BENIGN BENIGN PROSTATIC PROSTATIC

HYPERPLASIAHYPERPLASIADR .MOHAMMAD H DR .MOHAMMAD H

DUMIRIEHDUMIRIEH

2014

DEFINTION DEFINTION Hyperplasia of stroma and epithelium in periurthral Hyperplasia of stroma and epithelium in periurthral

area of prostate (transition zone)area of prostate (transition zone)

Tone of prostatic smooth muscle plays role in addition Tone of prostatic smooth muscle plays role in addition to hyperplasiato hyperplasia

ETIOLOGY ETIOLOGY Etiology unknownEtiology unknown

Androgen dihydrotestosterone(DHT)required Androgen dihydrotestosterone(DHT)required (converted from testosteron by 5-alpha (converted from testosteron by 5-alpha reductase)reductase)

Possiple role of impaired apoptosis, estrogen. Possiple role of impaired apoptosis, estrogen. other growth factorsother growth factors

EpidemiologyEpidemiology Age related,extremly common(50% of 50 year olds,80% of Age related,extremly common(50% of 50 year olds,80% of

80 year olds)80 year olds)

25 % of men will require treatment25 % of men will require treatment

Clinical FeatureClinical Feature Reslut from outlet obstruction and Reslut from outlet obstruction and

compensatory changes in detrusor compensatory changes in detrusor functionfunction

Voiding symptoms:Voiding symptoms:

..hesitancy,straining,weak/interrupted hesitancy,straining,weak/interrupted stream,incomplete bladder emptyingstream,incomplete bladder emptying

..decreased flow rates may be seen on decreased flow rates may be seen on uroflowmetry.uroflowmetry.

.due to out flow obstruction and/or impaired .due to out flow obstruction and/or impaired detrusor contractility.detrusor contractility.

Clinical FeatureClinical Feature

storage symptoms:storage symptoms:

..urgency,frequency,nocturia,urgency urgency,frequency,nocturia,urgency incontinenceincontinence

..thought to be due to detrusor overactivity thought to be due to detrusor overactivity and decreased compiliance.and decreased compiliance.

Prostate is smooth ,rubbery and Prostate is smooth ,rubbery and symmeetrically enlarged on DREsymmeetrically enlarged on DRE

Complication:Complication:

- Retention- Retention

- Overflow incontinence- Overflow incontinence

- Hydronephrosis and renal compromise- Hydronephrosis and renal compromise

OVERFLOWOVERFLOW

Complication:Complication:

- infection- infection

- gross hematuria- gross hematuria

- bladder stones- bladder stones

AUA prostate symptom AUA prostate symptom scorescore

funwisefunwise

ffrequencyrequency uurgencyrgency nnocturiaocturia WWeak streameak stream iintermittency ntermittency sstrainingtraining EEmptying,incomplete feeling mptying,incomplete feeling

funwisefunwise

Each symptom graded out of 5Each symptom graded out of 5

0-7 mildy symptomatic0-7 mildy symptomatic

8-19-moderately symptomatic8-19-moderately symptomatic

20-35 severely symptomatic20-35 severely symptomatic

NoteNote: dysuria not included in score : dysuria not included in score but is commonly associated with but is commonly associated with BPHBPH

Prostate size does not correlate well Prostate size does not correlate well with symptoms in BPHwith symptoms in BPH

APPROXIMATE PROSTATE SIZEAPPROXIMATE PROSTATE SIZE

20cc20cc-chestnut-chestnut

25cc25cc –plum –plum

50cc50cc-lemon-lemon

75cc75cc-orange-orange

100cc100cc-grapefruit-grapefruit

investigationinvestigation historyhistory Assess LUTS and effect on quality of Assess LUTS and effect on quality of

life ,may include self –administrede life ,may include self –administrede questionnires (AUA symptom and impact questionnires (AUA symptom and impact score)score)

Physical exam:DREPhysical exam:DRE Urinalysis to exclude UTIUrinalysis to exclude UTI Creatinine to assess renal function +-renal Creatinine to assess renal function +-renal

ultra sound to assess for hydronephrosis.ultra sound to assess for hydronephrosis. PSA to rule out malignancy (if life PSA to rule out malignancy (if life

expectancy more than 10 y)expectancy more than 10 y)

investigationinvestigation Uroflowmetry (optional)Uroflowmetry (optional)

Bladder ultra sound post voiding urine(optional)Bladder ultra sound post voiding urine(optional)

Cystoscopy prior to potential surgical management.Cystoscopy prior to potential surgical management.

Biopsy if suspicious for malignancyBiopsy if suspicious for malignancy

TREATMENTTREATMENT

Conservative for those with mild Conservative for those with mild symptom:symptom:

.watchful waiting-50% of patients .watchful waiting-50% of patients improve spontaneously.improve spontaneously.

.includes lifestyle changes(e.g evening .includes lifestyle changes(e.g evening fluid restriction,planned voiding) fluid restriction,planned voiding)

Medical treatment:Medical treatment:

.a-adrenergic antagonist-reduce stromal .a-adrenergic antagonist-reduce stromal smooth muscle tonesmooth muscle tone

.5-a reductase inhibitor _block conversion of .5-a reductase inhibitor _block conversion of testosteron to DHT;acts on the epithelial testosteron to DHT;acts on the epithelial component of prostate –reduces prostate component of prostate –reduces prostate size[e.g.finastride(proscar),dustride(avodasize[e.g.finastride(proscar),dustride(avodart)]rt)]

Transurethral resection of Transurethral resection of prostate(TURP)prostate(TURP)

ObjectiveObjective

To partially resect the periurethral To partially resect the periurethral area of prostate (transition zone)to area of prostate (transition zone)to decrease symptoms of urinary tract decrease symptoms of urinary tract obstruction.obstruction.

IndicationsIndications Obstructive uropathy (large bladder Obstructive uropathy (large bladder

diverticula ,renal insufficiency)diverticula ,renal insufficiency) Refractory urinary retention Refractory urinary retention Recurrent utisRecurrent utis Recurrent gross hematuria Recurrent gross hematuria Bladder stoneBladder stone Failure of medical therapyFailure of medical therapy

complicationcomplication Acute:Acute:

*intra or extraperitoneal rupture of bladder*intra or extraperitoneal rupture of bladder

*rectal perforation*rectal perforation

*incontinence*incontinence

*hemorrhage*hemorrhage

*epididymitis*epididymitis

*sepsis*sepsis

*trance urethral resection *trance urethral resection syndrome(post –TURP)syndrome(post –TURP)

.caused by absorption of large volume .caused by absorption of large volume of hypotonic irrigation solution of hypotonic irrigation solution used ,usually through perforated used ,usually through perforated venous sinusoid,leading to venous sinusoid,leading to hypervolemic hyponatremic hypervolemic hyponatremic state.state.

..characterized by: characterized by: dilutional hyponatremia dilutional hyponatremia ,confusion,nausea,vomiting,hypertension,,confusion,nausea,vomiting,hypertension,visual distrubance,pulmonary visual distrubance,pulmonary edema,bradycardia.edema,bradycardia.

..treattreat with diuresis and (if with diuresis and (if severe)hypertonic saline administrationsevere)hypertonic saline administration

complicationcomplication chronic:chronic:

*retrograde ejaculation(>75%)*retrograde ejaculation(>75%)

*erectile dysfunction(5-10% risk increase with *erectile dysfunction(5-10% risk increase with increasing use of cautery)increasing use of cautery)

*incontinence(<1%)*incontinence(<1%)

*urethral stricture*urethral stricture

*bladder neck contracture.*bladder neck contracture.

Open prostatectomy:Open prostatectomy:.for large prostates or assochiated .for large prostates or assochiated

problems(e.g.bladder stones)problems(e.g.bladder stones).suprapubic (transvesically to deal .suprapubic (transvesically to deal

with bladder pathology)with bladder pathology).retropubic(through the prostatic .retropubic(through the prostatic

capsule)capsule)

Absolute indication for Absolute indication for surgerysurgery

Refractory urinary retention Refractory urinary retention Recurrent utisRecurrent utis Recurrent hematuria refractory to Recurrent hematuria refractory to

medical treatmentmedical treatment Renal insufficiency (rule out other causes)Renal insufficiency (rule out other causes) Bladder stonesBladder stones

Simple Simple prostatectomyprostatectomy

ALMOUSATE ALMOUSATE HOSPITALHOSPITAL

Minimally invasive therapyMinimally invasive therapy

.prostatic stent, microwave therapy , .prostatic stent, microwave therapy , laser ablation, water –induced laser ablation, water –induced thermotherapy, cryotherapy, high thermotherapy, cryotherapy, high intensity focoused ultra sound intensity focoused ultra sound (HIFU), transurethral needle (HIFU), transurethral needle ablation (TUNA).ablation (TUNA).

Stent within Stent within prostateprostate

The passage The passage way is wide and way is wide and the lumen of the lumen of bladder clearly bladder clearly seenseen

Prostate specific Prostate specific Antigen(PSA)Antigen(PSA)

PSAPSA Enzyme produced by epithelial cells of Enzyme produced by epithelial cells of

prostate gland to liquify the ejaculateprostate gland to liquify the ejaculate

Leaks into circulation and is present < Leaks into circulation and is present < 4ng/ml4ng/ml

Measuerd total serum PSA is a combination Measuerd total serum PSA is a combination of free(unbound)PSA (15%)and complexed of free(unbound)PSA (15%)and complexed PSA(85%)PSA(85%)

Screening Prostate Screening Prostate cancer : PSA and DREcancer : PSA and DRE

PSA may be elevated in prostate PSA may be elevated in prostate cancer and many other condition; cancer and many other condition; not specific to cancer not specific to cancer

Population –based ,routine screening Population –based ,routine screening not recommendednot recommended

Must discuss risk factors,test Must discuss risk factors,test characteristic , risk of over-detection characteristic , risk of over-detection and over treatment,treatment and and over treatment,treatment and active surveillanceactive surveillance

Well –informed patients can elect to Well –informed patients can elect to undergo PSA and DREundergo PSA and DRE

The decision to proceed to prostate The decision to proceed to prostate biopsy should be based primarily on biopsy should be based primarily on PSA and DRE results,but should take PSA and DRE results,but should take into account multiple factors into account multiple factors (free and (free and total PSA,patient age,PSA velocity,PSA total PSA,patient age,PSA velocity,PSA density,family history,ethnicity,prior density,family history,ethnicity,prior biopsy history and comorbidities)biopsy history and comorbidities)

AGE RANGE SERUM PSA (mg/L) 40-49 <2.5

50-59 <3.5

60-69 <4.5

70-79 <6.5

PSA is specific to the PROSTATE, but PSA is specific to the PROSTATE, but not to prostate cancer.not to prostate cancer.

In PSA testing , think “free and easy” : In PSA testing , think “free and easy” : increased free/total ratio suggests increased free/total ratio suggests benign cause of high PSAbenign cause of high PSA

Causes of Increased PSACauses of Increased PSA BPH,prostatitis,prosatic ischemia BPH,prostatitis,prosatic ischemia

/infarction/infarction Acute urinary retention, prostate Acute urinary retention, prostate

biobsy/surgery/ messagebiobsy/surgery/ message Urethral catheteraization,TRUS Urethral catheteraization,TRUS Ejaculation ,acute renal failureEjaculation ,acute renal failure Coronary bypass graft.Coronary bypass graft. Radiation therapyRadiation therapy

**free-to –total PSA ratio:free-to –total PSA ratio: Complexed PSA increases in Complexed PSA increases in

prostate cancer,decreasing the prostate cancer,decreasing the percentage of the free fractionpercentage of the free fraction

<10% free PSA suggestive of <10% free PSA suggestive of cancer ,>20% free suggest benign cancer ,>20% free suggest benign cause cause

**PSA velocityPSA velocity:: Change of >0.75ng/ml/year Change of >0.75ng/ml/year

associated with increased risk of associated with increased risk of cancer cancer

**PSA densityPSA density:: PSA divided by prostate volume of as PSA divided by prostate volume of as

found on TRUSfound on TRUS >0.15 ng/ml/ associated with >0.15 ng/ml/ associated with

increased risk of cancerincreased risk of cancer

Other Uses for PSAOther Uses for PSA*Therapeutic decision making*Therapeutic decision making: patients : patients

with serum PSA level<10.0 are most with serum PSA level<10.0 are most likely to respond to local therapylikely to respond to local therapy

*Work –up *Work –up : bone scans are generally : bone scans are generally not necessary in patients with newly not necessary in patients with newly diagnosed prostate cancer who have diagnosed prostate cancer who have a PSA <20 ng/ml unless the history a PSA <20 ng/ml unless the history or clinical examination suggests bony or clinical examination suggests bony involvementinvolvement

Other Uses for PSAOther Uses for PSA*Disease monitoring*Disease monitoring:: serum PSA should fall to low level serum PSA should fall to low level

following radiation following radiation therapy,cryotherapy and should not therapy,cryotherapy and should not rise on successive occasions. PSA rise on successive occasions. PSA should remain undetectable after should remain undetectable after radical prostatectomyradical prostatectomy

Other Uses for PSAOther Uses for PSA*Outcome prediction: *Outcome prediction: in patients with metastatic disease in patients with metastatic disease

receiving androgen suppresion receiving androgen suppresion therapy ,failur to achieve a PSA therapy ,failur to achieve a PSA of<4.0 ng /ml seven months after of<4.0 ng /ml seven months after initiation of therapy is associated initiation of therapy is associated with a very poor prognosis(median with a very poor prognosis(median survival :one year) survival :one year)

NOTENOTE

there is no easy , infallible method there is no easy , infallible method of determining when biopsies may of determining when biopsies may be avoidable and when they are be avoidable and when they are necessary.Until a perfect test is necessary.Until a perfect test is developed this determination must developed this determination must be made on the basis of clinical be made on the basis of clinical judgment and experience.judgment and experience.

NOTENOTE

Normal , hyperplastic, and Normal , hyperplastic, and neoplastic epithelial cells make PSA, neoplastic epithelial cells make PSA, but the amount of PSA produced by but the amount of PSA produced by cancer cells is 10 times higher per cancer cells is 10 times higher per gram of tissue than the amount by gram of tissue than the amount by normal or hyperplastic tissue.normal or hyperplastic tissue.

NOTENOTE

Most PSA is produced in the Most PSA is produced in the hyperplastic transitional zone of hyperplastic transitional zone of prostate .A relatively small amount prostate .A relatively small amount of PSA is produced in the peripherial of PSA is produced in the peripherial zone,where 80% of prostate cancers zone,where 80% of prostate cancers orginate.cancers developing in the orginate.cancers developing in the transitional zone tend to produce transitional zone tend to produce large amount of PSA.large amount of PSA.

NOTENOTE

High-grade cancer cells tend to lose High-grade cancer cells tend to lose their ability to produce PSA. A their ability to produce PSA. A

GLEASON grade 5 prostate cancer GLEASON grade 5 prostate cancer produces less than a grade 3 cancer produces less than a grade 3 cancer does. Some patients with advanced does. Some patients with advanced

prostate cancer may have low or prostate cancer may have low or undetectable PSA level.undetectable PSA level.

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