BENIGN PROSTATIC HYPERPLASIA

 Occurs in the transition zone

 Most a-adrenergic receptors are a-1A
o Mediate contraction of prostatic smooth muscle and are
located predominantly in the prostate stroma
 5a-reductase converts testosterone to dihydrotestosterone
 Changes in the prostate
o Increase in the amount of prostate stroma (5a-reductase
inhibitor)
o Increase in the number of a-1 receptors in the prostate
stroma (increase tone within the prostate and bladder neck) –
most important factor contributing to LUTS
 Bladder Outlet Obstruction – best test is video urodynamics
o Low flow rate on uroflowmetry
o Elevated post void residual
o Trabeculation of bladder and enlarged prostate on cystoscopy
o Low flow rate and high detrusor pressure on urodynamics

Presentation:
1. LUTS
Frequency
Urgency Irritative
Nocturia
Weak stream
Intermittency
Incomplete voiding Obstructive
Straining

2. Progressive BOO  overworked  Overactive Bladder

3. Severe BPH  bladder decompensate  absent or ineffective
contractions that do not empty the bladder
4. Hematuria
Progression of BPH
 High PSA increases risk of prostate growth
 MTOPS and CombAT trial showed that a-blockers and 5a-reductase
inhibitors can prevent BPH progression

Non-invasive therapy
1. A-blockers
- Relaxation of smooth muscles in the bladder neck and prostate
- a-1A relaxation of smooth muscle in the prostate, bladder neck,
seminal vesicles and vas deferens
o improves voiding symptoms but may cause retrograde
ejaculation
- dose dependent improvement
o improvement occurs within 8 hours (silodosin,
Tamsulosin) – highest rate of retrograde ejaculation
o 2-4 weeks for other a-blockers
o Maximal improvement may take 1-3 months
- IFIS (Intraoperative Floppy Iris Syndrome)
- ALLHAT study – immediate release doxazosin – higher risk of CHF,
angina, stroke (men with HTN)

2. 5a-reductase inhibitors
- Reduces prostate volume by 20-25%
- Increases maximum urinary flow rate by 10%
- Improve symptom scores by 20-30%
- Reduces risk of urinary retention by 50%
- Reduces risk of surgical BPH by 50%
- Reduces total PSA by >50% after 9-12 months of treatment
 - Increases testosterone by 10-20% (clinically insignificant)
- Stops chronic hematuria from prostate
- 6-9 months to have a noticeable change
- CombAT – 12 to 18 months improve as much as a-blocker
- PLESS – improve in men with PSA >1.4 and prostate volume of
>40cc
- SE: impotence (<5%), decreased libido (<4%), decrease ejaculate
(<3%), gynecomastia (<1%)

3. Tadalafil
- Men with BPH and erectile dysfunction
- PDE5 inhibitor
- Improvement within a week, max at 2 months

Minimally Invasive Therapy

1. Transurethral Needle Ablation (TUNA)
- Prostate size <75cc and mainly lateral lobe prostate enlargement
- Should not be used for voiding symptoms caused by bladder neck
obstruction

2. Transurethral Microwave Thermotherapy (TUMT)

- Prostrate size 30 to 100cc, no median lobe enlargement, and
adequate prostatic urethra
Surgical Therapy
1. Transurethral Resection of the Prostrate (TURP)
- Up to cephalad to verumontanum
- Higher success rate when
o Preop max flow rate <15ml/sec
o Men substantially bothered by symptoms
- Prostate <80cc
- Bipolar TURP = less bleeding
 - Complications
o Bleeding
o TUR syndrome – hyponatremia, mental confusion,
nausea, vomiting, visual disturbances

2. Transurethral Laser Therapies

- Lower risk of bleeding
- Shorter post-op catheterization time
- Shorter length of stay in the hospital

3. Transurethral Electrovaporization of Prostate (TUVP)

- Efficacy similar to TURP but has higher rate of post-op irritative
voiding symptoms and retention

4. Transurethral Incision of the Prostrate (TUIP)

- Similar efficacy with TURP but has a lower rate of retrograde
ejaculation and other complications
- Prostate size <30cc

5. Open or Laparoscopic Prostatectomy

- Prostate size >80cc
- Suprapubic, retropubic, perineal

Persistent Symptoms After Surgical Treatment

 15-20% remain symptomatic
 Urodynamics
o 38% remain obstructed
o 25% have poor detrusor contraction
o 50-70% detrusor overactivity