Benign Prostatic Hyperplasia

1. Benign Prostatic Hyperplasia Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. Bladder Outlet obstruction • Bladder neck dysfunction • Prostatic enlargement • Urethral stricture • External sphincter dyssynergia • Urethral meatal stenosis • BOO is a condition of progressive degree

3. Lower urinary tract symptomsIPSS & AUA symptom score • Frequency • Urgency • Nocturia • Small caliber of urine • Dysuria • Intermittency • Residual urine sensation

4. LUTS and BOO • 1/3 of men with LUTS do not have BOO • 5% - 35% of patients with BPH & LUTS do not improve symptoms after TURP • LUTS have a poor diagnostic specificity for BOO • Prostate size and uroflowmetry have better correlation with urodynamic study than symptoms alone

5. Pathogenesis of Bladder outlet obstruction • Progressive increased urethral resistance • High voiding pressure and low flow • Bladder compensation in energy • Increased residual urine volume • Elevated intravesical pressure at end-filling • Bladder stone, diverticulum, UTI • Hydroureter, hydronephrosis, azotemia

6. Reduction in AChE-positive nerve fibers after BOO

7. Differential diagnosis of male BOO and LUTS • Benign prostatic enlargement • Bladder neck dysfunction • Spastic urethral sphincter • Poor relaxation of urethral sphincter • Urethral stricture • Low detrusor contractility • Pseudodyssynergia due to neuropathy

8. Relation of prostate and urethra

9. Benign prostatic hyperplasia • Prostatic enlargement – benign or malignant, a sign • Prostatic hyperplasia – histological term • Prostatic obstruction – a clinical diagnosis • Bladder outlet obstruction – an urodynamic term • Lower urinary tract symptoms – symptom

10. Anatomy of Prostate gland

11. Anatomy of Prostate gland

12. Prostatic glandular anatomy

13. Cystoscopic Prostatic obstruction

14. Benign Prostatic Hyperplasia • BPH requires testicular androgen during prostatic development • Basic fibroblast growth factor, epidermal growth factor, keratinocyte growth factor, transforming growth factor-beta play some part in prostate growth • Decreased endogenous apoptosis in prostate cause abnormal tissue growth in prostate

15. Histology of Benign prostatic hyperplasia

16. Clinical BPH • LUTS ( storage or empty symptoms) due to histological benign prostatic hyperplasia and urodynamical bladder outlet obstruction which has been proven by urodynamic pressure flow study as prostatic obstruction • Treatment for LUTS and restoration of normal storage and empty function by reducing prostatic enlargement either medically or surgically

17. Pathophysiology of BPH and LUTS • Nodular proliferation of prostate gland • Increased stroma to epithelial ratio to 2:1 to 5:1 in benign prosatic hyperplasia • Increased smooth muscle component • Detrusor compensatory change and bladder dysfunction, detrusor overactivity • LUTS may related to BPH or detrusor dysfunction,or combination

18. Symptom scores of BPH as treatment guideline • 1970 Boyarsky and Madsen-Iverson • 1992 AUA symptom index • International prostatic symptom score adds quality of life index • Bothersomeness and health related quality of life (HRQOL) • Symptom problem index • BPH impact index (BII)

19. Clinical evaluation of BPH • Digital rectal examination of prostate -- Prostate size, consistency, surface nodularity, tenderness • Bladder palpation – residual urine volume • Cystography, Intravenous pyelography • Transrectal sonography of prostate • Cystourethroscopy

20. Cystography of Bladder base elevation indicating BPH

21. Sonography of BPH

22. Clinical evaluation of BPH • Uroflowmetry, prstatic volume • Postvoid residual urine volume • Prostatic specific antigen (PSA) • Pressure flow study improves in diagnosis and aid in selection for specific invasive treatment • Videourodynamic study is helpful in determining complicated case

23. Uroflowmetry in BPH without or with obstruction

24. Pressure flow study in BPH with Obstruction

25. Videourodynamic study in BPH with Obstruction

26. Causes of non-obstructive Men with LUTS • Normal bladder and urethra 25 • Bladder hypersensitivity 17 • Detrusor instability 6 • Detrusor underactivity 3 • Poor relaxed urethral sphincter 61

27. Videourodynamic study in Man with normal bladder and urethra

28. Videourodynamic study in Man with low detrusor contractility

29. Videourodynamic study in Man with Poor relaxation of sphincter

30. Subjective improvement rate in patients after prostatectomy

31. Improvement in Qmax after Prostatectomy

32. Causes of 185 Men with LUTS after prostatectomy • Normalbladder and urethra 17 • Detrusor instability 18 • Low detrusor contractility 35 • Poor relaxation of urethral sphincter 36 • Detrusor instability and low contractility 27 • Bladder outlet obstruction 52

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

34. Urodynamic parameters in BPH

35. Relationship of Qmax and Age in BPH patients

36. Clinical Prostate Score in BPH

37. Calculation of Clinical Prostate Score for Diagnosis of BPO • Prostate score = Qmax + TPV + voided volume + residual urine Score ≧ 3: sensitivity = 90.7%, specificity = 33% • Prostate score = Qmax + flow pattern + voided volume + residual urine + TPV + TZI + prostatic configuration Score ≧ 3: sensitivity of BPO = 87.2%, specificity = 60.8% Score ≧ 4: sensitivity of BPO = 90.7%, specificity = 50.5% Score ≧ 5: sensitivity of BPO = 97.6%, specificity = 38.2% • Sensitivity and specificity of BPO diagnosis in patients with at least 1 favorable predictive factor (n = 148) Score ≧ 3: sensitivity of BPO = 91.6%, specificity = 87.27% • Exclusion of patients with at least 1 favorable predictive factor (n=176) Score ≧ 3: sensitivity of BPO = 68.9%, specificity = 23.0%

38. Prostatic Transition Zone Index

39. A-G Number in Diagnosis of BPO

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

41. Therapeutic modalities for LUTS ascribed to the prostate • Watchful waiting and fluid restriction, natural history of BPO may wax and wan • Medical treatment to reduce prostate size or decrease intraprostatic resistance • Surgical treatment to remove prostatic obstruction or reduce urethral resistance • Minimally invasive therapies

42. Surgical Treatment for BPH • Suprapubic & retropubic prostatectomy • Transurethral prostatectomy (TUR-Prostate) • Laser interstitial prostatectomy • Transurethral incision of prostate • Intraprostatic stent • Balloon dilatation of prostatic urethra • Prostatic hyperthermia

43. Prostate Resectoscope and TURP

44. Complications of TUR-Prostate • Peri-operative bleeding • Urinary tract infection and urosepsis • Electrolyte imbalance, hemolysis, acute tubular necrosis • Acute pulmonary edema • Bladder neck or urethral contracture • Retrograde ejaculation and erectile dysfunction • Urge or stress urinary incontinence

45. Minimally invasive procedure • Transurethral vaporization- resection of prostate (TUVRP) • Ho-YAG laser coagulation of prostate • Visual laser ablation of prostate (VLAP) • Transurethral needle ablation (TUNA) • High intensity focused ultrasound (HIFU) • Microwave hyperthermia • Minimally invasive = minimally effective? • A higher re-treatment rate than TURP although less complication occurs

46. Intra-Prostatic Stent

47. Interstitial Laser Coagulation

48. Hyperthermia of BPH

49. Transurethral Dilatation of Prostate

50. Medical Therapy for BPH • Prostatic smooth muscle tension was mediated by alpha 1-adrenoreceptors • Smooth muscle contractions contribute 40% of outflow obstruction • Alpha 1- blockers can rapidly improve Qmax and relieve LUTS • Phenoxybenzamine, terazosin, doxazosin have side effect of dizziness and hypotension