Benign prostatic hyperplasia BPH

*BPH is the most common benign tumor in men. *Its age related disease. ( when the hair become grey &scanty, when specks of earthy matter begin to deposit in tunica of artery, when white zone is formed at the margin of cornea, at this same period the prostate gland usually, if not invariably, enlarge.)

Etiology. Is not completely understood, but it seem to be multifactorial, including age & endocrine. *risk factors are genetic & race. Pathology. The prostate composed of -stroma (smooth muscle & fibrous tissue) and -epithelium. BPH can arise from any one of them or in combination

Anatomically the prostate had 3 zones -peripheral (70%) of the prostate commonest site for Ca, -central (25%) around ejaculatory duct, & -transitional (5%) periurethral. BPH uniformly originate from the transitional zone & as the nodule enlarge compress the outer zones of the prostate resulting in surgical capsule.

Clinical features Either obstructive or irritative. obstructive symptoms -hesitancy, -decrease force & caliber of stream, -sensation of incomplete bladder emptying, -double voiding (urinating a second time within 2 hr. of the previous void), -straining to urinate, & post void dribbling. -retention may occur usually precipitated by prostatic infection or infarction, ingestion of diuretic, anticholenergic, antidepresent,& tranquilizer, and prolong postponement of voiding

Irritative symptoms urgency, frequency, & nocturia. * The amount of post void residual urine is extremely variable in sequential evaluation of same patient. DRE, used to determine the size, consistency of the prostate -a smooth firm usually BPH while -induration signify the possibility of Ca & need further evaluation.

Investigation GUE, infection & hematuria. Boold. Renal function b.urea & s.creatinine. PSA is optional. IVU &U/S is some time recommended. Cystoscopy. Used to choose surgical approach when surgery is indicated.

D.Dx. Obstructive condition of lower tract like -urethral stricture, -bladder neck contracture, -bladder stone, & -Ca prostate. irritative -UTI, -CIS, & -neurogenic bladder

Treatment A-Medical therapy. 1-Alpha blocker: The human prostate & bladder neck contain alph-1a receptors. Alpha blocker lead to smooth muscle relaxation & dilatation of bladder neck. Alpha blocker either nonselective act on alpha receptors which either short acting e.g prazosin or, long acting e.g terazosin & doxazosin . These need dose titration to decrease their side effect

side effect include -orthostatic hypotension, -dizziness, -tiredness, -retrograde ejaculation, -rhinitis, & -headach . selective act on alpha 1a receptors like tamsolusin no need for dose titration because it had fewer side effect.

2- 5-alpa reductase inhibitor finasteride is 5 alpha reductase inhibitors that block the conversion of testosterone to dihydrotestosteron. This drug act on epithelial component (adenoma) of the prostate reduce the size of the gland (20% reduction of weight in 6 months). side effect -decrease libido & -reduce PSA level to 50% complicating cancer detection.

B-Surgical management. Absolutetely Indicated in 1-refractory retention (after at least 1 trial of catheter removal), 2-recurrent UTI, 3-recurrent gross hematuria, 4-bladder stone, 5-renal insufficiency & 6-bladder diverticulum *provide these are from BPH.

1-TURP (transurethral resection of the prostate) -resection of the prostate endoscopically into small pieces which removed by bladder wash. -Used in95% of BPH. complications of TURP include. -Retrograde ejaculation, -impotence, & incontinence, -bleeding, -urethral stricture, bladder neck contracture, -perforation of the prostate, and -TURP syndrome

TURP syndrom resulting from hypervolemic hyponatremic state due to absorption of hypotonic irrigating solution. Manifested by nausea, vomiting, confusion, hypertension, bradycardia,& visual disturbance.

2-open simple prostatectomy. Indicated when TURP not performed due to 1- large prostate >100g. 2- concomitant bladder pathology like stone or diverticulum, & 3- when dorsal lithotomy positioning is not possible. Its either transvesical or retropubic.

3-minimal invasiae therapy. 1- laser therapy, 2- electrovaporization of the prostate, 3- transurethral needle ablation, 4- high intensity focused ultrasound, 5- intraurethral stent, & 6- balloon dilation of the prostate.