostate, causes of BPH, pathophysiology and effects of BPH, symptoms, diagnostic tests including DRE, PSA, uroflowmetry, and management options like watchful waiting, lifestyle changes, medications such as alpha blockers and 5-ARIs, and surgeries.

1. BPH & Its Management
PRESENTED BY-
DR. NESAR AHMAD
MODERATOR-
DR. ABDUL HAQUE
D/O JARAHAT, AKTC, AMU

2. Introduction
• Benign Prostatic Hyperplasia is a chronic condition that
clinically manifests with LUTS
• It is a benign enlargement of the prostate gland
– age-related phenomenon in nearly all men, starting at approx
40 years of age.
• Histologically
– 10% of men in their 30s
– 20% in 40s
– 50-60% in 60s
– 80-90% in their 70s and 80s.
• Prostate size increases from
– 25g to 30g for men in 40s
– 30g to 40g in 50s
– 35g to 45g in 60s.

3. Anatomy of Prostate
Prostate is an accessory gland of the male reproductive system
It is fibro-muscular and glandular organ
In female the prostate is represented by the paraurethral glands
of Skene
Shape: Pyramidal shape, base-up, apex-down
Size: anteroposterior-2 cm, vertical-3 cm, width-4 cm
Situation: between neck of UB and urogenital diaphragm

4. Anatomical Relations
Base – bladder neck
Inferior – urogenital diaphragm
Anterior – pubic symphysis
separated by extraperitoneal fat;
puboprostatic ligaments
Posterior – rectum; fascia of
Denonvilliers
Lateral – Pubococcygeal of
levator ani

5. Lobes of prostate: 5 in numbers
1 Anterior- anterior to prostatic urethra
1 Posterior- behiond the ejaculatory duct
1 Median- b/w urethra and ejaculatory duct
2 Lateral- lie one on each side of urethra
Capsules of prostate:
True capsule: formed by the condensation of the peripheral part of
the gland, fibromuscular in structure. It contains no plexus
False capsule: it is outside the true capsule and is derived from
pelvic fascia. Anteriorly the prostatic venous plexus is embedded in
it

6. Zones of prostate gland:
A) Inner smaller zone
1. zone of mucosal gland – involved in BPH
2. zone of submucosal glands
B) Outer larger zone – involved in malignancy

7. Arterial supply:
– Inferior vesical, middle rectal and internal pudendal arteries
Venous drainage:
– form a rich venous plexus and drain into the internal iliac vein
Lymphatic drainage:
- drain chiefly into internal Iliac LN and partly into external
iliac nodes
Innervations:
 from pelvic plexuses (inferior hypogastric plexus) formed by
the parasympathetic fibers that arise from the sacral levels(S2-
S4)
sympathetic fibers from the thoracolumbar levels (L1-L2).

8. Causes of BPH
• The exact cause of BPH is unclear.
• Two theories
1) Hormonal: serum testosterone levels decrease with
advancing age, however oestrogen levels are not
decreased equally, so the prostate enlarges because of
increased oestrogenic effects.
2) Neoplastic: acc.to this theory BPH is due to a benign
neoplasm i.e. adenoma or adenomyoma of the gland

9. BPH
Pathophysiology
• Slow and insidious changes occur in two main types—
overgrowth of the glandular elements and overgrowth of
connective tissue elements
• Initial hypertrophydetrussor decompensation poor
tonediverticula formationincreasing urine
volumehydronephrosisupper tract dysfunction

10. BPH Pathophysiology
Normal BPH
Hypertrophied
detrusor muscle
Obstructed
urinary flow
PROSTATE
BLADDER
URETHRA
Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

11. Effects of BPH
1. Changes in Urethra: prostatic urethra elongated, more above the
verumontanum about twice of its normal size. Normal posterior
curve may be so exaggerated that it recquires a curved catheter to
negotiate it.
2. Changes in Bladder: if BPH causes BOO, the detrusor muscle
hypertrophies ,due to this there will be (a) trabeculation of UB
wall, (b)hypertrophy of trigone, (c ) formation of diverticula
BPH may compress the prostatic venous plexus and causes
haematuria
3. Changes in ureters and kidneys: due to hypertrophy of
trigone and interureteric ridge, there is downward traction on the
intramural segmant of ureter. This causes hydroureter and
hydronephrosis
4. Changes in Sexual urge: in early stage of BPH there is
increased libido. Later on patient may become impotent

12. Lower Urinary Tract Symptoms (LUTS)
• Storage/ Irritative Symptoms
– Increased frequency
– Urgency ± urge
incontinence
– Nocturia
– Dysuria
– bladder pain
• Voiding/Obstructive Symptoms
– Hesitency
– Decreased urinary stream
– Straining to void
– Incomplete emptying
– Urinary retention
– Overflow incontinence
– Dribbling at the end of urination
– Pain or burning during urination
*LUTS does not equate to BPH but BPH is the most common
cause of LUTS*
Symptoms of BPH

13. Physical signs
General examination: performed carefully to exclude renal
insufficiency. Vitals should be examined
E/o Nervous system: to elimenate neurological lesions e.g. tabes
dorsalis, disseminated sclerosis, DM, Parkinson’s disease. Which
may give rise to bladder outflow obstruction
Local examination: Abdominal examination may only reveal a
full bladder at times
D.R.E.: when lateral lobes are enlarged, rectal examination detects
such enlargement. The surface of enlarged prostate is usually
smooth and convex and usually firm in consistency. A sulcus felt in
the midline b/w two lobes

14. 4/25/2019 14
Diagnostic Tests
• History & Examination
– Abdominal/GU exam
– Focused neuro exam
• Digital rectal exam (DRE)
• IPSS based questionnaire.
• Urinalysis
• Urine culture
• RFT
• Prostate specific
antigen (PSA)
• Transrectal ultrasound –
biopsy
• Uroflometry
• Postvoid residual

15. Diagnosis of BPH
• Symptom assessment
– the International Prostate Symptom Score (IPSS) is
recommended
as it is used worldwide
– IPSS is based on a survey and questionnaire developed
by the
American Urological Association (AUA). It contains:
• seven questions about the severity of symptoms;
total score 0–7 (mild), 8–19 (moderate), 20–35 (severe)
• eighth standard question on QoL

16. AUA Symptom Score Sheet
Not at all
Less
than 1
time
in 5
Less
than
half the
time
About
half the
time
More
than
half
the
time
Almost
always
Your
score
Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your
bladder completely after you finish urinating?
0 1 2 3 4 5
Frequency
Over the past month, how often have you had to urinate again less than two hours
after you finished urinating?
0 1 2 3 4 5
Intermittency
Over the past month, how often have you found you stopped and started again several
times when you urinated?
0 1 2 3 4 5
Urgency
Over the last month, how difficult have you found it to postpone urination?
0 1 2 3 4 5
Weak stream
Over the past month, how often have you had a weak urinary stream?
0 1 2 3 4 5
Straining
Over the past month, how often have you had to push or strain to begin urination?
0 1 2 3 4 5
None 1 time 2 times 3 times 4 times
5 times
or more
Your
score
Nocturia
Over the past month, many times did you most typically get up to urinate from the
time you went to bed until the time you got up in the morning?
0 1 2 3 4 5
Quality of life due to urinary symptoms
Delighted Pleased Mostly satisfied
Mixed – about equally
satisfied and dissatisfied
Mostly
dissatisfied
Unhappy Terrible
If you were to spend the rest of your life with your
urinary condition the way it is now, how would you
feel about that?
0 1 2 3 4 5 6
Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

17. Investigations
Urine examination: to evaluate infection, presence of RBCs and
sugar. Urine should be cultured and tested for sensitivity to
different antibiotics
Blood examination: Serum urea, N.P.N. and creatinine should
be performed to assess renal function. Also haemogram should be
done.
Estimation of PSA: PSA is a glycoprotein measured by
immunoassay technique
Normal upper limit is about 4nmol/ml
in BPH the level goes upto 4-10nmol/ml
in Prostatic Ca the level goes upto 15-30nmol/ml

18. Cystourethroscopy: either done transurethrally or by the open
route to exclude a urethral stricture, a bladder Ca and the occasional
non-opaque vesical calculus.
USG: to detect size of prostate most accurately. Also indicate if
there is hydronephrosis or hydroureter.
Transrectal ultrasound scanning: used when the level of PSA is
high or the surface of prostate is hard and irregular. It offers
accurate estimation of prostaic size. More effective in detection of
associated early prostatic Ca.

19. Uroflowmetry
•Simple, non invasive, funnel or machine
•Calculates flow of urine over time
•Measures:- volume of urine voided
rate of flow in seconds
length of time until completion
•Converts information into a graph
•Helps evaluate function of LUT’S or determine if there is obstruction
Normal Values in Men
Average Flow Rate ;-
•Age 8-13 yrs = 12mls/sec
•Age 14-45 yrs = 21mls/sec
•Age 46-65yrs = 12mls/sec
•Age 66-80yrs = 9mls/sec

20. Management
• Watchful waiting & Life style modification
• Medical Therapies:
 Alpha 1-Blockers: e.g. Alfuzosin, Doxazosin, Tamsulosin,
Terazosin, Silodosin
 5- Alpha-reductase inhibitors (5-ARIs)
- Dutasteride
- Finasteride
 Combination Therapy
- Alpha blocker and 5-alpha-reductase inhibitor
- Alpha blocker and anticholinergics
 Anticholinergic Agents
 The Drug Speman has also been used with some success

21. • Surgery
Endoscope: TURP
Electrosurgical: TURVP
Laser: PVP, HoLRP, HoLEP
Ablation: TUMT, TUNA
Open surgery: open prostatectomy

22. Watchful Waiting and Behavioral
Modification
• Patients with mild symptoms of LUTS secondary to BPH (AUA-SI
score <8) and patients with moderate or severe symptoms (AUA-SI
score ≥8) who are not bothered by their LUTS should be managed using
a strategy of watchful waiting (active surveillance)
• Decrease caffeine, alcohol )diuretic effect(
• Avoid taking large amounts of fluid over a short period of time
• Void whenever the urge is present, every 2-3 hours
• Maintain normal fluid intake, do not restrict fluid
• Avoid bladder irritants to include dairy products, artificial sweeteners,
carbonated beverages
• decrease fluid intake at bedtime
• Regular prostatic massage may combat prostatic congestion
• Testosteron, if given, has produce improvement in the obstructive
symptoms by increasing vesical tone

23. Pharmacological Treatment
• Alpha-1-adrenergic antagonists
– appropriate and effective treatment alternatives for
patients with bothersome, moderate to severe LUTS
secondary to BPH (AUA-SI score ≥8(
– Relax smooth muscle in the bladder neck, prostate
capsule, and prostatic urethra
– Examples
• Terazosin, Doxazosin
– Initiate at bedtime (hypotension)
• Tamsulosin, Alfuzosin
– Lower potential to cause hypotension, syncope
– Major Side Effects
• HYPOTENSION!
• Ejaculatory Dysfunction (particularly Tamsulosin)

24. Pharmacological Treatment
• 5-alpha-reductase inhibitors
– 5-ARIs may be used to prevent progression of LUTS
secondary to BPH and to reduce the risk of urinary
retention and future prostate-related surgery
– Reduces the size of the prostate gland
– Prevents conversion of testosterone into
dihydrotestosterone (DHT)
– Indefinite treatment, as discontinuation may lead to
symptom relapse.
– Examples
• Finasteride (initiated and maintained at 5 mg once daily)
• Dutasteride
– Side Effects
• Sexual dysfunction
• Decrease PSA

25. Pharmacological Treatment
• Anticholinergics
– Use as monotherapy or in combination with alpha-
blockers for patients with predominantely irritated
symptoms related to overactive bladder
– Frequency, urgency, incontinence
– Examples
• Oxybutynin, Tolterodine
– Side Effects
• Dry mouth, blurred vision, tachycardia, constipation etc

26. Pharmacological Treatment
• Combination therapy
– Severe symptoms without maximal response to
maximal monotherapy
– Alpha 1 and anticholinergics
– Alpha 1 and reductase inhibitors

27. Drug Dosage Mechanism Side effects
Finasteride 5 mg OD 5-alpha-reductase
inhibitors
Impotence, decreased libido, decreased
semen quantity
Dutasteride 0.5 mg OD 5-alpha reductase
inhibitors
Impotence, decreased libido, decreased
semen quantity
terazosin 1 mg OD to
start; may
increase upto
10mg/day
Alpha-1-adrenergic
antagonists
Asthenia, hypotension, dizziness
Doxazosin 1 mg OD to
start; may
increase upto
8mg/day
Alpha-1-adrenergic
antagonists
Orthostatic hypotension, fatigue,
dysnoea
Tamsulosin 0.4 – 0.8 mg
OD
Alpha-1-adrenergic
antagonists
Dizziness, rhinitis, abnormal ejaculation
Alfuzosin 2.5mg TDS/
5mg BD/
10mg OD
Alpha-1-adrenergic
antagonists
Fatigue, oedema, rhinitis, headache,
URTI
Drugs with potential use in the management of BPH

28. Herbal Supplements
Herbal: Commonly available OTC supplements
– Saw palmetto extract (Serenoa repens)
– Pumpkin seed
– Pygeum africanum (African Plum)
Mineral:
– Zinc (however, no proven benefit)

29. Surgical approach
Indications:
• Bothersome symptoms despite treatment
• Acute retention: in fit men with no other cause for retention
• Chronic retention: a residual urine of 200 mL or more, a raised blood
urea, hydroureter or hydronephrosis
• Complication of BOO: stone, infection and diverticulum formation
• Prostatism: considerable frequency of micturition in day and night,
dysuria, delay in starting and poor stream – all indicate for
prostatectomy
• Haemorrhage: venous bleeding from a ruptured vein overlying the
prostate will recquire prostectomy
• Surgical approach will depend on:
• Patient’s prostate size
• Surgeon’s judgment
• Patient’s co-morbidities

30. Surgical approaches for prostatectomy
1. Retropubic
• is the enucleation of the hyperplastic
prostatic adenoma through a direct
incision of the anterior prostatic capsule.
In this operation the prostate is
approached through the retropubic space
infront of the bladder
2. Perineal
– An invertsd U-shaped incision
between the scrotum and anus
1. Suprapubic
• Suprapubic prostatectomy is the
enucleation of the hyperplastic prostatic
adenoma through an extraperitoneal
incision of the lower anterior bladder wall

31. Suprapubic
prostatectomy
Retropubic
prostatectomy

32. 4. Transurethral Resection of Prostate (TURP)
TURP is “Gold Standard” of care for BPH
Uses an electrical “knife” to surgically cut and remove excess
prostate tissue
Effective in relieving symptoms and restoring urine flow
Strips of tissue are cut from the bladder neck down to the level of the
verumontanum
Cutting is performed by a high-frequency diathermy current, which
is applied across a loop mounted on the hand-held trigger of the
resectoscope.
Coagulation of bleeding points can be accurately achieved, and
damage to the external sphincter is avoided provided one uses the
verumontanum as a guide to the most distal point of the resection

34. Complications of Prostatectomy
1. Haemorrhage: reactionary haemorrhage occurs after any type of
prostatectomy, so the bladder promptly washed out using strict
aseptic technique
Secondary haemorrhage may occur around the 10th postoperative day due
to urinary infection or over exertion of the patient
2. Infection
3. Epididymitis
4. Renal failure
5. Stricture of urethra or baldder neck
6. Incontinence and perforation
7. Retrograde ejaculation and impotence
8. Cardiac and respiratory complication: pulmonary atelectasis,
pneumonia, MI, congestive cardiac failureand deep venous
thrombosis
9. Osteitis pubis

35. Minimally invasive therapy for BPH
• Transurethral balloon dilatation of the prostate (TUBDP)
• Transurethral incision of the prostate (TUIP)
• Intraprostatic stent
• Transurethral microwave thermotherapy (TUMT)
• Transurethral needle ablation of the prostate (TUNA)
• Transurethral electrovaporization of the prostate (TUVP)
• Photoselective vaporization of the prostate (PVP)
• Cryotherapy
• Transurethral ethanol ablation of the prostate (TEAP)

36. Minimally invasive therapy for BPH
• Transurethral laser-induced prostatectomy (TULIP)
• Visual laser ablation of the prostate (VLAP)
• Contact laser prostatectomy (CLP)
• Interstitial laser coagulation of the prostate (ILC)
• Holmium:YAG laser resection of the prostate (HoLRP)
• Holmium:YAG laser enucleation of the prostate (HoLEP)
• High-intensity focused ultrasound (HIFU)
• Coagulation
• Botulinum toxin-A injection of the prostate

37. TUIP:
 Indicated for the management of BOO secondary to a small
prostate esp. in younger men. The advantage is that antegrade
ejaculation is preserved
Intraurethral stents: are now being used in the management of
retention who are grossly unfit for surgery
Ballooof prostaten dilatation:
 It is simply performed, it is safe, minimal hospitalization, it
does not produced retrograde ejaculation.
 It is not used in decompensated bladder ,UTI, long large gland,
prominent middle lobe.

38. Hyperthermia:
 Prostate is susceptible to desiccation. Microwave hyperthermia
has been employed both transrectally and transurethrally.
Laser Treatment: two method has been used
 Non contact probe method: in this the probe is used to vaporize
the prostatic tissue under direct vision. Its advantage is that the
bleeding is minimal.
 Contact side-firing laser: in this method lower energy is used in
laser with greater penetration. This causes necrosis of the
prostate gland. The necrotic tissue slough out and a suprapubic
catheter is kept for several weeks for this purpose