Benign prostate hyperplasia

Dr. Syah Mirsya Warli, SpU Div. of Urology, Dept. Surgery Medical Faculty, University of Sumatera Utara

Ref :
Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd ed, 2001 Smiths General Urology (Tanagho & McAninch eds), Lange Medical Books, 17th ed, 2008

Definition
Regional nodular growth of varying combinations of glandular and stromal proliferation that occurs in almost all men who have testes and who live long enough

TERMINOLOGY
BPH (Benign Prostatic Hyperplasia): histopathologic diagnosis BPE (Benign Prostatic Enlargement) : anatomic diagnosis

BOO (Bladder Outlet Obstruction): anatomic diagnosis

BPO (Benign Prostatic Obstruction): BOO caused by BPE LUTS (Lower Urinary Tract Symptoms): clinical manifestation of lower urinary tract obstruction

Introduction
Common non-neoplastic lesion. Involves peri urethral zone.

BPH is common as men age.

25% by 50y, but 90% By 80y..! About 10% are symptomatic.

Prevalence
The Most Frequent Benign Tumor in Men

70 % of men above 60 years.* 90 % of men above 80 years.** 30 40 % of men above 70 years Indonesia : The Second after Stone Disease in Urology Clinic ***
* Berry SJ et all J Urol 1984 ;132:474-79 ** Carter HB , Coffey DS. Prostate 1990;16 : 39-48 *** Rahardjo D,Birowo P,Pakasi LSMed . J of Ind 1999 ; 8(4) : 260 - 63

Impact of ageing population

With life expectancy approaching 80 years in many countries 88% chance developing histological BPH in life expectancy significantly the number of men affected by BPH The number of men presenting with BPH symptoms will 45% in the next 10 years and further in the following decade

Prevalence of histological BPH with age

Prevalence (%)

100
80 60 40 20 0 11% 29% 48% 77%

87%

92%

3140

4150

5160

6170

7180

80+

Berry SJ et al. J Urol 1984; 132: 4749

Anatomy
N 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

Causes
- Many theories - The actual cause still not clear - Factors are known to be important:
1. Male sex 2. Aging 3. Testosterone 4. Growth Factors (EGF, FGF, IGF II)

Pathophysiology
Nodular hyperplasia of glands and stroma. Normal 20 to 30 50 to 100 gm.

Press upon the prostatic urethra.

Obstruction - difficulty on urination Dysuria, retention, dribbling, nocturia Infections, hydronephrosis, renal failure. Not a premalignant condition*

Prostate growth

Increased urethral resistance

Decompensation Flow

Bladder emptying , hesitancy, intermittency

Mechanism
Hormonal imbalance with ageing. Estrogen sensitive peri-urethral glands.

Accumulation of DHT in the prostate and its growth-promoting androgenic effect

Some Drugs (Finasteride) inhibit DHT diminishes prostatic enlargement.

Symptoms LUTS
Weaker, smaller stream Hesitancy Intermittent / interrupted flow Feeling of incomplete emptying or retention Terminal dribbling Nocturia Frequency Urgency dysuria Symptoms may worsen with alcohol and caffeine, cold remedies

How to Assess the Patient?

Diagnosis

Anamnesis Cardinal symptoms: Weak Stream Frequency Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

BPH SYMPTOM SCORE Gejala

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(by :AUA)
< 50 % 2 =50% 3 > 50 % Hampir Selalu 4 5

Tidak Pernah < 20 % 0 1

0 0

1 1

2 2

3 3

4 4

5 5 5kali, =5

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

.
IPSS (International Prostate Scoring System ). 07 : Mild 8 - 19 : Moderate 20 35 : Severe 7 7 : : Watchful & Waiting Medical treatment

Diagnosis
Physical examination: DRE Prostate: 1. Size 2. Nodule 3. Consistency 4. Tenderness

DRE

Diagnosis
Uroflowmetry Qmax Voided volume

Residual urine TAUS Catheter

Diagnostic for BPH

Uroflowmetry :

Lab test
Blood Count Serum Electrolyte Serum Creatinine Serum PSA Urine : Proteinuria Sediment Culture

IMAGING
TRUS Transabdominal Ultrasound With Indication : IVP Cystography CT-Scan MRI

Trans Rectal Ultra Sonography : Volumometry Identification of hypoechoic lesions Calcification Periprostatic vein

Differential diagnosis

Urethral stricture Bladder neck contracture Small bladder stone Locally advanced prostate ca Poor bladder contractility

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

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

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

Treatment
Watchful waiting
Medical therapies Intervention therapies
Minimally invasive therapies Surgical therapies

Watchful waiting
Altering modifiable factor such as:
Concomitant drug Regulation of fluid intake especially in the evening Life style change (avoid sedentary life) Dietary advice (avoid excessive intake of alcohol, and highly seasoned or irritative foods)

Evaluation/ monitoring : after 6 months/ 1 year IPSS, uroflowmetry, post-void residual urine volume

Medical therapy
I.P.S.S. > 7 Flow > 5 ml/s Residual urine < 100 ml No hard nodule PSA < 4 ng/dl

Medical therapy
Reducing smooth muscle tone (dynamic component) : -1 adrenergic blocker
Short acting : prazosin, afluzosin Long acting : doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):

5 redutase inhibitor (finasteride, epristeride) estrogen aromatase inhibitor LHRH agonist / antagonist GF inhibitor antiandrogens

Unknown
phytotherapy

Adrenergic stimuli
Alpha adrenergic stimuli increases tonus of smooth muscle cell in the trigonum, bladder neck and prostate Location of alpha receptor:
Bladder Trigonum Prostate gland

Mode of action alpha blocking agent

Alpha adrenergic blocking agent blocks adrenergic stimuli relaxation of the smooth muscle cell:
intra urethral pressure Improvement of urine flow

Rationale of 5Alpha reductase inhibitor

Hipotalamus
LHRH Sintesis Protein

ACTH

Transkripsi DNA Reseptor Inti

+
DHT

T 5- reductase

DHT

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 Qmax Refuse medical treatment Failure in medical treatment

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) Open prostatectomy TUVP (Transurethral Vaporization of the Prostat) Laser

Invasive Treatment for BPH

TURP (gold standar) Laser resection (Hol Yag Laser)

TURP

JARINGAN PROSTAT

TUIP

ADENOCARCINOMA OF THE PROSTATE

Dr. Syah Mirsya Warli, SpU Div. of Urology, Dept. Surgery Medical Faculty, University of Sumatera Utara

Ref :
Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd ed, 2001 Smiths General Urology (Tanagho & McAninch eds), Lange Medical Books, 15th ed, 2000

 The most common cancer in men 2nd most common cause of cancer related death after lung ca The choice of th/ for localized disease must be based on many factors : - grade & stage - personal preference - age - performance status

 Prostate tumors are generally androgen sensitive and advanced disease is most often treated by single or combined androgen ablation

Etiology
Risk factor : - age > 50 - family history - ethnic origin African American >> - androgens - diet (>> animal fat) - environmental exposure - insulin-like growth factors

pathology
Benign cystadenoma Prostatic intraepithelial neoplasia (PIN) - high grade (2 & 3) 30 40% chance of developing prostat Ca need repeat biopsies Malignant - conventional adenocarcinoma - transitional cell carcinoma - sarcoma - metastatic tumour - hematologic malignancies

Conventional adenocarcinoma (small acinar carcinoma)

Vast majority (95 97%) is adenoCa from acinar epith Majority lesion in peripheral zone, 20 25% from the transitional zone Classically discovered after TURP

Patterns of spread
Direct extension into the seminal vesicles & extracapsularly through the periprostatic nerve routes Direct extension into the rectum is uncommon Ureteral obstruction 10 35%

 Lymphatic spread is not uncommon hypogastric, obturator, external iliac, presacral, common iliac 90% distant metastate osseous Visceral meta (lung, liver, adrenal) less common

Grading & Staging

Gleason grade based on the degree of glandular diff and growth pattern Mostofi grade based on the degree of nuclear irregularity. The lesion are graded as well, moderately and poorly differentiated Staging systems The American Joint Committee on Cancer , modified TNM system

Signs & symptoms

A prostatic nodule or induration of the gland hallmark sign Consist of : - symptom of bladder outflow obstruction - symptom resulting from local extension - symptom from distant metastase (bone pain, low back pain, weight loss)

diagnosis
Digital rectal examination (DRE) any palpable irregularity 50% chance TRUS very sensitive but non specific Serum marker PSA Prostate needle biopsy Bone scan CT & MRI

DRE findings that may indicate cancer :

Asymmetry of the gland A nodule within one lobe of the gland Induration of part or all of the prostate Lack of mobility due to adhesion to surrounding tissue Palpable seminal vesicles

Treatment for localized disease

Radical or complete prostatectomy Radiation th/ : - external beam radiation th/ - interstitial brachyth/ Follow up after treatment for localized disease - serum PSA single most important parameter

Treatment for advanced disease

Prostate Ca is an androgen-sensitive tumor Methods of androgen ablation : bilateral simple orchiectomy diethylstilbesterol DHT receptor blockade (flutamide, bicalutamide LHRH agonist (leuprolide) aminoglutethimide ketoconazole

 Castration - easily accomplished, relatively inexpensive, well-tolerated, almost free of complication - side effects : vasomotor instability, loss of libido, ED LHRH agonist - long term effects of bone mineralization - as effective as castration with similar side effects, administered subcutaneously

 Antiandrogens - act by blocking DHT receptor - not as effective as castration or LHRH th/ - do not lower the serum testosterone level do not cause impotence or decreased libido - side effects : diarrhea & liver function abN

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