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BENIGN PROSTATE

HYPERPLASIA

Div. of Urology, Dept. Surgery

Medical Faculty,University of Sumatera Utara

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REFERENCES

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DEFINITION

BPH is :

Enlargement of the prostate gland from the progressive

hyperplasia of stromal and glandular prostatic cells

Pathologic process that contributes to, but is not the

sole cause of, lower urinary tract symptoms (LUTS) in

aging men

Uro l Clin N Am 35 (2007) 109115

Campbell-Walsh Urolo gy, 9th ed.2007

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TERMINOLOGY

BPH (Benign Pros tat ic Hyperplasia) histopathologic

diagnosis

BPE (Benign Prostat ic Enlargement) anatomicdiagnosis

BOO (Bladder Outlet Obs truc t ion ) anatomic

diagnosis

BPO (Benign Prostat ic Obs truct ion ) BOO caused

by BPE

LUTS (Lower Urinary Tract Symp tom s) clinical

manifestation of lower urinary tract obstruction

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INTRODUCTION

Most common benign tumor in men

Age related

in life expectancysignificantlythe number of men

affected by BPH

BPH is said to be a stromal disease, but it remains unclear

whether the initiating events occur in the stomal

compartment, the epithelial compartment, or both

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ANATOMY

Normal weight about 20 g

Classification of Lowsley: 5 lobes : anterior,

posterior, median, right lateral, left lateral

According to Mc Neal :

- peripheral zone

- central zone

- transitional zone

- an anterior segment

- a preprostatic sphincter zone

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PREVALENCE

20 % of men 40 -50 years

50 % of men 50 60 years

> 90 % of men older than 80 years

The Most Frequent Benign Tumor in Men

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Storage

Total

51.3%

Storage

Total

51.3%

BPH

LUTS

BO

O

All Men > 40

yrs

BPE

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ETIOLOGY

Multifactorial and endocrine controlled

(Androgens, estrogens, stromal-

epithelial interactions, growth

factors, and neurotransmitters may

play a role )

BUT not completely understood

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THEORIES FOR THE CAUSE OF BPH

Theory

Dihydrotestosteron hypothesis

Oestrogen-testosteron

imbalance

Stromal-epithelial interactions

Reduced cell death

Stem cell theory

Cause

5-reductase andandrogen receptors

Oestrogens

TestosteronEpidermal growthfactor/fibroblastgrowth factorTransforming growth

factor

Oestrogens

Stem cells

Effect

Epithelial andstromal hyperplasia

Stromal hyperplasia

Epithelial andstromalhyperplasia

Longevity ofstromaand epithelium

Proliferation oftransit

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MORPHOLOGY

Microscopically, nodular prostatic hyperplasia

consists of nodules of glands and intervening

stroma (mostly glands)

The glands variably sized, with larger glands have

more prominent papillary infoldings

Nodular hyperplasia is NOT a precursor to carcinoma

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PATHOPHYSIOLOGY

1. Pathogenesis hyperplasia

2. Symptoms disorders ( Voidingphase or storage phase )

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PATHOPHYSIOLOGY

Nodular hyperplasia of glands and stroma

Normal 20 to 3050 to 100 gm

Press upon the prostatic urethra

Obstruction - difficulty on urination

Dysuria, retention, dribbling, nocturia

Infections, hydronephrosis, renal failure

Not a premalignant condition

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Prostate growth

Increased urethral resistance

Decompensation

Flow

Bladder emptying ,

hesitancy, intermittency, etc

PATHOPHYSIOLOGY

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PATHOPHYSIOLOGY

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PATHOPHYSIOLOGY

Static

component

Dynamic

component

LUTS

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STATIC COMPONENT

Prostate mass (volume)

Urethral closure pressure

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DYNAMIC COMPONENT

Bladder pressure

Prostate smooth muscle tone:

in stroma

capsule

bladder neck

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LUTS ARE A CONSTELLATION OF

STORAGE AND VOIDING SYMPTOMS

Storage Voiding Post-micturition

Urgency Hesitancy Post-void dribble

Frequency Poor flowSense of

incomplete emptying

Nocturia Intermittency

Urgencyincontinence Straining

Other incontinence

Terminal dribble

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Prevalence of LUTS in Men

Voiding

Total

25.7

Post-

micturition

Total

16.9

Storage

Total

51.3

Percentage of men in the general male population who

report at least 1 symptom representative of a particular

type of LUTS

Irwin DE et al. Eur Urol . 2006;50:1306-1315

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How to Assess the Patient?

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RECOMMENDED INVESTIGATIONS

Clinical history

Physical examination

Validated symptom score, e.g IPSS

Laboratory

Uroflowmetry

Imaging

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1. CLINICAL HISTORY

Obstructive :

Hesitancy

Poor flow

Intermittency

Straining

Terminal dribble

Irritative :Urgency

Frequency

NocturiaUrgency

incontinence

Other incontinence

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2. PHYSICAL EXAMINATION

DRE :

Size

Consistency :

smooth or elastic/hard

Nodule/ tender

Mobility

Anatomical limits:

Lateral/ cranial/ medial sulcus

DRE is recommended in the evaluation

of men with LUTS

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DRE

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3. VALIDATED SYMPTOM SCORE

IPSS (International Prostate ScoringSystem ).

07 : Mild

8 - 19 : Moderate

2035 : Severe

7 : Watchful & Waiting

7 : Medical treatment

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1. KENCING TIDAK LAMPIAS Dalam sebulan ini berapa sering anda merasakan sensasi tidak lampias

saat kencing (terasa belum habis) ?

2. Sering Kencing

Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam

2 jam setelah anda Kencing

3.KENCING TERPUTUS PUTUS Dalam sebulan ini berapa sering kencing anda terhenti sejenak, lalu mulai

lagi ( Terputus putus)

4.TIDAK DAPAT MENUNDA KENCING

Dalam Sebulan ini Berapa sering anda merasa kesulitan untuk menunda

Kencing

5.PANCARAN KENCING YANG LEMAH Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah

6. MENGEDAN SAAT KENCING

Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing

7.KENCING DI MALAM HARI

Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk

Kencing

Gejala Tidak Pernah < 20 % < 50 % =50% > 50 % Hampir Selalu

0 1 2 3 4 5

0 1 2 3

0 1 2 3

2 3

4 5

4 5

0 1

0 1

4 5

4 5

1 2 3

2 3

BPH SYMPTOM SCORE (by :AUA)

4 5

Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4 5kali, =5

0

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4. LAB TEST

Blood Count

Serum Electrolyte

Serum Creatinine Serum PSA

Urine :

ProteinuriaSediment

Culture

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UROFLOWMETRY

Uroflowmetry Qmax

Voided volume

Residual urine TAUS

Catheter

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DIAGNOSTIC FOR BPH

Uroflowmetry:

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UROFLOWMETRY

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5. IMAGING

TRUS ( Transrectal ultrasound

)

Transabdominal UltrasoundWith Indication :

IVP

Cystography

CT-Scan

MRI

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Trans Rectal Ultra Sonography :

Volumometry

Identification of hypoechoic lesions

Calcification

Periprostatic vein

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Urethral stricture

Bladder neck contracture Small bladder stone

Locally advanced prostate ca

Poor bladder contractility

Differential diagnosis

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Differential Diagnosis

BladderDetrusor overactivityImpaired detrusor contractilitySensory urgency

Sphincteric incontinencePolyuria/nocturnal polyuriaMedications

AntihistaminesAntidepressants

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EFFECTS OF BENIGN PROSTATIC

OBSTRUCTION

Irreversible bladder changes

Thickening of the bladder wall

Recurrent haematuria

Bladder diverticulum formation Repeat urinary tract infections

Bladder stone formation

Upper tract dilatation

Renal impairment

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COMPLICATIONS

Increased risk of UTI due to urinary retention

Calculi due to alkalinization of residual urine

Hematuria due to overstretched blood

vessels

Pyelonephritis

Renal failure

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INDICATION FOR TREATMENT

Absolute or near absolute :

- refractory or repeated urinary retention

- azotemia due to BPH

- recurrent gross hematuria- recurrent or residual infection due to BPH

- bladder calculi

- large residual urine

- overflow incontinence

- large bladder diverticula due to BPH

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TREATMENT

Watchful waiting

Medical therapies

Intervention therapies

Minimally invasive therapiesSurgical therapies

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WATCHFUL WAITING

Component:

Education ( about the patients condition )

Reassurance ( cancer is not a cause )Periodic monitoring

Lifestyle advice ( alcohol, caffein etc )

Evaluation/ monitoring : after 6 months/ 1 year

IPSS, uroflowmetry, post-void

residual urine volume

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MEDICAL THERAPY

I.P.S.S. > 7

Flow > 5 ml/sResidual urine < 100 ml

No hard nodule

PSA < 4 ng/dl

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MEDICAL THERAPY

Reducing smooth muscle tone (dynamiccomponent) :-1 adrenergic blocker

Short acting : prazosin, afluzosin

Long acting : doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):5redutase inhibitor (finasteride, epristeride)estrogen aromatase inhibitor

LHRH agonist / antagonist GF inhibitor

antiandrogens

Unknownphytotherapy

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MODE OF ACTION ALPHA BLOCKING

AGENT

Alpha adrenergic blocking agent blocks

adrenergic stimulirelaxation of the

smooth muscle cell:

intra urethral pressure

Improvement of urine flow

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RECOMMENDATIONS-blockers should be offered to men with

moderate to severe LUTS5-reductase inhibitors should be offered tomen who have moderate to severe LUTS and an

enlarged prostate. 5-reductase inhibitors can

prevent disease progression with regard toacute

urinary retention and need for surgery

The Guidelines committee is unable to make

specific recommendations about phytotherapyof male LUTS

because of the heterogeneity of the productsand the methodological problems associatedwith meta analyses

EAU guid el ine 2010

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INVASIVE TREATMENT FOR BPH

Absolute indication:Chronic Retention

With Hematuria

Concomitant Bladder stone

Intractable UTI

Deteriorating kidney function

Relative indication:

Huge PVR due to obstruction or low QmaxRefuse medical treatment

Failure in medical treatment

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INTERVENTION THERAPY

Minimally invasive therapy Thermotherapy

TUNA (Trans Urethral Needle Ablation) HIFU (High Intensity Focused Ultrasound) TUMT (Trans Urethral Microwave Theraphy) Laser

Stent

Surgical therapy TUIP (Trans Urethral Incision of the Prostate) TURP (Trans Urethral Resection of Prostate) GOLD

STANDARD

Open prostatectomy TUVP (Transurethral Vaporization of the Prostat) Laser

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TURP

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JARINGAN PROSTAT

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TUIP

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