1. Benign Prostatic Hyperplasia
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital

2. Bladder Outlet obstruction
Bladder neck dysfunction
Prostatic enlargement
Urethral stricture
External sphincter dyssynergia
Urethral meatal stenosis
BOO is a condition of progressive degree

3. Lower urinary tract symptoms IPSS & AUA symptom score
Frequency
Urgency
Nocturia
Small caliber of urine
Dysuria
Intermittency
Residual urine sensation

4. LUTS and BOO 1/3 of men with LUTS do not have BOO
5% - 35% of patients with BPH & LUTS do not improve symptoms after TURP
LUTS have a poor diagnostic specificity for BOO
Prostate size and uroflowmetry have better correlation with urodynamic study than symptoms alone

5. Pathogenesis of Bladder outlet obstruction
Progressive increased urethral resistance
High voiding pressure and low flow
Bladder compensation in energy
Increased residual urine volume
Elevated intravesical pressure at end-filling
Bladder stone, diverticulum, UTI
Hydroureter, hydronephrosis, azotemia

6. Reduction in AChE-positive nerve fibers after BOO

7. Differential diagnosis of male BOO and LUTS
Benign prostatic enlargement
Bladder neck dysfunction
Spastic urethral sphincter
Poor relaxation of urethral sphincter
Urethral stricture
Low detrusor contractility
Pseudodyssynergia due to neuropathy

8. Relation of prostate and urethra

9. Benign prostatic hyperplasia
Prostatic enlargement – benign or malignant, a sign
Prostatic hyperplasia – histological term
Prostatic obstruction – a clinical diagnosis
Bladder outlet obstruction – an urodynamic term
Lower urinary tract symptoms – symptom

10. Anatomy of Prostate gland

11. Anatomy of Prostate gland

12. Prostatic glandular anatomy

13. Cystoscopic Prostatic obstruction

14. Benign Prostatic Hyperplasia
BPH requires testicular androgen during prostatic development
Basic fibroblast growth factor, epidermal growth factor, keratinocyte growth factor, transforming growth factor-beta play some part in prostate growth
Decreased endogenous apoptosis in prostate cause abnormal tissue growth in prostate

15. Histology of Benign prostatic hyperplasia

16. Clinical BPH
LUTS ( storage or empty symptoms) due to histological benign prostatic hyperplasia and urodynamical bladder outlet obstruction which has been proven by urodynamic pressure flow study as prostatic obstruction
Treatment for LUTS and restoration of normal storage and empty function by reducing prostatic enlargement either medically or surgically

17. Pathophysiology of BPH and LUTS
Nodular proliferation of prostate gland
Increased stroma to epithelial ratio to 2:1 to 5:1 in benign prosatic hyperplasia
Increased smooth muscle component
Detrusor compensatory change and bladder dysfunction, detrusor overactivity
LUTS may related to BPH or detrusor dysfunction,or combination

18. Symptom scores of BPH as treatment guideline
1970 Boyarsky and Madsen-Iverson
1992 AUA symptom index
International prostatic symptom score adds quality of life index
Bothersomeness and health related quality of life (HRQOL)
Symptom problem index
BPH impact index (BII)

19. Clinical evaluation of BPH
Digital rectal examination of prostate
-- Prostate size, consistency, surface nodularity, tenderness
Bladder palpation – residual urine volume
Cystography, Intravenous pyelography
Transrectal sonography of prostate
Cystourethroscopy

20. Cystography of Bladder base elevation indicating BPH

21. Sonography of BPH

22. Clinical evaluation of BPH
Uroflowmetry, prstatic volume
Postvoid residual urine volume
Prostatic specific antigen (PSA)
Pressure flow study improves in diagnosis and aid in selection for specific invasive treatment
Videourodynamic study is helpful in determining complicated case

23. Uroflowmetry in BPH without or with obstruction

24. Pressure flow study in BPH with Obstruction

25. Videourodynamic study in BPH with Obstruction

26. Causes of non-obstructive Men with LUTS
Normal bladder and urethra 25
Bladder hypersensitivity 17
Detrusor instability 6
Detrusor underactivity 3
Poor relaxed urethral sphincter 61

27. Videourodynamic study in Man with normal bladder and urethra

28. Videourodynamic study in Man with low detrusor contractility

29. Videourodynamic study in Man with Poor relaxation of sphincter

30. Subjective improvement rate in patients after prostatectomy
HPOB
LPOB
LPNOB
Qmax
<10
10-15
>15
Total
Irritative symptoms
good 23 2 1 10 9 7
26(52%)
fair 4 12
21(42%)
Got worse - 3
3(2%)
Obstructive symptoms 28 5 21
35(70%)
13(26%)
2(4%)
Subjective results
Successful 31 18 14
34(68%)
Unchanged 6
10(20%)
Failed
6(12%)

31. Improvement in Qmax after Prostatectomy

32. Causes of 185 Men with LUTS after prostatectomy
Normalbladder and urethra 17
Detrusor instability 18
Low detrusor contractility 35
Poor relaxation of urethral sphincter 36
Detrusor instability and low contractility 27
Bladder outlet obstruction 52

33. Prostate volume, Qmax, resected prostate weight in patients with LUTS after prostatectomy
prostatic weight,g
Preoperative
prostatic vol, ml
PreoperativQmax, ml/s
Normal tracing(n=17)
12.3 ± 7.4
22.5 ± 14.2
11.0 ± 5.2
DI (n=18)
14.3 ± 15.4
26.5 ± 21.7
10.9 ± 4.0
LC (n=35)
8.9 ± 8.7
17.6 ± 13.8
9.6 ± 4.5
PRS (n=35)
9.2 ± 5.2
17.6 ± 8.8
8.4 ± 4.6
DHIC (n=27)
10.3 ± 7.1
19.9 ±10.3
10.5 ± 4.5
BOO (n=52)
14.4 ± 12.6
25.6 ± 18.7
9.7 ± 4.5
Statistics (ANOVA)
P=0.131
P=0.140
P=0.559

34. Urodynamic parameters in BPH
Age N
FSF
Capacity
Pves
Voided
Qmax
CQmax
MUCP
PPA
≦45 9
77.5±24.9
238.4±87.4
106.2±31.3
173.6±73.2
12.5±3.6
0.99±0.25
86.7±12.5
87.5±0
46-55 30
95.8±28.4
263.3±98.5
84.5±36.3
240.7±123.6
10.8±3.9
0.74±0.24
82.5±21.6
111.4±32
56-65
156
116.2±49.8
263.4±103.1
92.0±38.4
215.9±113.4
10.2±3.3
0.74±0.23
90.0±35.1
107.8±90.1
66-75
159
129.7±74.4
256.6±116.8
85.9±35.9
186.7±103.2
9.9±5.9
0.78±0.53
99.4±46.2
137.9±84.5
≧76 64
128.9±81.1
214.9±115.5
90.7±44.4
166.4±76.6
9.3±4.1
0.74±0.28
96.7±45.3
126.±112.3
All
418
124.2±70.8
244±114.3
89±39.6
198.1±109.9
10.1±4.6
0.76±0.38
94.8 ±41.8
125.1±91.4

35. Relationship of Qmax and Age in BPH patients

36. Clinical Prostate Score in BPH
Clinical prostate scoring system for patients with lower urinary tract symptoms
Uroflowmentry (ml/s)
Residual urine (mL)
Qmax ≧ 15 -1
< 100
10 Qmax <15
≧ 100 2
Qmax ≦ 10 1
Voided volume (mL)
Flow pattern
≧ 250
Normal
< 250
Compressive obstructive
TZI
Comstrictive obstructive
≦ 0.3
Intermittent
> 0.3 but < 0.5
TPV (mL)
≧ 0.5
≦ 20
Median lobe enlargement
> 20 but <40
Presence
≧ 40
Absence

37. Calculation of Clinical Prostate Score for Diagnosis of BPO
Prostate score = Qmax + TPV + voided volume + residual urine
Score ≧ 3: sensitivity = 90.7%, specificity = 33%
Prostate score = Qmax + flow pattern + voided volume + residual urine + TPV + TZI + prostatic configuration
Score ≧ 3: sensitivity of BPO = 87.2%, specificity = 60.8%
Score ≧ 4: sensitivity of BPO = 90.7%, specificity = 50.5%
Score ≧ 5: sensitivity of BPO = 97.6%, specificity = 38.2%
Sensitivity and specificity of BPO diagnosis in patients with at least 1 favorable predictive factor (n = 148)
Score ≧ 3: sensitivity of BPO = 91.6%, specificity = 87.27%
Exclusion of patients with at least 1 favorable predictive factor (n=176)
Score ≧ 3: sensitivity of BPO = 68.9%, specificity = 23.0%

38. Prostatic Transition Zone Index

39. A-G Number in Diagnosis of BPO

40. Treatment of BPH Treating an enlarged prostate ?
Treating lower urinary tract symptoms?
Treating bladder outlet obstruction?
Can LUTS disappear after treatment?
Can BOO be relieved after treatment?
Any complication may occur?
Is the treatment cost- effective ?

41. Therapeutic modalities for LUTS ascribed to the prostate
Watchful waiting and fluid restriction, natural history of BPO may wax and wan
Medical treatment to reduce prostate size or decrease intraprostatic resistance
Surgical treatment to remove prostatic obstruction or reduce urethral resistance
Minimally invasive therapies

42. Surgical Treatment for BPH
Suprapubic & retropubic prostatectomy
Transurethral prostatectomy (TUR-Prostate)
Laser interstitial prostatectomy
Transurethral incision of prostate
Intraprostatic stent
Balloon dilatation of prostatic urethra
Prostatic hyperthermia

43. Prostate Resectoscope and TURP

44. Complications of TUR-Prostate
Peri-operative bleeding
Urinary tract infection and urosepsis
Electrolyte imbalance, hemolysis, acute tubular necrosis
Acute pulmonary edema
Bladder neck or urethral contracture
Retrograde ejaculation and erectile dysfunction
Urge or stress urinary incontinence

45. Minimally invasive procedure
Transurethral vaporization- resection of prostate (TUVRP)
Ho-YAG laser coagulation of prostate
Visual laser ablation of prostate (VLAP)
Transurethral needle ablation (TUNA)
High intensity focused ultrasound (HIFU)
Microwave hyperthermia
Minimally invasive = minimally effective?
A higher re-treatment rate than TURP although less complication occurs

46. Intra-Prostatic Stent

47. Interstitial Laser Coagulation

48. Hyperthermia of BPH

49. Transurethral Dilatation of Prostate

50. Medical Therapy for BPH
Prostatic smooth muscle tension was mediated by alpha 1-adrenoreceptors
Smooth muscle contractions contribute 40% of outflow obstruction
Alpha 1- blockers can rapidly improve Qmax and relieve LUTS
Phenoxybenzamine, terazosin, doxazosin have side effect of dizziness and hypotension

51. Prostatic specific alpha- adrenoreceptor
Alpha 1A- AR subtype comprises 70% of all alpha-1 receptors
Alpha 1A-AR agonist – tamslosin has 13 x more affinity to prostatic smooth muscle than urethral muscle , 10 x than vascular smooth muscle
Side effects are still reported
Long-acting (once daily) dose

52. Hormone based medical therapy
5-alpha-reductase catalyzes conversion of testosterone to dihydrotestosterone
Inhibition of 5-alpha-reductase can arrest prostatic growth and relieve obstruction
Finasteride can improve symptom score,Qmax, QOL score
Effective especially in prostatic weight of >40 gm and effective in prostatic hematuria

53. Combination therapy with alpha-blocker and finasteride
Terazosin is effective therapy, finasteride was not, combination was no more effective than terazosin alone (Lepor, N Engl J Med 1996; 335: 533)
Combined dibenyline and finasteride has an additive effect than dibenyline or finasteride alone in improvement of Qmax and prostatic size

54. Consideration in treating BPH
Patients are old in symptomatic BPH
Too early surgery may lead to undesired sequalae such as erectile dysfunction
Too late surgery cannot reverse detrusor overactivity and leads to urge incontinence
Etiology of LUTS (DI? DHIC? BOO?) should be clarified to prevent unsuccessful surgical results

55. Therapeutic guideline for BPO
Calculation of clinical prostatic score and QOL index, medical treatment for BPO
Monitoring Qmax, residual urine volume, and prostate volume during treatment
If obstructive or irritative symptom exacerbate, detailed pressure flow study to confirm the BOO diagnosis
Surgery for patients with poor QOL index