This document discusses benign prostatic hyperplasia (BPH). It begins with the anatomy of the prostate gland and defines BPH as non-malignant prostate tissue growth due to aging. Risk factors for BPH include increasing age and family history. Clinical evaluation involves history, physical exam including digital rectal exam, and testing like PSA and ultrasound. Treatment options range from lifestyle changes and medications like alpha blockers and 5-alpha-reductase inhibitors for mild-moderate BPH to surgical interventions like TURP for severe cases. The document provides details on evaluation and management approaches for BPH.

1. Benign Prostatic Hyperplasia
Presented by
Dr. IBRAHIM HAKAMI

2. Objectives :
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Anatomy of the prostatic gland
What’s Benign Prostatic Hyperplasia ?
Approach to patient with BPH.
History, Examination, Investigation, Management.
Indications For Referral.
Prevalence of BPH

3. Anatomy of The Prostatic Gland

4. About Prostatic Gland
Male sex gland
Pear-shape, weight 7-16 gm
Size of walnut
Help to control urine outflow.
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Produces fluid component of the
semen.
Produces prostate specific antigen
(PSA)

6. The prostate gland is made up of differe
nt types of cells:
- gland cells that produce the fluid
portion of semen.
-muscle cells ( epithelial ) control
urine flow and ejaculation.
-fibrous cells ( stromal )provide the
supportive structure of gland.
Prostatic Gland

7. Benign Prostatic Hyperplasia

8. What’s Benign Prostatic Hyperplasia ?
Benign prostatic hyperplasia (BPH) refers to neoplastic,
non- malignant proliferation of the prostatic tissue surrounding the urethra.
BPH is a condition that occurs in aging men as the prostate gland
undergoes exposure to androgenic and estro- genic stimulation over time.
Other names include:
• Benign prostatic hypertrophy.
• Enlarged prostate.
• BPH.

9. NORMAL PROSTATE VS BPH

10. NORMAL PROSTAT VS BPH

11. Prevalence of BPH
Male in their 30s
8%
Male in their 50s
50%
Male in their 80s
80%

13. RISK FACTORS
• Age.
• Family Hx.
• Black Men.
• Use Of Beta-blockers.
• Lack Of Physical Exercise.
• Obesity.
BPH does not predispose to the development of
prostate cancer.

14. Approach to patient with
BPH

15. Clinical Manifestations. (LUTS)
Voiding Symptoms
Straining
Dribbling At The End Of Urination
Decrease In The Urinary Stream
Hesitancy
Burning During Urination
Feeling Of Incomplete Bladder E
mptying.
Irritative Symptoms
Frequency
Urgency
Dysuria
Nocturia
Incontinence

16. Differential Diagnosis
• Urethral stricture
• Bladder neck contracture
• Carcinoma of the prostate
• Carcinoma of the bladder
• Bladder calculi
• Urinary tract infection and prostatitis
• Neurogenic bladder

17. Complete Hx Taking.
• The goals of the history are to clarify symptoms consistent with BPH
and exclude conditions that mimic BPH.
• Important point for pt. with symptoms of BPH.
1. Onset and duration of symptoms.
2. Urethral or bladder trauma (including instrumentation).
3. STDs
4. Fever, dysuria, gross hematuria, pain suggestive of stones.

18. Important Hx. point for pt. with symptoms of BPH.
5. Medication use is helpful because medications account for 10%
of LUTS in men.
6. DM, tobacco use, intake of bladder irritants (e.g., Caffeine),
7. Sexual dysfunction, or conditions resulting in neurologic impairm
ent (e.g., Neurogenic bladder),
8. Family history of prostate or bladder cancer.

19. Physical examination
The examination for suspected BPH focuses on the:
ABDOMEN
Genital
area
RECTUM

20. Digital rectal examination (DRE)
• A digital rectal examination is recommended by the
American Urological Association (AUA).
• Performed to assess the size, consistency, and
shape of the prostate .
• Nodularity, and asymmetry, which may raise
suspicion for malignancy.

21. Investigation
Urinalysis.
Serum prostate-specific antigen (PSA).
U/S of the prostate.
Serum Cr. is not indicated.
because the incidence of baseline renal in
sufficiency in men with BPH is similar to th
at in the general population.

22. Investigation (optional)
Post-void residual urine should be performed if
history and physical examination suggest urinary
retention.
Uroflowmetry
Urine cytology

23. Uroflowmetry

24. Management of BPH

25. Management :
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Behavioral modification
Pharmacological treatment
Herbal therapy
Surgical or invasive management
Indications of referral
01 Severity Guide Management

26. AUA symptom score
# Used to :
-assess the severity of symptoms of BPH.
-measure the outcome of BPH treatments.
# It consists of 7 questions:
1-Frequency 2-nocturia
3-weak urinary stream 4-hesitancy
5-incomplete emptying 5-intermittence
7-urgency

27. Severity Guide
Management.
0-7
8-19
20+
Mild
Moderate
Severe

28. Behavioral modification
Mild to moderate symptoms with little ”bother” Manage with
watchful waiting & lifestyle modification :
• Losing weight.
• Decreasing evening fluid intake.
• Avoiding excess alcohol, caffeine, or highly seasoned foods
• Limiting medications that cause lower urinary tract symptoms.
• Double voiding to empty the bladder more completely.

29. Pharmacological Treatment
Alpha blockers.
 5-alpha-reductase inhibitors.
 Anticholinergic agents.

30. Alpha blockers.
Tamsulosin
Prazosin
Terazosin
Alfuzosin
Doxazosin

31. Alpha blockers.
Mild to moderate symptoms of BPH whose symptoms have a
sufficient effect on quality of life we suggest initial treatment with
Alpha blockers. (Grade 2A).
MOA:
Relaxing smooth muscle in the bladder neck,prostate capsul
e, and prostatic urethra.
Side effects:
• Hypotension, dizziness.
• Ejaculatory Dysfunction.
• Interaction with phosphodiesterase-5 inhibitors
The AUA recommends avoidance of all alpha blockers in men with planned catara
ct surgery because of the risk of intraoperative floppy iris syndrome.
2 to 4 weeks after initiation

32. 5-alpha-reductase inhibitors.
Finasteride
Dutasteride

33. 5-alpha-reductase inhibitors.
MOA:
block the conversion of testosterone to dihydrotestosterone, resulting in a gradual decr
ease in prostatic volume.
The combination of alpha blockers and 5-alpha reductase inhibitors is eff
ective for long-term management of BPH and demonstrated large prostate
s.
Side effects.
• Ejaculation Disorder, Decreased Libido.
• Erectile Dysfunction
Decrease PSA About 50% 3 to 6 months

34. Anticholinergic agents.
Tolterodine
Oxybutynin
Darifenacin
Trospium
Solifenacin

35. Anticholinergic agents.
MOA:
Anticholinergic agents block the effects of acetylcholine on muscarinic rece
ptors in the bladder, resulting in decreased bladder contractions.
Side effects.
• Dry mouth and eyes.
• constipation.

37. Herbal therapy.
Data of herbal therapies for BPH are confl
icting.
Commonly used in Europe.
Until additional studies of herbals are perfo
rmed, we do not suggest using these f
or the treatment of BPH.
No herbal therapies have been approved
by the FDA for BPH.

38. Surgical Or Invasive Management.
Out-patient based therapies:
• Transurethral microwave therapy (TUMT)
• Transurethral needle ablation (TUNA)
OR based therapies:
• Open simple prostatectomy.
• Transurethral Resection Of The Prostate TURP.
• Transurethral incision of the prostate.
• Laser photoselective vaporization of the prostate (PVP).
• Laser Prostatectomy.

39. Surgical Or Invasive Management.
Is considered the gold-standard surgical tr
eatment for BPH.
Transurethral Resection Of The Prostate (TURP)

42. Postoperative guidelines for the patient
 There may be urgency even to the point of incontinence for a few
days.
 Bleeding can occur intermittently for 3 weeks, so increase fluid i
ntake.
 Avoid intercourse for 3 weeks.
 Orgasms continue but there is usually no emission with ejaculati
on. The semen is ejaculated back into the bladder.

44. Indications For Referral.
 Complications of Bladder outflow Obstruction :
-upper tract (hydronephrosis , renal insufficiency)
-lower tract (urinary retention, recurrent UTI )
- bladder decompensation
 Symptoms following invasive treatment of the urethra or prostate.
 Abnormality on prostate exam (nodule, induration, asymmetry)
 Hematuria.
 Bladder calculi.

46. References

47. THANK YOU