Benign Prostatic Hyperplasia (BPH)

Prostate gland : is a fbromuscular and glandular organ lying Just inferior to the bladder. According to Mcneal, the prostate has a peripheral zone, central zone and transitional zone. According to Lowsley, the prostate has posterior,two lateral, anterior and middle lobes what is the prostate gland

Half of all men over the age of 60 will develop an enlarged prostate By the time men reach their 70’s and 80’s, 80% will experience urinary symptoms Benign prostatic hyperplasia (BPH)

Etiology : is not completely understood, but it seems to be multifactorial and endocrine controlled. Hormones : androgen deprivation in older man reduces prostate size, additional investigation have demonstrated a positive correlation between level of free testesterone and estrogen and the volume of the BPH. Stromal - epithelial interaction theory. This caused by various growth factors.

Pathology : BPH develops in the transitional zone. It is truly hyperplasia process resulting from increase in cell number. Microscopically reveal a nodular growth pattern that it is composed of varying amount of stromal and epithelial tissue, stromal tissue composed from collagen and smooth muscle

obstructive component of BPH. Mechanical obstruction. Dynamic obstruction. Irritative voiding complaints Pathophysiology

Clinical Feachers: Symptoms: Irritative symptoms Obstructive symptoms Signs: Neurological examination. Digital rectal examination,it shows size of the prostate (not compatible with severity of the symptoms) In BPH,it reveals smooth,firm,elastic enlargement of the prostate.

Lab. Findings: Urinalysis Renal function There is 10% renal insufficiency observed in BPH. PSA (prostatic specific antigen) Imaging : IVP and ultrasound are indicated in concomitant urinary tract disease or complicated BPH Cystoscopic examination Additional testes : cystometrogram and urodynamic prophile for patient with Neurological disease. Failed prostatic surgery.

Complications of BPH: Bladder stones UTI Hematuria Bladder decompensation Renal failure Acute and chronic urine retention

Treatment : 1.Watchful waiting 2.Medical treatment a- alpha blockers : -Phenoxybenzamine, it is non selective α blocker (Dose 10mg ). -prazosin it is short acting selective α1 blocker. -terazosin (5mg,10mg ),doxazosin (4mg, 8mg),these are long acting α 1 blockers. -tamsulosin (0.4mg,0.8mg),silodosin (8mg) α1a selective blocker. This is the most potent α blockers.

Side effects : -orthostatic hypotension -dizziness -tiredness -retrograde ejaculation -rhinitis -headack

b- 5α-reductase inhibitors : Side effects : -decreased libido -decreased ejaculatory volume -impotence

c-Combination therapy : d-Phyto therapy

3-conventional surgical therapy : (a)Taransurethral resection of the prostate (TURP) 90% of simple prostatectomy can be done endoscopically,symptoms and flow rate improvement is superior to that of any minimally invasive therapy.

Complications: Impotence Incontinence Bleeding May require blood transfusion Retrograde ejaculation. TUR syndrome :

TUR syndrome : It is a clinical manifestation of nausea,vomiting, confusion,hypertension bradycardia and visual disturbance. Treatment: 1-Diuresis 2-Hypertonic saline in severe case.

C- open prostatectomy Indications: prostate gland over 100 gm. BPH with bladder diverticule. BPH with vesical stone. if dorsal lithiotomy position is not possible. b-Transurethral incision of the prostate (TUIP)

Minimally invasive therapy : (1) Laser therapy Advantages: -minimal blood loss. -rare instance of TUR syndrome. -ability to treat patient with anti coagulant therapy. -ability to done in out patient procedure. Disadvantages : --longer postoperative catheterization time -more irritative voiding complaints. -high cost of laser fibers and generators.

2- Transurethral evaporization of the prostate

3-hyperthermia Micro wave thermal therapy

(4) High Intensity Focused Ultrasound (HIFU):

(5) Intra urethral stents

Transurethral balloon dilation of the prostate

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