BENIGN PROSTATE HYPERPLASIA

Div. of Urology, Dept. Surgery

Medical Faculty,
University of Sumatera Utara
REFERENCES
 DEFINITION

BPH is :
Enlargement of the prostate gland from the progressive
hyperplasia of stromal and glandular prostatic cells
Pathologic process that contributes to, but is not the
sole cause of, lower urinary tract symptoms (LUTS) in
aging men

Urol Clin N Am 35 (2007) 109–115

Campbell-Walsh Urology, 9th ed.2007
 TERMINOLOGY

BPH (Benign Prostatic Hyperplasia) histopathologic

diagnosis
BPE (Benign Prostatic Enlargement)  anatomic diagnosis
BOO (Bladder Outlet Obstruction)  anatomic diagnosis
BPO (Benign Prostatic Obstruction)  BOO caused by BPE
LUTS (Lower Urinary Tract Symptoms)  clinical
manifestation of lower urinary tract obstruction
 INTRODUCTION

Most common benign tumor in men

Age related

 in life expectancy  significantly  the number of men

affected by BPH

BPH is said to be a “stromal disease,” but it remains unclear

whether the initiating events occur in the stomal
compartment, the epithelial compartment, or both
 ANATOMY

Normal weight about 20 g

Classification of Lowsley : 5 lobes : anterior,
posterior, median, right lateral, left lateral
According to Mc Neal :
- peripheral zone
- central zone
- transitional zone
- an anterior segment
- a preprostatic sphincter zone
 PREVALENCE

20 % of men 40 - 50 years
50 % of men 50 - 60 years
> 90 % of men older than 80 years
The Most Frequent Benign Tumor in Men
PREVALENCE OF HISTOLOGICAL BPH WITH AGE

Prevalence (%)
100 92%
87%
77%
80

60
48%

40 29%

20 11%

0
31–40 41–50 51–60 61–70 71–80 80+

Berry SJ et al. J Urol 1984; 132: 474–9

All Men > 40
yrs

BPH

Storage
Total
51.3%

BPE Storage
Total
51.3%

LUTS

BOO
 ETIOLOGY

Multifactorial and endocrine controlled

(Androgens, estrogens, stromal-
epithelial interactions, growth factors,
and neurotransmitters may play a role )
BUT not completely understood
 THEORIES FOR THE CAUSE OF BPH

 Theory Cause Effect

 Dihydrotestosteron  5- reductase and Epithelial and
 hypothesis androgen receptors stromal hyperplasia

 Oestrogen-  Oestrogens Stromal hyperplasia

testosteron  Testosteron
 imbalance
 Epidermal growth Epithelial and
 Stromal-epithelial factor/fibroblast stromal
 interactions growth factor hyperplasia
 Transforming growth
factor 
 Longevity of
stroma
 Reduced cell death  Oestrogens and epithelium

Proliferation of
 Stem cell theory Stem cells transit
 MORPHOLOGY

Microscopically, nodular prostatic hyperplasia

consists of nodules of glands and intervening
stroma (mostly glands)

The glands variably sized, with larger glands have

more prominent papillary infoldings

Nodular hyperplasia is NOT a precursor to carcinoma

PATHOPHYSIOLOGY

1. Pathogenesis hyperplasia
2. Symptoms disorders ( Voiding phase or
storage phase )
 PATHOPHYSIOLOGY

Nodular hyperplasia of glands and stroma

Normal 20 to 30  50 to 100 gm
Press upon the prostatic urethra
Obstruction - difficulty on urination
Dysuria, retention, dribbling, nocturia
Infections, hydronephrosis, renal failure
Not a premalignant condition
PATHOPHYSIOLOGY

Prostate growth

Increased urethral resistance

Decompensation

Flow

Bladder emptying ,
hesitancy, intermittency, etc
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY

Static Dynamic
component component

LUTS
STATIC COMPONENT

Prostate mass (volume)

Urethral closure pressure

 DYNAMIC COMPONENT

• Bladder pressure
• Prostate smooth muscle tone:
• in stroma
• capsule
• bladder neck
 LUTS ARE A CONSTELLATION OF
STORAGE AND VOIDING SYMPTOMS

Storage Voiding Post-micturition

Urgency Hesitancy Post-void dribble

Sense of
Frequency Poor flow
incomplete emptying
Nocturia Intermittency
Urgency
Straining
incontinence

Other Terminal dribble

incontinence
 PREVALENCE OF LUTS IN MEN

Percentage of men in the general male population who

report at least 1 symptom representative of a particular
type of LUTS

Voiding Storage
Total Total
25.7% 51.3%

Post-
micturition
Total
16.9%
Irwin DE et al. Eur Urol. 2006;50:1306-
1315
HOW TO ASSESS THE PATIENT?
 RECOMMENDED INVESTIGATIONS

Clinical history
Physical examination
Validated symptom score, e.g IPSS
Laboratory
Uroflowmetry
Imaging
1. CLINICAL HISTORY

Obstructive : Irritative :
Urgency
Hesitancy
Frequency
Poor flow
Nocturia
Intermittency
Urgency
Straining
incontinence
Terminal dribble
Other incontinence
 2. PHYSICAL EXAMINATION

DRE :
Size
Consistency :
smooth or elastic/hard
Nodule/ tender
Mobility
Anatomical limits:
Lateral/ cranial/ medial sulcus
DRE is recommended in the evaluation
of men with LUTS
DRE
 3. VALIDATED SYMPTOM SCORE

 IPSS (International Prostate Scoring

System ).
0–7 : Mild
8 - 19 : Moderate
20 – 35 : Severe

 7 : Watchful & Waiting

 7 : Medical treatment
 BPH SYMPTOM SCORE (by :AUA)
Tidak Pernah < 20 % < 50 % =50% > 50 % Hampir Selalu
Gejala
1. KENCING TIDAK LAMPIAS
Dalam sebulan ini berapa sering anda merasakan sensasi tidak lampias 0 1 2 3 4 5
saat kencing (terasa belum habis) ?
2. Sering Kencing
Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam 0 1 2 3 4 5
2 jam setelah anda Kencing
3.KENCING TERPUTUS PUTUS
Dalam sebulan ini berapa sering kencing anda terhenti sejenak, lalu mulai 0 1 2 3 4 5
lagi ( Terputus putus)
4.TIDAK DAPAT MENUNDA KENCING
Dalam Sebulan ini Berapa sering anda merasa kesulitan untuk menunda 0 1 2 3 4 5
Kencing
5.PANCARAN KENCING YANG LEMAH
Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah 0 1 2 3 4 5
6. MENGEDAN SAAT KENCING
Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing 0 1 2 3 4 5
7.KENCING DI MALAM HARI
Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4 5kali, =5
Kencing
4. LAB TEST

 Blood Count
 Serum Electrolyte
 Serum Creatinine
 Serum PSA
 Urine :
Proteinuria
Sediment
Culture
5. UROFLOWMETRY

Uroflowmetry Qmax
Voided volume

Residual urine TAUS

Catheter
DIAGNOSTIC FOR BPH

Uroflowmetry :
UROFLOWMETRY
5. IMAGING

TRUS ( Transrectal ultrasound )

Transabdominal Ultrasound
With Indication : IVP
Cystography
CT-Scan
MRI
 TRANS RECTAL ULTRA SONOGRAPHY

 Volumometry
 Identification of
hypoechoic lesions
 Calcification
 Periprostatic vein
DIFFERENTIAL DIAGNOSIS

l Urethral stricture
l Bladder neck contracture
l Small bladder stone
l Locally advanced prostate ca
l Poor bladder contractility
DIFFERENTIAL DIAGNOSIS

Bladder
– Detrusor overactivity
– Impaired detrusor contractility
– Sensory urgency
– Sphincteric incontinence
– Polyuria/nocturnal polyuria
Medications
– Antihistamines
– Antidepressants
Effects of benign prostatic obstruction

 Irreversible bladder changes

 Thickening of the bladder wall
 Recurrent haematuria
 Bladder diverticulum formation
 Repeat urinary tract infections
 Bladder stone formation
 Upper tract dilatation
 Renal impairment
COMPLICATIONS

 Increased risk of UTI due to urinary retention

 Calculi due to alkalinization of residual urine
 Hematuria due to overstretched blood
vessels
 Pyelonephritis
 Renal failure
 INDICATION FOR TREATMENT

 Absolute or near absolute :

- refractory or repeated urinary retention
- azotemia due to BPH
- recurrent gross hematuria
- recurrent or residual infection due to BPH
- bladder calculi
- large residual urine
- overflow incontinence
- large bladder diverticula due to BPH
TREATMENT

 Watchful waiting

 Medical therapies

 Intervention therapies
 Minimally invasive therapies
 Surgical therapies
 WATCHFUL WAITING

Component:
Education ( about the patient”s condition )
Reassurance ( cancer is not a cause )
Periodic monitoring
Lifestyle advice ( alcohol, caffein etc )
Evaluation/ monitoring : after 6 months/ 1 year
IPSS, uroflowmetry, post-void
residual urine volume
MEDICAL THERAPY

 I.P.S.S. > 7
 Flow > 5 ml/s

 Residual urine < 100 ml

 No hard nodule

 PSA < 4 ng/dl

 MEDICAL THERAPY

 Reducing smooth muscle tone (dynamic

component) : α-1 adrenergic blocker
 Short acting : prazosin, afluzosin
 Long acting : doxasosin, terazosin, tamsulosin

 Reducing prostatic mass (static component):

5α redutase inhibitor (finasteride, epristeride)
estrogen aromatase inhibitor
LHRH agonist / antagonist GF inhibitor
antiandrogens
 Unknown
phytotherapy
ADRENERGIC STIMULI

 Alpha adrenergic
stimuli increases
tonus of smooth
muscle cell in the
trigonum, bladder
neck and prostate
 Location of alpha
receptor:
 Bladder
 Trigonum
 Prostate gland
MODE OF ACTION ALPHA BLOCKING AGENT

 Alpha adrenergic blocking agent blocks

adrenergic stimuli  relaxation of the
smooth muscle cell:
urethral pressure 
 intra

 Improvement of urine flow

 RECOMMENDATIONS

α-blockers should be offered to men with moderate to

severe LUTS
5α-reductase inhibitors should be offered to men who
have moderate to severe LUTS and an
enlarged prostate. 5α-reductase inhibitors can prevent
disease progression with regard to acute
urinary retention and need for surgery
The Guidelines committee is unable to make specific
recommendations about phytotherapy of male LUTS
because of the heterogeneity of the products and the
methodological problems associated with meta
analyses
EAU guideline 2010
INVASIVE TREATMENT FOR BPH

Absolute indication:
Chronic Retention
With Hematuria
Concomitant Bladder stone
Intractable UTI
Deteriorating kidney function
Relative indication:
Huge PVR due to obstruction or low Qmax
Refuse medical treatment
Failure in medical treatment
INTERVENTION THERAPY

 Minimally invasive therapy

 Thermotherapy
 TUNA (Trans Urethral Needle Ablation)
 HIFU (High Intensity Focused Ultrasound)
 TUMT (Trans Urethral Microwave Theraphy)
 Laser
 Stent
 Surgical therapy
 TUIP (Trans Urethral Incision of the Prostate)
 TURP (Trans Urethral Resection of Prostate) GOLD
STANDARD
 Open prostatectomy
 TUVP (Transurethral Vaporization of the Prostat)
 Laser
TURP
JARINGAN PROSTAT
TUIP