BENIGN PROSTATIC

HYPERPLASIA
 Benign prostatic hyperplasia is a pathologic process that
is one but certainly not the only cause of lower urinary
tract symptoms (LUTS) in aging men, also described as
“male LUTS.”

Histopathologically, it is characterized by an increased

number of epithelial and stromal cells in the
periurethral area of the prostate and thus correctly
referred to as hyperplasia and not hypertrophy

Roehrborn CG. Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and Natural History. Campbell-Walsh Urology. 11 ed: Elsevier; 2016. p. 2425-62.
 DIAGNOSTIC EVALUATION
1 2 3 4 5

Physical Laboratory Urethrocystoscopy

Medical history Examination Imaging and Urodynamics
examination

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 MEDICAL HISTORY
• Aims to identify the potential causes and relevant comorbidities, including
medical and neurological diseases
• Review current medication, lifestyle habits, emotional and psychological
factors
• As part of the urological/surgical history, a self-completed validated symptom
questionnaire should be obtained : The International Prostate Symptom Score
(IPSS), The International Consultation on Incontinence Questionnaire (ICIQ-
MLUTS), Danish Prostate Symptom Score (DAN-PSS)
• Sexual function and Voiding diaries

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 PHYSICAL EXAMINATION
• To seek potential influences. Particularly focusing on the kidney,
suprapubic area, the external genitalia, the perineum and lower
limbs
• Urethral discharge, meatal stenosis, phimosis and penile cancer must
be excluded
• Performs digital-rectal examination and prostate size evaluation

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 LABORATORY EXAMINATION
• Urinalysis
• Prostate-specific antigen (PSA)
• Renal function measurement
• Post-void residual urine
• Uroflowmetry

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Imaging
• Upper urinary tract
• Lower urinary tract
• Prostate {can be performed by transabdominal
US, TRUS, computed tomography (CT), and
magnetic resonance imaging (MRI)}

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 URETHROCYSTOSCOPY AND
URODYNAMICS
• Perform urethrocystoscopy to exclude suspected bladder or urethral
pathology and/or prior to minimally invasive/surgical therapies if the
findings may change treatment
• Diagnosing bladder outlet obstruction, videourodynamics

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 DISEASE MANAGEMENT

Conservative Pharmacological Surgical treatment

treatment treatment

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
 Conservative treatment
Watchful Behavioural and Practical
waiting dietary modifications considerations

Men with Education, Men with LUTS lifestyle

mild/moderate reassurance, periodic advice prior to or
symptoms, minimally monitoring, lifestyle concurrent with
bothered by their advice treatment
symptoms

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
 Pharmacological
treatment
• α1-Adrenoceptor antagonists (α1-
blockers)
• 5α-reductase inhibitors
• Muscarinic receptor antagonists
• Phosphodiesterase 5 inhibitors
• Plant extracts - phytotherapy
• Beta-3 agonist
• Combination therapies

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European

Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
 α1-Adrenoceptor antagonists
(α1-blockers)
Mechanism of action : α1-blockers aim to inhibit the effect of
endogenously released noradrenaline on smooth
muscle cells in the prostate and thereby reduce
prostate tone and BOO

Currently available : alfuzosin hydrochloride (alfuzosin); doxazosin

mesylate (doxazosin); silodosin; tamsulosin
hydrochloride (tamsulosin); terazosin hydrochloride
(terazosin)
- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 5α-reductase inhibitors
Mechanism of action: 5-ARIs act by inducing apoptosis of prostate epithelial
cells, leading to prostate size reduction of about 18-28%
and a decrease in circulating PSA levels of about 50%
after six to twelve months of treatment

Currently available : dutasteride and finasteride

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Muscarinic receptor antagonists
Mechanism of action : Aims to inhibit or reduce muscarinic receptor
stimulation thus reducing bladder muscle cell
contraction

Currently available : darifenacin hydrobromide (darifenacin); fesoterodine

fumarate (fesoterodine); oxybutynin hydrochloride
(oxybutynin); propiverine hydrochloride (propiverine);
solifenacin succinate (solifenacin); tolterodine tartrate
(tolterodine); trospium chloride

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Phosphodiesterase 5 inhibitors
Mechanism of action : increase intracellular cyclic guanosine monophosphate,
thus reducing smooth muscle tone of the detrusor,
prostate and urethra

Currently available : only tadalafil (5 mg once daily) has been licensed for the
treatment

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Plant extracts - phytotherapy
Mechanism of action : Pharmacological data on the content of active
substances that support the mechanism of action of
pharmaceutical drugs until now is not known with
certainty

Currently available : Cucurbita pepo (pumpkin seeds), Hypoxis rooperi

(South African star grass), Pygeum africanum (bark of
the African plum tree), Secale cereale (rye pollen),
Serenoa repens (syn. Sabal serrulata; saw palmetto) and
Urtica dioica (roots of the stinging nettle)

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Beta-3 agonist
Mechanism of action : Beta-3 adrenoceptors are the predominant beta
receptors expressed in the smooth muscle cells of the
detrusor and their stimulation is thought to induce
detrusor relaxation

Currently available : Mirabegron 50 mgMirabegron 50 mg

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. 2017. European Association of Urology Guidelines. Edisi 2017. European Association of Urology
 Combination therapies

• α1-blockers + 5α-reductase inhibitors

• α1-blockers + muscarinic receptor antagonists

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Surgical treatment
• Transurethral resection of the prostate
and transurethral incision of the prostate
• Open prostatectomy
• Transurethral microwave therapy (TUMT)
• Transurethral needle ablation of the
prostate
• Laser treatments of the prostate
• Prostatic stents
• Prostatic urethral lift
• Novel interventions

- Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines. 2017 ed: European Association of Urology; 2017.
- Mochtar CA, Umbas R, Soebadi DM, Rasyid N. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (Benign Prostatic Hyperplasia/BPH): Ikatan Ahli Urologi Indonesia (IAUI); 2015.
 Treatment algorithm
(without surgery indication)

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. 2017.

European Association of Urology Guidelines. Edisi 2017. European Association of
Urology
 Treatment algorithm
(surgery indication)

Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. 2017.

European Association of Urology Guidelines. Edisi 2017. European Association of
Urology
THANK YOU