❏ Symptoms and Signs of BPH

❏ Bedside Digital Rectal Examination

Symptoms of BPH

❏ BPH symptoms are generally referred to as “Lower urinary tract symptoms”

(LUTS)
❏ Can be subdivided into voiding symptoms and storage symptoms
❏ Most symptoms can be directly attributed to the prostatic hyperplasia that
constrict the flow of urine
❏ 30% of men have concurrent bladder detrusor muscle overactivity (overactive
bladder)
❏ Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to
urinary retention, renal insufficiency, recurrent urinary tract infections, gross
hematuria, and bladder calculi.
American urological association symptom index

❏ Single most important tool used in the ec=valuation of patients BPH

❏ Should be calculated for all patients before starting therapy

❏ Quantitate the severity of the BPH

❏ 7 Questions ,each carrying grade 0-5

Signs

❏ The aim of the physical examination is to exclude a palpable bladder as well

as phimosis,meatal stenosis or other pathology including balanitis

❏ General physical examination may demonstrate signs of chronic renal

impairment with anemia

❏ Abdominal examination usually normal

❏ In retention, distended bladder will be found on palpation and percussion

❏ External urinary meatus ? stenosis ?palpable mass

❏ Epididymis ? inflammation
❏ Detailed neurological examination should be performed for patients with

possible neurogenic lower urinary tract dysfunction

❏ Digital rectal examination most important aspect of physical examination

❏ Size, Shape, Symmetry, Nodularity, and Consistency of prostate must be

evaluated
Digital rectal examination

DRE is recommended to evaluate the size of the prostate and to exclude a

grossly malignant or hard prostate nodule s/o prostate cancer
Preparing the patient

❏ Reason & Technique of rectal examination should be explained

❏ Reassure the patient that examination may be uncomfortable, but it should

not be painful

❏ The clinical room must be appropriate for an intimate examination

Preparing the patient
❏ Rotate wrist so that finger pulp faces anteriorly
and examine the anterior rectal wall
❏ In the male the prostate gland may be
palpated and in females the cervix may be
palpated
Prostate examination
Palpation of prostate
DRE

❏ DRE should be performed to estimate prostate size

❏ Normal prostate is approximately the size of a walnut (7-16 gm) ,firm and

nontender

❏ Although DRE is not a precise tool for measuring prostate volume, serial

examination are useful to follow prostate size

DRE

❏ Tender prostate gland ? prostatitis

❏ Asymmetry or nodules ? Malignancy

❏ Decreased sphincter tone or absence of perineal sensation ? neurological

etiology
❏ A number of herbal formulations and plant-derived compounds have gained
popularity worldwide for the management of BPH
❏ Most of the phytotherapeutic agents used in the treatment of LUTS secondary
to BPH are extracted from the roots, seeds, bark, or fruits of plants
❏ Some suggested active components include phytosterols, fatty acids, lectins,
flavonoids, plant oils, and polysaccharides.
❏ Some preparations derive from a single plant; others contain extracts from 2
or more sources.
Proposed MOA

● Antiandrogenic effect
● Antiestrogenic effect
● Inhibition of 5-alpha-reductase
● Blockage of alpha receptors
● Antiedematous effect
● Anti-inflammatory effect
● Inhibition of prostatic cell proliferation
● Interference with prostaglandin metabolism
● Protection and strengthening of detrusor
Phytotherapeutic agents

● Saw palmetto, (American dwarf palm; Serenoa repens, Sabal serrulata)

fruit
● South African star grass (Hypoxis rooperi) roots
● African plum tree (Pygeum africanum) bark
● Stinging nettle (Urtica dioica) roots
● Rye (Secale cereale) pollen
● Pumpkin (Cucurbita pepo) seeds
Saw palmetto (American dwarf palm)

❏ Extracts of saw palmetto berries are the most popular botanical products for
BPH.
❏ The active components are believed to be a mixture of fatty acids,
phytosterols, and alcohols.
❏ The proposed mechanisms of action are antiandrogenic effects,
5-alpha-reductase inhibition, and anti-inflammatory effects.

❏
❏ The proposed mechanisms of action are antiandrogenic effects, 5-alpha-reductase

inhibition, and anti-inflammatory effects.

❏ The recommended dosage is 160 mg orally twice daily.

❏ Studies show significant subjective improvement in symptoms without objective

improvements in urodynamic parameters.

❏ Minimal adverse effects include occasional GI discomfort.

Saw palmetto (American dwarf palm)

❏ The 2010 AUA guidelines, do not detect a clinically meaningful effect of saw
palmetto on LUTS. Further clinical trials are underway.
❏ In a double-blind, multicenter, placebo-controlled randomized trial at 11 North
American clinical sites, saw palmetto extract was studied at up to 3 times the
standard dose on lower urinary tract symptoms attributed to BPH.
❏ Saw palmetto extract was no more effective than placebo on the American
Urological Association Symptom Index. No clearly attributable adverse effects
were identified.
Rye (Secale cereale)

❏ This extract is made from pollen taken from rye plants growing in southern
Sweden.
❏ Suggested mechanisms of action involve alpha-blockade, prostatic zinc level
increase, and 5-alpha-reductase activity inhibition. Significant symptomatic
improvement versus placebo has been reported.
Pumpkin seeds (Cucurbita pepo)

❏ Observational studies, retrospective surveys, and randomized controlled trials have

provided evidence that pumpkin seeds may reduce urinary urgency and frequency

in men with LUTS related to BPH.

❏ Adverse effects are mild.

❏ Suggested mechanisms of action include increased prostaglandin synthesis, due to

their high amounts of linoleic acid, and anti-inflammatory effects from gamma-

tocopherol and nitric acid precursors.