cp2 - urology - bph

7/31/2019 CP2 - Urology - BPH

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BENIGN PROSTATIC HYPERPLASIA (BPH):

Urological Aspects

Dr. Taha Abo-Almagd

Associate Professor and Consultant

Department of Urology


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Learning objectives

Zonal anatomy of the prostate

Pathophysiology and complications of BPH

Symptoms and signs of BPH Evaluation of BPH

Treatment of BPH


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Content of the lecture

Anatomical aspects

Incidence and Epidemiology of BPH

Pathology Pathophysiology

Symptoms and signs

Investigations Treatment


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Anatomy of

Prostate


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Gross appearance ofhyperplastic prostatic tissueobstructing the prostaticurethra forming lobes.

A, Isolated middle lobeenlargement.

B, Isolated lateral lobeenlargement.

C, Lateral and middle lobe

enlargement.

D, Posterior commissuralhyperplasia (median bar).


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Zonal anatomy of the prostate (J. E. McNeal , Am J Surg Pathol 1988;12:619-633). The transition zone surrounds the urethra proximal to the ejaculatory ducts.

The central zone surrounds the ejaculatory ducts and projects under the bladder base.

The peripheral zone constitutes the bulk of the apical, posterior, and lateral aspects of the prostate.

The anterior fibromuscular stroma extends from the bladder neck to the striated urethral sphincter.

BPH uniformlyoriginates in the

transition zone.


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The prostate is composed of both:

stromal and epithelial elements

Each, either alone or in combination, can give riseto hyperplasia and the symptoms associated with

BPH The stroma is composed of smooth muscle and

collagen, rich in adrenergic nerve supply

The level of autonomic stimulation sets a tone tothe prostatic urethra

Each element may be targeted in medicalmanagement schemes


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Incidence and Epidemiology of BPH

BPH is the most common benign tumor in men, and itsincidence is age related.

The prevalence of histologic BPH in autopsy studies: 4150: 20%

51-60: 50%

Above 80: > 90%

Clinical BPH is also age related: At age 55: 25%

At age 75: 50%


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Risk factors

Risk factors for the development of BPH arepoorly understood.

Some studies have suggested a geneticpredisposition, and some have noted racialdifferences.

Approximately 50% of men under the age of 60who undergo surgery for BPH may have aheritable form of the disease. This form is most

likely an autosomal dominant trait, and first-degree male relatives of such patients carry anincreased relative risk of approximately fourfold.


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Etiology

The etiology of BPH is not completely understood.

Multifactorial and endocrine controlled.

Observations and clinical studies in men have clearly

demonstrated that BPH is under endocrine control.

Castration results in the regression of established

BPH and improvement in urinary symptoms.

Additional investigations have demonstrated apositive correlation between levels of free

testosterone and estrogen and the volume of BPH.


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Pathology

BPH is truly a hyperplastic process (increase in cell number).

Microscopic evaluation reveals a nodular growth pattern that iscomposed of varying amounts of stroma and epithelium.

Stroma is composed of varying amounts of collagen and

smooth muscle.

The differential representation of histologic components of BPHmay explain the potential responsiveness to medical therapy.

Alpha-blocker therapy may result in excellent responses in patients with BPH

that has a significant component of smooth muscle.

5-alpha-reductase inhibitors might give better results in patients with BPH

predominantly composed of epithelium.

Patients with significant components of collagen in the stroma may not respond

to either form of medical therapy.

Unfortunately, responsiveness to a specific therapy is not

reliably predictable.


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Pathophysiology

Symptoms of BPH are related to either:

obstructive component of the prostate or

secondary response of the bladder to outlet resistance.

The obstructive component can be subdivided into:

Mechanical obstruction. Dynamic obstruction.

Mechanical obstruction may result from intrusioninto the urethral lumen or bladder neck, leading to a

higher bladder outlet resistance. The dynamic component results from the effect of

smooth muscle fibers (regulated by alpha adrenergicinnervation) and collagen.


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Secondary response of the bladder to

the increased outlet resistance:

Bladder outlet obstruction leads to:

detrusor muscle hypertrophy, hyperplasia and collagen

deposition.

Grossly, detrusor muscle bundles are thickened and

seen as:

Trabeculations Diverticula (mucosal herniations between detrusor

muscle bundles , composed of only mucosa and serosa)

Resulting: irritative voiding symptoms (see below).

Pathophysiology


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Lower Urinary Tract Symptoms (LUTS)

Irritative Symptoms

frequency

Nocturia

Urgency

Urge incontinence

Dysuria: painful urination

Obstructive Symptoms

Hesitancy

Weak stream

Interrupted stream

Need to strain

Post void dribbling

Prolonged voiding time Sense of incomplete void

Double void

AUR

SYMPTOMS


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SIGNS DRE (Digital rectal examination).

Focused neurologic examination.

Size and consistency of the prostate are noted.

BPH usually results in a smooth, firm, elasticenlargement of the prostate.

Induration must alert the physician to possibility ofcancerand the need for further evaluation (ie,prostate-specific antigen [PSA], transrectal ultrasound[TRUS], and biopsy).

Prostate size does not correlate withseverity of symptoms or degree of

obstruction.


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LABORATORY FINDINGS

Urinalysis to exclude infection or hematuria.

Serum creatinine measurement to assess renalfunction: Renal insufficiency may be observed in 10% of

patients with LUTS and warrants upper-tract imaging.

Patients with renal insufficiency are at an increasedrisk of developing postoperative complicationsfollowing surgical intervention for BPH.

Serum prostate specific antigen (PSA):

increases the ability to detect prostate cancer. there is much overlap between levels seen in BPH and

cancer.

Normal is 0 4 ng/ ml


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IMAGING

Upper-tract imaging (intravenous pyelogram

or renal ultrasound) is recommended onlyin

presence of concomitant urinary tract disease

or complications from BPH:

hematuria,

urinary tract infection,

renal insufficiency (U/S),

history of stone disease.


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Urodynamic Studies

Measurement of

flow rate,

post-void residual urine,

pressure-flow studies are considered optional.

Cystometrograms and detailed urodynamic

profiles are reserved for patients withsuspected neurologic disease or those whohave failed prostate surgery.


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Cystoscopy

Cystoscopy is not recommended to determine

the need for treatment.

May assist in choosing the surgical approach inpatients opting for invasive therapy.


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Differential Diagnosis Other obstructive conditions of the lower urinary tract:

urethral stricture

bladder neck contracture

bladder stone

prostate cancer

A history of previous urethral instrumentation, urethritis, or trauma shouldbe elucidated to exclude urethral stricture or bladder neck contracture.

Hematuria and pain are commonly associated with bladder stones. Prostate cancer may be detected by abnormalities on the DRE or an

elevated PSA.

Urinary tract infections, which can mimic the irritative symptoms of BPH,can be readily identified by urinalysis and culture; however, urinary tractinfections can also be a complication of BPH.

Bladder cancer, especially carcinoma in situ, (irritative voiding symptoms):urinalysis usually shows evidence of hematuria.

Neurogenic bladder disorders: history of neurologic disease, stroke,diabetes mellitus, or back injury and simultaneous alterations in bowelfunction (constipation) may be present. In addition, examination may show

diminished perineal or lower extremity sensation or alterations in rectalsphincter tone or the bulbocavernosus reflex.


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TREATMENT

WATCHFUL WAITING

MEDICAL THERAPY

CONVENTIONAL SURGICAL THERAPY

MINIMALLY INVASIVE THERAPY


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For mild symptoms watchful waiting only is

advised.

The risk of progression or complications is

uncertain.

However, in men with symptomatic BPH, it is clear

that progression is not inevitable

some men undergo spontaneous improvement orresolution of their symptoms.

TREATMENT: WATCHFUL WAITING


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Alpha-blockers

5-Alpha-reductase inhibitors

Combination Therapy Phytotherapy

TREATMENT: Medical Treatment


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The human prostate and bladder base contains alpha-1-adrenoreceptors, and the prostate shows a contractileresponse to corresponding agonists.

The level of autonomic stimulation thus sets a tone to theprostatic urethra. Use of alpha-blocker therapy decreases

this tone, resulting in a decrease in outlet resistance. Alpha-blockade has been shown to result in both objective

and subjective degrees of improvement in the symptomsand signs of BPH in some patients.

Identification of subtypes of alpha-1-receptors (alpha-1a

receptors) , which are localized in the prostate and bladderneck, and selective blockade of them results in fewersystemic side effects (orthostatic hypotension, dizziness,tiredness, rhinitis, and headache).

Medical Treatment: Alpha-blockers


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Block the conversion of testosterone to

dihydrotestosterone. This drug affects the epithelial component of the

prostate, resulting in a reduction in the size of thegland and improvement in symptoms.

Six months of therapy are required to see the

maximum effects on prostate size (20% reduction) andsymptomatic improvement.

Symptomatic improvement is better seen in men withenlarged prostates (>30 ml).

Side effects include decreased libido, decreasedejaculate volume, and impotence.

Serum PSA is reduced by approximately 50% in patientsbeing treated with 5-Alpha-reductase inhibitors

Medical Treatment: 5-Alpha-reductase inhibitors


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Absolute surgical indications include:

Refractory urinary retention (failing at least oneattempt at catheter removal)

Recurrent urinary tract infection

Recurrent gross hematuria

Bladder stones

Renal insufficiency

Large bladder diverticula with narrow neck

TREATMENT: CONVENTIONAL SURGICAL THERAPY

CONVENTIONAL SURGICAL THERAPY


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Transurethral resection of the prostate (TURP)

90% of simple prostatectomies

Complications of TURP include bleeding, perforation of the

prostate capsule with extravasation, and if severe, TUR syndrome.

Late complications: retrograde ejaculation, impotence,

incontinence, urethral stricture or bladder neck contracture, Transurethral incision of the prostate

moderate to severe symptoms and a smallprostate

This procedure is more rapid and less morbid than TURP

Open simple prostatectomy (Enucleation) When the prostate is too large to be removed endoscopically

(usually >100 g).

Large bladder stone

Large bladder diverticula

TREATMENT: CONVENTIONAL SURGICAL THERAPY


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Laser Therapy

Transurethral electro-vaporization of the prostate

Hyperthermia Transurethral needle ablation of the prostate

(TUNA)

High-intensity focused ultrasound Prostatic Stents

TREATMENT: MINIMALLY INVASIVE THERAPY


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Independent learning from textbooks

Toronto Notes 2010

Smiths General Urology

Seventeenth Edition (2008)

Editors: Emil A. Tanagho, MD

Jack W. McAninch, MD, FACS

a LANGE medical book


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Independent learning from theInternet

http://emedicine.medscape.com/article/4373

59-overview


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Self- Assessment

1. BPH uniformly originates in :

a) The peripheral zone

b) The central zone

c) The transition zone

d) The central and transition zones

e) Any of the above zones


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Self- Assessment

2. Absolute surgical indications include all of

the followings EXCEPT:

a) Refractory urinary retention

b) Recurrent urinary tract infection

c) Recurrent gross hematuria

d) Renal insufficiency

e) Any bladder diverticula


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Self- Assessment

3. Treatment options of BPH include all of the

followings EXCEPT:

a) Alpha-blockers

b) 5-alpha reductase inhibitors

c) Radical prostatectomyd) Transurethral resection of the prostate

e) Watchful waiting


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Thank You

cp2 - urology - bph

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