1. BENIGN PROSTATE HYPERPLASIA
Assistant Professor Hakan KOYUNCU
Yeditepe University Medical Faculty
Urology Department

4. BPH
GLANDULA
FIBROMUSCULAR STROMA
is the hyperplasia of these components of the prostate and it is not malignant.

5. Hystological existence of BPH
Around fourties % 8
years old % 40
years old % 60
Above the age of % 90

6. BPH Prevalence-1 40–49 years old % 13.8 50–59 years old % 24
About % 30 of male population is having a surgical operation because of the longer lifetimes.

7. BPH Prevalence-2 Hystologic BPH is not seen before the age of 30.
The incidence increases by the age and it reaches the maximum level at 9th decade.
Palpable hyperplasia of the prostate is seen in %20 of the patients aged at 60 and in %43 of the patients at the age 80.
Prostate hyperplasia is not always correlated with the clinical symptoms and signs.

8. Histology of the prostate
Prostate consists of three distinct zones: a central zone, transitional zone and peripheral zone. The TZ is the site of development of BPH.
According to the anatomy of the ducts; the prostate is composed of approximately glandular structures which are spread out into a matrix of fibromuscular stroma.
The glands open to the prostatic urethra from both sides of veru montanum, by excretuar channels.
Approximate weight of the prostate in adults is gr.

10. Epithelial cells consist of 4 main cell group.
Prostatic aciner and secretory cells
Basal cells
Transitional cells
Endocrin-paracrin cells

11. Bph is a clinical terminology.
There is a lower urinary system disfunction composed of the changes secondary to obstruction or the age. The changes are on the stability and the contractility of the bladder because of the infravesical obstruction dependant to prostate hyperplasia.

12. Etiology
Histopathologically, BPH is characterised by the increase of the epithelial and stromal cells on the periuretral side of the prostate.
The molecular mechanism of this hyperplastic formation is not clear but it is concluded that there are a lot of factors effecting the formation of BPH.

13. Etiology
Aging Functional Testis

14. Factors on etiology-1 Aging -Testesteron (leydig cells) decrease.
-SHBG increases, serum testesteron levels decrease.
-Intraprostatic DHT and androgen reseptor levels increase.
-Free estrogen / free testesteron level increase.

15. Factors on etiology-2 Role of androgens 5α reductase
They are the major trigger in the formation of BPH.
5α reductase
Testosteron Dihydrotestosteron (DHT)
DHT is the major intraprostatic testosteron and its’ affinity to androgen receptors are more than testosterons’ .

16. Factors on etiology-3 Role of estrogens
It is concluded that estrogens have a synergistic effect together with androgens.
Increases the number of androgenic receptors (?)
Increases the level of intraprostatic DHT by increasing the transformation of testosteron to DHT.

17. Factors on etiology-4
Prostate evolution in embrionic life occurs by the stromal-epithelial interaction under the support of androgens.
Mitogenic effect of the androgens take place only if there are stromal cells around.

18. Factors on etiology-5
5-alpha-reductase are mostly in stroma, also androgen dependant epithelial growth is only possible by the existence of stromal components in tissue cultures.
These information support the idea of stroma-epithelium interaction.

19. There are studies showing that epithelial growth effect of stromal cells take place by the mediation of paracrin mechanism, growth factors and proto-oncogens.

21. Growth Factors effective on BPH
Keratinocyte growth factor (KGF)
Epidermal growth factor (EGF)
Insulin-like growth factor (IGF-1/2)
Fibroblast growth factor (FGF)
Transforming growth factor (TGF)

22. Result
BPH appears as the reactivation of the embrionic growth potential in stroma, by the effect of age-dependant hormonal changes and peptid-like growth factors.

23. Factors on etiology-6 Genetic predisposition BPH Familial Sporadic
1- 3 or more people who has Prostate volume
BPH in family history (Approx. 55.5)
2- Starts at early age ( There is a
hereditary effect in % 50 of the people
who had a prostate operation before
the age 60)
3- Big prostate volume (Approx. 82.7)

24. Patophysiology of Obstruction
Consists of 3 stages
Anatomic obstruction
Primary patophysiologic obstruction (High pressure in the proximal of the obstruction)
Secondary patophysiologic obstruction (Retantion - Infection – Hydronephrosis)

25. Changes in the uretra in BPH
Morphologic deformity
***(Deformation)
Longer in length
***(Elongation)
Changing the position
***(Deviation)

28. Answer of the Bladder to BPH
Starting period
Compensatory stage
Decompensatory stage

29. Lesions in Compensatory stage
Trabeculation
Cellula
Diverticula

30. Lesions in Decompensatory stage
The scar tissue replaces the muscle.
The ejaculation function decreases progressively.
Compliance decreases.
The pressure increases.
As a result: Detrusor instability

31. Upper urinary system in future time
Bilateral ureterectasia
Ureterohydronephrosis
Result: Chronic renal failure

32. BPH-Clinical Features
In time, prostate volume can increase, symptoms get worse, urinary flow rate decrease, acute urinary retention can form, and in some patients surgery can be a necessity.
!!!! BPH IS MOSTLY A PROGRESSİVE DISEASE!

33. Complications Acute urinary retantion Urinary system infection
Bladder stone
Bladder injury
Renal failure
Hematuria

34. Diagnose Medical history Symptom Score Physical examination
DRE and limited neurological examination
Diary of miction
Urine analysis
Creatinine
PSA ??
Urinary flow rate
PMR

35. Symptoms in BPH Irritative Obstructive Nokturia Poor urine flow
Pollakiuria
Disuria
Urgency
Obstructive
Poor urine flow
Delay and difficulty in starting the miction
Postmictional dripping
Feel of not-emptying after miction
Urinary retantion
Overflow incontinence

36. Symptom Scores in BPH Boyarsky AUA I-PSS
Turkish Symptom Score adapted from I-PSS

38. IPSS
Total symptom score differs between 0-35 and grades the mictional disfunction
0-7 mild
8-19 moderate
20-35 severe

42. Laboratory and Radiologic Evaluation
Urine analysis, creatinine
PSA
Ultrasonography Urinary Transrectal
IVP
Uroflowmetry

43. Uriner analysis
Recommended because of that it shows the hematuria and urinary infection

44. Creatinine
It is established that higher creatinine levels increase the post-operative complications
Creatinine examination is recommended

45. PSA
Prostat spesific antigen (PSA) is a glicoproteine based protease which is secreted from the prostate epithelium cells.
BPH causes a mild/moderate increase in PSA.
Normal PSA level?
4? 2.5?

46. PSA Between 50-70 years old, every year PSA ve DRE is recommended.
PSA ve DRM starts at 40 years old for the ones who has family history

47. USG or IVP (for who?) Hematuria Urinary stone history
Urinary infection history
Urogenital surgery history
Failure in renal functions

48. IVP Prostatic indentation - Fish-hook like presentation
- Bladder stone
- İncrease in trabeculation, cellulas and diverticulas.
- Determining residual urine in post-voiding graphy.

51. Uroflowmetry Most important parameter is maximum flow rate. (MFR)
MFR> 15 ml/ sec.. No obstruction
MFR< 10 ml/ sec Yesobstruction

52. Uroflowmetry of a patient who has obstructive BPH

53. PMR(Post-mictional residue)
It is less than 12 cc. in normal male.
It shows the failure of emptying the bladder if it is more than 100 cc.

54. Examinations which are needed rarely in BPH
Voiding cystouretrography
Retrograde uretrography CT
MRI
Pressure-flow studies

55. Pressure-flow studies
Age<50
Age>80
PMR >300 cc
History of neurogenic disease
History of surgery

56. Differential diagnosis in BPH
Prostat adenocarsinoma
Stricture of uretra
Prostatitis
Bladder stone
Bladder tumor
Neurogenic bladder

57. Factors that predict the worsening in BPH
Prostate volume (>30ml)
PSA level (>2 ng/ml)
PMR (>150ml)
Qmax (<10ml/sn)
Acute urinary retantion

58. Treatment Options Conservative followup Medical treatment
Surgical treatment

59. Conservative Followup
Once a year for the patients having mild symptoms.
Once in every 6 monts time, after 40 years for the patients who has relatives with the prostate adenocarsinoma history.
Once a year, after 50 years old for the patients who have no family history.

60. Conservative Followup
Cold weather
Cayenne pepper
Constipation
Tough places to sit
Food that are irritative to bladder

61. Medical Treatment Options
Alpha-blockers
5-Alpha-reductase inhibitors

62. Alpha-1 Blockers
Non-selective alpha-blocker
Fenoxibenzamine
Selective alpha blockers
Prazosin
Alfuzosin
Selective long-time effective alpha blockers
Doxazosin
Terazosin
Tamsulosin
Alpha 1 subgroup receptors are mostly seen in prostate, bladder neck and üretra.

63. Indications:
Mild/moderate symtomatic patients
Patients who don’t want surgery
Prophylaxis to acute urinary retantion

64. Contrendications:
Renal failure secondary to BPH
Chronic urinary retantion
Postural hypotension
Frequent acute urinary retantion
Frequent acute urinary retantion with BPH

65. Side effects Dizziness Syncope Postural hypotension Weakness Headache
Nasal congestion
Failure in accomodation
Retrograd ejaculation

66. Alfa-blockers & Result-1
They have similar efficiencies.
After a few doses, the symptomatic improvement starts. On the responsive cases, the efficiency exists till 5 years time.
If the symptoms doesn’t get better in about 8 weeks time, we shouldn’t insist on this medical therapy.
Side effects are also similar.

67. Alfa-blockers & Result-2
The effect is free of prostate size.
They are better than finasteride and placebo on the effect of easing the LUTS
They don’t stop the enlarging of the prostate and don’t change the natural course of BPH.
They are the most common and primary medical treatment option for the patients who have mild and moderate LUTS.

68. Hormonal Therapy
5-alpha reductase inhibitors
Finasteride
Dutasteride

69. 5-alpha Reductase Inhibitors-1
The firstly used 5-alpha-Reductase inhibitor in BPH is finasteride and it inhibits type-2 isoenzyme competitively.
Dutasteride inhibits both type 1 and type 2 enzymes.
They decrease intraprostatic DHT (% 85-90) and serum DHT (% 65-70)

70. 5-alpha Reductase Inhibitors-2
They make a % 50 decrease in PSA values in one year time.
There may be a % 24 decrease in prostate volume in 6th month control, but the volume comes to the normal value after giving up the drug.

71. 5-alpha Reductase Inhibitors-Side effects
Increase in impotence (% )
Decrease in libido (% )
Decrease in ejaculate (%1.4 - %3.7)
Ejaculation disorders, erythema, enlargement in mamilla, stress (<%1)
Generally a tolerable drug. The ratio of giving up the drug because of side effects is %2.6 – 14.7

72. 5-alpha Reductase Inhibitors-Conclusion
The effect starts on 1-3rd monts but maximum efficiency is seen mostly in 6 months time.
The drug changes the natural course of BPH
-Decreases the risk of acute urinary retention
-Decreases the risk of surgery dependant to BPH
Side effects are mostly about sexual intercourse
Treatment with 5-Reductase inhibitors don’t prevent the diagnose of prostate cancer. The correct PSA level can be found by just multiplying the serum PSA value found.

73. Who has more benefit from 5-alpha-reductase inhibitors
Patients who have;
PSA > ng/mL
Larger prostate volume (>40 gr)
Moderate-severe LUTS

74. Combination Treatment
The combination of 5-alpha-reductase inhibitors and alpha-1-blockers seems very helpful but more studies about this topic are needed.

75. Surgical Treatments Open prostatectomy TUR-P
Transuretral vaporization and electrovapor-rezection
Transuretral incision
Laser prostatectomy
Hypertermia and Termotherapy
TUNA
HIFU
Balloon dilatation and intrauretral stents

76. Endications for surgery-1
Absolute endications
Episodic urinary infections
Episodic urinary retentions
Hematuria
Bladder stone and diverticula
BPH not responsive to medical treatment
BPH with more and aggressive symptoms

77. Endications for surgery-2
Relative endications
Existence of residual urine.
Retrogression in quality of life because of symptoms related to BPH

78. Surgical Treatment
TUR-P is GOLD Standart.

79. Surgical Treatment
TUIP If prostate volume < ml, and there is no enlarged middle lobe.
TUR-P If prostate volume < ml
Open prostatectomy If prostate volume > ml, or there is big bladder stone and big diverticula of bladder.

80. THANK YOU