1. Prostate

6. Prostate
Functions of the Prostate (are primarily exocrine and mechanical in nature) ❏ zinc (a component of prostatic fluid) has potent bactericidal properties ❏ prostatic fluid alkalinizes semen and therefore protects sperm in the acidic environment of the vagina ❏ prevents the seminal fluid from coagulating and therefore increases sperm motility and fertility ❏ smooth muscle fibres of the prostate help to maintain continence

7. Benign Prostatic Hyperplasia
Dr.Santosh Jha
TMU

8. BPH refers to the stromal and epithelial proliferation in the prostate gland that may eventually result in voiding symptoms
BPH occurs primarily in the transition zone of the prostate gland
It is found in approximately 70% of men in their seventies, and in nearly all men in their nineties.

9. Natural History
Patients with BPH can present with both obstructive and irritative voiding symptoms, which are often referred to collectively as lower urinary tract symptoms (LUTS).
Patients may complain of a decreased urinary stream, frequency, nocturia, urgency, hesitancy, intermittency, and a sense of incomplete emptying

10. n
The size of prostate enlarged microscopically since the age of 40.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 symptoms
But only 25% of men aged 80 will be receiving BPH treatment n

11. What is Benign Prostatic Hyperplasia?
Peripheral zone
Transition zone
Urethra

12. Peripheral zone
Transition zone
Urethra

13. BPH is part of the natural aging process, like getting
BPH is part of the natural aging process, like getting gray hair or wearing glasses
BPH cannot be prevented
BPH can be treated

14. Aetiology Still not established properly The hormone theory
Dihydrotestosterone
Imbalance between androgen & oestrogen

15. Pathology
Overgrowth of the glandular elements & overgrowth of connective tissue elements

16. Clinical features Hesitancy Dysuria
Frequency: initially mostly nocturnal
Urgency
Haematuria
Pain: due to:
Cystitis
Acute retention
Hydronephrosis
Retention of urine: acuter or chronic
Renal failure
Prostatism: LUTS

17. Lower urinary tract symptoms (LUTS)
Voiding (obstructive)
symptoms
Hesitancy
Weak stream
Straining to pass urine
Prolonged micturation
Feeling of incomplete bladder emptying
Urinary retention
Storage (irritative or
filling) symptoms
Urgency
Frequency
Nocturia
Urge incontinence
LUTS is not specific to BPH – not everyone with LUTS has BPH and not everyone with BPH has LUTS

18. The differential diagnosis
Urinary tract infection,
Prostatitis,
Bladder stones,
Urethral stricture, and
Neurogenic bladder

19. Diagram showing the relationship between histologic benign prostatic hyperplasia (BPH), lower urinary tract symptoms (LUTS), benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO).

21. Diagnosis A digital rectal exam Neurologic exam Urinalysis
Urine culture
Serum creatinine
Cystoscopy
Post-void residual should be measured by ultrasound or by catheterization
Pressure-flow study

22. Treatment BPH needs to be treated ONLY IF:
Symptoms are severe enough to bother the patient and affect his quality of life
Complications related to BPH n n

23. Treatment options Watchful waiting Medication Surgical approaches
Minimal invasive
TURP
Invasive “open” procedures n n n

24. For mild symptoms. follow up1 to 2 times yearly
“watchful waiting” n
For mild symptoms. follow up1 to 2 times yearly
Offer suggestions that help reduce symptoms
Avoid caffeine and alcohol
Avoid decongestants and antihistamines n n n

25. Medical Therapy
Absolute indications for treatment include urinary retention, bladder stones, upper tract dilation, and renal failure.
Relative indications for treatment include large postvoid residuals, hematuria, and recurrent urinary tract infections.
The first line therapy for BPH is an alpha blocker(terazosin, doxazosin, and tamsulosin)
Patients in urinary retention require emergent catheterization and the catheter should be left in place for at least 24 hours
Other common medical therapies for BPH include saw palmetto and finasteride

26. -Blockers Nonselective Short-acting selective a1-blocker
Phenoxybenzamine
Short-acting selective a1-blocker
Prazosin, Alfuzosin
Long-acting selective a1-blockers
Terazosin
Doxazosin
Long-acting selective a1A-subtype
Tamsulosin
Alfuzosin-SR

27. Surgical Management Indications- Acute urinary retention
upper tract dilation,
renal insufficiency secondary to BPH, or
If the prostate gland is greater than 80 to 100 g, an open prostatectomy should be performed)
The standard endoscopic procedure for BPH is a transurethral resection (TUR) of the prostate
Acute urinary retention
Gross hematuria
Frequent UTI
Vesical stone
BPH related hydronephrosis or renal function deterioration

28. Conventional Surgical Therapy
Transurethral resection of the prostate (TURP)
Open simple prostatectomy

29. TURP “Gold standard” of surgical treatment for BPH
80~90% obstructive symptom improved
30% irritative symptom improved
Low mortality rate 0.2%

30. The “gold standard”- TURP
Benefits
Widely available
Effective
Long lasting
Disadvantages
Greater risk of side effects and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery

31. Complication of TURP Immediate complication bleeding Late complication
capsular perforation with fluid extravasation
TUR syndrome
Late complication
urethral stricture
bladder neck contracture (BNC)
retrograde ejaculation
impotence (5-10%)
incontinence (0.1%)

32. TUR syndrome
TUR is performed with a non-hemolytic fluid such as 1.5% glycine (not Saline)
TUR syndrome may develop from the resulting hypervolemia and dilutional hyponatremia.
Patients with TUR syndrome may experience hypertension, bradycardia, nausea, vomiting, visual disturbance, mental status changes, and even seizures.
Occurs in approximately 2% of patients

33. Minimally invasive therapy for BPH
transurethral balloon dilatation of the prostate (TUBDP)
transurethral incision of the prostate (TUI)
intraprostatic stent
transurethral microwave thermotherapy (TUMT)
transurethral needle ablation of the prostate (TUNA)
transurethral electrovaporization of the prostate (TUVP)
photoselective vaporization of the prostate (PVP),
Cryotherapy
Transurethral ethanol ablation of the prostate (TEAP),

34. Minimally invasive therapy for BPH
transurethral laser-induced prostatectomy (TULIP)
visual laser ablation of the prostate (VLAP)
contact laser prostatectomy (CLP)
interstitial laser coagulation of the prostate (ILC)
holmium:YAG laser resection of the prostate (HoLRP)
holmium:YAG laser enucleation of the prostate (HoLEP)
high-intensity focused ultrasound (HIFU) coagulation
botulinum toxin-A injection of the prostate