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Benign Prostatic

Hyperplasia
Benign Prostatic
Hyperplasia
Generalised disease of
the prostate due to
hormonal derangement
which leads to
enlargement of the gland
(increase in the number
of epithelial cells and
stromal tissue)to cause
compression of the
urethra leading to
symptoms

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BPH
Proposed Etiologies
Cause not completely understood
Reawakening of the urogenital sinus to proliferate
Change in hormonal milieu with alterations in the
testosterone/estrogen balance
Induction of prostatic growth factors
Increased stem cells/decreased stromal cell death
Accumulation of dihydroxytestosterone, stimulation by
estrogen and prostatic growth hormone actions
BPH facts
Occurs in 50% of men over 50 and in
80% of men over 80 have BPH
BPH progresses differently in every
individual
Many men with BPH may have mild
symptoms and may never need
treatment
BPH does not predispose to the
development of prostate cancer

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Benign Prostatic
Hyperplasia

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BPH Pathophysiology
Normal BPH

BLADDER

Hypertrophied
detrusor muscle
PROSTATE

URETHRA Obstructed
urinary flow

Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.


BPH
Pathophysiology
Slow and insidious changes over time
Complex interactions between prostatic urethral
resistance, intravesical pressure, detrussor
functionality, neurologic integrity, and general
physical health.
Initial hypertrophydetrussor decompensation
poor tonediverticula formationincreasing
urine volumehydronephrosisupper tract
dysfunction
Complications
Urinary retention
UTI
Sepsis secondary to UTI
Residual urine
Calculi
Renal failure
Hematuria
Hernias, hemorroids, bowel habit change

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Clinical manifestations
Voiding symptoms
decrease in the urinary stream
Straining
Dribbling at the end of urination
Intermittency
Hesitancy
Pain or burning during urination
Feeling of incomplete bladder emptying

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Clinical manifestations
Irritative symptoms
urinary frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection
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Benign Prostatic
Hyperplasia

Leading to symptom bother


and worsened QOL
Other Relevant History
GU History (STD, trauma, surgery)
Other disorders (eg. neurologic,
diabetes)
Medications (anti-cholinergics)
Functional Status
Diagnostic Tests
History & Examination Prostate specific
Abdominal/GU exam
antigen (PSA)

Focused neuro exam


Digital rectal exam
Transrectal
(DRE) ultrasound
Validated symptom biopsy
questionnaire. Uroflometry
Urinalysis Postvoid residual
Urine culture
BUN, Cr

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AUA Symptom Score Sheet
More
Less Less
than
than 1 than About half Almost Your
Not at all half
time half the the time always score
the
in 5 time
time

Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your 0 1 2 3 4 5
bladder completely after you finish urinating?

Frequency
Over the past month, how often have you had to urinate again less than two hours after 0 1 2 3 4 5
you finished urinating?

Intermittency

Over the past month, how often have you found you stopped and started again several 0 1 2 3 4 5
times when you urinated?

Urgency
Over the last month, how difficult have you found it to postpone urination? 0 1 2 3 4 5
Weak stream
Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
Straining
Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5

5 times Your
None 1 time 2 times 3 times 4 times
or more score

Nocturia
Over the past month, many times did you most typically get up to urinate from the 0 1 2 3 4 5
time you went to bed until the time you got up in the morning?

Quality of life due to urinary symptoms Mixed about equally Mostly


Delighted Pleased Mostly satisfied Unhappy Terrible
satisfied and dissatisfied dissatisfied

If you were to spend the rest of your life with your


urinary condition the way it is now, how would you 0 1 2 3 4 5 6
feel about that?

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.
DRE

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BPH
Danger Signs on DRE
Firm to hard nodules
Irregularities, unequal lobes
Induration
Stony hard prostate
Any palpable nodular abnormality
suggests cancer and warrants
investigation
Optional Evaluations and
Diagnostic Tests
Urine cytology in patients with:
Predominance of irritative voiding symptoms.

Smoking history

Flow rate and post-void residual


Not necessary before medical therapy but

should be considered in those undergoing


invasive therapy or those with neurologic
conditions
Upper tract evaluation if hematuria, increased
creatinine
Cystoscopy
PSA
Elevated levels of PSA
0 4 ng/ml
Prostatic pathology
Correlates with tumor mass
Some men with prostate cancer
have normal PSA levels

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BPH SYMPTOMS
Differential Diagnosis
Urethral stricture
Bladder neck contracture
Carcinoma of the prostate
Carcinoma of the bladder
Bladder calculi
Urinary tract infection and prostatitis
Neurogenic bladder
BPH TREATMENT
INDICATIONS
Absolute vs Relative
Severe Moderate
obstruction symptoms of
Urinary retention prostatism
Signs of upper Recurrent UTIs
tract dilatation Hematuria
and renal Quality of life
insufficiency issues
Treatment Options
Mild to severe symptoms with little
bother
Manage with watchful waiting.
Risk of therapy outweighs the benefit of medical or
surgical treatment

Moderate to severe symptoms with


bother
Management options include watchful
waiting, medical management and surgical
treatment.
Therapy
Watchful waiting and behavioral
modification
Medical Management
Alpha blockers
5-alpha reductase inhibitors
Combination therapy
Surgical Management
Office based therapy
OR based therapy
Urethral stents
Watchful Waiting and
Behavioral Modification

is the preferred management technique


in patients with mild symptoms and
minimal bother

AUA score < 7,

1/3 improve on own.


Watchful Waiting and
Behavioral Modification
Decrease caffeine, alcohol )diuretic effect(
Avoid taking large amounts of fluid over a short
period of time
Void whenever the urge is present, every 2-3 hours
Maintain normal fluid intake, do not restrict fluid
Avoid bladder irritants to include dairy products,
artificial sweeteners, carbonated beverages
Limit nighttime fluid consumption
BPH symptoms can be variable, intermittent
Medical Management

Nutritional supplements
Saw Palmetto
Alpha blockers
Doxazosin (Cardura), Terazosin (Hytrin),
Tamsulosin (Flomax), Alfuzosin (Uroxatral)
5-alpha reductase inhibitors
Finasteride (Proscar), Dutasteride
(Avodart)
Combination therapy
Alpha blocker and 5-alpha reductase
inhibitor
medication
Benefits Disadvantages
Convenient Expensive
No loss of work Drug Interactions
time
Must be taken every
day
Minimal risk
Manages the problem
instead of fixing it
Medical Management
Alpha adrenergic receptor blockers
promote smooth muscle relaxation in the prostate

Relaxation of the muscles facilitates urinary flow

Doxazosin (Cardura), Terazosin (Hytrin),

Tamsulosin (Flomax), Alfuzosin (Uroxatral)


Side effects: postural hypotension, dizziness,

fatigue,
Other problems can occur when pt is also taking

cardiac or other hypertensive drugs

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Alpha-Adrenergic Blockers
Equal clinical effectiveness
Slight differences in adverse event profile
Orthostasis (lower in tamsulosin)

Ejaculatory dysfunction (higher in
tamsulosin)
Decreased energy levels
Nasal congestion

Increase in CHF risk with doxazosin
Must titrate doxazosin and terazosin to
effective levels
Medical Management
5 alpha reductase inhibitor ) finasteride: Proscar(
Reduce size of prostate gland by up to 30 %

Blocks the enzyme of 5 alpha reductase which


is nec, for the conversion of testosterone to
dihydroxytestostersone
Regression of hyperplastic growth

Dont work immediately

Small effect on symptom score and flow rates

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5-Alpha Reductase
Inhibitors
Agents are effective and appropriate treatment
for patients with lower urinary tract symptoms
and demonstrable enlargement of the prostate.

Average prostate size is 30 ccs. Original


studies showed benefit only in men with
prostate sizes greater than 50 ccs.
5-Alpha Reductase
Inhibitors
Finasteride (Proscar) and Dutasteride (Avodart)
Less effective for relief of BPH symptoms

than alpha blockers


Adverse events include

Decreased libido

Worsened sexual function (erectile dysfunction)

decrease volume of ejaculation

Breast enlargement and tenderness

Reduces risk of urinary retention by 3%/year.

PSA must be doubled if screening for prostate

cancer
Combination Therapy
Concomitant use of alpha blockers
and 5-alpha reductase inhibitors
Should be reserved for patients
who are at significant risk of
progression and adverse outcome

Poor surgical candidate

Patient wants to avoid surgery

Significant cost associated with dual
medications
Medical Management
Herbal therapy
saw palmetto fruit
use to improve
urinary symptoms
and urinary flow
Problem with
herbal therapy
long term
effectiveness

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surgical treatment
Surgical Management

Office based therapies:


Transurethral microwave therapy (TUMT)
Transurethral needle ablation (TUNA)

Therapies are effective
or partially effective for
relieving the symptoms of BPH

Significant side effects/complications
associated with these treatments
have prompted a FDA warning
Surgical Management
OR based therapies
Open simple prostatectomy
TURP
Transurethral incision of the prostate
Laser photoselective vaporization of
the prostate (green light laser PVP)
Laser Prostatectomy
Surgical Management
Patients may select surgical treatment as
initial therapy if moderate or severe bother is
present.

Patients who have developed complications of


BPH (i.e urinary retention, renal insufficiency,
recurrent UTI) are best treated surgically.

New surgical treatment have not


demonstrated better outcomes than TURP to
date.
BPH TREATMENT
Surgical
Indicated for AUA score >16
Transurethral Prostatectomy(TURP): 18%
morbidity with .2% mortality. 80-90%
improvement at 1 year but 60-75% at 5 years
and 5% require repeat TURP.
Transurethral Incision of Prostate (TUIP): less
morbidity with similar efficacy indicated for
smaller prostates.
Open Prostatectomy: indicated for glands >
60 grams or when additional procedure
needed for suprapubic/retropubic approaches
TURP

Gold Standard of care for BPH


the gold standard- TURP
Benefits Disadvantages
Widely available Greater risk of side
effects and complications
Effective

1-4 days hospital stay
Long lasting
1-3 days catheter

4-6 week recovery

possible side effects of
TURP
Greater than 5% risk of:


Irritative voiding symptoms

Bladder neck contracture

UTI
Risk of incontinence 1%
Decline in erectile function

65% of retrograde ejaculation

TUR syndrome (acute hyponatremia from free water

absorption)
Hemorrhage

Bladder spasms
Preoperative Goals
Restoration of urinary drainage
Treatment of any urinary tract
infection
Understanding of procedure,
implications for sexual functioning
and urinary control

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Preoperative care
Antibiotics
Allow pt to discuss concerns about
surgery on sexual functioning
Prostatic surgery may result in
retrograde ejaculation

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Postoperative Goals
No complications
Restoration of urinary control
Complete bladder emptying
Satisfying sexual expression

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Postoperative Care
Monitoring
Continuous irrigation & maintain
catheter patency
Blood clots and hematuria are expected
for the first 24-36 hours
After catheter is removed check for
urinary retention and urinary stream

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TURP
Sphincter tone may be poor after
catheter is removed. Kegal exercise
pelvic muscle floor technique is
encouraged. Starting and stopping
the urinary stream is helpful.
Stool softeners to avoid straining
Sitting and walking for long periods
should be avoided

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Discharge planning
Catheter care
Managing urinary incontinence
Oral fluid intake 2,000-3,000 cc per day
Observe for s/s of urinary tract infection
Prevent constipation
Avoid lifting
No driving or intercourse after surgery

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Surgical approaches for
prostatectomy
Retropubic
Midline abd.
incision
Perineal
Incision between
the scrotum and
anus
Suprapubic
Abdominal incision

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Prostatectomy
Complications:
Bleeding
Postoperative pain
Risk for infection
Erectile dysfunction

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BPH TREATMENT
New Modalities
Minimally invasive: (Prostatic
Stents,TUNA,TUMT, HIFU,Water-
induced Thermotherapy)
Laser prostatectomy
(VLAP,ILC,CLAP,TULIP,HoLRP)
Electrovaporization (TUVP,TVRP)
heat therapies
Destroy prostate tissue with heat
Tissueis left in the body and is
expelled over time (called
sloughing)

Transurethral Microwave Therapy (TUMT)


Transurethral Needle Ablation (TUNA)
Interstitial Laser Coagulation (ILC)
Water Induced Thermotherapy (WIT)
heat therapies
Benefits Disadvantages
Office treatments Some symptoms will
Local anesthesia persist for up to 3
months
Minimally
invasive Cannot predict who

Reduced risk of will respond


complications as May require
compared to prolonged
invasive surgical catheterization
TURP
possible side effects
of heat therapies
Urinary Tract Infection

Impotence
Incontinence
Laser Photoselective
Vaporization of the Prostate
(Laser PVP)
TURP-equivalent 7 year improvement in
symptom score and urination parameters
Decreased risk of bleeding and TUR
syndrome, otherwise similar adverse
effect profile
May be done on anti-coagulated patients