Benign Prostatic Hyperplasia

1
Benign Prostatic Hyperplasia

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

2
Bladder Outlet obstruction

• Bladder neck dysfunction
• Prostatic enlargement
• Urethral stricture
• External sphincter dyssynergia
• Urethral meatal stenosis
• BOO is a condition of progressive degree

3
Lower urinary tract symptomsIPSS AUA symptom
score

• Frequency
• Urgency
• Nocturia
• Small caliber of urine
• Dysuria
• Intermittency
• Residual urine sensation

4
LUTS and BOO

• 1/3 of men with LUTS do not have BOO
• 5 - 35 of patients with BPH LUTS do not
  improve symptoms after TURP
• LUTS have a poor diagnostic specificity for BOO
• Prostate size and uroflowmetry have better
  correlation with urodynamic study than symptoms
  alone

5
Pathogenesis of Bladder outlet obstruction

• Progressive increased urethral resistance
• High voiding pressure and low flow
• Bladder compensation in energy
• Increased residual urine volume
• Elevated intravesical pressure at end-filling
• Bladder stone, diverticulum, UTI
• Hydroureter, hydronephrosis, azotemia

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Reduction in AChE-positive nerve fibers after BOO
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Differential diagnosis of male BOO and LUTS

• Benign prostatic enlargement
• Bladder neck dysfunction
• Spastic urethral sphincter
• Poor relaxation of urethral sphincter
• Urethral stricture
• Low detrusor contractility
• Pseudodyssynergia due to neuropathy

8
Relation of prostate and urethra
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Benign prostatic hyperplasia

• Prostatic enlargement benign or malignant, a
  sign
• Prostatic hyperplasia histological term
• Prostatic obstruction a clinical diagnosis
• Bladder outlet obstruction an urodynamic term
• Lower urinary tract symptoms symptom

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Anatomy of Prostate gland
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Anatomy of Prostate gland
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Prostatic glandular anatomy
13
Cystoscopic Prostatic obstruction
14
Benign Prostatic Hyperplasia

• BPH requires testicular androgen during prostatic
  development
• Basic fibroblast growth factor, epidermal growth
  factor, keratinocyte growth factor, transforming
  growth factor-beta play some part in prostate
  growth
• Decreased endogenous apoptosis in prostate cause
  abnormal tissue growth in prostate

15
Histology of Benign prostatic hyperplasia
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Clinical BPH

• LUTS ( storage or empty symptoms) due to
  histological benign prostatic hyperplasia and
  urodynamical bladder outlet obstruction which has
  been proven by urodynamic pressure flow study as
  prostatic obstruction
• Treatment for LUTS and restoration of normal
  storage and empty function by reducing prostatic
  enlargement either medically or surgically

17
Pathophysiology of BPH and LUTS

• Nodular proliferation of prostate gland
• Increased stroma to epithelial ratio to 21 to
  51 in benign prosatic hyperplasia
• Increased smooth muscle component
• Detrusor compensatory change and bladder
  dysfunction, detrusor overactivity
• LUTS may related to BPH or detrusor
  dysfunction,or combination

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Symptom scores of BPH as treatment guideline

• 1970 Boyarsky and Madsen-Iverson
• 1992 AUA symptom index
• International prostatic symptom score adds
  quality of life index
• Bothersomeness and health related quality of life
  (HRQOL)
• Symptom problem index
• BPH impact index (BII)

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Clinical evaluation of BPH

• Digital rectal examination of prostate
• -- Prostate size, consistency, surface
  nodularity, tenderness
• Bladder palpation residual urine volume
• Cystography, Intravenous pyelography
• Transrectal sonography of prostate
• Cystourethroscopy

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Cystography of Bladder base elevation indicating
BPH
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Sonography of BPH
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Clinical evaluation of BPH

• Uroflowmetry, prstatic volume
• Postvoid residual urine volume
• Prostatic specific antigen (PSA)
• Pressure flow study improves in diagnosis and aid
  in selection for specific invasive treatment
• Videourodynamic study is helpful in determining
  complicated case

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Uroflowmetry in BPH without or with obstruction
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Pressure flow study in BPH with Obstruction
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Videourodynamic study in BPH with Obstruction
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Causes of non-obstructive Men with LUTS

• Normal bladder and urethra 25
• Bladder hypersensitivity 17
• Detrusor instability 6
• Detrusor underactivity 3
• Poor relaxed urethral sphincter 61

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Videourodynamic study in Man with normal bladder
and urethra
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Videourodynamic study in Man with low detrusor
contractility
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Videourodynamic study in Man with Poor relaxation
of sphincter
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Subjective improvement rate in patients after
prostatectomy
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Improvement in Qmax after Prostatectomy
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Causes of 185 Men with LUTS after prostatectomy

• Normalbladder and urethra 17
• Detrusor instability 18
• Low detrusor contractility 35
• Poor relaxation of urethral sphincter 36
• Detrusor instability and low contractility 27
• Bladder outlet obstruction 52

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Prostate volume, Qmax, resected prostate weight
in patients with LUTS after prostatectomy
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Urodynamic parameters in BPH
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Relationship of Qmax and Age in BPH patients
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Clinical Prostate Score in BPH
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Calculation of Clinical Prostate Score for
Diagnosis of BPO

• Prostate score Qmax TPV voided volume
  residual urine
• Score ? 3 sensitivity 90.7,
  specificity 33
• Prostate score Qmax flow pattern voided
  volume residual urine TPV TZI prostatic
  configuration
• Score ? 3 sensitivity of BPO 87.2,
  specificity 60.8
• Score ? 4 sensitivity of BPO 90.7,
  specificity 50.5
• Score ? 5 sensitivity of BPO 97.6,
  specificity 38.2
• Sensitivity and specificity of BPO diagnosis in
  patients with at least 1 favorable predictive
  factor (n 148)
• Score ? 3 sensitivity of BPO 91.6,
  specificity 87.27
• Exclusion of patients with at least 1 favorable
  predictive factor (n176)
• Score ? 3 sensitivity of BPO 68.9,
  specificity 23.0

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Prostatic Transition Zone Index
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A-G Number in Diagnosis of BPO
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Treatment of BPH

• Treating an enlarged prostate ?
• Treating lower urinary tract symptoms?
• Treating bladder outlet obstruction?
• Can LUTS disappear after treatment?
• Can BOO be relieved after treatment?
• Any complication may occur?
• Is the treatment cost- effective ?

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Therapeutic modalities for LUTS ascribed to the
prostate

• Watchful waiting and fluid restriction, natural
  history of BPO may wax and wan
• Medical treatment to reduce prostate size or
  decrease intraprostatic resistance
• Surgical treatment to remove prostatic
  obstruction or reduce urethral resistance
• Minimally invasive therapies

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Surgical Treatment for BPH

• Suprapubic retropubic prostatectomy
• Transurethral prostatectomy (TUR-Prostate)
• Laser interstitial prostatectomy
• Transurethral incision of prostate
• Intraprostatic stent
• Balloon dilatation of prostatic urethra
• Prostatic hyperthermia

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Prostate Resectoscope and TURP
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Complications of TUR-Prostate

• Peri-operative bleeding
• Urinary tract infection and urosepsis
• Electrolyte imbalance, hemolysis, acute tubular
  necrosis
• Acute pulmonary edema
• Bladder neck or urethral contracture
• Retrograde ejaculation and erectile dysfunction
• Urge or stress urinary incontinence

45
Minimally invasive procedure

• Transurethral vaporization- resection of prostate
  (TUVRP)
• Ho-YAG laser coagulation of prostate
• Visual laser ablation of prostate (VLAP)
• Transurethral needle ablation (TUNA)
• High intensity focused ultrasound (HIFU)
• Microwave hyperthermia
• Minimally invasive minimally effective?
• A higher re-treatment rate than TURP although
  less complication occurs

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Intra-Prostatic Stent
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Interstitial Laser Coagulation
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Hyperthermia of BPH
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Transurethral Dilatation of Prostate
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Medical Therapy for BPH

• Prostatic smooth muscle tension was mediated by
  alpha 1-adrenoreceptors
• Smooth muscle contractions contribute 40 of
  outflow obstruction
• Alpha 1- blockers can rapidly improve Qmax and
  relieve LUTS
• Phenoxybenzamine, terazosin, doxazosin have side
  effect of dizziness and hypotension

51
Prostatic specific alpha- adrenoreceptor

• Alpha 1A- AR subtype comprises 70 of all alpha-1
  receptors
• Alpha 1A-AR agonist tamslosin has 13 x more
  affinity to prostatic smooth muscle than urethral
  muscle , 10 x than vascular smooth muscle
• Side effects are still reported
• Long-acting (once daily) dose

52
Hormone based medical therapy

• 5-alpha-reductase catalyzes conversion of
  testosterone to dihydrotestosterone
• Inhibition of 5-alpha-reductase can arrest
  prostatic growth and relieve obstruction
• Finasteride can improve symptom score,Qmax, QOL
  score
• Effective especially in prostatic weight of gt40
  gm and effective in prostatic hematuria

53
Combination therapy with alpha-blocker and
finasteride

• Terazosin is effective therapy, finasteride was
  not, combination was no more effective than
  terazosin alone (Lepor, N Engl J Med 1996 335
  533)
• Combined dibenyline and finasteride has an
  additive effect than dibenyline or finasteride
  alone in improvement of Qmax and prostatic size

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Consideration in treating BPH

• Patients are old in symptomatic BPH
• Too early surgery may lead to undesired sequalae
  such as erectile dysfunction
• Too late surgery cannot reverse detrusor
  overactivity and leads to urge incontinence
• Etiology of LUTS (DI? DHIC? BOO?) should be
  clarified to prevent unsuccessful surgical results

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Therapeutic guideline for BPO

• Calculation of clinical prostatic score and QOL
  index, medical treatment for BPO
• Monitoring Qmax, residual urine volume, and
  prostate volume during treatment
• If obstructive or irritative symptom exacerbate,
  detailed pressure flow study to confirm the BOO
  diagnosis
• Surgery for patients with poor QOL index