排尿障礙治療中心版權所有 Benign Prostatic Hyperplasia Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有

Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia

Hann-Chorng KuoHann-Chorng Kuo

Department of UrologyDepartment of Urology

Buddhist Tzu Chi General HospitalBuddhist Tzu Chi General Hospital


Bladder Outlet obstructionBladder Outlet obstruction

Bladder neck dysfunctionBladder neck dysfunction Prostatic enlargementProstatic enlargement Urethral strictureUrethral stricture External sphincter dyssynergiaExternal sphincter dyssynergia Urethral meatal stenosisUrethral meatal stenosis BOO is a condition of progressive degreeBOO is a condition of progressive degree


Lower urinary tract symptomsLower urinary tract symptomsIPSS & AUA symptom scoreIPSS & AUA symptom score

FrequencyFrequency UrgencyUrgency NocturiaNocturia Small caliber of urineSmall caliber of urine DysuriaDysuria IntermittencyIntermittency Residual urine sensationResidual urine sensation


LUTS and BOOLUTS and BOO

1/3 of men with LUTS do not have BOO1/3 of men with LUTS do not have BOO 5% - 35% of patients with BPH & LUTS do 5% - 35% of patients with BPH & LUTS do

not improve symptoms after TURPnot improve symptoms after TURP LUTS have a poor diagnostic specificity for LUTS have a poor diagnostic specificity for

BOOBOO Prostate size and uroflowmetry have better Prostate size and uroflowmetry have better

correlation with urodynamic study than symcorrelation with urodynamic study than symptoms aloneptoms alone


Pathogenesis of Pathogenesis of Bladder outlet obstructionBladder outlet obstruction

Progressive increased urethral resistanceProgressive increased urethral resistance High voiding pressure and low flowHigh voiding pressure and low flow Bladder compensation in energyBladder compensation in energy Increased residual urine volumeIncreased residual urine volume Elevated intravesical pressure at end-fillingElevated intravesical pressure at end-filling Bladder stone, diverticulum, UTIBladder stone, diverticulum, UTI Hydroureter, hydronephrosis, azotemiaHydroureter, hydronephrosis, azotemia


Reduction in AChE-positive nervReduction in AChE-positive nerve fibers after BOOe fibers after BOO


Differential diagnosis of Differential diagnosis of male BOO and LUTSmale BOO and LUTS

Benign prostatic enlargementBenign prostatic enlargement Bladder neck dysfunctionBladder neck dysfunction Spastic urethral sphincterSpastic urethral sphincter Poor relaxation of urethral sphincterPoor relaxation of urethral sphincter Urethral strictureUrethral stricture Low detrusor contractilityLow detrusor contractility Pseudodyssynergia due to neuropathyPseudodyssynergia due to neuropathy


Relation of prostate and urethraRelation of prostate and urethra


Benign prostatic hyperplasiaBenign prostatic hyperplasia

Prostatic enlargement – benign or malignant,Prostatic enlargement – benign or malignant, a sign a sign

Prostatic hyperplasia – histological termProstatic hyperplasia – histological term Prostatic obstruction – a clinical diagnosisProstatic obstruction – a clinical diagnosis Bladder outlet obstruction – an urodynamic Bladder outlet obstruction – an urodynamic

termterm Lower urinary tract symptoms – symptomLower urinary tract symptoms – symptom


Anatomy of Prostate glandAnatomy of Prostate gland


Anatomy of Prostate glandAnatomy of Prostate gland


Prostatic glandular anatomyProstatic glandular anatomy


Cystoscopic Prostatic obstructionCystoscopic Prostatic obstruction


Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia

BPH requires testicular androgen during proBPH requires testicular androgen during prostatic developmentstatic development

Basic fibroblast growth factor, epidermal grBasic fibroblast growth factor, epidermal growth factor, keratinocyte growth factor, tranowth factor, keratinocyte growth factor, transforming growth factor-beta play some part sforming growth factor-beta play some part in prostate growthin prostate growth

Decreased endogenous apoptosis in prostate Decreased endogenous apoptosis in prostate cause abnormal tissue growth in prostatecause abnormal tissue growth in prostate


Histology of Histology of Benign prostatic hyperplasiaBenign prostatic hyperplasia


Clinical BPHClinical BPH

LUTSLUTS ( storage or empty symptoms) due to ( storage or empty symptoms) due to histological histological benign prostatic hyperplasiabenign prostatic hyperplasia an and urodynamical d urodynamical bladder outlet obstructionbladder outlet obstruction w which has been proven by urodynamic pressuhich has been proven by urodynamic pressure flow study as re flow study as prostatic obstructionprostatic obstruction

Treatment for LUTS and restoration of norTreatment for LUTS and restoration of normal storage and empty function by reducing mal storage and empty function by reducing prostatic enlargementprostatic enlargement either medically or su either medically or surgicallyrgically


Pathophysiology of Pathophysiology of BPH and LUTSBPH and LUTS

Nodular proliferation of prostate glandNodular proliferation of prostate gland Increased stroma to epithelial ratio to 2:1 to Increased stroma to epithelial ratio to 2:1 to

5:1 in benign prosatic hyperplasia5:1 in benign prosatic hyperplasia Increased smooth muscle componentIncreased smooth muscle component Detrusor compensatory change and bladder Detrusor compensatory change and bladder

dysfunction, detrusor overactivitydysfunction, detrusor overactivity LUTS may related to BPH or detrusor dysfuLUTS may related to BPH or detrusor dysfu

nction,or combinationnction,or combination


Symptom scores of BPH as Symptom scores of BPH as treatment guidelinetreatment guideline

1970 Boyarsky and Madsen-Iverson1970 Boyarsky and Madsen-Iverson 1992 AUA symptom index1992 AUA symptom index International prostatic symptom score adds International prostatic symptom score adds

quality of life indexquality of life index Bothersomeness and health related quality oBothersomeness and health related quality o

f life (HRQOL)f life (HRQOL) Symptom problem indexSymptom problem index BPH impact index (BII)BPH impact index (BII)


Clinical evaluation of BPH Clinical evaluation of BPH

Digital rectal examination of prostateDigital rectal examination of prostate

-- Prostate size, consistency, surface nodul-- Prostate size, consistency, surface nodularity, tendernessarity, tenderness

Bladder palpation – residual urine volumeBladder palpation – residual urine volume Cystography, Intravenous pyelographyCystography, Intravenous pyelography Transrectal sonography of prostateTransrectal sonography of prostate CystourethroscopyCystourethroscopy


Cystography of Bladder base eleCystography of Bladder base elevation indicating BPHvation indicating BPH


Sonography of BPHSonography of BPH


Clinical evaluation of BPHClinical evaluation of BPH

Uroflowmetry, prstatic volumeUroflowmetry, prstatic volume Postvoid residual urine volumePostvoid residual urine volume Prostatic specific antigen (PSA)Prostatic specific antigen (PSA) Pressure flow study improves in diagnosis aPressure flow study improves in diagnosis a

nd aid in selection for specific invasive treatnd aid in selection for specific invasive treatmentment

Videourodynamic study is helpful in determVideourodynamic study is helpful in determining complicated caseining complicated case


Uroflowmetry in BPH Uroflowmetry in BPH without or with obstructionwithout or with obstruction


Pressure flow study in Pressure flow study in BPH with ObstructionBPH with Obstruction


Videourodynamic study in Videourodynamic study in BPH with ObstructionBPH with Obstruction


Causes of non-obstructive Causes of non-obstructive Men with LUTSMen with LUTS

Normal bladder and urethra 25Normal bladder and urethra 25 Bladder hypersensitivity 17Bladder hypersensitivity 17 Detrusor instability 6Detrusor instability 6 Detrusor underactivity 3Detrusor underactivity 3 Poor relaxed urethral sphincter 61Poor relaxed urethral sphincter 61


Videourodynamic study in Man Videourodynamic study in Man with normal bladder and urethrawith normal bladder and urethra


Videourodynamic study in Man Videourodynamic study in Man with low detrusor contractilitywith low detrusor contractility


Videourodynamic study in Man Videourodynamic study in Man with Poor relaxation of sphincterwith Poor relaxation of sphincter


Subjective improvement rate in Subjective improvement rate in patients after prostatectomypatients after prostatectomy

HPOBHPOB LPOBLPOB LPNOBLPNOBQmaxQmax

<10<10

QmaxQmax

10-1510-15

QmaxQmax

>15>15TotalTotal

Irritative symptomsIrritative symptoms

goodgood 2323 22 11 1010 99 77 26(52%)26(52%)

fairfair 1010 77 44 1212 77 22 21(42%)21(42%)

Got worseGot worse -- -- 33 11 11 11 3(2%)3(2%)

Obstructive symptomsObstructive symptoms

good good 2828 55 22 2121 1212 22 35(70%)35(70%)

fairfair 55 33 55 22 44 77 13(26%)13(26%)

Got worseGot worse -- 11 11 -- 11 11 2(4%)2(4%)

Subjective resultsSubjective results

SuccessfulSuccessful 3131 22 11 1818 1414 22 34(68%)34(68%)

UnchangedUnchanged 22 66 22 44 11 55 10(20%)10(20%)

FailedFailed -- 11 55 11 22 33 6(12%)6(12%)


Improvement in Qmax after ProstImprovement in Qmax after Prostatectomyatectomy


Causes of 185 Men with LUTS Causes of 185 Men with LUTS after prostatectomyafter prostatectomy

Normalbladder and urethra 17Normalbladder and urethra 17 Detrusor instability 18Detrusor instability 18 Low detrusor contractility 35Low detrusor contractility 35 Poor relaxation of urethral sphincter 36Poor relaxation of urethral sphincter 36 Detrusor instability and low contractility 27Detrusor instability and low contractility 27 Bladder outlet obstruction 52Bladder outlet obstruction 52


Prostate volume, Qmax, resected prostate weight Prostate volume, Qmax, resected prostate weight in patients with LUTS after prostatectomyin patients with LUTS after prostatectomy

ResectedResected

prostatic weight,gprostatic weight,g

PreoperativePreoperative

prostatic vol, mlprostatic vol, mlPreoperativPreoperativQQmaxmax, ml/s, ml/s

Normal tracing(n=17)Normal tracing(n=17) 12.3 ± 7.412.3 ± 7.4 22.5 ± 14.222.5 ± 14.2 11.0 ± 5.211.0 ± 5.2

DI (n=18)DI (n=18) 14.3 ± 15.414.3 ± 15.4 26.5 ± 21.726.5 ± 21.7 10.9 ± 4.010.9 ± 4.0

LC (n=35)LC (n=35) 8.9 ± 8.78.9 ± 8.7 17.6 ± 13.817.6 ± 13.8 9.6 ± 4.59.6 ± 4.5

PRS (n=35)PRS (n=35) 9.2 ± 5.29.2 ± 5.2 17.6 ± 8.817.6 ± 8.8 8.4 ± 4.68.4 ± 4.6

DHIC (n=27)DHIC (n=27) 10.3 ± 7.110.3 ± 7.1 19.9 ±10.319.9 ±10.3 10.5 ± 4.510.5 ± 4.5

BOO (n=52)BOO (n=52) 14.4 ± 12.614.4 ± 12.6 25.6 ± 18.725.6 ± 18.7 9.7 ± 4.59.7 ± 4.5

Statistics (ANOVA)Statistics (ANOVA) P=0.131P=0.131 P=0.140P=0.140 P=0.559P=0.559


Urodynamic parameters in BPHUrodynamic parameters in BPH

AgeAge NN FSFFSF CapacityCapacity PvesPves VoidedVoided QmaxQmax CQmaxCQmax MUCPMUCP PPAPPA

≦≦4545 99 77.5±24.977.5±24.9 238.4±87.4238.4±87.4106.2±31.106.2±31.

33173.6±73.2173.6±73.2 12.5±3.612.5±3.6 0.99±0.250.99±0.25 86.7±12.586.7±12.5 87.5±087.5±0

46-5546-55 3030 95.8±28.495.8±28.4 263.3±98.5263.3±98.5 84.5±36.384.5±36.3 240.7±123.6240.7±123.6 10.8±3.910.8±3.9 0.74±0.240.74±0.24 82.5±21.682.5±21.6 111.4±32111.4±32

56-6556-65 156156116.2±49.116.2±49.

88263.4±103.1263.4±103.1 92.0±38.492.0±38.4 215.9±113.4215.9±113.4 10.2±3.310.2±3.3 0.74±0.230.74±0.23 90.0±35.190.0±35.1

107.8±90.107.8±90.11

66-7566-75 159159129.7±74.129.7±74.

44256.6±116.8256.6±116.8 85.9±35.985.9±35.9 186.7±103.2186.7±103.2 9.9±5.99.9±5.9 0.78±0.530.78±0.53 99.4±46.299.4±46.2

137.9±84.137.9±84.55

≧≧7676 6464128.9±81.128.9±81.

11214.9±115.5214.9±115.5 90.7±44.490.7±44.4 166.4±76.6166.4±76.6 9.3±4.19.3±4.1 0.74±0.280.74±0.28 96.7±45.396.7±45.3

126.±112.126.±112.33

AllAll 418418124.2±70.124.2±70.

88244±114.3244±114.3 89±39.689±39.6 198.1±109.9198.1±109.9 10.1±4.610.1±4.6 0.76±0.380.76±0.38 94.8 ±41.894.8 ±41.8

125.1±91.125.1±91.44


Relationship of Qmax and Age in Relationship of Qmax and Age in BPH patientsBPH patients


Clinical Prostate Score in BPHClinical Prostate Score in BPHClinical prostate scoring system for patients with lower urinary tract symptomsClinical prostate scoring system for patients with lower urinary tract symptoms

Uroflowmentry (ml/s)Uroflowmentry (ml/s) Residual urine (mL)Residual urine (mL)

Qmax 15≧Qmax 15≧ -1-1 < 100< 100 00

10 Qmax <1510 Qmax <15 00 ≧ ≧ 100100 22

Qmax 10≦Qmax 10≦ 11 Voided volume (mL)Voided volume (mL)

Flow patternFlow pattern ≧ ≧ 250250 00

Normal Normal -1-1 < 250< 250 11

Compressive obstructiveCompressive obstructive 11 TZITZI

Comstrictive obstructiveComstrictive obstructive 22 ≦ ≦ 0.30.3 -1-1

IntermittentIntermittent 22 > 0.3 but < 0.5 > 0.3 but < 0.5 11

TPV (mL)TPV (mL) ≧ ≧ 0.50.5 22

≦ ≦ 2020 00 Median lobe enlargementMedian lobe enlargement

> 20 but <40 > 20 but <40 11 PresencePresence 22

≧ ≧ 4040 22 AbsenceAbsence 00


Calculation of Clinical Prostate Calculation of Clinical Prostate Score for Diagnosis of BPOScore for Diagnosis of BPO

Prostate score = Qmax + TPV + voided volume + residual urineProstate score = Qmax + TPV + voided volume + residual urine

Score 3: sensitivity = 90.7%, specificity = 33%≧Score 3: sensitivity = 90.7%, specificity = 33%≧ Prostate score = Qmax + flow pattern + voided volume + residual urinProstate score = Qmax + flow pattern + voided volume + residual urin

e + TPV + TZI + prostatic configuratione + TPV + TZI + prostatic configuration

Score 3: sensitivity of BPO = ≧Score 3: sensitivity of BPO = ≧ 87.2%87.2%, specificity = , specificity = 60.8%60.8%


Score 5: sensitivity of BPO = ≧Score 5: sensitivity of BPO = ≧ 97.6%97.6%, specificity = , specificity = 38.2%38.2% Sensitivity and specificity of BPO diagnosis in patients with at least 1 Sensitivity and specificity of BPO diagnosis in patients with at least 1

favorable predictive factor (n = 148)favorable predictive factor (n = 148)

Score 3: sensitivity of BPO = ≧Score 3: sensitivity of BPO = ≧ 91.6%91.6%, specificity = , specificity = 87.27%87.27% Exclusion of patients with at least 1 favorable predictive factor (n=17Exclusion of patients with at least 1 favorable predictive factor (n=17

6)6)



Prostatic Transition Zone IndexProstatic Transition Zone Index


A-G Number in Diagnosis of BPOA-G Number in Diagnosis of BPO


Treatment of BPHTreatment of BPH

Treating an enlarged prostate ?Treating an enlarged prostate ? Treating lower urinary tract symptoms?Treating lower urinary tract symptoms? Treating bladder outlet obstruction?Treating bladder outlet obstruction? Can LUTS disappear after treatment?Can LUTS disappear after treatment? Can BOO be relieved after treatment?Can BOO be relieved after treatment? Any complication may occur?Any complication may occur? Is the treatment cost- effective ?Is the treatment cost- effective ?


Therapeutic modalities for LUTS Therapeutic modalities for LUTS ascribed to the prostateascribed to the prostate

Watchful waitingWatchful waiting and fluid restriction, natur and fluid restriction, natural history of BPO may wax and wanal history of BPO may wax and wan

Medical treatmentMedical treatment to reduce prostate size or to reduce prostate size or decrease intraprostatic resistancedecrease intraprostatic resistance

Surgical treatmentSurgical treatment to remove prostatic obstr to remove prostatic obstruction or reduce urethral resistanceuction or reduce urethral resistance

Minimally invasive therapiesMinimally invasive therapies


Surgical Treatment for BPHSurgical Treatment for BPH

Suprapubic & retropubic prostatectomySuprapubic & retropubic prostatectomy Transurethral prostatectomy (TUR-Prostate)Transurethral prostatectomy (TUR-Prostate) Laser interstitial prostatectomyLaser interstitial prostatectomy Transurethral incision of prostateTransurethral incision of prostate Intraprostatic stentIntraprostatic stent Balloon dilatation of prostatic urethraBalloon dilatation of prostatic urethra Prostatic hyperthermiaProstatic hyperthermia


Prostate Resectoscope and TURPProstate Resectoscope and TURP


Complications of TUR-ProstateComplications of TUR-Prostate

Peri-operative bleedingPeri-operative bleeding Urinary tract infection and urosepsisUrinary tract infection and urosepsis Electrolyte imbalance, hemolysis, acute tubular Electrolyte imbalance, hemolysis, acute tubular

necrosisnecrosis Acute pulmonary edemaAcute pulmonary edema Bladder neck or urethral contractureBladder neck or urethral contracture Retrograde ejaculation and erectile dysfunctionRetrograde ejaculation and erectile dysfunction Urge or stress urinary incontinenceUrge or stress urinary incontinence


Minimally invasive procedureMinimally invasive procedure

Transurethral vaporization- resection of prostate Transurethral vaporization- resection of prostate (TUVRP)(TUVRP)

Ho-YAG laser coagulation of prostateHo-YAG laser coagulation of prostate Visual laser ablation of prostate (VLAP)Visual laser ablation of prostate (VLAP) Transurethral needle ablation (TUNA)Transurethral needle ablation (TUNA) High intensity focused ultrasound (HIFU)High intensity focused ultrasound (HIFU) Microwave hyperthermia Microwave hyperthermia Minimally invasive = minimally effective?Minimally invasive = minimally effective? A higher re-treatment rate than TURP although A higher re-treatment rate than TURP although

less complication occursless complication occurs


Intra-Prostatic StentIntra-Prostatic Stent


Interstitial Laser Coagulation Interstitial Laser Coagulation


Hyperthermia of BPHHyperthermia of BPH


Transurethral Dilatation of Transurethral Dilatation of ProstateProstate


Medical Therapy for BPHMedical Therapy for BPH

Prostatic smooth muscle tension was mediateProstatic smooth muscle tension was mediated by alpha 1-adrenoreceptorsd by alpha 1-adrenoreceptors

Smooth muscle contractions contribute 40% oSmooth muscle contractions contribute 40% of outflow obstructionf outflow obstruction

Alpha 1- blockers can rapidly improve Qmax Alpha 1- blockers can rapidly improve Qmax and relieve LUTSand relieve LUTS

Phenoxybenzamine, terazosin, doxazosin havPhenoxybenzamine, terazosin, doxazosin have side effect of dizziness and hypotensione side effect of dizziness and hypotension


Prostatic specific Prostatic specific alpha- adrenoreceptoralpha- adrenoreceptor

Alpha 1A- AR subtype comprises 70% of alAlpha 1A- AR subtype comprises 70% of all alpha-1 receptorsl alpha-1 receptors

Alpha 1A-AR agonist – tamslosin has 13 x Alpha 1A-AR agonist – tamslosin has 13 x more affinity to prostatic smooth muscle thamore affinity to prostatic smooth muscle than urethral muscle , 10 x than vascular smootn urethral muscle , 10 x than vascular smooth muscleh muscle

Side effects are still reportedSide effects are still reported Long-acting (once daily) dose Long-acting (once daily) dose


Hormone based medical therapyHormone based medical therapy

5-alpha-reductase catalyzes conversion of te5-alpha-reductase catalyzes conversion of testosterone to dihydrotestosteronestosterone to dihydrotestosterone

Inhibition of 5-alpha-reductase can arrest prInhibition of 5-alpha-reductase can arrest prostatic growth and relieve obstructionostatic growth and relieve obstruction

Finasteride can improve symptom score,QmFinasteride can improve symptom score,Qmax, QOL scoreax, QOL score

Effective especially in prostatic weight of >Effective especially in prostatic weight of >40 gm and effective in prostatic hematuria40 gm and effective in prostatic hematuria


Combination therapy with alpha-Combination therapy with alpha-blocker and finasterideblocker and finasteride

Terazosin is effective therapy, finasteride wTerazosin is effective therapy, finasteride was not, combination was no more effective tas not, combination was no more effective than terazosin alone han terazosin alone (Lepor, N Engl J Med 1996; 335: 533)(Lepor, N Engl J Med 1996; 335: 533)

Combined dibenyline and finasteride has an Combined dibenyline and finasteride has an additive effect than dibenyline or finasteride additive effect than dibenyline or finasteride alone in improvement of Qmax and prostatialone in improvement of Qmax and prostatic sizec size


Consideration in treating BPHConsideration in treating BPH

Patients are old in symptomatic BPHPatients are old in symptomatic BPH Too early surgery may lead to undesired seqToo early surgery may lead to undesired seq

ualae such as erectile dysfunctionualae such as erectile dysfunction Too late surgery cannot reverse detrusor ovToo late surgery cannot reverse detrusor ov

eractivity and leads to urge incontinenceeractivity and leads to urge incontinence Etiology of LUTS (DI? DHIC? BOO?) shouEtiology of LUTS (DI? DHIC? BOO?) shou

ld be clarified to prevent unsuccessful surgild be clarified to prevent unsuccessful surgical resultscal results


Therapeutic guideline for BPOTherapeutic guideline for BPO

Calculation of clinical prostatic score and QCalculation of clinical prostatic score and QOL index, medical treatment for BPOOL index, medical treatment for BPO

Monitoring Qmax, residual urine volume, aMonitoring Qmax, residual urine volume, and prostate volume during treatmentnd prostate volume during treatment

If obstructive or irritative symptom exacerbIf obstructive or irritative symptom exacerbate, detailed pressure flow study to confirm ate, detailed pressure flow study to confirm the BOO diagnosisthe BOO diagnosis

Surgery for patients with poor QOL indexSurgery for patients with poor QOL index

Documents

排尿障礙治療中心 版權所有 Benign Prostatic Hyperplasia Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有 Benign Prostatic Hyperplasia Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital