Benign Prostatic Hyperplasia Etiology, Incidence, Symptoms, Evaluation.

Benign Prostatic Hyperplasia Etiology, Incidence, Symptoms, Evaluation.

Dr. Wajeed gul Bangash PG Ms Urology Supervised by Prof. Dr Khursheed Anwar

Prostate Gland What is the Prostate?

Developmental Background  Develop

as series of ENDODERMAL BUDS….Lining of Primitive Urethra….adjacent part of UrogenitalSinus  03 month of intrauterine life  Surronding Mesenchyme condense ….Stroma of gland

Histolgy (zonal anatomy)  03

zones % Cap  Peripheral zone 70% 60-70%  Central zone 25% 10-20%  Trasition zone 05% 05-10%  BPH originate in TRANSITION Zone

Zonal origin of BPH Normal Urethra

Peripheral zone

Transition zone

Central zone

Prostate  An

accessory gland of male reproductive system  Conical & firm…below neck of Bladder  Surroundes commencement of male urethra  In Female represented by Paraurethral gland( of SKENE)

Understanding the prostate

 Walnut-shaped gland that forms part of the male

reproductive system Surrounds the urethra - the tube that carries urine  from the bladder out of the body

Understanding the prostate 



Secretes semen which carries sperm During orgasm, prostate muscles contract and propel ejaculate out of the penis

SITUATION  Lesser

pelvise  Below neck of U bladder  Behind lower part of pubic symphysis (space of Retizus) & upper part of pubic arch n in front of ampulla of rectum (Denonvilliers fascia).

Prostate Gland

Prostate Gland

Shape, Size, Weight  Inverted

cone  Measurment  03-04cm at base  04-06cm Cephalocaudal  02-03cm Antero-posterior  Weight 08-20 gm

Male Urogenital System

Gross Feature  Apex..directed

down ward..Urogenital Diaphargm…Perineal body….Anus  Base…upward..surround neck of bladder…mark by circular grove (lodges veins of vesical & Prostic plexuses)  04 surfaces (Anterior, Posterior(ejaculatory duct) 02 inferolateral

LOBES  Urethra

& ejaculatory D …05 lobes  Anterior L …small isthmus…small or NO Glandular tissue(seldom ADENOMA)  Posterior L…lies behind Median l n E.D….Adenoma never occurs…?primary Ca start here  Median L behind upper part Urethra…front E.D…Uvula vesicae…much gladular T… ADENOMA  Lateral L…enough G tissue…Adenoma in old age

Capsules of prostate  True

capsule…deep to false..continous wz stroma of gland….no venous plexues  False capsule…outer…derived 4rm pelvic fascia..prostatic venous plexues in it… posteriorly avascular…

Prostate gland  Blood

Supply  Brs..inferior vesicle middle rectal, internal pudendle aa.  Forms Larger outer SUBCAPSULAR plxs  Small inner(periurethral plxs)

 Venous

supply

Rich at base, sides  Plexs communicate..vesicle p & internal pudendle v…..vesicle &internal iliac vein  Valveless connection b/w prostatic &vesicle v….Cap ….vertebral columes, skull 

Lymphatic supply  Internal

iliac, sacral nodes, partly external iliac nodes

Nerve supply  Sympathatic

& parasympathatic  (sensory impulses relay Lower three lumber & upper sacral segments)

What is Benign Prostatic Hyperplasia?

Peripheral zone Transition zone Urethra

Peripheral zone Transition zone Urethra

What is BPH?  Benign

prostatic hyperplasia (BPH) is defined as a benign enlargement of the prostate gland caused by the growth of new cells  One of the most common conditions affecting older men which can lead to LUTS  Advancing age and testicular androgens play a central role  Age related enlargement of the prostate seen in men with BPH may be caused by increased cellular proliferation combined with a decreased rate of apoptosis

Cause of BPH  The

primary androgenic stimulator of prostate growth is dihydrotestosterone (DHT)  DHT is produced from testosterone via the 5alpha-reductase (5AR) isoenzymes type I and II

Regulation of cell growth Serum DHT

Serum testosterone (T)

T 5AR (I and II) Growth factors

DHT

Prostate cell

DHT-androgen receptor complex Cell death

Increased Unbalanced Cell growth Adapted from Kirby RS, McConnell. Benign Prostatic Hyperplasia. Health Press Ltd, 1999

Type I and type II isoenzyme distribution Type II Type I Scalp Brain Liver Sebaceous glands Liver

Seminal vesicles Prostate

Prostate Skin

Genital tissues (genital skin and epididymis) Anderson JB et al. Eur Urol 2001; 39: 390–399 Bartsch G et al. Eur Urol 2000; 37: 367–380 Thigpen AE et al. J Clin Invest 1993; 92: 903–910

Pathology  Transition

zone…hyperplastic process  Microscopically…nodular growth pattren… composed of Stroma, Epithelium  Stroma composed…collagen, smooth muscle  Explain potential responsivness to medical therapy  Smooth M(alpha blocker) epithelium(5alpa reductase inhibitors)

Classification of Medical Therapy and Recommended Dosage in BPH. Classification Oral Dosage Alpha-blockers Nonselective Phenoxybenzamine Alpha-1, short-acting Prazosin Alpha-1, long-acting Terazosin Doxazosin Alpha-1a selective Tamsulosin Alfuzosin 10 mg daily 5-alpha-reductase inhibitors Finasteride Dutasteride Subcutaneous implant Yearly Triptorelin pamoate

10 mg twice a day 2 mg twice a day 5 or 10 mg daily 4 or 8 mg daily 0.4 or 0.8 mg daily 5 mg daily 0.5 mg daily 3.75 mg every month

Pathophysiologh of BPH  Symptom…obstractive

/ secondry response to

BOO  Obstractive component…Mechanical / dynamic obstraction  Mechanical obs: as bph…intrusion into urethral lumen…lead to high bladder outlet resistence  Dynamic obs: alpha1 mediated smooth muscle contraction occur…variable symptoms…bladder outlet obs occur…use alpha blocker…dec tone..dec in outlet resistence

Causes of BOO  In

Men  BPH (major)  Urethral stricture, malignant enlargment prostate(less common)

 In

female  Less common Pelvic prolapse (cystocele,rectocele,u terine)…directly compress urethra..U stricture, U diverticulm  Fowler,s syndrom  Pelvic masses

BPH: symptoms  Symptoms

associated with BPH include the OBSTRACTIVE and IRRITATIVE symptoms

 LUTS

is not specific to BPH – not all men with LUTS have BPH and not all men with BPH have LUTS

Cunningham GR et al. Epidemiology and pathogenesis of benign prostatic hyperplasia. Up To Date Literature Review, Apr 29; 1998 EAU BPH guidelines. Madersbacher S et al. Eur Urol 2004; 46: 547–554

Symptom type

Symptom

Obstructive (voiding)

Weak urinary stream Prolonged voiding Abdominal straining Hesitancy Intermittency Incomplete bladder emptying Terminal and post-void dribbling

Irritative

Frequency Nocturia Urgency Incontinence

Associated symptoms Dysuria Haematuria Haematospermia

IPSS by AUA ( Barry & colleagues early 1990s)  Incomplete

emptying

 Frequency  Intermetency  Urgency  Weak

stream  Straining  Nocturia

0

1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4  Total= 35

5 5 5 5 5 5 5

Total IPSS* score indicates symptom severity IPSS ScoreSymptom severity

Symptom description

0–7

Mild

Little bother, reasonable urine flow and low residual volume

8–19

Moderate

Bothersome, reduced residual volume but no evidence of complications

20-35

Severe

Complications of obstruction

•A

detailed Focused history Urinary tract (Exclude) UTI,s Neurogenic Bladder Urethral stricture Prostate cancer

ASSESSMENT Recommended investigations (EAU guidelines)

EAU 2004 recommendations regarding initial assessment of BPH Medical history

Recommended

Symptom score

Recommended

Physical Recommended examination including digital rectal examination (DRE) Prostate specific antigen (PSA)

Recommended

Creatinine measurement

Recommended

Urinalysis

Recommended

Flow rates

Recommended

Post-void residual Recommended volume Pressure flow studies

Optional

Imaging of the Optional upper urinary tract Imaging of the prostate

Optional

Voiding charts

Optional

PSA  PSA

is a protein produced almost exclusively in the epithelial cells of the prostate  Elevated levels of PSA signify change in the prostate typically caused by:     

BPH Prostate cancer Prostatitis ? Ageing Instrumentation

Guideline recommendations A

PSA-test should be offered to those with at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management

 PSA

can be used to evaluate the risks of either requiring surgery or developing AUR

Factors influencing the serum levels of PSA  architecture

of the prostatic gland is disrupted  PSA will ‘leak’ into the circulation  prostatic carcinoma, BPH, prostatitis and after urinary retention  PSA is not considered as being cancer-specific, but organ-specific  PSA serum elevations occur in biopsy of the prostate gland and ejaculation , small and clinically insignificant changes occur after DRE.

 Two

other important factors, age and race  African-Americans with no evidence of prostate carcinoma have higher PSA values after their fourth decade of life.

Age-Adjusted Reference Ranges For PSA  Age

(y)

 40–49  50–59  60–69  70–79   

PSA Normal Ranges (ng/ml) 0–2.5 0–3.5 0–4.5 0–6.5

Data from Oesterling JE et al: Serum prostate-specific antigen in a community-based population of healthy men. Establishment of age-specific reference ranges. JAMA 1993;270:860.

BPHComplications: 1. 2. 3. 4. 5. 6. 7.

Urethral compression Ball valve mechanism Bladder hypertrophy Trabeculation Diverticula formation Hydroureter – bilateral Hydronephrosis

BPH-Bladder Gross – Identify Cues?  Trabeculations  Hypertrophy

of wall  Stone - urolithiasis  Inflammation  Median lobe- ball valve.  Enlarged prostate.

BPH-Bladder morphology:  Hypertrophy  Trabeculation  Median

lobe protrusion.

Benign Prostatic Hyperplasia:

Normal Prostate:

Nodular BPH:

THE END