BENIGN PROSTATIC HYPERPLASIA Incidence & Epidemiology BPH is the most common benign tumor in men, and its incidence is age related. Symptoms of prostatic obstruction are also age related. At age 55, approximately 25% of men report obstructive voiding symptoms. At age 75, 50% of men complain of a decrease in the force and caliber of their urinary stream.

Prostate Anatomy The prostate is a male sex accessory gland located within the pelvis below the bladder and above the urogenital diaphragm. The prostate encircles the urethra like a doughnut and is derived from the urogenital sinus. The role of the prostate is to secrete fluid into the ejaculate that accompanies sperm and seminal vesicle fluid to make up the semen. The contribution of the prostate to the ejaculate includes; acid, zinc and a serine protease known as PSA (prostate specific antigen) that is an enzyme responsible for the liquefaction of semen. The prostate continues to grow (hyperplasia) with age and may cause voiding dysfunction.

Hyperplasia In a given organ, the number of cells, and thus the volume of the organ, is dependent upon the equilibrium between cell proliferation and cell death .

Pathology BPH develops in the transition zone. It is truly a hyperplastic process resulting from an increasein cell number. Microscopic evaluation reveals a nodular growth pattern that is composed of varying amounts of stroma and epithelium. Stroma is composed of varying amounts of collagen and smooth muscle.

Anatomic Features One of the unique features of the human prostate is the presence of the prostatic capsule, which plays an important role in the development of LUTS . The size of the prostate does not correlate with the degree of obstruction.

Pathophysiology 1- Prostatic hyperplasia increases urethral resistance, resulting in compensatory changes in bladder function. 2- The elevated detrusor pressure required to maintain urinary flow in the presence of increased outflow resistance occurs at the expense of normal bladder storage function. 3- Obstruction-induced changes in detrusor function, compounded by age-related changes in both bladder and nervous system function, lead to urinary frequency, urgency, and nocturia, the most bothersome BPH-related complaints.

SYMPTOMS The symptoms of BPH can be divided into obstructive and irritative complaints. Obstructive symptoms include: hesitancy, decreased force and caliber of stream, sensation of incomplete bladder emptying, double voiding, straining to urinate, and post-void dribbling. Irritative symptoms include urgency, frequency, and nocturia.

Symptom Assessment The International Prostate Symptom Score (IPSS), which is identical to the AUA Symptom Index, is recommended as the symptom scoring instrument to be used for the baseline assessment of symptom severity in men presenting with LUTS .

IPSS Mild (score 0-7) Moderate (score 8-19) Severe (score 20-35)

Physical Exam Digital Rectal Exam (DRE): -. - Assess size, contour, anal sphincter tone. - BPH: Rubbery, uniformly enlarged. -Malignancy: nodules, asymmetry, induration. - Prostatic abscess: fluctuance - Prostatitis: pain. Suprapubic: Bladder distension Neurologic Exam: Sensory or motor deficits of lower extremity and anal sphincter.

LABORATORY FINDINGS A urinalysis to exclude infection or hematuria Serum creatinine measurement to assess renal function are required. Serum PSA is considered optional, but most physicians will include it in the initial evaluation. PSA, compared with DRE alone, certainly increases the ability to detect CAP.

Imaging Ultrasonography: In BPH, it is most useful for measuring bladder & prostate volume as well as residual urine. IVP: For UTI & complications of BPH

Differential Diagnosis Other obstructive conditions of the lower urinary tract, such as urethral stricture, bladder neck contracture, bladder stone, or CaP,must be entertained when evaluating men with presumptive BPH: A history of previous urethral instrumentation, urethritis, or trauma should be elucidated to exclude urethral stricture or bladder neck contracture. Hematuria and pain are commonly associated with bladder stones. Ca.Prostate may be detected by abnormalities on the DRE or an elevated PSA.

A urinary tract infection, which can mimic the irritative symptoms of BPH, can be readily identified by urinalysis and culture. patients with neurogenic bladder disorders may have many of the signs and symptoms of BPH, but a history of neurologic disease, stroke, diabetes mellitus, or back injury.

Treatment After patients have been evaluated, they should be informed of the various therapeutic options for BPH. It is advisable for patients to consult with their physicians to make an educated decision on the basis of the relative efficacy and side effects of the treatment options.

A. WATCHFUL WAITING watchful waiting is the appropriate management of men with mild symptom scores (0–7). Patients in the placebo arm of the study had a 7% risk of developing urinary retention over 4 years. Timed voiding, Decrease Fluid intake…

B. MEDICAL THERAPY Medical therapies investigated for BPH include : α-adrenergic blockers, 5α-reductase inhibitors, aromatase inhibitors, numerous plant extracts . Anticholinergics Phosphodiastrase inhibitors.

1. Alpha-blockers The human prostate and bladder base contains alpha-1-adrenoreceptors, and the prostate shows a contractile response to corresponding agonists. The contractile properties of the prostate and bladder neck seem to be mediated primarily by the subtype alpha-1a receptors. Alpha-blockade has been shown to result in both objective and subjective degrees of improvement in the symptoms and signs of BPH in some patients. Alpha blockers can be classified according to their receptor selectivity as well as their half-life.

5-Alpha-reductase inhibitors Finasteride is a 5- alpha-reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone. This drug affects the epithelial component of the prostate, resulting in a reduction in the size of the gland and improvement in symptoms. Six months of therapy are required to see the maximum effects on prostate size (20% reduction) and symptomatic improvement.

C. CONVENTIONAL SURGICAL THERAPY Absolute surgical indications include : refractory urinary retention (failing at least one attempt at catheter removal), recurrent urinary tract infection from BPH, recurrent gross hematuria from BPH, bladder stones from BPH, renal insufficiency from BPH, or large bladder diverticula. Types: 1. Transurethral resection of the prostate…Gold standard. 2. open prostatectomy.

Indications for open surgery When the prostate is too large to be removed endoscopically, an open enucleation is necessary. What constitutes “too large” is subjective and will vary depending upon the surgeon’s experience with TURP. Glands >100 gm are usually considered for open enucleation. Open prostatectomy may also be initiated when concomitant bladder diverticulum or a bladder stone is present or if dorsal lithotomy positioning is not possible. Open prostatectomies can be done with either a suprapubic or retropubic approach.

MINIMALLY INVASIVE THERAPY 1. Laser therapy—Many different techniques of laser surgery for the prostate have been described. Two main energy sources of lasers have been utilized—Nd:YAG and holmium:YAG. 2. Transurethral electrovaporization of the prostate— Transurethral electrovaporization uses the standard resectoscope but replaces a conventional loop with a variation of a grooved rollerball. 3. Hyperthermia—Microwave hyperthermia is most commonly delivered with a transurethral catheter. Some devices cool the urethral mucosa to decrease the risk of injury.

4. Transurethral needle ablation of the prostate. 5-Transurethral incision of the prostate. 5. High-intensity focused ultrasound. 6. Intraurethral stents.

Laser Prostatectomy There are four types of laser that can be used to treat the prostate. 1-Neodymium:Yttrium-Aluminum-Garnet Laser 2-Potassium Titanyl Phosphate Laser 3-Holmium:Yttrium-Aluminum-Garnet Laser. 4-Diode Laser . Procedures: Prostatectomy with Holmium Laser : Now considered the standard care in many centre it has the advantage of being less blood loss and urethral catheterization and hospitalization time.

New method Prostatic artery embolization: is performed by an interventional radiologist, a physician who is trained to perform this and other types of embolization and minimally invasive procedures. An interventional radiologist makes a tiny nick in the skin in the groin and inserts a micro catheter into the femoral artery. Using real-time imaging, the physician guides the catheter through the artery and then releases tiny particles, the size of grains of sand, into the prostatic arteries that supply blood to the tumor. These tiny particles block blood flow to the tumor, causing it to shrink. Following PAE treatment, most men experience no pain to light pain and leave the hospital four to eight hours after intervention. "There is no sexual dysfunction following prostatic artery embolization, and a quarter of our patients report that sexual function improved after the procedure," added Pisco.

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