Benign prostatic hyperplasia

‫احمد علي الحمزاوي‬.‫د‬

Epidemiology of BPH
BPH is the most common benign tumor in men, and its incidence is age
related and the symptoms of prostatic obstruction are also age related as by
age 80year, 80% develop microscopic changes characteristic of BPH, but
only 50% develop symptomatic BPH
The other risk factor is hereditary factors in a form of autosomal dominant
trait as first –degree relative of BPH patient has four fold risk of developing
prostatism.

Etiology of BPH
The etiology of BPH is not completely understood, but it seems to be
multifactorial and endocrine controlled. The risk factors include:
1. Aging: Second prostate growth spurt occur after age 40 until age
80-90 due to increase sensitivity of the prostate gland to androgen.
2. Dihydrotestosterone (DHT) and 5-α reductase levels constant in
stromal tissues vs. decline in epithelial tissue.

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Pathophysiology of BPH
(How cause symptoms)
•Static Factors :

Mechanical obstruction may result from intrusion into the urethral lumen or
bladder neck, leading to a higher bladder outlet resistance.
•Dynamic Factors

Related to smooth muscle tone of prostate gland which innervated by α-

adrenergic autonomic nerves and when Contracts around urethra obstructs
urinary flow.

Symptoms and signs:

•Obstructive voiding symptoms (early)

–Weak urinary stream.

–Hesitancy. (Hesitate in initiation of urination).

–Abdominal straining on urination.

–Terminal dribbling

–Incomplete emptying of the bladder.

–Intermittency (intermittent stream (start and stop))

–Retention.

•Irritative voiding symptoms (late)

–Nocturia (nocturnal frequency of urination)

–Frequency of urination

–Urgency (intense desire to urinate)

–Dysuria (painful micturition)

–Urge incontinence.

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Physical Examination:
• Digital rectal examination (DRE):
- The prostate gland of healthy adult male is soft, non-tender,
symmetrical mobile/elastic.
- BPH usually results in a smooth, firm, elastic enlargement of the
prostate.
• Abdominal examination: may reveal bladder distension and the
presence of inguinal hernia which developed secondary to increase
intra-abdominal pressure from straining at voiding.

Investigations:
1. GUE.
2. B. urea, s. creatinine
3. PSA. (Prostatic specific antigen).
4. Sonography: save and non-coasty technique to calculate the size of the
prostate , state of upper tract and the post voiding residual volume of
urine .
5. Pressure flow studies and flow rate.

Management
A. Assessment of severity:
1. The self-administered questionnaire developed by the American
Urological Association AUA) is both valid and reliable in identifying the
need to treat patients and in monitoring their response to therapy. This
assessment focuses on 7 items that ask patients to quantify the severity of
their obstructive or irritative complaints on a scale of 0–5. Thus, the score

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 can range from 0 to 35. A symptom score of 0–7 is considered mild, 8–19
is considered moderate, and 20–35 is considered severe.
2. Postvoiding residual urine volume: this can be measured by ultrasound
before and after urination or by a catheter inserted into the bladder after
urination and volume of urine obtained measured. (Normal 12-
28mL).Residual volume more than 200 ml indicates poor response to
medical therapy.
3. Upper tract affection (hydronephrosis)

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 B. Differential diagnosis:
1. Urethral stricture. History of urethral trauma or instrumentation or
discharge.
2. Bladder neck contracture.
3. Neurogenic bladder: history of CVA, D.M. and spinal cord injury.
4. Cystitis. Simulate BPH and can be a complication of this disease.
5. Bladder tumor. Esp. CIS which cause irritative Voiding symptom
6. Vesicle stone.
7. Ca. prostate.
C. Goal for BPH Treatment
a. Reduce symptoms of BPH
b. Decrease bladder outlet obstruction
c. Decrease residual urine volume
d. Reduce incidence of urinary retention and renal insufficiency
e. Improve quality of life (QOL).
D. Treatment Options
1. Watchful Waiting
It is an option for patients with mild symptom score (0-7) .In this treatment
modality advises given to the patients to avoid the use of drug that worsen the
symptoms and to modify their behaviors. Some drugs may be prescribed to
relief the symptoms like antibiotics and urinary sedatives. Careful follow up
of patients for symptoms progression or worsening of the condition in such
case a shift to other modality of treatment should be done.
Medications that Worsen Symptoms
o α-Adrenergic agonists
o Cold remedies topical and oral
o Anticholinergics

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 o Antihistamines
o TCA (tricyclic antidepressant)
o Antispasmodics
o Testosterone replacement
o Diuretics

Behavior Modifications
•Reduce late day/evening water consumption.

•Limit alcohol intake

•Limit coffee or other caffeine containing products

2. Pharmacologic Treatment for BPH

i. α-Adrenergic antagonists :
They act on the dynamic component and cause relaxation of musculature of
prostatic stroma, capsule, and bladder neck.
•1st Generation like phenoxibenzamine which associated with unacceptable

SE and not recommended any more.

•2nd Generation longer acting like doxazosin and terazosin.

•3rd Generation act selectively on (alpha1a) receptor and associated with less
side effects like tamsulosin and alfuzosin.
α-Adrenergic Antagonists Side Effects :
✓ Hypotension and Syncope.
✓ Weakness
✓ Nausea/Vomiting
✓ Retrograde ejaculation.
✓ Headache.
✓ Rhinitis.

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 ii. 5-α Reductase Inhibitors:
These act on static component and decrease size of prostate gland like
Finasteride and Dutasteride they have similar effectiveness but Delayed onset
of improvement about 6 month of continuous therapy to reduce the prostate
size by 20 %. These drugs are more useful in larger prostate size.

5-α Reductase Inhibitors Side Effects

✓ Erectile dysfunction.
✓ Decreased libido.
✓ Gynecomastia.
✓ Ejaculation disorders.

iii. Combination Therapy:

•α-Adrenergic antagonists and 5-α reductase inhibitors

•Prostate Size ≥ 40 g

•Relief of dynamic symptoms

•Long-term benefits of 5-α reductase inhibitors

•Decreased need for surgical intervention

iv. Phytotherapy:
Saw Palmetto an herb used if the previous drugs fail.

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v. Surgical Intervention
Indications:
1. Failure of medical treatment.
2. Reluctant urinary retention.
3. Recurrent UTI.
4. Upper tract affection.
5. Recurrent hematuria due to BPH.
6. Associated vesical stone or bladder diverticulum.
•Transurethral resection of the prostate (TURP)

•Transurethral incision of the prostate (TUIP)

•Open prostatectomy

•Minimally invasive techniques:

1. Laser prostatectomy.
2. TUNA (transurethral needle ablation)
3. HIFU (high focused ultrasonography)
4. TUMT (transurethral microwave thermotherapy)
5. Intra-urethral prostatic stent.

BPH Follow Up
The patients should be followed every 6 weeks where a disease specific
history and symptoms score should be evaluated. DRE should be performed
in the follow up visit. Routine laboratory tests as Blood urea and serum
creatinine should be done in addition to PSA. Ultrasonography may be used
to assess the state of upper tract and measure the residual urine volume.

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