Benign Prostatic Hyperplasia

BPH
(Adenoma of Prostate)

Ahmar Munir
 Prostate
• The prostate is a fibromuscular and glandular organ lying just
inferior to the bladder .
The normal prostate weighs about 20 g and contains the
posterior urethra, which is about 2.5 cm in length.
• It is supported anteriorly by the puboprostatic ligaments and
inferiorly by the urogenital diaphragm . The prostate is
perforated posteriorly by the ejaculatory ducts, which pass
obliquely to empty through the verumontanum on the floor of
the prostatic urethra just proximal to the striated external
urinary sphincter
• Arterial Supply
• The prostate and seminal vesicles are supplied by branches of the inferior vesical artery. The first
prostatic branch of the artery is the urethral artery that enters the gland posterolaterally at 5 and 7
0’clock positions while the second branch, the cavernous, runs with the neurovascular bundles at the
level of the prostatic capsule.

• Venous Supply
• The venous drainage of the prostate and seminal vesicles is composed of the inferior vesical veins
which feed into the internal iliac vein.
• Lymphatic Drainage
• The primary lymph node drainage sites of the prostate are the obturator and internal iliac lymph node
chains.1 Additional drainage is to the external iliac and presacral nodes.

• Innervation.
• Autonomic innervation of the prostate is via the cavernous nerve and facilitates seminal emission
What is the normal prostate size ?
• A small prostate has a volume of 30 ml to 40 ml and a
weight of 20 g to 70 g. A medium prostate has a volume of
40 ml to 80 ml and a weight of 20 g to 125g . A large
prostate has a volume of 40ml to 100 ml and a weight of
40 g to 125 g.

• Around age 40, prostate gland begins to grow. With a

benign prostatic hyperplasia (a mild disease), gland’s size
can increase by 4 to 5 times compared to its initial size.
Def;
• Benign prostatic hyperplasia (BPH) refers to an increase
in the number of prostatic stromal and epithelial cells,
resulting in the formation of large, discrete nodules in the
transition zone of the prostate
Etiology
• The prostate is composed of both stromal and epithelial elements, and each,
either alone or in combination, can give rise to hyperplastic nodules and the
symptoms associated with BPH,
• A positive correlation between levels of free testosterone and estrogen and
the volume of BPH. The latter may suggest that the association between
aging and BPH might result from the increased estrogen levels of aging
causing induction of the androgen receptor, which thereby sensitizes the
prostate to free testosterone.
• There is evidence that estrogens acting through stromal and epithelial
estrogen receptors may contribute, in part, to diseases of the prostate.
conti.......
• BPH growth is influenced by multiple factors including androgen
levels, estrogen levels, paracrine factors in the prostatic stroma
and epithelium, growth factors
• (FGF-1,2,7,17; VEGF, IGF; TGF-β),
• cytokines (IL-2, 4, 7, 17; IFN-γ),
• sympathetic nerve signaling, and genetic inheritance
Pathology
• BPH develops in the transition zone.
• It is a hyperplastic process resulting from an increase in cell
number.
• Microscopic evaluation reveals a nodular growth pattern that is
composed of varying amounts of stroma and epithelium.
• Stroma is composed of varying amounts of collagen and smooth
muscle.
Cont.....
• As BPH nodules in the transition zone enlarge, they compress the
outer zones of the prostate, resulting in the formation of a so-
called surgical capsule.
• This boundary separates the transition zone from the peripheral
zone and serves as a surgical plane for enucleation of the
prostate during open simple prostatectomies or holmium laser
enucleation of the prostate procedures.
Classification
• The clinical course can be divided into three stages
• Stage I (compensation) - disturbances of urination appear
at some retention of urinary bladder
• Stage II (subcompensation) - large dysfunction of urinary
bladder and appearance of residual urine
• Stage III (decompensation) - complete decompensation of
urinary bladder function and ischuria.
cont,,,,,,,
• Modern clinical classification is based on characteristics of functional
condition of urinary bladder, upper urinary tracts and kidneys.

• Stage 1 compensatory changes and hypertrophy of detrusor, absence large

changes of functional condition of kidneys and upper urinary tracts.

• Stage II intermediate stage> of dysfunction of urinary bladder, upper urinary

tracts and kidneys, increase of residual urine volume.

• Stage III explicit widening of upper urinary tracts, progressive disorder of

partial functions of kidneys due to obstructive uropathy, chronic kidney
disease (insufficiency).
Clinical Symptoms of infravesical obstruction
• 1:Obstructive Symptoms
• week thin discontinuous flow of urine
• difficulty to start urination,straining effort
• feeling of incomplete emptying of bladder
• terminal leak
Irritative Symptoms
• Nocturia
• Enuresis
• painfull urination
• Urgency
• Frequency
DIAGNOSIS AND EVALUATION
• The evaluation of all patients presenting with
• LUTS suggestive of
• BOO (bladder outlet obstruction)should begin with a
medical history
• physical exam(DRE)
• A urinalysis should be performed at initial evaluation to
screen for confounding or contributory diagnoses like
• hematuria
• urinary tract infection.
IPSS
IPSS
• 0-7 is considered mildly symptomatic,
• 8-19 moderately symptomatic,
• 20-35 severely symptomatic
Urodynamics
• uroflow may be suggestive of urinary obstruction, a flow
rate of less than 10ml/sec
Non BPH Male LUTs
• It is important to keep in mind that LUTs in men may be
multifactorial and several conditions may mimic each
other. Conditions such as overactive bladder, pelvic floor
dysfunction, etc may cause irritative symptoms such as
urgency, frequency, or urgency incontinence. Urodynamic
evaluation may be helpful to determine the underlying
cause of the symptoms.
PSA
Treatment
• Behavioral modification may be beneficial in appropriate
patients with strategies including double voiding, timed voiding,
avoidance of caffeine (and other bladder irritants), alcohol and
other diuretics, as well as night-time fluid restriction.

• A recent study of both medical and surgical trends in LUTS/BPH

treatment found mediation usage increased from 2004 to 2013
with a corresponding decrease in surgical interventions.
Medication use increased with patient age, with the most
pronounced increase amongst men 40 to 60 years of age.
Herbal Medications
• Over 30 phytotherapeutic compounds have been
described for the management of BPH
• One of the most commonly utilized supplements, saw
palmetto, is derived from Serenoa repens
• Other examples include the use of beta-sitosterols from
the Hypoxis rooperi plant and pygeum from the Prunus
africana plant
Αlpha-Adrenergic Antagonists
• Alpha (α1)-blockers relax smooth muscle at the bladder neck and
prostate thereby helping to relieve bladder outlet obstruction.
Alpha blockers represent the most common initial therapy for
treating LUTS/BPH
• Prazosin 2mg bid
• Terazosin up to 10mg daily
• Tamsulosin 0.4mg daily
• The most common side effects associated with alpha blockade
include a decline in blood pressure that can result in dizziness (5
to 15% with α1a-selective agents), retrograde ejaculation (6%),
and rhinitis (12%).
• The cardiovascular effects are particularly seen when less
selective drugs and higher doses of α-blockade are used
(tamsulosin 0.8mg daily).
5-α-Reductase Inhibitors
• 5-ARIs block the conversion of testosterone to
dihydrotestosterone (DHT). DHT has a more potent effect on the
prostate and suppression with 5-ARIs leads to a reduction in
prostate volume/PSA and decrease in symptoms associated with
BOO.
• Finasteride Up to 5 mg daily
• Dutasteride 0.5mg daily
Combination Therapy
• Alpha-blockers and 5-ARIs may be used in combination
to compound therapeutic effect.
• Current guidelines published by the AUA and EAU
recommend combination therapy with alpha-blockers and
5ARIs and is most beneficial for patients with moderate-
severe symptoms, prostates larger than 40cc and higher
PSA values (> 1.3 - 1.5ng/dL)
• Finasteride 5mg + terazosin up to 10mg
• Dutasteride 0.5mg + tamsulosin 0.4mg daily
Anticholinergics
• Anticholinergics have been used to minimize LUTS in men from
detrusor overactivity occurring with (from obstruction), or
independently, of BPH.59 Anticholinergics block the acetylcholine
signal at the neuromuscular junctions of the detrusor muscle, thus
leading to inhibition of detrusor contractions.
• Tolterodine 4mg daily
• Solifenacin 3mg
• Adverse Effects: The most common side effects associated with
the use of anticholinergics include dry mouth (up to 71%),
constipation (up to 21%), and blurry vision (5%).
Phosphodiesterase type 5 Inhibitors (PDE5i)
• PDE5i function by blocking the breakdown of cGMP to GMP by
phosphodiesterase, thus leading to vasodilation. There are 11
PDE subtypes and the prostate contains several, most abundantly
4, 5 and 11. All PDE5i have significant cross-reactivity on PDE
enzymes other than the target PDE5. They have classically been
utilized for the treatment of erectile dysfunction (ED); however,
improvements in LUTS have been observed in patients using
sildenafil, tadalafil and vardenafil
Beta-3 Adrenoceptor Agonists (Mirabegron)

• Mirabegron interacts primarily with the beta-3

adrenoreceptor to relax the detrusor muscle of the
bladder both increasing bladder storage volumes and
decreasing bladder overactivity