Benign Prostatic Hyperplasia (BPH)

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Benign Prostatic Hyperplasia(BPH)
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The prostate

• Walnut-shaped gland surrounds the urethra.
• Prostate weights about 20g.
• Measures about 4 X3X2.
• Apex inferior portion of prostate.
• Base superior portion and continuous with
  bladder neck.

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Lobes of the Prostate

• Anterior lobe
• Median lobe
• Two lateral lobes
• Posterior lobe

Image Source SEER Training Website
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Histology of the prostate

• The prostatic gland consists of glandular
  component and fibromuscular stroma.
• The glandular component is formed of prostatic
  acini arranged in lobules. The acini are highly
  folded and lined by epithelial cells. The
  percentage of glandular tissue vary between the
  different zones of the gland.

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Prostate zones

• Central zone (CZ)
• Cone shaped region that surround the ejaculatory
  ducts (extends from bladder base to the
  verumontanum)
• Accounts for 25 of glandular tissue.
• Peripheral zone (PZ)
• Posterolateral prostate
• Accounts for the majority of glandular tissue.
• The site of prostate adenocarcinoma

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• Transitional zone (TZ)
• Surrounds the prostatic urethra proximal to the
  verumontanum
• Accounts for only 5-10 of glandular tissue.

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Functions of the prostate

• Secretes prostatic secretions.
• During orgasm, prostate muscles contract and
  propel ejaculate out of the penis

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Benign prostatic hyperplasia (BPH)
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Causes BPH

• BPH is part of the natural aging process, like
  getting gray hair or wearing glasses
• BPH cannot be prevented
• BPH can be treated

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Proposed Etiologies of BPH

• The causes of benign prostatic hyperplasia are
  not fully understood. Several theories have been
  proposed to explain BPH, the most accepted one is
  hormonal changes.

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• Estrogen may play a role in BPH. As men age,
  testosterone levels drop, and the proportion of
  estrogen increases, possibly triggering prostate
  growth.
• In addition to the mechanical effects of the
  enlarged prostate, clinical symptoms of lower
  urinary tract obstruction are also due to smooth
  muscle-mediated contraction of the prostate. The
  tension of prostate smooth muscle is mediated by
  the a1-adrenoreceptor localized to the prostatic
  stroma.

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Morphological features of BPH

• Gross Findings
• The periurethral part of the gland is most
  commonly involved.
• Overall, the gland is enlarged, often reaching
  massive size, and has a firm, rubbery
  consistency. Small nodules are present throughout
  the gland, usually 0.51 cm in diameter but
  sometimes much larger. Some of the larger nodules
  show cystic change.
• The urethra appears slit-like and compressed.

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• Microscopic Findings
• The nodules are composed of a variable mixture of
  hyperplastic glandular elements and hyperplastic
  stromal muscle. The glands are larger than normal
  and lined by tall epithelium that is frequently
  thrown into papillary projections.

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BPH
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Clinical Course

• Symptoms of nodular hyperplasia, when present,
  relate to two secondary effects
• 1. Compression of the urethra with difficulty in
  urination.
• 2. Retention of urine in the bladder with
  subsequent distention and hypertrophy of the
  bladder, infection of the urine, and development
  of cystitis and renal infections.
• Symptoms
• Patients experience frequency, nocturia,
  difficulty in starting and stopping the stream of
  urine, overflow dribbling, and dysuria (painful
  micturition). In many cases, sudden, acute
  urinary retention appears for unknown reasons and
  persists until the patient receives emergency
  catheterization.

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• In addition to these difficulties in urination,
  prostatic enlargement results in the inability to
  empty the bladder completely, so a considerable
  amount of residual urine is left. This residual
  urine provides a static fluid that is vulnerable
  to infection. On this basis, catheterization or
  surgical manipulation provides a real danger of
  the introduction of organisms and the development
  of pyelonephritis.

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• Many secondary changes occur in the bladder, such
  as hypertrophy and diverticulum formation.
  Hydronephrosis or acute retention, with secondary
  urinary tract infection and even uremia, may
  develop.
• BPH is not considered to be a premalignant lesion.

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• Treatment of BPH
• A. Mild cases
• May be treated without medical or surgical
  therapy, by decreasing fluid intake, especially
  prior to bedtime moderating the intake of
  alcohol and caffeine-containing products and
  following timed voiding schedules. The most
  commonly used and effective medical therapy for
  symptoms relating to benign hyperplasia are
  a-blockers, which decrease prostate smooth muscle
  tone via inhibition of a1-adrenergic receptors.

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• B. Moderate to severe cases
• With no response to medical therapy, a wide range
  of more invasive procedures exists.
• Transurethral resection of the prostate (TURP).
  It is indicated as a first line of therapy in
  certain circumstances, such as recurrent urinary
  retention.
• Laser therapy.

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TURP
(Transurethral resection of the prostate)

• Uses an electrical knife to surgically cut and
  remove excess prostate tissue
• Effective in relieving symptoms and restoring
  urine flow.

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C. Open prostatectomy

• Too large prostate -- gt100 gm
• Combined with bladder diverticulum or vesical
  stone surgery

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References

• Robbins and Cotrans Pathologic Basis of
  Disease. Seventh edition.

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