BENIGN PROSTATIC HYPERPLASIA

(BPH)
A widely prevailing pathology among elderly
males
BPH can cause bothersome day & night LUTS
A negative impact on quality of life (QOL).

Definition Of BPH
Normal prostate:
A compound tubulo-alveolar gland
composed of 3 histological elements:

Epithelial structure: prostatic

acini&ducts
(androgen dependent) lying within
a:

fibro-muscular smooth m. innervated

by alpha adrenergic fibres

Stroma
Normal prostate is about 15 g. in the young
adult
BPH results from abnormal (proliferation) of
the 3 histological elements of the prostate:

glandular (acinar)

fibrous

muscular
in different proportions
It can be regarded as a benign tumor:
fibro-myo-adenoma
Aetiogy Of BPH

Aging

Androgens

PATHOLOGY OF BPH
BPH arises from the transition zone or the periurethral zone of the gland closely relayed to
urethra & BN.

What about P Ca?

Pathogenesis
BPH starts as one or more hyperplasic nodules
within
the gland..
gradually enlarging .
may coalesce together
compressing the intervening &
outer normal prostatic tissue
which eventually forms a
surgical capsule around the adenoma

The result will be:

An elongated & compressed prostatic
Urethra
Macroscopically BPH can be:
Monolobar - middle lobe
Bilobar
- 2 lateral lobes
Trilobar
- 2 lateral lobes & middle lobe

Pathophysiology of Urethral Obstruction in BPH

Static component:
- formed by the obstructing prostatic mass
Dynamic component:
- formed by the tone of smooth muscle within
the stroma & capsule

Pathological complications of BPH

Increased intravesical pressure:

Early : bladder muscle hypertrophy

Later : atony, thinning out of bladder

muscle,
diverticulation
The result will be:
High intra-vesical (P) : Bil
hydroureteronephrosis

Outlet obstruction : significant amount of PV

residual urine
Stasis:
-Rec UTI
-Stone formation

Diagnosis of BPH
Clinical Picture
Symptoms:

Old male (over 50 ys) suffering from

LUTS
Storage symptoms:

Urinary frequency

nocturia

urgency ,..urgency incontinence

Evacuation symptoms:

Straining during voiding

diminished force & calibre of the

stream

bifurcated stream

interrupted stream

PV dribbling

AUR

Symptoms of complications

Rec. UTI
Haematuria
Bladder stone
chronic retention:
SP mass (full bladder)
overflow incontinence
renal insufficiency

Physical examination
General examination
Abdominal examination:

Renal swelling (hydronephrosis)

SP area ( full bladder)

Hernial orifices
Genital examination


associated epididymo-orchitis
Digital rectal examination (DRE)

size , shape, symmetry, consistency

Complications:

Rec. UTI

Hydronephrosis

Bladder stones or diverticula

Is it suspicious of P Ca ?

Investigations
Lab investigations

Urinalysis
Serum creatinine
Serum PSA

Imaging
Abdominal ultrasonography:

size of the gland, PVR,

associated stones

hydronephrosis,
KUB:

radio-opaque calculi
Intravenous Urography:

secretory function of the kidney

basal smooth filling defect in

the bladder
Uroflowmetry : to document obstruction
Urethro-cystoscopy : in case of hematuria

Differential Diagnosis
Other causes of LUTS

Bladder & urethral calculi

Bladder cancer
BN fibrosis
Prostate cancer
Urethral stricture
Neurogenic voiding dysfunction

TREATMENT of BPH
Non- symptomatic BPH
Reassurance---- Follow up
Symptomatic BPH:
Conservative Treatment:
- non-specific measures:
* Avoid causes of prostatic congestion
* Phytotherapy
Specific medical treatment:
5- alpha - reductase inhibitors
prevent the conversion of testosterone
to 5-dihydro testosterone
gradual atrophy of the glandular
component of BPH
(slow effect on static component)
Alpha adrenergic blockers
Cause decrease of the smooth muscle
tone within the prostatic stroma&capsule
better urine flow
(rapid effect on dynamic component)
Surgical Intervention
Indications

Repeated AUR

Chronic UR

Severe obstructive symptoms

Failure of medical treatment

Haematuria

Methods of Surgical intervention

1. Trans-urethral resection of the prostate
(TURP)
(Gold standard 90% of cases)
2. Open surgical prostatectomy
(enucleation adenectomy)
- when ?

Very large BPH

Concomitant bladder lesion that needs
open surgery
Patient limitation (limited hip joint
mobility)

Conclusions

BPH is a disease of aging males

It can cause disabling LUTS (QOL)

Corner stone of diagnosis

old male,
LUTS,
DRE, sonography
exclude cases of suspected P ca

Most cases ( 70 90 % ) can be managed by

medical treatment with reasonable pt.
satisfaction
Only a small percentage will need surgical
intervention where TURP is the standard of
care