Benign Prostatic
Hypertophy
Yasar BOZKURT, M.D.
Visitting Associate Professor
The university of Texas
MD Anderson Cancer Center
Department of Urology
Presentation Plan
Anatomy
Incidence & Epidemiology
Etiology
Pathology
Prognosis
Signs and symptoms
Diagnosis
Treatment
Prostate Anatomy
• The prostate is a walnut-sized gland.
• It is located anterior to the rectum
and just distal to the urinary bladder.
• It is in continuum with the urinary
tract and connects directly with the
penile urethra.
The gland is composed of several
zones or lobes.
These include the peripheral, central,
anterior fibromuscular stroma, and
transition zones.
BPH originates in the transition zone
Incidence & Epidemiology
BPH is the most common
benign tumor in men, and its
incidence is age related.
The prevalence of histologic
BPH in autopsy studies
Symptoms of prostatic
obstruction are age related.
• 20% in men aged 41–50
• 50% in men aged 51–60
• >90% in men older than 80
• 25% at age 55
• 50% at age 75
Risk factors for the
development of BPH are
poorly understood.
Genetic predisposition
• 50% of men under the age of 60 who undergo surgery
for BPH may have a heritable form of the disease.
• Autosomal dominant
• First-degree male increased relative risk of fourfold
• BPH is affects the quality of life in
approximately 1/3 of men older than 50
years.
• As many as 14 million men in the United
States have symptoms of BPH.
• Worldwide, approximately 30 million men
have symptoms related to BPH
Prevalence of BPH with age
• The etiology of BPH is not completely understood,
but it seems to be multifactorial and endocrine controlled.
• The prostate is composed of both stromal and epithelial elements.
• hyperplastic nodules and the symptoms associated with BPH.
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Androgens
Estrogens
Stromal-epithelial interactions
Growth factors
Neurotransmitters
BPH
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Growth factors
Hormonal changing
Stromal-epithelial interactions
İnflammation and citokines
Pathophysiology
BPH develops in the transition zone
It is truly a hyperplastic process resulting from
an increase in cell number.
• Stroma and epithelium.
• 1- Obstructive
• Mechanical
• Dynamic obstruction
• 2-Irritative voiding complaints
• Result from the secondary response of the bladder
to the increased outlet resistance.,
• Bladder outlet obstruction leads to detrusor muscle
hypertrophy and hyperplasia as well as
collagen deposition.
Symptoms
Obstructive
• Hesitancy
• Decreased force and
caliber of stream
• Sensation of incomplete
bladder emptying
• Double voiding
• Straining to urinate, and
post-void dribbling
İrritative
• Urgency
• Frequency
• Nocturia
Diagnosis
Digital rectal
examination
Laboratory
studies
• Urinalysis
• Urine culture
• Prostatespecific
antigen
• Electrolytes
• blood urea
nitrogen
• creatinine
Ultrasonography
International
Prostate Symptom
Score (IPSS)
Other tests
• Flow rate
• PVR urine
volume
• Pressure flow
studies
• Urodynamic
studies
• Cytologic
examination
of the urine
Treatment
Refractory urinary
retention
Watchful waiting
For those with mild symptoms (0–7)
Recurrent urinary
tract infection
Pharmacologic
Treatment
Surgery
Absolute surgical
indications
Recurrent gross
hematuria
Bladder stones
Renal insufficiency
Large bladder
diverticula
Pharmacologic
treatment
Surgery
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Alpha-adrenergic receptor blockers (1A)
Phosphodiesterase-5 enzyme inhibitors
5-alpha reductase inhibitors
Anticholinergic agents
Vasopressin
• Transurethral resection of the prostate
(TURP)
• Open prostatectomy
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Reserved for patients with very large prostates (>75 g)
patients with concomitant bladder stones or bladder
diverticula
• patients who cannot be positioned for transurethral surgery
BPH, LUTS &ERECTILE
DIYSFONCTION
• Sexual activity decreases with age
• Sexual problems increase with age
• Men aged 50 to 80 years
• The incidence of LUTS
• The sexuality and the incidence of sexual disorders
• The possible relationship between LUTS, sexual
dysfunction, and co-morbid medical conditions
• PDE5İ reduce moderate-to-severe LUTS in men with or without erectile
dysfunction
• Only tadalafil (5 mg once Daily) has been licensed fötr the treatment of
LUTS.
Phytotherapy
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The use of phytotherapy in BPH has been popular in Europe for years.
Its use in the United States is growing as a result of patient-driven enthusiasm.
The mechanisms of action of these phytotherapies are unknown
the efficacy and safety of these agents have not been well tested in multicenter,
randomized, double-blind, placebo-controlled studies.
• saw palmetto berry
• (Serenoa repens) the bark of Pygeum africanum
• the roots of Echinacea purpurea and Hypoxis rooperi
• pollen extract
Transurethral resection of the prostate (TURP)
Efficacy
Symptom improvement in 90 % of
patients
decrease Symptom Score 80%
Complications
Clot Retention
15%
Urethral Stricture 8%
Transfusions 7%
improvement in peak flow rate 120 %
TUR Syndrome 1%
Re-op rate approx. 1.5 %/year
Incontinence 1%
OPEN PROSTATECTOMY
Minimally invasive treatment
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Transurethral incision of the prostate (TUIP)
Laser treatment
Transurethral microwave therapy (TUMT)
Transurethral needle ablation of the prostate (TUNA)
High-intensity ultrasonographic energy therapy
Prostatic stents
Laparoscopic prostatectomy
Prognosis
Chronic end-stage BPH
• Urinary retention
• Renal insufficiency
• Recurrent urinary tract infections
• Gross hematuria
• Bladder calculi
Take-Home Messages
The etiology of BPH is multifactorial
Symptoms of prostatic obstruction are age related.
Not all Male LUTS=BPH, Not all BPH=LUTS
Symptoms: obstructive + irritative
Terapy: Pharmacologic or Surgery
Quality of life issues is important