Benign Prostatic Hyperplasia BPH

Prostate volume in young is about 20 cm3 . it is divided to three zones.

Central zone near bladder neck , Transition zone in the pre urethral area
which is the origin of nodular enlargement in BPH and Peripheral zone in
the posterior and lateral aspect of the prostate .
BPH is enlargement of prostate size by hyperplasia of stromal
(fibromuscular) and acinar (glandular) component to a variable degree . it
is an aging process not related to environment or genetic factors . it is
slowly progressive disease begin in 3rd decade of life . affect 50% of male
in 5th decade and 75% in 8th decade of life .
The etiology of BPH is unclear, one hypothesis is that BPH occur by
changes in the hormonal states that as the male ages S.testosterone
decrease while the relative level of estrogen rises . this is related to both
absolute decrease in testosterone production and an increased conversion
of S.testosterone to estrogen in peripheral adipose tissue .
Hyperplasia changes mainly in the transition zone, this zone
enlargement externally lead to compression of peripheral zone and central
zone leading to what is known as false or surgical capsule . internal
growth of transition zone causing urine flow impairment . B.P.H progress
over prolonged period and its effect on the urinary tract slow and insidious
as urethral resistance increase the bladder musculature hypertrophied to
compensate that resistance . bladder thickness double or triple and the
bladder can evacuate the urine completely without residual urine due to
this compensation .by increase vording prossure. Normal vesical mucosa is
smooth but with detrusor hypertrophy and increase voiding pressure
individual muscle bundle is stretched and voiding pressure push the
mucosa between muscle bundle outward giving coarsely interwoven
appearance of the mucosa this known as trabiculation, as obstruction
progress vesical mucosa is pushed between full thickness of muscle giving
what is known as sacculation and known as diverticulation when vesical
mucosa is pushed out the muscular thickness to pre vesical fat . Diverticule
have no muscular wall so they unable to expel them content of urine during
voiding. If urethral obstruction progress or may aggrevated by prostate
infection , odema, decomposition of detruser may occur resulting in
unability of bladder to evacuate all urin during voiding , with time this
residual post voiding volume increas . the destended bladder wall become
thin and hydro ureteronephrosis may progress due to secondary vesico
ureteric reflux so high intra vesical pressure transmited up word leading to
renal impairment .
Symptoms of B.P.H
Voiding symptoms are either obstructive or irretative in nature .
obstructive features are :
1- hesitancy (the patient need time to initiate voiding by increasing intra
vesical pressure by increasing abdominal pressure .
2- intermittency (due to unability of detrusor muscle to maintain high
prolong pressure.
3- terminal drippling
4- impairment of size and force of urinary stream .
5- sensation of incomplete emptying .
from irretative symptoms :
1- frequency due decrease of functional capacity by incomplete bladder
emptying and due to bladder unstability .
2- nocturea . sleep interruption more than once for urination .
3- urgency and dysurea by infection , stone , detrusor instability
also the patient may has overflow incontenance , or acute urinary retention
which may triggered by low temperature , alchole , ignorance of first
sensation to void , anti cholinergic or alpha adrenergic drugs .

Signs :
1- Digital rectal exam DRE - may revel big prostate , firm , smooth or
nodular , may there is haemorrhoid by abdominal straining .
2- abdominal exam may show palpable kidney or flanke tenderness ,
distanded bladder may evident or may there abdominal hernias by
straining.
3- may there is features of renal impairment which is evident by increase
blood pressure , increase pulse rate or increase respiratory rate , acidotic
breathing , anemia .

Investigations :
1- G.U.E to exclude any hematurea which necessat work up to exclude
other causes as stone , tumor or pus cells in presence of infection .
2- urine culture and sensitivity
3- B . urea , S.createnin , S. electrolyte to have base line information
4- Prostatic specific antigen PSA pre operatively before treatment that
some time B.P.H has incidental prostatic malignancy .pre operative PSA
will form base line to fellow those with malignancy .
5- Uroflowmetery - normal maximum flow in adult male is 20-25 cm . in
obstructive prostate the max flow rate become less than 10 ml/s and have
prolonged flow time and with features of abdominal straining .
6- U/S to evaluate upper urinary system , renal cortex thickness and
echogenecity, any dilation , stone and lower urinary system as vesical
stone , tumor , diverticulation , prostatic size , and post voiding resuidal
volume .
7- I.V.U indicated in presence of Hematurea to evaluate upper and lower
urinary system . also give idia about prostatic size and post voiding
residual volume .
8- Urethrocystoscopy is done just pre operatively to exclude bladder tumor
not evident by U/S and to evaluate prostatic size and exclude urethral
stricture which mimic obstructive prostate .

Treatment :
Acute urinary retention is treated by urethral catheterization to releaf
pain . chronic urinary retention which is painless need catheterization and
slow decompression when there is over flow incontenance or renal
impairment .

1- Medical therapy :
A- α blockers - obstruction in B.P.H is by 2 elements , anatomical one
(hyperplasia) and physiological or dynamic one by α receptors stimulation
specially α1 at bladder neck those receptors can be blocked by α blockers
as (Minipress) prazocin , Terazocin or Doxazocin .
B- 5 α reductase inhibitors (proscar) finesteride . Testosterone activated to
Dihydrotestosterone by 5α reductase . this enzyme inhibited by finesteride
so no active testosterone which causing reduction of prostatic size by 20%
after maximal effect in 6 months. It is ideal for big prostate . α blocker and
5 α reductase inhibitors can be used in the same time .

2- Operative treatment :
Absolute surgical indication :
1- refractory urinary retention .
2- recurrent UTI .
3- recurrent gross Hematurea .
4- bladder stone from B.P.H .
5- renal insufficiency from B.P.H .
6- large bladder diverticulation
A- Trans urethral resection of the prostate indicated for small - medium
size prostate . from complication is TUR- syndrome which is due to
absorption of irregant non electrolyte fluid by opened venous channels
leading to hypervolemia and hyponetremia. TUR - syndrome treated by
diuretic and normal saline .
B- open surgical methods :
By transvesical approach when there is associated vesical stone with large
prostate or by retropubic approach by enoculation of the prostate through
transverse incision in prostatic capsule .

3-Minimal invasive procedures:

A. Laser prostatectomy
The mechanism is by either vaporization of the prostatic tissue – so no tissue for
.histopathology as by green laser or by thallium laser
Or by laser enoculation of the prostate and the specimen pushed to the bladder
than morcellated and evacuated out for histopathology. This can be done by
.holmium laser
Laser management is strongly indicated for patients with anticoagulant and for
patients with co morbidity to be managed by mild analgesia instead of
anesthesia.

B. Microwave thermothreapy weither by transurethral or transrectal

root , in both technique the tissues near the microwave probe which is
prostatic urethra or rectal mucosa are cooled to prevent tissue damage
while the microwave heat is maximized to the area of transition zone .
the object is to achieve a temperature of 42-45 Cْ in transition zone .
C. High intensity focused U/S by U/S wave focused to transition zone. the
resulted heat cause cellular damage .
D. Prostatic stent - metallic spirals or stents are used as permenant or
temporar indwelling prosthesis . the stent is placed endoscopically or by
radiologic guidance those stent are covered by urothelium within 6
months.
E. Transurethral needle ablation of the prostate interstitial
radiofrequency needle are introduced from the tip of the catheter ,
pentrate the mucosa of the prostatic urethra . the resultant heet results in
a coagulative necrosis .