2 Normal Prostate Anatomy Prostate weights ~20gMeasures ~3 by 4 by 2 cmApex = inferior portion of prostate, continuous with striated sphincter. Base = superior portion and continuous with bladder neck.
3 PROSTATE histology Prostatic tissue is formed of two components : fibromuscular tissue (30%)glandular epithelial cells (70%)
4 Normal histology of prostate: formed of glands and fibromuscular stroma
5 Normal histology of the prostate formed of glands and stroma glands: lined by two layers of cells which are inner cuboidal cells and outer basal cells stroma :fibro muscular stroma
6 Prostate zones Central zone (CZ) Cone shaped region that surround the ejaculatory ducts (extends from bladder base to the verumontanum)Only 1-5% of prostate cancer from this region .Peripheral zone (PZ)Posteriolateral prostateMajority of prostatic glandular tissueOrigin of up to 70% of prostate adenocarcinomaTransitional zone (TZ)Surrounds the prostatic urethraCommonest site for benign prostatic hyperplasia.
9 What causes BPH?BPH is part of the natural aging process, like getting gray hair or wearing glassesBPH cannot be preventedBPH can be treatednnn
10 Half of all men over the age of 60 will develop an enlarged prostate. By the time men reach their 70’s and 80’s, 80% will experience urinary symptomsBut only 25% of men aged 80 will be receiving BPH treatment
11 BPH Proposed Etiologies 1-alterations in the testosterone/estrogen balance:enlarged prostate may be caused by lower levels of testosterone (male hormone) production in middle to old age. As men age, the levels of testosterone in their blood decreases, leaving a higher proportion of estrogen (female hormone), so a higher amount of estrogen within the prostate gland can increase activity that promotes cell growth.2-Induction of prostatic growth factors.3- Increased stem cells/decreased stromal cell death
12 Benign Prostatic Hypertrophy (BPH)—Pathophysiology Common in older men; varies from mild to severeChange is actually hyperplasia of prostateNodules form around urethraNot change to cancer prostate.Rectal exams reveals enlarged glandIncomplete emptying of bladder leads to infectionsContinued obstruction leads to distended bladder, dilated ureters, renal damageIf significant, surgery required
14 What’s Lower Urinary Tract Symptoms secondary to prostatic urethra obstruction? Abnormal Voiding (obstructive)symptomsHesitancyWeak streamStraining to pass urineProlonged micturitionFeeling of incomplete bladder emptyingUrinary retentionStorage (irritative orfilling) symptomsUrgency:an increasingly strong desire to void)FrequencyNocturiaUrge incontinenceLUTS can arise from a variety of causes, for example as a consequence of prolonged urinary obstruction due to BPH.LUTS are categorised as being obstructive (voiding) or irritative (storage) symptoms.Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention.Irritative symptoms include urgency, frequency, nocturia, and urge incontinence. LUTS may also be due to inflammatory or infectious processes.LUTS is not specific to BPH – not everyone with LUTS has BPH and not everyone with BPH has LUTS
15 BPH—Signs and Symptoms Initial signsObstruction of urine flowHesitancy : delay between trying to urinate and the flow actually beginning.dribblingdecreased force of urine streamIncomplete bladder emptyingFrequency,nocturia : need to urinate at nightrecurrent Urinary Tract Infections
16 BPH complicationshypertrophy of the prostatedetrussor muscle of the bladder undergo hypertrophy to overcome the obstruction in the prostatic urethra. Later on decompensation occur .Increase pressure inside bladderdiverticula formationincreasing urine retentionhydronephrosis renal failure.
19 Diagnosis of BPH Symptom assessment Digital rectal examination(DRE) inaccurate for size but can detect shape and consistencyProstate Volume (PV) determination by ultrasonographyUrodynamic analysisMeasurement of prostate-specific antigen (PSA)high correlation between PSA and PV,men with larger prostates have higher PSA levelsPSA is a predictor of disease progression and screening tool for Cancer Prostate.as PSA values tend to increase with increasing Prostatic Volume and increasing age, PSA may be used as a prognostic marker for BPH.The initial evaluation can be done either by a Primary Care Practitioner (PCP) or by a urologist. If the initial evaluation suggests a diagnosis of BPH, the physician can proceed to develop an appropriate treatment plan. The physical examination should include specific attention to the presence or absence of a distended bladder, urethral discharge, genital abnormalities, and neurologic abnormalities that can affect voiding. A digital rectal examination (DRE) is considered an important part of the physical examination of any patient complaining of symptoms of prostatism. This examination is conducted with a well-lubricated, gloved index finger, which is used to palpate the prostate gland and the surrounding tissues through the wall of the rectum. Because of the prevalence of prostatic disease in older men, many physicians conduct DREs as part of the routine annual physical examination of any man over the age of 50 years. The size, consistency, shape, and symmetry of the prostate gland can be felt through the rectal wall during a DRE. Several questionnaires are used to assess the severity of symptoms and their impact on a patient’s QoL. American Urology Association-Symptom Score (AUA-SI) or International Prostate Symptom Score (IPSS), QoL score and BPH-II. In men with symptoms of BPH, a urine sample should be examined for signs of a urinary tract infection or haematuria, both of which suggest a non-BPH cause for the LUTS. Both urinary tract infections and bladder cancer can produce symptoms similar to those produced by BPH.
20 BPH : show marked hyperplasia in the number of prostatic glands
21 When should BPH be treated? BPH needs to be treated ONLy IF:Symptoms are severe enough to bother the patient and affect his quality of lifeComplications related to BPHnn
22 Treatment options 1- Transurethral resection of the prostate (TURP) Medication :α blockers - relax the smooth muscle of prostate and provide a larger urethral openingSurgical approaches1- Transurethral resection of the prostate (TURP)2- Open simple prostatectomynnn
23 Indication of surgical intervention Acute urinary retentionGross hematuriaFrequent urinary tract infection (UTI)Vesical stoneBPH related hydronephrosis or renal function deteriorationObstruction
24 Differential Diagnosis of BPH(i Differential Diagnosis of BPH(i.e from other causes of urinary obstruction)Urethral strictureBladder neck contractureCarcinoma of the prostateCarcinoma of the bladderBladder calculiUrinary tract infection and prostatitisNeurogenic bladder