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Benign Prostatic Hyperplasia

Etiology, Incidence, Symptoms,
Evaluation.

Dr. Wajeed gul Bangash
PG Ms Urology
Supervised by
Prof. Dr Khursheed Anwar
Prostate Gland
What is the Prostate?
Developmental Background
 Develop as series of ENDODERMAL
BUDS….Lining of Primitive
Urethra….adjacent part of UrogenitalSinus
 03 month of intrauterine life
 Surronding Mesenchyme condense
….Stroma of gland
Histolgy
(zonal anatomy)
 03zones % Cap
 Peripheral zone 70% 60-70%
 Central zone 25% 10-20%
 Trasition zone 05% 05-10%
 BPH originate in TRANSITION Zone
Zonal origin of BPH

Normal

Urethra Transition
zone

Peripheral
zone Central
zone
Prostate
 An accessory gland of male reproductive
system
 Conical & firm…below neck of Bladder
 Surroundes commencement of male
urethra
 In Female represented by Paraurethral
gland( of SKENE)
Understanding the prostate

 Walnut-shaped gland that forms part of the male
reproductive system
Surrounds the urethra - the tube that carries urine

from the bladder out of the body
Understanding the prostate

 Secretes semen which
carries sperm

 During orgasm,
prostate muscles
contract and propel
ejaculate out of the
penis
SITUATION
 Lesser pelvise
 Below neck of U bladder
 Behind lower part of pubic symphysis
(space of Retizus) & upper part of pubic
arch n in front of ampulla of rectum
(Denonvilliers fascia).
Prostate Gland
Prostate Gland
Shape, Size, Weight
 Inverted
cone
 Measurment
 03-04cm at base
 04-06cm Cephalocaudal
 02-03cm Antero-posterior
 Weight 08-20 gm
Male
Urogenital
System
Gross Feature
 Apex..directed down ward..Urogenital
Diaphargm…Perineal body….Anus
 Base…upward..surround neck of
bladder…mark by circular grove (lodges
veins of vesical & Prostic plexuses)
 04 surfaces (Anterior,
Posterior(ejaculatory duct) 02 inferolateral
LOBES
 Urethra & ejaculatory D …05 lobes
 Anterior L …small isthmus…small or NO
Glandular tissue(seldom ADENOMA)
 Posterior L…lies behind Median l n
E.D….Adenoma never occurs…?primary Ca
start here
 Median L behind upper part Urethra…front
E.D…Uvula vesicae…much gladular T…
ADENOMA
 Lateral L…enough G tissue…Adenoma in old
age
Capsules of prostate
 True capsule…deep to false..continous wz
stroma of gland….no venous plexues
 False capsule…outer…derived 4rm pelvic
fascia..prostatic venous plexues in it…
posteriorly avascular…
Prostate gland
 Blood Supply  Venous supply
 Brs..inferior vesicle  Rich at base, sides
 Plexs communicate..vesicle p &

middle rectal, internal internal pudendle v…..vesicle
&internal iliac vein
pudendle aa.  Valveless connection b/w prostatic

 Forms Larger outer &vesicle v….Cap ….vertebral
columes, skull
SUBCAPSULAR plxs
 Small
inner(periurethral
plxs)
Lymphatic supply
 Internal iliac, sacral nodes, partly external
iliac nodes
Nerve supply
 Sympathatic & parasympathatic
 (sensory impulses relay Lower three
lumber & upper sacral segments)
What is Benign Prostatic
Hyperplasia?

Peripheral zone

Transition zone

Urethra
Peripheral zone

Transition zone

Urethra
What is BPH?
 Benign prostatic hyperplasia (BPH) is defined as a
benign enlargement of the prostate gland caused by the
growth of new cells
 One of the most common conditions affecting older men
which can lead to LUTS
 Advancing age and testicular androgens play a central
role
 Age related enlargement of the prostate seen in men
with BPH may be caused by increased cellular
proliferation combined with a decreased rate of
apoptosis
Cause of BPH

 The primary androgenic stimulator of prostate growth
is dihydrotestosterone (DHT)
 DHT is produced from testosterone via the
5alpha-reductase (5AR) isoenzymes type I and II
Regulation of cell growth
Serum testosterone (T) Serum DHT

T Prostate
5AR (I and II) DHT cell

Growth DHT-androgen
factors receptor complex
Cell death
Increased Unbalanced
Cell growth

Adapted from Kirby RS, McConnell. Benign Prostatic Hyperplasia. Health Press Ltd, 1999
Type I and type II isoenzyme
distribution
Type I Type II
Scalp

Brain

Liver
Sebaceous glands
Seminal vesicles
Liver
Prostate
Prostate

Genital tissues
Skin (genital skin and
epididymis)
Anderson JB et al. Eur Urol 2001; 39: 390–399
Bartsch G et al. Eur Urol 2000; 37: 367–380
Thigpen AE et al. J Clin Invest 1993; 92: 903–910
Pathology
 Transitionzone…hyperplastic process
 Microscopically…nodular growth pattren…
composed of Stroma, Epithelium
 Stroma composed…collagen, smooth
muscle
 Explain potential responsivness to medical
therapy
 Smooth M(alpha blocker) epithelium(5-
alpa reductase inhibitors)
Classification of Medical Therapy
and Recommended Dosage in BPH.
Classification Oral Dosage
Alpha-blockers
Nonselective
Phenoxybenzamine 10 mg twice a day
Alpha-1, short-acting
Prazosin 2 mg twice a day
Alpha-1, long-acting
Terazosin 5 or 10 mg daily
Doxazosin 4 or 8 mg daily
Alpha-1a selective
Tamsulosin 0.4 or 0.8 mg daily
Alfuzosin 10 mg daily
5-alpha-reductase inhibitors
Finasteride 5 mg daily
Dutasteride 0.5 mg daily
Subcutaneous implant Yearly
Triptorelin pamoate 3.75 mg every month
Pathophysiologh of BPH
 Symptom…obstractive / secondry response to
BOO
 Obstractive component…Mechanical / dynamic
obstraction
 Mechanical obs: as bph…intrusion into urethral
lumen…lead to high bladder outlet resistence
 Dynamic obs: alpha1 mediated smooth muscle
contraction occur…variable symptoms…bladder
outlet obs occur…use alpha blocker…dec
tone..dec in outlet resistence
Causes of BOO
 In Men  In female
 BPH (major)  Less common Pelvic
 Urethral stricture, prolapse
malignant enlargment (cystocele,rectocele,u
prostate(less terine)…directly
common) compress urethra..U
stricture, U
diverticulm
 Fowler,s syndrom
 Pelvic masses
BPH: symptoms

 Symptoms
associated with BPH include the
OBSTRACTIVE and IRRITATIVE symptoms

 LUTS is not specific to BPH – not all men with
LUTS have BPH and not all men with BPH
have LUTS

Cunningham GR et al. Epidemiology and pathogenesis of benign
prostatic hyperplasia. Up To Date Literature Review, Apr 29; 1998
EAU BPH guidelines. Madersbacher S et al. Eur Urol 2004; 46: 547–554
Symptom type Symptom
Obstructive (voiding) Weak urinary stream
Prolonged voiding
Abdominal straining
Hesitancy
Intermittency
Incomplete bladder emptying
Terminal and post-void dribbling

Irritative Frequency
Nocturia
Urgency
Incontinence
Associated symptoms Dysuria
Haematuria
Haematospermia
IPSS by AUA
( Barry & colleagues early 1990s)
 Incomplete emptying 0 1 2 3 4 5
 Frequency 0 1 2 3 4 5
 Intermetency 0 1 2 3 4 5
 Urgency 0 1 2 3 4 5
 Weak stream 0 1 2 3 4 5
 Straining 0 1 2 3 4 5
 Nocturia 0 1 2 3 4 5
 Total= 35
Total IPSS* score indicates symptom
severity
IPSS ScoreSymptom Symptom description
severity

0–7 Mild Little bother, reasonable
urine flow and low
residual volume
8–19 Moderate Bothersome, reduced
residual volume but no
evidence of complications

20-35 Severe Complications of
obstruction
•A detailed Focused history
Urinary tract

(Exclude)

UTI,s
Neurogenic Bladder
Urethral stricture
Prostate cancer
ASSESSMENT
Recommended investigations
(EAU guidelines)
EAU 2004 recommendations regarding
initial assessment of BPH

Medical history Recommended
Symptom score Recommended
Physical Recommended
examination
including digital
rectal examination
(DRE)

Prostate specific Recommended
antigen (PSA)
Creatinine Recommended
measurement
Urinalysis Recommended
Flow rates Recommended
Post-void residual Recommended
volume
Pressure flow Optional
studies
Imaging of the Optional
upper urinary tract

Imaging of the Optional
prostate
Voiding charts Optional
PSA
 PSA is a protein produced almost exclusively in
the epithelial cells of the prostate
 Elevated levels of PSA signify change in the
prostate typically caused by:
 BPH
 Prostate cancer
 Prostatitis
 ? Ageing
 Instrumentation
Guideline recommendations
A PSA-test should be offered to those with
at least a 10-year life expectancy and for
whom knowledge of the presence of
prostate cancer would change management

 PSA can be used to evaluate the risks of
either requiring surgery or developing AUR
Factors influencing the serum levels of
PSA
 architecture of the prostatic gland is disrupted
 PSA will ‘leak’ into the circulation
 prostatic carcinoma, BPH, prostatitis and after
urinary retention
 PSA is not considered as being cancer-specific, but
organ-specific
 PSA serum elevations occur in biopsy of the
prostate gland and ejaculation , small and clinically
insignificant changes occur after DRE.
 Two other important factors, age and race
 African-Americans with no evidence of
prostate carcinoma have higher PSA
values after their fourth decade of life.
Age-Adjusted Reference Ranges
For PSA

 Age (y) PSA Normal Ranges
(ng/ml)
 40–49 0–2.5
 50–59 0–3.5
 60–69 0–4.5
 70–79 0–6.5
 Data from Oesterling JE et al: Serum prostate-specific antigen in a
 community-based population of healthy men. Establishment of
 age-specific reference ranges. JAMA 1993;270:860.
BPH-
Complications:
1. Urethral compression
2. Ball valve mechanism
3. Bladder hypertrophy
4. Trabeculation
5. Diverticula formation
6. Hydroureter – bilateral
7. Hydronephrosis
BPH-Bladder Gross – Identify
Cues?
 Trabeculations
 Hypertrophy of wall
 Stone - urolithiasis
 Inflammation
 Median lobe- ball valve.
 Enlarged prostate.
BPH-Bladder morphology:

 Hypertrophy
 Trabeculation
 Median lobe
protrusion.
Benign Prostatic Hyperplasia:
Normal Prostate:
Nodular BPH:
THE END