BENIGN PROSTATIC
HYPERPLASIA
DR .MOHAMMAD H DUMIRIEH
2014
DEFINTION

Hyperplasia of stroma and epithelium in
periurthral area of prostate (transition zone)

Tone of prostatic smooth muscle plays role in
addition to hyperplasia
ETIOLOGY

Etiology unknown

Androgen dihydrotestosterone(DHT)required
(converted from testosteron by 5-alpha
reductase)

Possiple role of impaired apoptosis, estrogen.
other growth factors
Epidemiology

Age related,extremly common(50% of 50 year
olds,80% of 80 year olds)

25 % of men will require treatment
Clinical Feature

Reslut from outlet obstruction and
compensatory changes in detrusor function

Voiding symptoms:
.hesitancy,straining,weak/interrupted stream,incomplete
bladder emptying
.decreased flow rates may be seen on uroflowmetry.
.due to out flow obstruction and/or impaired detrusor
contractility.
Clinical Feature

storage symptoms:
.urgency,frequency,nocturia,urgency incontinence
.thought to be due to detrusor overactivity and decreased
compiliance.

Prostate is smooth ,rubbery and symmeetrically
enlarged on DRE
Complication:
- Retention
- Overflow incontinence
- Hydronephrosis and renal compromise
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
OVERFLOW
Complication:
- infection
- gross hematuria
- bladder stones

 AUA
prostate symptom score
 funwise
funwise
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frequency
urgency
nocturia
Weak stream
intermittency
straining
Emptying,incomplete feeling
Each symptom graded out of 5
0-7 mildy symptomatic
8-19-moderately symptomatic
20-35 severely symptomatic
Note: dysuria not included in score but is
commonly associated with BPH
Prostate size does not correlate well with
symptoms in BPH
APPROXIMATE PROSTATE SIZE
20cc-chestnut
25cc –plum
50cc-lemon
75cc-orange
100cc-grapefruit
investigation
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history
Assess LUTS and effect on quality of life ,may
include self –administrede questionnires (AUA
symptom and impact score)
Physical exam:DRE
Urinalysis to exclude UTI
Creatinine to assess renal function +-renal ultra
sound to assess for hydronephrosis.
PSA to rule out malignancy (if life expectancy
more than 10 y)
investigation

Uroflowmetry (optional)

Bladder ultra sound post voiding urine(optional)

Cystoscopy prior to potential surgical
management.

Biopsy if suspicious for malignancy
TREATMENT
Conservative for those with mild symptom:
.watchful waiting-50% of patients improve
spontaneously.
.includes lifestyle changes(e.g evening fluid
restriction,planned voiding)

Medical treatment:
.a-adrenergic antagonist-reduce stromal smooth muscle
tone
.5-a reductase inhibitor _block conversion of testosteron
to DHT;acts on the epithelial component of prostate –
reduces prostate
size[e.g.finastride(proscar),dustride(avodart)]


Transurethral resection of prostate(TURP)
Objective

To partially resect the periurethral area of prostate
(transition zone)to decrease symptoms of urinary
tract obstruction.
Indications

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
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Obstructive uropathy (large bladder diverticula
,renal insufficiency)
Refractory urinary retention
Recurrent utis
Recurrent gross hematuria
Bladder stone
Failure of medical therapy
complication
Acute:
*intra or extraperitoneal rupture of bladder
*rectal perforation
*incontinence
*hemorrhage
*epididymitis
*sepsis

*trance urethral resection syndrome(post –TURP)
.caused by absorption of large volume of
hypotonic irrigation solution used ,usually
through perforated venous sinusoid,leading to
hypervolemic hyponatremic state.
.characterized by: dilutional hyponatremia
,confusion,nausea,vomiting,hypertension,visual
distrubance,pulmonary edema,bradycardia.
.treat with diuresis and (if severe)hypertonic saline
administration
complication
chronic:
*retrograde ejaculation(>75%)
*erectile dysfunction(5-10% risk increase with
increasing use of cautery)
*incontinence(<1%)
*urethral stricture
*bladder neck contracture.

Open prostatectomy:
.for large prostates or assochiated
problems(e.g.bladder stones)
.suprapubic (transvesically to deal with bladder
pathology)
.retropubic(through the prostatic capsule)

Absolute indication for surgery
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Refractory urinary retention
Recurrent utis
Recurrent hematuria refractory to medical treatment
Renal insufficiency (rule out other causes)
Bladder stones

Simple prostatectomy
ALMOUSATE
HOSPITAL
Minimally invasive therapy
.prostatic stent, microwave therapy , laser ablation,
water –induced thermotherapy, cryotherapy,
high intensity focoused ultra sound (HIFU),
transurethral needle ablation (TUNA).


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Stent within prostate
The passage way is
wide and the lumen
of bladder clearly
seen
Prostate specific
Antigen(PSA)
PSA

Enzyme produced by epithelial cells of prostate
gland to liquify the ejaculate

Leaks into circulation and is present < 4ng/ml

Measuerd total serum PSA is a combination of
free(unbound)PSA (15%)and complexed
PSA(85%)
Screening Prostate cancer : PSA
and DRE

PSA may be elevated in prostate cancer and
many other condition; not specific to cancer

Population –based ,routine screening not
recommended

Must discuss risk factors,test characteristic , risk
of over-detection and over treatment,treatment
and active surveillance

Well –informed patients can elect to undergo
PSA and DRE

The decision to proceed to prostate biopsy
should be based primarily on PSA and DRE
results,but should take into account multiple
factors
(free and total PSA,patient age,PSA velocity,PSA
density,family history,ethnicity,prior biopsy
history and comorbidities)
AGE RANGE
SERUM PSA (mg/L)
40-49
<2.5
50-59
<3.5
60-69
<4.5
70-79
<6.5
PSA is specific to the PROSTATE, but not to
prostate cancer.
In PSA testing , think “free and easy” : increased
free/total ratio suggests benign cause of high
PSA
Causes of Increased PSA
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BPH,prostatitis,prosatic ischemia /infarction
Acute urinary retention, prostate
biobsy/surgery/ message
Urethral catheteraization,TRUS
Ejaculation ,acute renal failure
Coronary bypass graft.
Radiation therapy
*free-to –total PSA ratio:
 Complexed PSA increases in prostate
cancer,decreasing the percentage of the free
fraction
 <10% free PSA suggestive of cancer ,>20% free
suggest benign cause
*PSA velocity:
 Change of >0.75ng/ml/year associated with
increased risk of cancer
*PSA density:
 PSA divided by prostate volume of as found on
TRUS
 >0.15 ng/ml/ associated with increased risk of
cancer
Other Uses for PSA
*Therapeutic decision making: patients with serum
PSA level<10.0 are most likely to respond to
local therapy
*Work –up : bone scans are generally not
necessary in patients with newly diagnosed
prostate cancer who have a PSA <20 ng/ml
unless the history or clinical examination
suggests bony involvement
Other Uses for PSA
*Disease monitoring:
 serum PSA should fall to low level following
radiation therapy,cryotherapy and should not
rise on successive occasions. PSA should
remain undetectable after radical prostatectomy
Other Uses for PSA
*Outcome prediction:
 in patients with metastatic disease receiving
androgen suppresion therapy ,failur to achieve a
PSA of<4.0 ng /ml seven months after initiation
of therapy is associated with a very poor
prognosis(median survival :one year)
NOTE

there is no easy , infallible method of
determining when biopsies may be avoidable
and when they are necessary.Until a perfect test
is developed this determination must be made
on the basis of clinical judgment and experience.
NOTE

Normal , hyperplastic, and neoplastic epithelial
cells make PSA, but the amount of PSA
produced by cancer cells is 10 times higher per
gram of tissue than the amount by normal or
hyperplastic tissue.
NOTE
Most PSA is produced in the hyperplastic
transitional zone of prostate .A relatively small
amount of PSA is produced in the peripherial
zone,where 80% of prostate cancers
orginate.cancers developing in the transitional
zone tend to produce large amount of PSA.
NOTE
High-grade cancer cells tend to lose their ability to
produce PSA. A GLEASON grade 5 prostate
cancer produces less than a grade 3 cancer does.
Some patients with advanced prostate cancer
may have low or undetectable PSA level.
THANK YOU