BENIGN PROSTATIC

HYPERPLASIA
(BPH)

Prostate anatomy
BPH definition
Etiology
Pathophysiology
Diagnosis
Classification
Complications
Management

Prostate

It is a tubuloalveolar exocrine
Anatomy gland

Site : behind symphysis

pubis. residing in the true
pelvis ( its fascia is contiuous
with levator ani fascia). It
surrounds the urethra just
below the urinary bladder.
Size : 3-4 cm at the base
4-6 cm cephalocaudal
2-3 cm anteroposterior.
Weight: 15-20 gm

Arterial supply
From the anterior division of the internal iliac artery
Inferior vesical artery,
Middle rectal artery
Internal pudendal artery originates (hypogastric) artery.
Venous drainage
Prostatic plexus of veins
Valveless communication exists between the prostatic and
vertebral plexus through which prostatic carcinoma spread
to vertebral column and to skull

Zones of the Prostate

Lobes of the Prostate

BPH Definition

is a noncancerous enlargement of the prostate gland that

may restrict flow of urine from the bladder. It is hyperplasia
rather than hypertrophy.
It is NOT premalignant

Epidemiology

Most common benign tumor in men.

Its incidence is age- related.

Rare before 30
Not common between 30 -50
50% above 60
90% above 80

Etiology

With advancing age

death of leyding
cells
estrogen:androgen increases
increase # of DHT receptors in prostate
hyperplasia

Pathophysiology of sx

Increase urinary flow resistance

increase
pressure in UB
hypertrophy
trabiculation
saculation
diverticulation
Small prostate,
Enlarged prostate,
retention
thin bladder wall

thick bladder wall

Diagnosis

Symptoms
Physical examination
investigations

symptoms
Obstructive
symptoms

Irritative symptoms

*Weak urine stream

*Hesitancy of stream
*Sensation of
incomplete bladder
emptying
*Straining to urinate
*postvoid dribbling
*intermittency

*Nocturia
*Urgency
*Frequency
*Painful or burning
urination

Physical exam

If the disease is advanced & has resulted in renal

failure. Signs of renal failure include elevated BP, rapid
pulse & respiration, uremic fetor, pericarditis & pallor of
nail beds.

Abdominal examination may reveal palpable kidney or

flank tenderness if there is hydronephrosis or
pyelonephritis.

A distended bladder may be noted on palpation or

percussion.

PR

Rectal examination may reveal an enlarged prostate.

The distinction between right & left lobes of the prostate

is usually lost in BPH.

Median sulcus always present.

Investigations

Urinalysis hematuria + culture pyuria

KFT

* Serum creatinine- patients with renal insufficiency are at an increased risk

of developing post operative complications following surgical intervention
for BPH.

Imaging ( US IVU postvoiding film

only in the presence of urinary tract disease or complications of BPH
(hematuria, UTI, renal insufficiency, history of stone disease).

Cystoscopy
most definite
can do endoscopic removal
Urodynamic study
PSA level

*ESSENTIALS OF DIAGNOSIS*
-prostatism: nocturia, hesitancy, slow stream,

terminal drippling, frequency.

-residual urine.
-acute urinary retention.
-uremia in advanced cases.

Differential Diagnosis
*Urethral stricture.
*Bladder neck contracture.
*Bladder stone.
*CA of the prostate.
*UTI.
*Neurogenic bladder disorder.

Classification
American Urological Association
(AUA) Score questionnaire
A symptom score of :
0-7 mild
8-19 moderate
20-35 severe

Or can be classified into stages according to

UB ability to compensate
Stage 1
UB can compensate ( symptoms without
residual urine)
Stage 2
Beginning of decompensation ( increased
frequency & severity of symptoms )
Stage 3
Decompensation with chronic retention, overflow
incontinence, renal damage, dribbling, uremia

Complications

1.Inguinal hernia
3.Bladder
hypertrophy
4.Trabeculation
5.Diverticula
formation
*predispose to tumors
6.Hydroureter
bilateral
7.Hydronephrosis
8.UTI
9.Stones formation
10.Epididymitis

Trabeculations
Hypertrophy of wall
Stone - urolithiasis

Inflammation
Median lobe- ball valve.

Enlarged prostate.

Hypertrophy
Trabeculation
Median lobe protrusion.

Management
when should BPH be treated?
BPH needs to be treated ONLY IF:
The symptoms are severe enough
to bother patient and affect the
quality of life

Renal insufficiency
Frequent urinary tract infections

Treatment options

Watchful waiting

Medical therapy

Surgical therapy

Minimally invasive therapy

Stage 1& 2

Hot sitz therapy

Prostatic massage
drugs

Medical therapy
1.

Alpha1 blockers

(effectivity 70 %)

Relax the prostate

The human prostate contains
alpha-1- adrenoreceptors.
Alpha blockers can classified according to their receptor
selectivity.
Alpha- 1 short acting:
Prazosin
Alpha- 1 long acting:
Hytrin

(terazosin)

Cardura (doxazosin)
** main SE : retrograde ejaculation

2.

5 -alpha -reductase inhibitors

Proscar (finasteride)
-Block the conversion of testosterone to

DHT by inhibiting 5-reductase enzyme.

-Affects the ephithelial component of the
prostate.
- Shrink the prostate gland
- decrese PSA by 50 %
SE: impotence , decrese libido, retrograde ejaculation

Stage 3

Can try drugs but surgery is much preferred

since retention has occured

Surgery

SURGICAL PROCEDURES

TURP
Transurethral electro-vaporisation
Transurethral incision
Transurethral laser
technique(holmium,KTP)
Balloon dilatation
Prostate stents
Prostatectomy:suprapubic,retropubic,perineal
Laproscopic

TURP
(transurethral resection of the
prostate)

Gold Standard of care for BPH

Uses an electrical knife to surgically

cut and remove excess prostate
tissue

Effective in relieving symptoms and

SURGICAL PROCEDURE
Operation is
performed through a
modified cystoscope
Prostatic tissue is
resected using an
electrically energized
wire loop.
the Prostatic capsule
is usually preserved.
Continuous irrigation
is necessary to distend
the bladder and to wash
away blood and
dissected prostatic
tissue.

Potential side effects:

Impotence
(5-10%)
Retrograde ejaculation (75%)
Incontinence (<1%)
Complications:
Bleeding,urethral stricture or bladder
neck contracture, perforation of the
prostate capsule, TUR syndrom.( finish
in <1 hour to avoid)

TURP SYNDROME:
DEFINITION

TURP syndrome: constellation of

signs and symptoms caused by
the absorption of large volumes of
isotonic irrigating fluids through
prostatic veins or breaches in the
prostatic capsule.
The syndrome is characterized by
hypervolemia,
hyponatremia
hypo-osmolarity

Transurethral incision of the prostate

(TUIP)

Transurethral procedure.
Small cuts made in bladder neck and
Prostate to widen urethra.
No prostate tissue removed.
Less risk of side effects when
compared to TURP.

Not suitable for large glands.

Open Simple Prostatectomy

Used for very enlarged prostates

(over 100 gm).
Major surgery requiring abdominal
incision.
Enlarged portion of prostate removed by
surgeon.
Greater risk of surgical complications.
Longer recovery time.

-A simple suprapubic prostatectomy

operation of choice with bladder pathology.
-A simple retropubic prostatectomy
The bladder is not entered.

Indications of transvesical
prostatectomy

Huge prostate >100 gm

Pt unfit for lithotomy position
UB Stones
Inguinal hernia
Urethral stricture

Transurethral Needle Ablation

(TUNA)