Benign Prostatic Hyperplasia BPH

1. Yedishtra Naidoo MSIV KMC April 2010

2. Anatomy

5. Anterior lobe (or isthmus) roughly corresponds to part of transitional zone Posterior lobe roughly corresponds to peripheral zone Lateral lobes spans all zones Median lobe (or middle lobe) roughly corresponds to part of central zone

7. DHT

10. Slit

11. Ball valve

12. Pathogenesis Androgen: -Androgen Receptors are located primarily in epithelial cells of normal prostate tissue, but in hyperplastic glands ARs are distrubted in epithelial and stromal cells. - Men with 5AR2 deficiency have rudimentary prostates throughout life. - Similar DHT levels in BPH and non BPH. - DHT is necessary but not sufficient to cause BPH. Estrogen: - Conflicting evidence. - 86 men between 52 and 82 years of age, TZ volume correlated w increasing serum estrone. Dysregulation of stromal growth factors: Prostate reverts embryonic state sensitive to IGF2 and TGFB stimulating growth. Anti-apoptosis: Involving bcl-2 disinhibition. Genetics:-Survey Olmsted County, Minnesota, 21 percent of 2,119 men between 40 and 70 years of age had a family history of an enlarged prostate (1) -Case-control study of men under 64 years of age who had undergone prostatectomy for BPH and in whom more than 37 grams of tissue was resected The first-degree relatives of these men had a four-fold increased risk of developing BPH that required surgical therapy as compared with the relatives of normal men. (2).

16. -Voiding diary that includes nocturia, diuria and void volume may provide more meaningful information of prostate volume and maximum urinary flow rates than AUA symptom score. -International Prostate Symptom Score (IPSS) uses the same questions and scale as the AUA symptom score and adds a disease-specific quality of life question: "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?"

17. Physical Exam Digital Rectal Exam (DRE): - Use index finger of dominant hand in windshield wiper mov’t. - Each finger breath is approx 15-20g of tissue, most asymptomatic men </=2 finger breaths. - Assess size, contour, anal sphincter tone. - BPH: Rubbery, uniformly enlarged. -Malignancy: nodules, asymmetry, induration. - Prostatic abscess: fluctuance - Prostatitis: pain. Suprapubic: Bladder distension Neurologic Exam: Sensory or motor deficits of lower extremity and anal sphincter.

18. Work-up Urinalysis: Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. If blood is detected, hematuria workup. Urine C&S Serum PSA: - measured in men 50-69 - <4 ng/ml is cut-off. -Men at risk for BPH are also at risk for prostate ca. - Linear rise in PSA with prostate size - DRE + PSA = most acceptable means of excluding prostate ca.

19. Optional Studies

20. Medical Treatment