Benign Prostatic HyperplasiaEtiology, Incidence, Symptoms, Evaluation.

Dr. Wajeed gul BangashDr. Wajeed gul BangashPG Ms UrologyPG Ms UrologySupervised bySupervised by Prof. Dr Khursheed AnwarProf. 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 lifeSurronding 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

Normal

Zonal origin of BPH

Transition zone

Peripheral zone Central

zone

Urethra

Prostate

An accessory gland of male reproductive system

Conical & firm…below neck of BladderSurroundes commencement of male

urethraIn 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

Secretes semen which carries sperm

During orgasm, prostate muscles contract and propel ejaculate out of the penis

Understanding the prostate

SITUATION

Lesser pelviseBelow neck of U bladderBehind 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 coneMeasurment 03-04cm at base 04-06cm Cephalocaudal 02-03cm Antero-posteriorWeight 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)

Peripheral zone

Transition zone

Urethra

What is Benign Prostatic Hyperplasia?

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

DHT-androgen receptor complex

Growth factors

Unbalanced

DHT T

5AR (I and II)

Serum DHT Serum testosterone (T)

Prostatecell

IncreasedCell growth

Cell death

Adapted from Kirby RS, McConnell. Benign Prostatic Hyperplasia. Health Press Ltd, 1999

Type I and type II isoenzyme distribution

Sebaceous glands

Liver

LiverProstate

Type I

Brain

Skin

Prostate

Genital tissues (genital skin and epididymis)

Seminal vesicles

Type II

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

Scalp

Pathology

Transition zone…hyperplastic processMicroscopically…nodular growth pattren…

composed of Stroma, EpitheliumStroma composed…collagen, smooth

muscleExplain potential responsivness to medical

therapySmooth M(alpha blocker) epithelium(5-

alpa reductase inhibitors)

Classification of Medical Therapyand Recommended Dosage in BPH. Classification Oral Dosage Alpha-blockersNonselectivePhenoxybenzamine 10 mg twice a dayAlpha-1, short-actingPrazosin 2 mg twice a dayAlpha-1, long-actingTerazosin 5 or 10 mg dailyDoxazosin 4 or 8 mg dailyAlpha-1a selectiveTamsulosin 0.4 or 0.8 mg dailyAlfuzosin 10 mg daily5-alpha-reductase inhibitorsFinasteride 5 mg dailyDutasteride 0.5 mg dailySubcutaneous implant YearlyTriptorelin pamoate 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,uterine)…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 benignprostatic 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 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 Total= 35

Total IPSS* score indicates symptom severity

IPSS Score

Symptom 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,sNeurogenic Bladder

Urethral strictureProstate cancer

ASSESSMENT

Recommended investigations(EAU guidelines)

Medical history Recommended

Symptom score Recommended

Physical examination including digital rectal examination (DRE)

Recommended

Prostate specific antigen (PSA)

Recommended

EAU 2004 recommendations regarding initial assessment of BPH

Creatinine measurement

Recommended

Urinalysis Recommended

Flow rates Recommended

Post-void residual volume

Recommended

Pressure flow studies

Optional

Imaging of the upper urinary tract

Optional

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 raceAfrican-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) PSA Normal Ranges

(ng/ml) 40–49 0–2.5 50–59 0–3.5 60–69 0–4.5 70–79 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.

BPH-Complications:

1. Urethral compression2. Ball valve mechanism3. Bladder hypertrophy4. Trabeculation5. Diverticula formation6. Hydroureter – bilateral7. 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