Bph2
- 1. Yedishtra Naidoo MSIV KMC April 2010
- 2. Anatomy
- 5. Anterior lobe (or isthmus) roughly corresponds to part of transitional zone Posterior lobe roughly corresponds to peripheral zone Lateral lobes spans all zones Median lobe (or middle lobe) roughly corresponds to part of central zone
- 6. Prostate - Composed of Glands, Fibromuscular stroma and outer tissue capsule which restricts expansion. Glands lined by outer low cuboidal, inner columnar secretory epithelium. Fibromuscular stroma helps expel semen during ejaculation and prevent urine flow through urethra during emission. - Function: Adds alkaline fluid (also from seminal vesicles) pH7.29, to semen (70% of total semen) which protects sperm from acidic vagina. Normal weight is 20g in young adult male.
- 7. DHT
- 8. BPH A diagnosis of histology Hyperplasia and hypertrophy of mostly Stroma and some epithelium in TZ. Increased tone of fibromuscular stromal smooth muscle. Both result in urethral compression Obstructive LUTS. Bladder distension results in compensatory hypertrophied, trabeculated bladder wall, which eventually weakens in contracility Irritative LUTS.
- 9. Mechanics Nodular Hyperplasia lateral to urethra Compresses urethra to slit Nodular Hyperplasia medially project into floor of lateral urethra Project into lumen of bladder producing ball valve obstruction.
- 10. Slit
- 11. Ball valve
- 12. Pathogenesis Androgen: -Androgen Receptors are located primarily in epithelial cells of normal prostate tissue, but in hyperplastic glands ARs are distrubted in epithelial and stromal cells. - Men with 5AR2 deficiency have rudimentary prostates throughout life. - Similar DHT levels in BPH and non BPH. - DHT is necessary but not sufficient to cause BPH. Estrogen: - Conflicting evidence. - 86 men between 52 and 82 years of age, TZ volume correlated w increasing serum estrone. Dysregulation of stromal growth factors: Prostate reverts embryonic state sensitive to IGF2 and TGFB stimulating growth. Anti-apoptosis: Involving bcl-2 disinhibition. Genetics:-Survey Olmsted County, Minnesota, 21 percent of 2,119 men between 40 and 70 years of age had a family history of an enlarged prostate (1) -Case-control study of men under 64 years of age who had undergone prostatectomy for BPH and in whom more than 37 grams of tissue was resected The first-degree relatives of these men had a four-fold increased risk of developing BPH that required surgical therapy as compared with the relatives of normal men. (2).
- 13. Differential Cystitis Prostatitis Prostatodynia Prostatic abscess Overactive bladder (OAB) Carcinoma of the bladder Foreign bodies in the bladder (stones or retained stents) Urethral stricture due to trauma or a sexually transmitted disease Prostate cancer Chronic Pelvic pain Interstitial cystitis Prostatitis Neurogenic bladder Pelvic floor dysfunction
- 14. Epidemiology prostate on average weighs 20 grams in normal 21- to 30-year-old men, and the weight changes little thereafter unless the man develops BPH. Due to prevalence, mean weight increases after age 50. Prevalence of histologically dx’d BPH: 8 percent in men aged 31 to 40, to 40 to 50 percent in men aged 51 to 60, to over 80 percent in men older than age 80. Prevalence in white and african american men similar, but more severe and progressive in latter. Massachusetts Male Aging Study, increased risk of BPH was associated with higher free PSA levels, heart disease, and use of beta-blockers (3) Obesity, fasting glucose and diabetes also associated with BPH Decreased risk of BPH was associated with cigarette smoking (1 to 20 per day) and higher levels of physical activity.
- 15. History Ask for Obstructive LUTS and Irritative LUTS. History of type 2 diabetes, which can cause nocturia and is a risk factor for BPH. Symptoms of neurologic disease that would suggest a neurogenic bladder. Sexual dysfunction, which is correlated with LUTS. General health and fitness for possible surgical procedures Gross hematuria or pain in the bladder region suggestive of a bladder tumor or calculi History of urethral trauma, urethritis, or urethral instrumentation that could lead to urethral stricture Family history of BPH and prostate cancer Treatment with drugs that can impair bladder function (anticholinergic drugs) or increase outflow resistance (sympathomimetic drugs)
- 16. -Voiding diary that includes nocturia, diuria and void volume may provide more meaningful information of prostate volume and maximum urinary flow rates than AUA symptom score. -International Prostate Symptom Score (IPSS) uses the same questions and scale as the AUA symptom score and adds a disease-specific quality of life question: "If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?"
- 17. Physical Exam Digital Rectal Exam (DRE): - Use index finger of dominant hand in windshield wiper mov’t. - Each finger breath is approx 15-20g of tissue, most asymptomatic men </=2 finger breaths. - Assess size, contour, anal sphincter tone. - BPH: Rubbery, uniformly enlarged. -Malignancy: nodules, asymmetry, induration. - Prostatic abscess: fluctuance - Prostatitis: pain. Suprapubic: Bladder distension Neurologic Exam: Sensory or motor deficits of lower extremity and anal sphincter.
- 18. Work-up Urinalysis: Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. If blood is detected, hematuria workup. Urine C&S Serum PSA: - measured in men 50-69 - <4 ng/ml is cut-off. -Men at risk for BPH are also at risk for prostate ca. - Linear rise in PSA with prostate size - DRE + PSA = most acceptable means of excluding prostate ca.
- 19. Optional Studies
- 21. Medical Treatment Second class: 5alph reductase inhibitors: finasteride, dutasteride. - reduce size of prostate. - takes 6-12 mo. - For patients w LUTS and enlarged prostate.
- 22. Medical Treatment Medical Therapy of Prostatic Symptoms (MTOPS) trial – 3047 men, 4.5 yrs. Combination 5AR2 inhibitors (long term benefit) and alpha antagonists(rapid relief) reduces clinical progression significantly more than either alone. Reduced risk of acute urinary retention and invasive procedure.
- 23. Other medical treatments Anti-muscarinics:-Tolteridone - For irritative LUTS, prevents bladder contraction. Saw Palmetto: - Extract from fruit w various effects - Not recommended at this point for BPH.
- 24. Surgical Treatment Indications: Acute urinary retention, recurrent gross hematuria, UTIs, Renal insuficciency, failure of medical management. TURP (transurethral resection of prostate): Criterion standard for BOO. Risk of impotence, urinary incontinence, bleeding, strictures (18%) Requires hospitalization. Open/lap Prostatectomy: For large prostates, >75g, concomitant bladder stones. TZ shelled out.
- 25. Surgical Treatment Minimally Invasive to reduce side-effects of ED, Incontinence (retrograde urine) and blood loss. TUNA – transurethral needle ablation High freq radio waves. TUMT – transurethral microwave therapy Considerable swelling. Laser devices: holmium, KTP. Transurethral, outpt, for pt. On blood thinners. TUIP – transurethral incision of prostate. Small prostates, pt cant tolerate TURP
- 26. Diet Low fat, low red meat, high protein and vegetables may reduce incidence of symptomatic BPH.
- 28. References 1. Roberts, RO, Rhodes, T, Panser, LA, et al. Association between family history of benign prostatic hyperplasia and urinary symptoms: results of a population-based study. Am J Epidemiol 1995; 142:965 . 2. Sanda, MG, Beaty, TH, Stutzman , RE, et al. Genetic susceptibility of benign prostatic hyperplasia. J Urol 1994; 152:115 . 3. Meigs, JB, Mohr, B, Barry, MJ, et al. Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. J Clin Epidemiol 2001; 54:935. 4. Up to Date - BPH epidemiology, pathology, clinical assesment. 5. Emedicine – BPH, urology