Transcript BPH SONN İNG - University of Yeditepe Faculty of Medicine, 2011

BENIGN PROSTATE
HYPERPLASIA
Assistant Professor Hakan KOYUNCU
Yeditepe University Medical Faculty
Urology Department
BPH
GLANDULA
FIBROMUSCULAR STROMA
is the hyperplasia of these components of
the prostate and it is not malignant.
Hystological existence of BPH
 Around fourties
%8
 51 - 60 years old
% 40
 61 - 70 years old
% 60
 Above the age of 80
% 90
BPH Prevalence-1
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40–49 years old % 13.8
50–59 years old % 24
60–69 years old % 43
About % 30 of male
population is having a
surgical operation because
of the longer lifetimes.
BPH Prevalence-2
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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.
Histology of the prostate
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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 30-50 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 16-32 excretuar channels.
Approximate weight of the prostate in adults is 18-20
gr.
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Epithelial cells consist of 4 main cell
group.
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Prostatic aciner and secretory cells
Basal cells
Transitional cells
Endocrin-paracrin cells
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.
Etiology
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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.
Etiology
Aging
Functional Testis
Factors on etiology-1
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Aging
-Testesteron (leydig cells) decrease.
-SHBG increases, serum testesteron
levels decrease.
-Intraprostatic DHT and androgen
reseptor levels increase.
-Free estrogen / free testesteron level
increase.
Factors on etiology-2
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Role of androgens
They are the major trigger in the formation of BPH.
5α reductase
Testosteron
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Dihydrotestosteron
(DHT)
DHT is the major intraprostatic testosteron and its’
affinity to androgen receptors are more than
testosterons’ .
Factors on etiology-3
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Role of estrogens
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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.
Factors on etiology-4
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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.
Factors on etiology-5
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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.
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There are studies showing that
epithelial growth effect of stromal cells
take place by the mediation of paracrin
mechanism, growth factors and protooncogens.
Growth Factors effective on
BPH
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Keratinocyte growth factor (KGF)
Epidermal growth factor (EGF)
Insulin-like growth factor (IGF-1/2)
Fibroblast growth factor (FGF)
Transforming growth factor (TGF)
Result
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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.
Factors on etiology-6
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Genetic predisposition
BPH
Familial
1- 3 or more people who has
BPH in family history
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)
Sporadic
1-Prostate volume
(Approx. 55.5)
Patophysiology of Obstruction
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Consists of 3 stages
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Anatomic obstruction
Primary patophysiologic obstruction (High
pressure in the proximal of the obstruction)
Secondary patophysiologic obstruction
(Retantion - Infection – Hydronephrosis)
Changes in the uretra in BPH
Morphologic deformity
***(Deformation)
Longer in length
***(Elongation)
Changing the position
***(Deviation)
Answer of the Bladder to BPH
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Starting period
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Compensatory stage
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Decompensatory stage
Lesions in Compensatory stage
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Trabeculation
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Cellula
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Diverticula
Lesions in Decompensatory stage
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The scar tissue replaces the muscle.
The ejaculation function decreases
progressively.
Compliance decreases.
The pressure increases.
As a result: Detrusor instability
Upper urinary system in future
time
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Bilateral ureterectasia
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Ureterohydronephrosis
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Result: Chronic renal failure
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!
Complications
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Acute urinary retantion
Urinary system infection
Bladder stone
Bladder injury
Renal failure
Hematuria
Diagnose
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Medical history
Symptom Score
Physical examination
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DRE and limited neurological examination
Diary of miction
Urine analysis
Creatinine
PSA ??
Urinary flow rate
PMR
Symptoms in BPH
Irritative
Nokturia
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
Symptom Scores in BPH
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Boyarsky
AUA
I-PSS
Turkish Symptom Score adapted from
I-PSS
IPSS
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Total symptom score differs between 035 and grades the mictional disfunction
0-7 mild
8-19 moderate
20-35 severe
Laboratory and Radiologic
Evaluation
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Urine analysis, creatinine
PSA
Ultrasonography
Urinary
Transrectal
IVP
Uroflowmetry
Uriner analysis
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Recommended because of that it shows
the hematuria and urinary infection
Creatinine
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It is established that higher creatinine
levels increase the post-operative
complications
Creatinine examination is recommended
PSA
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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?
PSA
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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
USG or IVP (for who?)
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Hematuria
Urinary stone history
Urinary infection history
Urogenital surgery history
Failure in renal functions
IVP
Prostatic indentation
- Fish-hook like presentation
- Bladder stone
- İncrease in trabeculation, cellulas and
diverticulas.
- Determining residual urine in postvoiding graphy.
Uroflowmetry
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Most important parameter is
maximum flow rate. (MFR)
MFR> 15 ml/ sec.. No obstruction
MFR< 10 ml/ sec Yesobstruction
Uroflowmetry
of a patient
who has
obstructive
BPH
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PMR(Post-mictional residue)
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It is less than 12 cc. in normal male.
It shows the failure of emptying the
bladder if it is more than 100 cc.
Examinations which are
needed rarely in BPH
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Voiding cystouretrography
Retrograde uretrography
CT
MRI
Pressure-flow studies
Pressure-flow studies
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Age<50
Age>80
PMR >300 cc
History of neurogenic disease
History of surgery
Differential diagnosis in BPH
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Prostat adenocarsinoma
Stricture of uretra
Prostatitis
Bladder stone
Bladder tumor
Neurogenic bladder
Factors that predict the
worsening in BPH
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Prostate volume (>30ml)
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PSA level (>2 ng/ml)
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PMR (>150ml)
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Qmax (<10ml/sn)
Acute urinary
retantion
Treatment Options
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Conservative followup
Medical treatment
Surgical treatment
Conservative Followup
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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.
Conservative Followup
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Cold weather
Cayenne pepper
Constipation
Tough places to sit
Food that are irritative to bladder
Medical Treatment Options
Medical
 Alpha-blockers
 5-Alpha-reductase inhibitors
Alpha-1 Blockers
Alpha 1 subgroup
receptors are mostly
seen in prostate, bladder
neck and üretra.
Non-selective alphablocker
Fenoxibenzamine
Selective alpha blockers
Prazosin
Alfuzosin
Selective long-time
effective alpha blockers
Doxazosin
Terazosin
Tamsulosin
Indications:
 Mild/moderate symtomatic patients
 Patients who don’t want surgery
 Prophylaxis to acute urinary retantion
Contrendications:
 Renal failure secondary to BPH
 Chronic urinary retantion
 Postural hypotension
 Frequent acute urinary retantion
 Frequent acute urinary retantion with
BPH
Side effects
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Dizziness
Syncope
Postural hypotension
Weakness
Headache
Nasal congestion
Failure in accomodation
Retrograd ejaculation
Alfa-blockers & Result-1
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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.
Alfa-blockers & Result-2
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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.
Hormonal Therapy
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5-alpha reductase inhibitors
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Finasteride
Dutasteride
5-alpha Reductase Inhibitors-1
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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)
5-alpha Reductase Inhibitors-2
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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.
5-alpha Reductase InhibitorsSide effects
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Increase in impotence (% 4.7 - 8.1)
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Decrease in libido (% 3 - 6.4)
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Decrease in ejaculate (%1.4 - %3.7)
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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
5-alpha Reductase InhibitorsConclusion
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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.
Who has more benefit from 5alpha-reductase inhibitors
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Patients who have;
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PSA >1.4-1.5 ng/mL
Larger prostate volume (>40 gr)
Moderate-severe LUTS
Combination Treatment
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The combination of 5-alpha-reductase
inhibitors and alpha-1-blockers seems
very helpful but more studies about
this topic are needed.
Surgical Treatments
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Open prostatectomy
TUR-P
Transuretral vaporization and
electrovapor-rezection
Transuretral incision
Laser prostatectomy
Hypertermia and Termotherapy
TUNA
HIFU
Balloon dilatation and intrauretral stents
Endications for surgery-1
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Absolute endications
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Episodic urinary infections
Episodic urinary retentions
Hematuria
Bladder stone and diverticula
BPH not responsive to medical treatment
BPH with more and aggressive symptoms
Endications for surgery-2
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Relative endications
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Existence of residual urine.
Retrogression in quality of life because of
symptoms related to BPH
Surgical Treatment
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TUR-P is GOLD Standart.
Surgical Treatment
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TUIP
If prostate volume < 20-30 ml, and
there is no enlarged middle lobe.
TUR-P
If prostate volume < 80-100ml
Open prostatectomy
If prostate volume > 80-100ml, or there
is big bladder stone and big diverticula
of bladder.
THANK YOU