Benign prostate hyperplasia

Div. of Urology, Dept. Surgery

Medical Faculty,
University of Sumatera Utara
 Ref :

• Clinical Manual of Urology, (Philip M.

Hanno et al eds), McGraw-Hill Int ed, 3rd
ed, 2001
• Smith’s General Urology (Tanagho &
McAninch eds), Lange Medical Books, 15th
ed, 2000
 Definition

• Regional nodular growth of varying

combinations of glandular and stromal
proliferation that occurs in almost all men
who have testes and who live long enough
 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

• Common non-neoplastic lesion.

• Involves peri urethral zone.
• BPH is common as men age.
• 25% by 50y, but 90% By 80y..!
• About 10% are symptomatic.
 Prevalence

The Most Frequent Benign Tumor in Men

• 70 % of men above 60 years.*
• 90 % of men above 80 years.**
• 30 – 40 % of men above 70 years
• Indonesia : The Second after Stone Disease in
Urology Clinic ***

* Berry SJ et all J Urol 1984 ;132:474-79

** Carter HB , Coffey DS. Prostate 1990;16 : 39-48
*** Rahardjo D,Birowo P,Pakasi LSMed . J of Ind 1999 ; 8(4) : 260 - 63
 Impact of ageing population

• With life expectancy approaching 80 years in

many countries  88% chance developing
histological BPH
•  in life expectancy  significantly  the
number of men affected by BPH
• The number of men presenting with BPH
symptoms will  ± 45% in the next 10 years
and  further in the following decade
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

 Anatomy

• N 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
 Causes
- Many theories
- The actual cause still not clear
- Factors are known to be important:

1. Male sex
2. Aging
3. Testosterone
4. Growth Factors (EGF, FGF, IGF II)
 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*
Prostate growth

Increased urethral resistance

Decompensation

Flow ↓

Bladder emptying ↓,
hesitancy, intermittency
 Mechanism

• Hormonal imbalance with ageing.

• Estrogen sensitive peri-urethral glands.
• Accumulation of DHT in the prostate and its
growth-promoting androgenic effect
• Some Drugs (Finasteride) inhibit DHT 
diminishes prostatic enlargement.
 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.
 Symptoms LUTS
• Weaker, smaller • Nocturia
stream • Frequency
• Hesitancy • Urgency
• Intermittent / • dysuria
interrupted flow • Symptoms may
• Feeling of incomplete worsen with alcohol
emptying or retention and caffeine, cold
• Terminal dribbling remedies
How to Assess the Patient?
 Diagnosis

• Anamnesis
Cardinal symptoms:
Weak Stream
Frequency
Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

 BPH SYMPTOM SCORE / IPSS
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
IPSS (International Prostate
Symptom Score ).

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

 7 : Watchful & Waiting

 7 : Medical treatment
 Diagnosis

Physical Prostate :
examination : 1. Size
DRE 2. Nodule
3. Consistency
4. Tenderness
DRE
 Diagnosis

Uroflowmetry Qmax
Voided volume

Residual urine TAUS

Catheter
Uroflowmetry
 Lab test

• Blood Count
• Serum Electrolyte
• Serum Creatinine
• Serum PSA
• Urine :
Proteinuria
Sediment
Culture
 IMAGING
• TRUS
• Transabdominal Ultrasound
• With Indication :
IVP
Cystography
CT-Scan
MRI
Trans Rectal Ultra Sonography :
• Volumometry
• Identification of hypoechoic lesions
• Calcification
• Periprostatic vein
 Differential diagnosis

 Urethral stricture
 Bladder neck contracture
 Small bladder stone
 Locally advanced prostate ca
 Poor bladder contractility
 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

Altering modifiable factor such as:

– Concomitant drug
– Regulation of fluid intake especially in the evening
– Life style change (avoid sedentary life)
– Dietary advice (avoid excessive intake of alcohol, and
highly seasoned or irritative foods)
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:
– intra urethral pressure 
– Improvement of urine flow
Rationale of 5Alpha reductase inhibitor

Hipotalamus
Sintesis Protein
LHRH

ACTH

Transkripsi DNA

Reseptor Inti
+
DHT

T DHT
5-α reductase
 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)
• Open prostatectomy
• TUVP (Transurethral Vaporization of the Prostat)
• Laser
 Invasive Treatment for BPH
• TURP (gold standard)
• Laser resection (Hol YAG Laser)
TURP
JARINGAN PROSTAT
TUIP