1. Benign Prostatic Hyperplasia
Aria F. Olumi, M.D.
Division of Urologic Surgery
Beth Israel Deaconess Medical Center

2. Epidemiology 90% of men by age 80 develop histologic evidence of BPH.
Prostatic growth initiated at age 30
Prostatic doubling
4.5 years between age 31 to 50
10 years between age 51 to 70
Degree of prostatic enlargement varies

3. Decreased force of stream
Definition
BPH is a histologic definition
Clinical manifestation is Lower Urinary Tract Symptoms (LUTS)
Symptoms: Irritative & Obstructive
Frequency
Urgency
Dysuria
Pelvic discomfort
Nocturia
Incomplete emptying
Dribbling
Decreased force of stream

4. Prostatic Anatomy

5. Prostate size, Urinary Symptoms and BPH
Prostate Size vs. Urinary Flow Rate
0.6
0.20
Prostate Size vs. Severity of Symptoms
0.22
0.008
Urinary Flow Rate vs. Severity of Symptoms
0.27
0.005
Barry et al., J Urol 150:351, 1993

6. BPH Histology
Proliferative process of both stromal and epithelial components

7. Differential Dx of LUTS
GU Pathology
BPH, UTI, Prostate Cancer, Urethral Cancer, Urethral Stricture,
Non-GU Pathology
Parkinson’s, CVA, Diabetes Mellitus, CHF, spinal cord injury

8. Pathophysiology Dynamic components Static components
secondary to the tension in the prostate smooth muscle
Static components
secondary to prostatic enlargement

9. Pathophysiology Prostatic growth is androgen dependent Androgens
KGF
EGF
IGF
TGF-
(+)
(-)
Proliferation
Cell Death

10. Androgens in Prostate Development and GrowthOH O OH H
Dihydrotestosterone (DHT)
5-Reductase (type 2)
Testosterone

11. Bladder Response to Outlet Obstruction Secondary to BPH
Smooth muscle hypertrophy
Subsequent increase in collagen mass
Poor bladder compliance

12. Bladder Response to Outlet Obstruction Secondary to BPH
Bladder instability/compliance
associated with symptoms of frequency and urgency
Impaired bladder contractility
associated with decreased force of stream, hesitancy, intermittency, increased residual urine volume

13. Assessment of Urinary Symptoms
AUA-Symptom Score
No correlation between prostatic growth and urinary symptoms

14. AUA Symptom Score 1. Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

15. AUA Symptom Score (Cont.)
2. Frequency
Over the past month, how often have you had to urinate again less than two hours after you finish urinating?        
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

16. AUA Symptom Score (Cont.)
3. Intermittency
Over the past month how often have you found you stopped and    started again several times when you urinated?        
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

17. AUA Symptom Score (Cont.)
4. Urgency
Over the past month, how often have you found it difficult to postpone urination?
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

18. AUA Symptom Score (Cont.)
5. Weak stream
Over the past month, how often have you had a weak urinary stream?
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

19. AUA Symptom Score (Cont.)
6. Straining
Over the past month, how often have you had to push or strain to begin urination?
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

20. AUA Symptom Score (Cont.)
7. Nocturia
Over the past month, how many times did you most typically get up to urinate from the time you when to bed at night  until  the time you got up in the morning?
Not at all
< 1 time in 5
< ½ the time
½ the time
More than
Almost always 1 2 3 4 5

21. Quality of Life Due to Urinary Symptoms
If you were to spend the rest of life with your urinary condition just the way it is now, how would you feel about that?
Mostly
satisfied
Mostly
dissatisfied
Delighted
Unhappy
Terrible
Pleased
Mixed 1 2 3 4 5 6

22. Evaluation
Detailed history focusing on the urinary tract symptoms, PMH/PSH
Physical exam: abdomen, GU, prostate
Labs: Urinalysis, BUN, Creatinine, PSA
Use the AUA-Symptom Score Index for initial assessment prior to initiating therapy (used to assess symptom severity, response to therapy, and detect symptom progression

23. Who Needs Therapy for BPH?
Do symptoms interrupt daytime activities, sleep, create anxiety, reduce general perception of health or quality of life?
Perception of bothersome symptoms may vary significantly for different patients with the same degree of symptom severity

24. Medical Therapy Watchful Waiting Phytotherapy
α-adrenergic receptor antagonists
5- α reductase inhibitor therapy

25. Watchful Waiting
Appropriate for patients with minimal to moderate urinary symptoms due to BPH
Many patients (especially in the PMD practice) can be treated with watchful waiting

26. Phytotherapy Saw Palmetto (Serenoa repens)
Grown in Southeastern U.S. and Western Indies
Used by Native Americans for impotence, inflammation, infertility and as an expectorant.   

27. α-Adrenergic Receptors in Bladder and Prostate
Alpha Adrenergic
Blockers
Terazosin (hytrin)
Doxazosin (cardura)
Tamsulosin (flomax)
Prostate

28. Lower Urinary Tract Symptoms after α-Adrenergic Blocking Therapy

29. 5 α-reductase Inhibitor Therapy for BPH
Imperato-McGinley J, et al. Steroid 5-alpha-reductase deficiency in man: an inherited form of male pseudohermaphroditism. Science. 1974;186:
2. Walsh PC, et al. Familial incomplete hermaphroditism, type 2. Decreased dihydrotestosterone formation in pseudovaginal perineoscrotal hypospadias. N Engl J Med. 1974;291:

30. Finasteride (Proscar)
and BPH Therapy O OH O OH H
Dihydrotestosterone (DHT)
5-Reductase (type 2)
Finasteride
Testosterone

31. Congenital Absence of 5-Reductase (type 2)
Other clinical characteristics
-Small prostates
-No lower urinary tract symptoms

32. Lower Urinary Tract Symptoms after 5α-Reductase Inhibitor Therapy
                                                                   

33. Other Treatments for BPH
Minimally invasive therapy
Microwave thermal therapy
Transurethral needle ablation
Prostatic stents
Transurethral Resection of Prostate (TURP)
Annual follow-up with PSA and DRE needs to continue
Open simple prostatectomy
Different than radical prostatectomy for cancer
Still have prostatic tissue left