3. Introduction
DEFINITION:
Benign prostatic hypertrophy also called BPH is a
condition in men in which the prostate gland is
enlarged and not cancerous.
Also called as benign prostatic hyperplasia.
4. Anatomy of prostate
The prostate: is a gland that forms part of
the male reproductive system.
It is a conduit between the bladder and
the urethra.
It is composed of several zones.
Peripheral, central, anterior fibromuscular
stroma, and transition zones.
BPH originates in the transition zone,
which surrounds the urethra.
5. Function of Prostate
The main function of the prostate gland is to secrete
an alkaline fluid that comprises 70% of the seminal
volume.
The secretions produce:
Lubrication and nutrition for the sperm.
Liquefaction of the seminal fluid.
Neutralize the acidic environment.
6. What is BPH ?
It is an enlarged prostate
gland.
The prostate gland surrounds
the urethra. As the prostate
gets bigger, it may squeeze or
partly block the urethra,
which causes problems with
urinating.
Benign prostatic hyperplasia
(BPH) is a common condition
which increases with age.
7. The narrowing of the urethra and urinary retention;
the inability to empty the bladder completely cause
many of the problems associated with benign prostatic
hyperplasia.
A combination of increased adrenergic tone in the
prostatic stroma and bladder neck as well as the
anatomical effects of an enlarging prostate lead to
lower urinary tract symptoms (LUTSs) and bladder
outflow obstruction (BOO).
8. Epidemiology
Benign prostatic hyperplasia (BPH) is the most common
in men and is responsible for urinary symptoms in the
majority of males over the age of 50 years.
Autopsy studies have revealed the histological presence of
BPH in 50% of males aged 51–60 years, increasing to
90% in those over 85.
By the age of 80 years, virtually all men exhibit one or
more of the symptoms associated with BPH.
9. Risk Factors
Aging: Prostate gland enlargement rarely causes signs and symptoms
in men younger than age 40. About one-third of men experience
moderate to severe symptoms by age 60, and about half do so by age
80.
Family history: Having a blood relative, such as a father or brother,
with prostate problems means the person likely to have problems.
Ethnic background: Prostate enlargement is less common in Asian
men than in white and black men. Black men might experience
symptoms at a younger age than white men.
Diabetes: Studies show that diabetes might increase the risk of BPH.
Lifestyle: Obesity increases the risk of BPH, while exercise can
lower risk.
10. Signs and Symptoms
The symptoms of BPH may involve
problems emptying the bladder or problems
with bladder storage, they include:
Urinary frequency
Urinary urgency
Incomplete bladder emptying
Nocturia
Decreased force of stream
Difficulty initiating the urinary stream;
interrupted, weak stream
Dribbling - The loss of small amounts of
urine due to a poor urinary stream
13. Diagnosis
1. Digital rectal examination (DRE):
The doctor inserts a finger into the
rectum and feels the part of the prostate
next to the rectum. This gives idea
about size and condition of gland.
2. Prostate specific antigen (PSA)
blood test: A protein produced by
prostate cell is frequently present at
elevated level in the blood of men and
thus diagnosed. Normal range is 1.4
ng/ml or less.
14. 3. Cystoscopy:
In this examination doctor inserts a small tube through the opening of
urethra in the penis. This procedure is done after a solution numbs inside
of the penis, so all sensation is lost. The tube is called cystoscope
containing a lens and light system that helps the doctor to see inside. It
allows to determine size of the gland and identify the location of
obstruction.
4. Urine Flow Study:
Doctor asks to urinate in special device to measure how quickly the urine
is flowing. A reduced flow often suggests BPH. Uroflowmetry, which
measures how rapidly the bladder releases urine.
16. Non Pharmacological Treatment
Lifestyle changes: To control BPH lifestyle plays an
important role.
Its important to bring lifestyle changes as follows:
Exercises to strengthen pelvic floor muscles
Lower the amount of fluids taken, especially before
going out or going to bed
Less caffeine and alcohol uptake.
18. Medicines
For mild to moderate BPH, doctor might suggest
medicine. Some medications work by relaxing the
muscles in prostate and bladder. Others help shrink
prostate. For some men, it takes a mix of medicines to
get the best results.
The suggested drugs are:
α1-adrenoceptor-blocking agents
5α-reductase inhibitors
Combination therapy
19. α1-ADRENOCEPTOR BLOCKERS
Drugs: Terazosin, Doxazosin, Tamsulosin, Alfuzosin, & Silodosin
Mechanism of action:
Works by relaxing muscles in your bladder and prostate, which
makes it easier to urinate.
By inhibiting these receptors, muscle tone along these tissues will
be reduced, allowing for easier passage of urine and reduction of
symptoms.
Adverse effects:
Dizziness, Tiredness, Ejaculatory problems, Nasal congestion,
Orthostatic hypotension
20. TAMSULOSIN
TAMSULOSIN (FLOMAX®)
Preparations: 0.4mg Cap.
Dosing: The dose may be
increased after 2-4 weeks if the
response is not adequate.
S/E: (anemia, nausea &
vomiting, weakness, headache ).
21. 5-α REDUCTASE INHIBITORS
Drugs: Finasteride & Dutasteride
Mechanism of Action:
They inhibit the enzyme 5-α reductase, which is responsible for
converting testosterone to the more active dihydrotestosterone
(DHT).
DHT is an androgen that stimulates prostate growth. By reducing
it, the prostate shrinks and urine flow improves.
Adverse effects:
Sexual side effects (decreased libido, gynecomastia).
23. Combination therapy:
Taking an alpha blocker and a 5-alpha
reductase inhibitor at the same time if
either medication alone isn't effective.
Example : Finasteride and doxazosin
24. Surgeries
1. Transurethral Needle Ablation of the Prostate:
The TUNA system delivers low level frequency energy
through twin needles to burn away a well defined region of
prostate. Shield protects the urethra from heat damage. It
improves the urine flow.
Adverse effects:
UTI, hematuria.
25. 2. Transurethral microwave therapy:
FDA approved a device that uses microwaves to heat and
destroy extra prostate tissue. The device sends computer
based microwaves through a catheter to heat extra portions
of the prostate to 45ºC for 60 mins. A cooling system
protects urinary system.
Thermaspec system
TUNA TUMT
Radiofrequency Microwave
Faster Slower
For 60g size prostate For 30-100g size
60% reduction in symptom 40-70% reduction
26. 3. Open prostatectomy:
Open prostatectomy involves the surgical removal of an
enlarged prostate.
Typically, an incision is made through the lower abdomen
although sometimes the incision is between the rectum
and the base of the penis.
28. Recent advances in laser treatment
for BPH
The treatment of BPH using lasers has been shown to lead to
significant improvements in symptoms and to have excellent
therapeutic effects.
Currently, 3 kinds of lasers are used: potassium-titanyl -
phosphate, holmium, and thulium lasers.
The most common surgical procedures are holmium laser
enucleation of the prostate (HoLEP). HoLEP is an effective
surgical procedure for large prostates.
29. Case study
A 55 year old man presents for routine physical checkup. His
BP is 161/98 mmHg. His only complain is that he has difficulty
in urinating and he recently begun experiencing nocturia and
urgency. Digital exam reveals enlargement of prostate. Which
following agent would be most likely to treat man’s urinary
tract symptoms as well as his HT?
a. Terazosin
b. Finasteride
c. Labetalol
d. Hydralazine
30. References:
1. Roger Walker, Clinical pharmacy and Therapeutics,
published by Churchill Livingstone Elsevier, fifth edition,
2012, pg. no 753.
2.Joseph T. Dipiro, Pharmacotherapy principles and practice
by The McGraw-Hill Companies, Inc. page no.791
3. International Journal of Impotence Research, by CG
Roehrborn, Department of Urology, UT Southwestern
Medical Center, Dallas, TX, USA.
4. Laura J. Martin, WebMD Medical Reference Reviewed,
MD.
