Benign prostatic

hiperplasia ( BPH )
Basuki B. Purnomo, Besut Daryanto, Kurnia Penta Seputra
Department of Urology
Saiful Anwar Hospital/ Brawijaya Medical Faculty
MALANG

Prostate Pyramid
UROLOGIST

GP

Lives with symptoms

Asymptomatic

Definition

BPH: benign prostatic hyperplasia

BPE: benign prostatic enlargement
BPO: benign prostatic obstruction
BOO: bladder outlet obstruction

Prostatic disease
Prostatic inflamation (prostatitis)
Benign prostatic Hyperplasia (BPH)
Prostatic carcinoma

Mean urinary flow rates VS

Age

Prevalence
60 years

80 years

Etiology???
Aging
Normal testis

NADPH

NADP

5-reduktase

Prostatic mass
(static component)

Smooth muscle tonus

(Dynamic component)

History : complications

Urinary retention
UTI
Bladder calculi
Haematuria
Renal impairment
Diverticulae

BPH
Static component

Bladder aging
Neuropathic

Dynamic component

Voiding
problems

Obstructive symptom

Storage
problems

Irritative symptoms

Diagnosis
Mandatory (highly recommended)

History
Physical examination and digital rectal
examination
Urinalysis
Recommended

PSA
Quantification of symptoms: IPSS and QoL
RFT
Voiding diary

Optional

Flow rates recording (uroflometri)

Post voiding residual urine
Imaging
Pressure flow study
Urethrocystoscopy*

Quantification of
symptoms
IPSS and bother symptoms
IPSS
0-7: mildly symptomatic
8-19 : moderately symptomatic
20-35: severely symptomatic

(IAUI BPH Guidelines, 2003)

Medical history
Nature and duration of reported GU tract
symptoms
Previous surgical procedure on GU tract
General health issues, sexual function
Medication
Patients fitness status

Physical Examination
Palpable bladder?
DRE
Prostate size, consistency
Anal sphincter tone

Neurological examination
Ambulatory status
Lower extremity neuromuscular function

Urinalysis
Dipstick testing
Microscopic examination
To screen:
Hematuria
UTI

PSA
Predictor of the natural history of BPH,
increasing PSA:
Future growth of the prostate
Symptom and flow rate determination
AUR

25% men with BPH have PSA 4 ng/dL

Most appropriate for patients < 70 years
or natural life span > 10 years.

Urethrocystoscopy
Maybe appropriate in men with a history of
Microscopic or gross haematuria
Bladder carcinoma
Urethral stricture

Recommended at the time of surgical

intervention (TUIP-TURP-Open prostatectomy)

Treatment
Watchful waiting
Medical therapies
adrenergic blocker,
5 reductase inhibitor,
phytotherapy

Intervention therapies
Minimally invasive therapies
Surgical therapies

INITIAL ASSESSMENT

Medical history
Physical
Physical Examination,
Examination, DRE
DRE
Urinalysis
Urinalysis
RFT
RFT
PSA
PSA
Voiding diary

IPSS and QoL

MILD (IPSS <7)
Symptoms not bothersome
Doesnt want treatment

MODERATE SEVERE
(IPSS 8-19) IPSS (20-35)
ADDITIONAL
ASSESSMENT

Flowrates
PVR
USG

ASSOCIATED WITH

Suspicious DRE
PSA abnormal
Hematuria
Pain
Neurological abnormal
Palpable bladder
RFT abnormal

Discuss treatment option with the patient

Choose non invasive

treatment

Watchfull waiting

Choose invasive treatment

Medical Treatment

REFER TO
UROLOGIST

Watchful waiting
Mild-moderate symptom (IPSS<7)
Refused medical treatment
Altering modifiable factor such as:

Concomitant drug
Regulation of fluid intake especially in the evening
Life style change (avoid sedentary life)
Dietary advice (avoid excessive intake of
alcohol, and highly seasoned or irritative foods)

Medical therapy
Moderate (IPSS 8-19) & severe symptoms
(IPSS20-35)
Failure after watchful waiting

Medical Therapy
Reducing smooth muscle tone (dynamic component):
adrenergic blocker
Short acting: prazosin, afluzosin
Long acting: doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):

5 reductase inhibitor
Finasteride
Dutasteride (6-azasteroid )

Phytotherapy

Medical Therapy
First choice: adrenergic blocker
Second choice: 5 reductase inhibitor
prostate weight >40 g

Combination??

Intervention therapy
Minimally invasive therapy
TUNA
HIFU
TUMT
Stent

Surgical therapy

TUIP
TURP
Open prostatectomy
TUVP
Laser

Thank you