1. Bruce B. Sloane, MD FACS Drexel University College of Medicine
BPH
Bruce B. Sloane, MD FACS
Drexel University College of Medicine

3. ZONAL ANATOMY OF THE PROSTATE

4. BPH

5. Benign Prostatic Hyperplasia
Afflicts many men
Interferes with normal activities
Reduces sense of well-being
Progresses in many men
* N Engl J Med 1998; 338:

6. Epidemiology of Benign Prostatic Hyperplasia
50% of men by age 50 yrs
90% of men by age 80 yrs 4

7. Epidemiology of BPH 17 Million Men Afflicted Only Half Diagnosed
-1/3 Receive Treatment
- 2/3 Watchful Waiting/Surveillence
88% Choose Pharmacologic Therapy (Alpha Blockers and 5-alpha reductase inhibitors
Direct Costs of BPH > $1 Billion Annually!

8. Major Risk Factors for BPH
Increasing Age
Normal Androgen Levels (Functioning Testes)
* McConnell, JD. Urol Clin N Amer, 1990.

9. Prostate Physiology

10. Normal Prostate vs. Prostate Hyperplasia
Coffey and Griffiths

11. Current Basic Science Research on BPH
Histopathology Strongly Implicates Local Paracrine and Autocrine Growth Factors and Inflamatory Cytokines in Pathogenesis of BPH
Growth Regulatory Proteins (members of fibroblast, insulin-like and tranforming growth factor, interleukins) are overexpressed in BPH
A Landscape of Increased Stromal and Epithelial Growth and Mesenchymal Transdifferentiation Leads to Progression
Inflammation may contribute to tissue injury and drive local Growth Factor Production
New Treatments aimed at these Pathways may emerge

12. Prostate Growth With Age

13. Prostate Size and Advancing Age Relationship to Progression
Prostate growth in population-based studies
0.7 to 1.5 mL/yr over 4 years
Prostate growth in BPH clinical study
1.8 mL/yr over 4 years
*J Urol 132: , 1984
*J Urol 152(5 Pt 1): , 1994
*JAMA 270: , 1993
*Br J Urol 75: , 1995
*NEJM 338(6), 2/26/98

14. Impact Of Size Progression With Age
45 years
60 years
75 Years
IPSS = 15
IPSS = 3
IPSS = 13
20 ml
30 ml
42 ml
2.5% Increase/year
IPSS =23
IPSS = 13
IPSS = 3
20 ml
42 ml
90 ml
5.0% Increase/year
Andersen, Nickel et al, 1997

15. The Definitions of Benign Prostatic Hyperplasia
Symptomatology
Histology
Prostate Volume
Peak Flow Rates
Pressure Flow Variables
Post-void Residuals
Quality of Life Quantitations
Combinations of these 2

16. Definition of BPH
HISTOLOGIC

17. Definition of BPH OBSTRUCTIVE Bladder Outlet Obstruction
Increasing Residual Urine leading to Urinary Retention
Recurrent Urinary Tract Infections
Pathologic Changes in Bladder Structure and Function
Hydronephosis/Renal Failure

18. Definition of BPH
SYMPTOMATIC
No Obstruction
Varying degrees of bother

19. Clinical Manifestations of BPH
*In the majority of men symptoms are:

20. Diagnosis of BPH A thorough History is essential!
Make sure voiding sx’s are from BPH

21. Other Causes of Voiding Symptoms
Diabetes, Parkinson’s, Stroke, Spinal Cord Injury, Multiple Sclerosis, Transverse Myelitis, Dementia, Urethral Stricture, Radical Pelvic Surgery
Medications: Anticholinergics, Alpha Agonists, Analgesics

22. Diagnosis of BPH PSA Medical history and Physical examination
Symptom score
Bother score
Urinary flow rate +/- Urodynamic Studies
Post Void Residual Measurement
Histology during biopsy, surgery, or autopsy
PSA
*Urology vol 58, no 6A, Suppl, Dec 2001

23. Initial Evaluation for BPH

24. Diagnosis of BPH

28. BPH Treatment Guidelines Need to Assess Symptoms and Size
Clinical Decision
Symptom Score
0 - 7
Watchful Waiting
Treatment
8 - 35

29. Evaluation and Treatment Algorithm

30. Acute Urinary Retention and Surgical Intervention Risk Factors
SYMPTOMS
PROSTATE
SIZE
AGE

31. Acute Urinary Retention or Surgery Who’s at risk?
AGE
Men in their 50s have 3 times the risk as men in their 40s
Men in their 70s have 8 times the risk as men in their 40s
SYMPTOMS
Men with moderate to severe symptoms have 3 times the risk as men with mild symptoms
PROSTATE SIZE
Men with larger prostates are at 3 times greater risk

32. Abstract #1085 at AUA 2001 PSA Predicts the Long-Term Risk of Prostate Enlargement: Results from the Baltimore Longitudinal Study of Aging
Age 40-49
Age 50-59
Age 60-69
20-Year Cumulative
Probability Freedom from
Prostate Enlargement
10-Year Cumulative
Probability Freedom from
Prostate Enlargement
10-Year Cumulative
Probability Freedom from
Prostate Enlargement
*Wright et al

33. Risk Factors for BPH Progession
Advance Age
Increased Total Prostatic Volume
Elevated PSA
Higher AUA Symptom Index
Increased Bother
Decreased Peak Urinary Flow Rate
Rising Post Void Residual
Obesity
Chronic Prostatic Inflammation

34. Abstract #1090 at AUA 2001 Acute Urinary Retention: What is the Impact on Quality of Life?
Introduction:
Acute urinary retention (AUR) is the most common urological emergency.
Objective:
To assess the impact of admission for AUR on patients’ health related quality of life (HRQoL)
*Kirby et al

35. Abstract #1090 at AUA 2001 Acute Urinary Retention: What is the Impact on Quality of Life?
Methods:
Consecutive male patients over 50 years old admitted to emergency room with AUR
Self completion questionnaire administered
HRQoL (general health, daily living activities, anxiety, pain, urological symptoms)
5 time points (within 72 hrs, 1, 2, 3, and 6 months)
*Kirby et al

36. Abstract #1090 at AUA 2001 Acute Urinary Retention: What is the Impact on Quality of Life?mo 2 mo 3 mo 6 mo
Admission
Within
72 hrs
Worst
HRQoL
Some
Improvement
But HRQoL score remained low
during the 6-month follow up
*Kirby et al

37. Abstract #1090 at AUA 2001 Acute Urinary Retention: What is the Impact on Quality of Life?
Results:
Mean HRQoL were lowest at admission
There was a modest improvement after discharge
HRQoL remained low during the 6-month follow up
*Kirby et al

38. Abstract #1090 at AUA 2001 Acute Urinary Retention: What is the Impact on Quality of Life?
Conclusions:
This study is the first to show that AUR appears to have a significant and persistent impact upon patients in terms of their HRQoL.
Further preventative measures may be justified to avoid episodes of AUR and its adverse effect on patients’ quality of life.
*Kirby et al

39. Treatment Alternatives for BPH
Medical Therapy
Surgery
Minimally Invasive
Watchful Waiting

40. Alpha Blockade in BPH Reduce the sympathetic tone of the prostate
Contraction of smooth muscle is predominantly mediated by alpha 1 (1A and 1D) receptors
Many of the side effects appear to be caused by alpha 2 receptors
Extraprostatic factors may be involved in symptoms of storage and voiding

41. Alpha Blocker Therapy

42. Alpha Blockade in BPH
There are no significant differences in efficacy among all alpha blockers
However, there are differences in the adverse events associated with their use.
Alfuzosin and Tamsulosin appear to have fewer adverse events associated with their use.
*Urology vol 58, no 6A, Suppl, Dec 2001

43. Treatment of BPH – Alpha Blockers
Medical Therapy with Alpha Blockers is mainstay of treatment
Several different Alpha Blockers available: Terazosin, Doxazosin, Tamsulosin, Alfuzosin
Tamsulosin and Alfuzosin = “prostate specific” – work on alpha 1a receptors
All have equal efficacy
Used in combination with 5 Alpha Reductase inhibitors in certain patients

44. 5 Alpha Reductase Inhibitors
Mechanism of action = Reduces intraprostatic DHT levels
Results in reduction in prostate size
Lowers PSA
Finasteride shown to decrease risk of Prostate Cancer by 22%
Reduces risk of urinary retention and need for surgery in some men (prostate size > 30 gms, PSA>1.2)
May interfere with natural history of progressive BPH
MTOPS Study generated above data

45. Prostate Physiology

46. 5 ARI’s Mechanism of Action

47. 5 ARI Mechanism of Action

48. CYSTOSCOPIC VIEW of BPH

49. TURP

50. Minimally Invasive Treatments for BPH
~~~~~~~~~~

51. HoTURP
Essentially an enucleation of prostate

52. TUEVP
Edges of grooves have highest current density.

53. TUMT
Different size catheters. Takes a while for channel creation

54. TUNA®
2 twin needles at 90o, not seen, act as thermal electrodes with insulating sheath to protect urethra.

55. Sonablate™ (HIFU)

56. Minimally Invasive Techniques for the Treatment of BPH

57. Phytotherapy in the Treatment of BPH

58. Phytotherapeutic Agents
The most frequently used plant extracts are:
bark of Pygeum africanum
pollen extract
leaves of trembling poplar
root of Hypoxis rooperi
seeds of Cucurbita pepo
fruit of Serenoa repens (Sabal serrulata)
roots of Echinacea purpura

59. Phytotherapeutic Agents
some patients like the idea of “natural” treatments
few placebo-controlled studies
no long-term data on side effects
no standardization in product formulations

60. BPH: Conclusion
BPH has a high prevalence among the aging male population
There are varying definitions of BPH – Symptomatic, Obstructive, Histologic
It is often (but not always) a progressive condition
Medical Treatment ( Alpha Blockers) is the Mainstay of Therapy
Be aware of other conditions which cause voiding sx’s in men
Minimally invasive procedures are available