Benign prostatic hyperplasia Niazy B Hussam Aldin

Benign prostatic hyperplasia (BPH) is the most common benign tumour in men and responsible for urinary symptoms in the majority of males over the age of 50 years .

Epidemiology Autopsy studies have revealed the histological presence of (BPH) in 50% of males aged 51-60 years ,increasing to 90% in those over 85 it has estimated double in the size of the time between the age of 31 and 50 years is 4.5 years.

Pathophsiology The prostate is a part glandular ,part fibromuscular structure about 3.5-2.5 cm in size surrounding the 1st part of male urethra at the base of the bladder it develops at the 12 weeks of embryonic life The prostate can be divided into an inner and the outer zone the site of malignant change. The inner zone is generally the site of (BPH) changes testosterone is converted by 5alfa-reductase to dihydrotestosterone (DHT) an androgen with five times the potency of testosterone. and responsible to cell division and lead to enlargement and hyperplasia .

Histology Histologically the hypertrophied prostate can vary depending on the predominance of the type of prostatic tissue present ,from stromal, fibromuscular or muscular to fibroadenomatus and fibromyoadenomatus enlargment.

BPH

Symptoms Lower urinary tract symptoms (LUTS) can be divided into symptoms of failure of urine storage (irritative)and those caused by failure to empty the bladder (obstructive or voiding ) (Irritative) – frequncy , nocturia, urgency (Obstructive)- poor flow, hesitancy in initiation of micturation, postmicturation dribble ,sensation of in complete emptying , occasional acute retention of urine requiring emergency treatment

Examination and investigation Digital rectal exam (DRE) for whom suspected benign prostatic hyperplasia The most important reason for doing a rectal examination is to detect prostate cancer with measurement of levels of prostate_ specific antigen (PSA). Urodynamic assessments- urinary flow through cystometry 25ml/s Imaging – ultrasound bladder for residual volume Flexible cystoscopy- to assessment type of prostatic obstruction Prostatic ultrasound scan-document the size of prostate and mlignant changes .

DRE

Treatment (surgery ) Transurethral resection of prostate (TRUP) is common and effective procedure which achieve a high level of improvement in symptoms and flow rate . section of prostate are removed using electrical loops attached to a recectoscope, Complication such as bleeding . Urinary tract infections and epididymitis and erectile dysfunction.

TURP

surgery Open prostectomy; involve the surgical removal of an enlarged prostate and is done under general or spinal anaesthesia . This procedure perform for very enlarged prostate gland individuals with bladder diverticula or stones . Open prostectomy associated with a high incidence of bleeding ad other complications .

Minimally invasive techniques -1-Thermotherapy ;such as electrovaporazation ,which heats the prostate using bipolar diathermy to cause vaporization of tissue, and transurethral microwave thermotherapy . 2-Laser therapy ; varies types of laser energy can be used to destroy prostatic tissue.

Non – invasive treatment هIf BPH does not progress significantly and one management option is that called ( watchful waiting ) Alfa- adrenoceptor blocking agent; prazocin , alfuzocin , indromin , doxazocin , terazocin . the prostate gland is very responsive to adrenergic stimulation ,50% of proststic patient response due to increasing to adrenergic tone which potentially reversible by drugs, alfa1-receptors predominate and mediate the contraction of gland smooth muscle. .

Aim of treatment Pt with BPH frequently experience problems with erectile and ejaculatory function. The treatment aim to restore sexual function the effect of alfa blockers on male sexual functions variable and influenced by drug chosen and patient characteristics

Tamsulosin Selective inhibitors at alfa 1A &alfa1B Increase urinary flow rates and reduces LUTs in patient with BPH. Has elimination half-life of about 10hrs allows once dialy Side effect; dizzines headche and syncope. Arthralgia, back pain and myalgia affecting 11% of patient . Drug interaction ; cimetidine diuretic antihypertensive drug .

Treatment 5alfa – reductase inhibitors finasteride – Dutasteride ; The primary androgen responsible for the development and progression of BPH is dihydrotestosteron. There are two isoenzyme of 5 alfa –reductase type 1 is found in most producing tissue such as the liver ,skin and hiar , type 2 is predomiant in genital tissue, including the prostate Finasterid reduce prostate size 30% and improve symptoms, it may take 6 months before symptomatic benefit. Side effect ;decreased libido ,impotence ,

Combination therapy Alfa- adrenoceptor antagonists have no impact on the rates of acute urinary retention or prostate surgery , the 5 alfa -reductase inhibitors have little impact on short term acute symptoms . Combination therapy provide to manage symptoms and decrease progression of BPH Trial confirmed the additional benefits of using acombination of doxazin and finasteride .

Patient care Most men tolerate a high degree of symptoms on quality of life Formal bladder training may be undertaken as part of a watch and wait approach or concurrently with drug therapy See table 48.1 include common therapeutic problem in (BPH) Note page 694 – 697 is recommended chapter 48