Benign prostate hyperplasia Div. of Urology, Dept. Surgery Medical Faculty, University of Sumatera Utara

Ref : Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3 rd ed, 2001 Smith’s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15 th ed, 2000

Definition Regional nodular growth of varying combinations of glandular and stromal proliferation that occurs in almost all men who have testes and who live long enough

TERMINOLOGY BPH (Benign Prostatic Hyperplasia): histopathologic diagnosis BPE (Benign Prostatic Enlargement) : anatomic diagnosis BOO (Bladder Outlet Obstruction): anatomic diagnosis BPO (Benign Prostatic Obstruction): BOO caused by BPE LUTS (Lower Urinary Tract Symptoms): clinical manifestation of lower urinary tract obstruction

Introduction Common non-neoplastic lesion. Involves peri urethral zone. BPH is common as men age. 25% by 50y, but 90% By 80y..! About 10% are symptomatic.

Prevalence The Most Frequent Benign Tumor in Men 70 % of men above 60 years.* 90 % of men above 80 years.** 30 – 40 % of men above 70 years Indonesia : The Second after Stone Disease in Urology Clinic *** * Berry SJ et all J Urol 1984 ;132: ** Carter HB, Coffey DS. Prostate 1990;16 : *** Rahardjo D,Birowo P,Pakasi LSMed. J of Ind 1999 ; 8(4) :

Impact of ageing population With life expectancy approaching 80 years in many countries  88% chance developing histological BPH  in life expectancy  significantly  the number of men affected by BPH The number of men presenting with BPH symptoms will  ± 45% in the next 10 years and  further in the following decade

Prevalence of histological BPH with age 11% 29% 48% 77% 87% 92% – 4041 – 5051 – 6061 – 7071 – Berry SJ et al. J Urol 1984; 132: 474–9 Prevalence (%)

Anatomy N weight about 20 g Classification of Lowsley : 5 lobes : anterior, posterior, median, right lateral, left lateral According to Mc Neal : - peripheral zone - central zone - transitional zone - an anterior segment - a preprostatic sphincter zone

Causes -Many theories -The actual cause still not clear -Factors are known to be important: 1.Male sex 2. Aging 3.Testosterone 4.Growth Factors (EGF, FGF, IGF II)

Pathophysiology Nodular hyperplasia of glands and stroma. Normal 20 to 30  50 to 100 gm. Press upon the prostatic urethra. Obstruction - difficulty on urination Dysuria, retention, dribbling, nocturia Infections, hydronephrosis, renal failure. Not a premalignant condition*

Prostate growth Increased urethral resistance Decompensation Flow ↓ Bladder emptying ↓, hesitancy, intermittency

Mechanism Hormonal imbalance with ageing. Estrogen sensitive peri-urethral glands. Accumulation of DHT in the prostate and its growth-promoting androgenic effect Some Drugs (Finasteride) inhibit DHT  diminishes prostatic enlargement.

Morphology Microscopically, nodular prostatic hyperplasia consists of nodules of glands and intervening stroma. (Mostly glands) The glands variably sized, with larger glands have more prominent papillary infoldings. Nodular hyperplasia is NOT a precursor to carcinoma.

Symptoms LUTS Weaker, smaller stream Hesitancy Intermittent / interrupted flow Feeling of incomplete emptying or retention Terminal dribbling Nocturia Frequency Urgency dysuria Symptoms may worsen with alcohol and caffeine, cold remedies

How to Assess the Patient?

Diagnosis Anamnesis Cardinal symptoms: Weak Stream Frequency Nocturia S torage symptoms, Voiding Symptoms Scoring System : M.I, IPSS

IPSS (International Prostate Symptom Score ). 0 – 7 : Mild : Moderate 20 – 35 : Severe  7 : Watchful & Waiting  7 : Medical treatment

Diagnosis Physical examination : DRE Prostate : 1. Size 2. Nodule 3. Consistency 4. Tenderness

DRE

Diagnosis Uroflowmetry Qmax Voided volume Residual urine TAUS Catheter

Uroflowmetry

Lab test Blood Count Serum Electrolyte Serum Creatinine Serum PSA Urine: Proteinuria Sediment Culture

IMAGING TRUS Transabdominal Ultrasound With Indication : IVP Cystography CT-Scan MRI

Trans Rectal Ultra Sonography : Volumometry Identification of hypoechoic lesions Calcification Periprostatic vein

Urethral stricture Bladder neck contracture Small bladder stone Locally advanced prostate ca Poor bladder contractility Differential diagnosis

Effects of benign prostatic obstruction Irreversible bladder changes Thickening of the bladder wall Recurrent haematuria Bladder diverticulum formation Repeat urinary tract infections Bladder stone formation Upper tract dilatation Renal impairment

Complications Increased risk of UTI due to urinary retention Calculi due to alkalinization of residual urine Hematuria due to overstretched blood vessels Pyelonephritis Renal failure

Indication for treatment Absolute or near absolute : - refractory or repeated urinary retention - azotemia due to BPH - recurrent gross hematuria - recurrent or residual infection due to BPH - bladder calculi - large residual urine - overflow incontinence - large bladder diverticula due to BPH

Treatment Watchful waiting Medical therapies Intervention therapies Minimally invasive therapies Surgical therapies

Watchful waiting Altering modifiable factor such as: –Concomitant drug –Regulation of fluid intake especially in the evening –Life style change (avoid sedentary life) –Dietary advice (avoid excessive intake of alcohol, and highly seasoned or irritative foods) Evaluation/ monitoring : after 6 months/ 1 year IPSS, uroflowmetry, post-void residual urine volume

Medical therapy I.P.S.S. > 7 Flow > 5 ml/s Residual urine < 100 ml No hard nodule PSA < 4 ng/dl

Medical therapy Reducing smooth muscle tone (dynamic component) : α-1 adrenergic blocker Short acting : prazosin, afluzosin Long acting : doxasosin, terazosin, tamsulosin Reducing prostatic mass (static component): 5α redutase inhibitor (finasteride, epristeride) estrogen aromatase inhibitor LHRH agonist / antagonist GF inhibitor antiandrogens Unknown phytotherapy

Adrenergic stimuli Alpha adrenergic stimuli increases tonus of smooth muscle cell in the trigonum, bladder neck and prostate Location of alpha receptor: –Bladder –Trigonum –Prostate gland

Mode of action alpha blocking agent Alpha adrenergic blocking agent blocks adrenergic stimuli  relaxation of the smooth muscle cell: –intra urethral pressure  –Improvement of urine flow

Sintesis Protein Reseptor Inti + Transkripsi DNA TDHT 5-α reductase Hipotalamus LHRH ACTH DHT Rationale of 5Alpha reductase inhibitor

Invasive Treatment for BPH Absolute indication: Chronic Retention With Hematuria Concomitant Bladder stone Intractable UTI Deteriorating kidney function Relative indication: Huge PVR due to obstruction or low Qmax Refuse medical treatment Failure in medical treatment

Intervention therapy Minimally invasive therapy –Thermotherapy TUNA (Trans Urethral Needle Ablation) HIFU (High Intensity Focused Ultrasound) TUMT (Trans Urethral Microwave Theraphy) Laser –Stent Surgical therapy TUIP (Trans Urethral Incision of the Prostate) TURP (Trans Urethral Resection of Prostate) Open prostatectomy TUVP (Transurethral Vaporization of the Prostat) Laser

Invasive Treatment for BPH TURP (gold standard) Laser resection (Hol YAG Laser)

TURP

JARINGAN PROSTAT

TUIP