BENIGN PROSTATE

HYPERPLASIA
Div. of Urology, Dept. Surgery
Medical Faculty,
University of Sumatera Utara

REFERENCES

DEFINITION
BPH is :
Enlargement of the prostate gland from the
progressive hyperplasia of stromal and
glandular prostatic cells
Pathologic process that contributes to, but is
not the sole cause of, lower urinary tract
symptoms (LUTS) in aging men
Urol Clin N Am 35 (2007) 109115
Campbell-Walsh Urology, 9th ed.2007

TERMINOLOGY
BPH (Benign Prostatic Hyperplasia)
histopathologic
diagnosis
BPE (Benign Prostatic Enlargement)
anatomic diagnosis
BOO (Bladder Outlet Obstruction)
anatomic diagnosis
BPO (Benign Prostatic Obstruction) BOO
caused by BPE
LUTS (Lower Urinary Tract Symptoms)
clinical

INTRODUCTION
Most common benign tumor in men
Age related
in life expectancy significantly the
number of men affected by BPH
BPH is said to be a stromal disease, but
it remains unclear whether the initiating
events occur in the stomal compartment,
the epithelial compartment, or both

ANATOMY
Normal weight about 20 g
Classification of Lowsley : 5 lobes :
anterior, posterior, median, right lateral, left
lateral
According to Mc Neal :
- peripheral zone
- central zone
- transitional zone
- an anterior segment
- a preprostatic sphincter zone

PREVALENCE
20 % of men 40 -50 years
50 % of men 50 60 years
> 90 % of men older than 80 years
The Most Frequent Benign Tumor
in Men

All Men >

40 yrs
BPH

Storage
Total
51.3%

BP
E

Storage
Total
51.3%

LUTS
BO
O

ETIOLOGY
Multifactorial and endocrine
controlled (Androgens,
estrogens, stromal-epithelial
interactions, growth factors,
and neurotransmitters may
play a role )
BUT not completely understood

THEORIES FOR THE CAUSE OF BPH

Theory

Cause

Effect

Dihydrotestosteron
hypothesis

5- reductase and
androgen receptors

Epithelial and
stromal hyperplasia

Oestrogen-testosteron
imbalance

Oestrogens
Testosteron

Stromal hyperplasia

Stromal-epithelial
interactions

Reduced cell death

Stem cell theory

Epithelial and
Epidermal growth
stromal
factor/fibroblast
hyperplasia
growth factor
Transforming growth
factor
Longevity of
stroma
and epithelium
Oestrogens
Stem cells

Proliferation of
transit

MORPHOLOG
Y
Microscopically, nodular prostatic
hyperplasia consists of nodules of glands
and intervening stroma (mostly glands)
The glands variably sized, with larger
glands have more prominent papillary
infoldings
Nodular hyperplasia is NOT a precursor
to carcinoma

PATHOPHYSIOLOGY

1. Pathogenesis hyperplasia
2. Symptoms disorders
( Voiding phase or storage
phase )

PATHOPHYSIOLOGY
Nodular hyperplasia of glands and stroma
Normal 20 to 30 50 to 100 gm
Press upon the prostatic urethra
Obstruction - difficulty on urination
Dysuria, retention, dribbling, nocturia
Infections, hydronephrosis, renal failure
Not a premalignant condition

PATHOPHYSIOLOGY
Prostate growth
Increased urethral resistance
Decompensation
Flow
Bladder emptying ,
hesitancy, intermittency, etc

PATHOPHYSIOL
OGY

PATHOPHYSIOLOGY

Static
component

LUTS

Dynamic
component

STATIC COMPONENT

Prostate mass
(volume)
Urethral closure
pressure

DYNAMIC
COMPONENT
Bladder pressure
Prostate smooth muscle tone:
in stroma
capsule
bladder neck

LUTS ARE A CONSTELLATION OF

STORAGE AND VOIDING
SYMPTOMS
Storage

Voiding

Post-micturition

Urgency

Hesitancy

Post-void dribble

Frequency

Poor flow

Sense of
incomplete emptying

Nocturia

Intermittency

Urgency
incontinence

Straining
Terminal dribble

Other incontinence

Prevalence of LUTS in
Men of men in the general male
Percentage
population who report at least 1 symptom
representative of a particular type of LUTS
Voiding
Total
25.7%

Storage
Total
51.3%

Postmicturition
Total
16.9%
Irwin DE et al. Eur Urol. 2006;50:13061315

How to Assess the Patient?

RECOMMENDED INVESTIGATIONS
Clinical history
Physical examination
Validated symptom score, e.g
IPSS
Laboratory
Uroflowmetry
Imaging

1. CLINICAL HISTORY
Obstructive :
Hesitancy
Poor flow
Intermittency
Straining
Terminal
dribble

Irritative :
Urgency
Frequency
Nocturia
Urgency
incontinence
Other incontinence

2. PHYSICAL EXAMINATION
DRE :
Size
Consistency :
smooth or elastic/hard
Nodule/ tender
Mobility
Anatomical limits:
Lateral/ cranial/ medial sulcus
DRE is recommended in the evaluation
of men with LUTS

DRE

3. VALIDATED SYMPTOM SCORE

IPSS (International Prostate

Scoring System ).
07
8 - 19
20 35
7
7

:
:
:

Mild
Moderate
Severe

:
:

Watchful & Waiting

Medical treatment

BPH SYMPTOM SCORE

Gejala

(by :AUA)

Tidak Pernah < 20 %

< 50 %

=50%

> 50 % Hampir Selalu

1. KENCING TIDAK LAMPIAS

0
1
2
3
4
Dalam sebulan ini berapa sering anda merasakan sensasi tidak lampias
saat kencing (terasa belum habis) ?
2. Sering Kencing
0
1
2
3
4
Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam
2 jam setelah anda Kencing
3.KENCING TERPUTUS PUTUS
0
1
2
3
4
Dalam sebulan ini berapa sering kencing anda terhenti sejenak, lalu mulai
lagi ( Terputus putus)
4.TIDAK DAPAT MENUNDA KENCING
0
1
2
3
4
Dalam Sebulan ini Berapa sering anda merasa kesulitan untuk menunda
Kencing
5.PANCARAN KENCING YANG LEMAH
Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah
0
1
2
3
4
6. MENGEDAN SAAT KENCING
Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing
0
1
2
3
4
7.KENCING DI MALAM HARI
Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4
Kencing

5
5
5kali, =5

4. LAB TEST

Blood Count
Serum Electrolyte
Serum Creatinine
Serum PSA
Urine :
Proteinuria
Sediment
Culture

UROFLOWMETRY
Uroflowmetry Qmax
Voided
volume
Residual
urine

TAUS
Catheter

DIAGNOSTIC FOR BPH

Uroflowmetry :

UROFLOWMETRY

5. IMAGING
TRUS ( Transrectal
ultrasound )
Transabdominal Ultrasound
With Indication :
IVP
Cystography
CT-Scan
MRI

Trans Rectal Ultra Sonography :

Volumometry
Identification of hypoechoic lesions
Calcification
Periprostatic vein

Differential diagnosis

Urethral stricture
Bladder neck contracture
Small bladder stone
Locally advanced prostate ca
Poor bladder contractility

Differential Diagnosis
Bladder
Detrusor overactivity
Impaired detrusor contractility
Sensory urgency
Sphincteric incontinence
Polyuria/nocturnal polyuria
Medications
Antihistamines
Antidepressants

EFFECTS OF BENIGN PROSTATIC OBSTRUCTION

Irreversible bladder changes

Thickening of the bladder
wall
Recurrent haematuria
Bladder diverticulum
formation
Repeat urinary tract
infections
Bladder stone formation
Upper tract dilatation
Renal impairment

COMPLICATIONS

Increased risk of UTI due to urinary

retention
Calculi due to alkalinization of residual
urine
Hematuria due to overstretched blood
vessels
Pyelonephritis
Renal failure

INDICATION FOR TREATMENT

Absolute or near absolute :

- refractory or repeated urinary retention
- azotemia due to BPH
- recurrent gross hematuria
- recurrent or residual infection due to BPH
- bladder calculi
- large residual urine
- overflow incontinence
- large bladder diverticula due to BPH

TREATMENT

Watchful waiting

Medical therapies

Intervention therapies

Minimally invasive therapies

Surgical therapies

WATCHFUL WAITING
Component:
Education ( about the patients condition )
Reassurance ( cancer is not a cause )
Periodic monitoring
Lifestyle advice ( alcohol, caffein etc )
Evaluation/ monitoring : after 6 months/ 1
year
IPSS, uroflowmetry, post-void
residual urine volume

MEDICAL THERAPY

I.P.S.S. > 7
Flow > 5 ml/s
Residual urine < 100 ml
No hard nodule
PSA < 4 ng/dl

MEDICAL THERAPY

Reducing smooth muscle tone (dynamic

component) : -1 adrenergic blocker

Short acting : prazosin, afluzosin

Long acting : doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):

5 redutase inhibitor (finasteride, epristeride)

estrogen
aromatase inhibitor
LHRH agonist / antagonist
GF inhibitor
antiandrogens

Unknown
phytotherapy

ADRENERGIC STIMULI

Alpha adrenergic
stimuli increases
tonus of smooth
muscle cell in the
trigonum, bladder
neck and prostate
Location of alpha
receptor:

Bladder
Trigonum
Prostate gland

MODE OF ACTION ALPHA BLOCKING

AGENT

Alpha adrenergic blocking agent

blocks adrenergic stimuli
relaxation of the smooth muscle cell:

intra urethral pressure

Improvement of urine flow

RECOMMENDATIONS
-blockers should be offered to men with
moderate to severe LUTS
5-reductase inhibitors should be offered to men
who have moderate to severe LUTS and an
enlarged prostate. 5-reductase inhibitors can
prevent disease progression with regard to acute
urinary retention and need for surgery
The Guidelines committee is unable to make
specific recommendations about phytotherapy of
male LUTS
because of the heterogeneity of the products and
the methodological problems associated with
meta analyses
EAU guideline 2010

INVASIVE TREATMENT FOR BPH

Absolute indication:
Chronic Retention
With Hematuria
Concomitant Bladder stone
Intractable UTI
Deteriorating kidney function
Relative indication:
Huge PVR due to obstruction or low Qmax
Refuse medical treatment
Failure in medical treatment

INTERVENTION THERAPY

Minimally invasive therapy

Thermotherapy

TUNA (Trans Urethral Needle Ablation)

HIFU (High Intensity Focused Ultrasound)
TUMT (Trans Urethral Microwave Theraphy)
Laser

Stent

Surgical therapy

TUIP (Trans Urethral Incision of the Prostate)

TURP (Trans Urethral Resection of Prostate) GOLD
STANDARD
Open prostatectomy
TUVP (Transurethral Vaporization of the Prostat)
Laser

Efikasi vs. risiko terapi BPH

efikasi

OPEN
OPEN
PROSTATECTOMY
PROSTATECTOMY
TURP
TURP
TUNA
TUNA
THERMOTHERAPY
THERMOTHERAPY

5-ALPHA
5-ALPHA
REDUCTASE
REDUCTASE
INHIBITORS
INHIBITORS

ALPHA
ALPHABLOCKERS
BLOCKERS

PHYTOTHERAPY
PHYTOTHERAPY

risiko

TURP

JARINGAN PROSTAT

TUIP

terimakasih