PRINCIPLES OF MANAGEMENTOF BENIGN PROSTATIC

HYPERPLASIA

BY DR E.S ENAMINE27/4/2011

OUTLINEINTRODUCTION

ANATOMYEPIDEMIOLOGY/NATURAL HISTORY

PATHOPHYSIOLOGYCLINICAL FEATURE

DIAGNOSISINVESTIGATION

TREATMENTCOMPLICATIONS

• BPH is the proliferation of the epithelial and stromal element of the prostate evidenced by enlargement of the gland as detected by DRE/ TRUS.

• Subdivided into 3; Histological BPH Macroscopic BPH Clinical BPH.

RELEVANT ANATOMY

• Divided into 4 glandular zones and 1 non-glandular zone:

• Peripheral zone (PZ). -70% of CAP originate here. -largest anatomical subdivision. -contains 70-75% of normal prostatic glandular

tissue -no contribution to BPH.

• Central zone (CZ); 25% of normal glandular tissue -10% of CAP originate here.• Transition zone (TZ); 5% of normal glandular

tissue. -lies adjacent to prostatic urethra. -site of BPH. -expands to compress the outer PZ to form the

false capsule.• Preprostatic zone; 1% of normal gland. -smallest and most complex. -sphincteric function prevents reflux ejaculation.

EPIDEMIOLOGY.

• One of the most common disease of the elderly male.

• Prevalence is age dependent. -initial devt usu after 40yrs. -By 60, prev is >50% -By 85, it is as high as 90%.

NATURAL HISTORY

• Symptoms worsen in 55% of patients.• Remain stable in 30%, improve in 15%.• Prostate size incr. at a rate of 0.6ml/yr.Factors associated with increased risk of

progression include:Age, symptom severity, prostate vol.,PSA.Change in size and force of stream,sensation of

incomplete voiding, enlarged prostate on DRE.

PATHOPHYSIOLOGY

• The devt of the histological BPH, requires age and androgens.

• Dihydrotestosterone (DHT) is the specific angdrogen mediating prostate growth.

• Testosterone is converted to DHT by 5-alpha reductase enz.• Others GF involved are IGF, EGF etc.• Obstruction to urine flow is due to static component from

the bulk of glandular and fibromuscular tissue.• Dynamic component is due to contraction of smooth

muscle mediated by alpha 1a adrenoceptors.

CLINICAL FEATURES

• IRRITATIVE SYMPTOMS: -frequency, urgency, nocturia.• OBSTRUCTIVE: -poor stream, incomplete bladder emptying. -straining on micturition. -intermittency, hesitancy. -urine retention (acute/chronic)

• Others: -haematuria. -recurrent UTI - AKI and CKD.

GUIDELINES FOR DIAGNOSIS

• 3 questions: Do you wake up at night?Do you have problem of urine flow?Is your bladder bothersome?• If ‘yes’ , IPSS score should be done.• General exam• UGS• DRE

INVESTIGATIONS

• Urinalysis/MCS.• FBC+ESR, E&U/Cr• PSA: age specific. However if abnormal, then -PSA velocity- a rise >0.75ng/ml/yr suggests CAP. -PSA density- (PSA/prostatic vol.) results

>0.15ng/ml suggests CAP. PSAD is aimed at differentiating rise in PSA due to

BPH from CAP.

CAP is usually a 10-fold rise in PSAD. -Free and Total PSA- the proportion of free to

total PSA maybe evaluated as % free PSA. - Total PSA= free PSA + bound PSA.• for an elevated PSA >10ng/ml, the chances of

prostate cancer being present may be further evaluated based on % free PSA and need for biopsy.

PERCENT FREE PSA PROBABILITY OF CANCER

0 - 10 56%

10-15 28%

15-20 20%

20-25 16%

>25 8%

• Prostatic biopsy. INDICATIONS:Abnormal DREElevated PSA >10ng/mlFree PSA percent < 20.

• Urine flow rate, post void residual urine, Pressure flow Urodynamics.

Indicated in patients with moderate to severe symptoms IPSS 8-20 where decisions have to be taken on modalities of treatment.

• URINE FLOW RATE. -Peak Flow Rate (PFR) >15ml/s = normal. 10-15ml/s = equivocal <10ml/s suggests BOO.• POST VOID RESIDUAL VOLUME. -measured by transabd USS. value >200ml indicate need for surgery.

• Urethrocystoscopy. Indicated prior to surgery to select the correct operative modalities.

• Imaging of upper tract: - IVU -Abdominal USS• TRUS and TRUS-guided biopsy.• Colour doppler imaging of the prostate.

TREATMENT

MODALTIES INCLUDE:• Waitful watching• Medical therapy• Minimally invasive Rx• Surgery.

• WATCHFUL WAITING:• Offer to pts with IPSS < or =8 who are not

bothered by their symptoms.• Involves regular assessment of IPSS, PSA, PFR,

PVR.• Contraindications: AUR, chronic retention,

recurrent UTI, dilatation of upper tracts.

• MEDICAL THERAPY:• Indicated for pts with IPSS <19 with bothersome

symptoms but no complication after exclusion of CAP.

Androgen suppression; i. 5-alpha reductase inhibitors- finesteride,

episteride. reduces prostate vol by 20% reduces PSA value by 50%. ii. Flutamide-an androgen receptor antagonist. has no effect on IPSS, PFR and bothersome

symptoms

Alpha adrenergic blockers; - e.g Tamsulosin.Combination therapy. -5 alpha reductase inhibitor+ alpha 1 blocker

shrinks the prostate by 25% in a year and 20% improvement of symptoms.

Phytotherapy. Various plant extract shave been used to treat

BPH empirically though without clinical and safety value proven scientifically.

• They include: pygeum africannum (African plum) serenoa repens B (American dwarf palm) sabal serrulatum (Dwarf palm) urtica spp (stinging nettle) hypoxis roopers (South African grass) cucurbitapepo (pumpkin seed)

• MINIMALLY INVASIVE TREATMENT.• indicated in pts with IPSS 8-19• Pts unfit for major surgery-pulmonary dxs,

liver dxs, MI etc.• CONTRAINDICATIONS: • Recurrent episodes of haematuria• Bladder stone due to BPH• Upper tract dilatation• Recurrent UTI• Renal insufficiency.

• OPTIONS:High intensity focused ultrasound (HIFU)Transurethral vapourisation of prostateTransurethral laser therapy (TULIP)Intra-urethral stentsTransurethral needle ablation of prostate

(TUNA)Transurethral balloon dilatation.

SURGERY

OPTIONS OPEN PROSTATECTOMY TRANSURETHRAL RESECTION OF PROSTATE TRANSURETHRAL INCISION OF PROSTATEINDICATIONS IPSS 19-35 Moderate to severe Bothersome symptoms

which are not Relieved By medical Rx/minimally invasive Rx

TUIP

• Suitable For small Prostate with tight Bladder Neck and No middle lobe Enlargement

• Incision made using a Collins Knife Below the ureteric orifice and carried thru to the Bladder neck

• Post op PFR-18mls/sec• Incidence of Retrograde Ejaculation is 10%• 10% of Px will Relapse and will Require TURP

TURP

• Done using a Resectoscope• Used to Remove the Obstructing tissue in all

but the most enormous tissue,thereby carving a passage way from the bladder

• Hospital stay is short

• Little Risk of DVT/Pulmonary Embolism• Performed by specialist Urologist• 80% of Px improve after TURP with reduction

in IPSS, improve PFR from 8 -18 mls/sec in 85% of Px.

• Likelihood of re-operation for BPH in 5yrs is 3.4%

Indications for TURP• Prostate <60g.• LUTS not responding to change in

lifestyle/medical therapy• Recurrent acute urinary retention.• Renal impairment due to BOO• Recurrent hematuria due to BPH• Small bladder stones due to BPH.

Complications of TURP• Hemorrhage; primary and secondary.

• Urinary incontinence; maybe due to pre existing detrusor instability +/- sphincter weakness. Stress incontinence maybe due to sphincter damage

• Retrograde Ejaculation; usually during ejaculation there is reflex closure of the internal sphincter when semen enters the prostatic urethra.

• Urethral stricture; common sites--- ext urethral meatus, bladder neck and penoscrotal jxn.

0ccurs 4-10 months post surgery.

Trans urethral Resection Syndrome Arises from infusion of large vol of Hypotonic

irrigating sol during the Procedure e.g glycine Manifest as confusion,seizures,visual

disturbance,bradycardia.Central to this syndrome is dilutional

Hyponatremia.Can be prevented thus;limit Resection time,

• Avoid aggressive resection near the the capsule

• Use a continous irrigating cystoscope-this provides low pressure irrigation

OPEN PROSTATECTOMY• Two types Retropubic Transvesical• IndicationsProstate gland 70-100gBladder diverticulumLarge Hard ca stoneMarked ankylosis of the Hip preventing

lithotomy position

• It is the most effective method of treating BOO due to BPH

• PFR inceasesto>20mls/s,symptoms improve markedly.

• Likelyhood of px requiring further surgery is 0.4%,compaared to TURP 3.4%

• Complication rate 31.7% compared to TURP 16.1%

COMPLICATIONS• Haemorrhage-Follows inadequate haemostas• Clot Retention,folows severe bleed and

inadequate nursing care• UTI• Epididymo-orchitis-Arise from retrograde spread

of infxn from prostatic fossa along the vas to the Epididymis

• Erectile Dysfxn-carvenosal nerve controlling erection may be destroyed during prostatectomy

• Damage to the ureters

• Retrograde ejaculation-bladder neck is removed in prostatectomy

• Infertility• Incontinence of urine-Due to mech effect of

the urethral catheter on the int sphincter of the bladder neck

• DVT

REFERENCES• Badoe E.A,Archampong E.Q et al. (Eds) the

prostate;3rd Edn. Ghana Publishing Corporation;2000; 47,850-866.

• Bailey and love 25th Ed pg 1344-1353• Surgical Oncology contemporary principle and

practice;Kirby .i.Baid,John .m. Daly• Campbell walsh urology 9th Ed,WB

Saunders,sect viii,chap 46;pg223-226• American Urology Association

• Oxford Hand Book of Urology 1st Ed

• THANK YOU FOR YOUR TIME