Benign Prostatic Hypertrophy is an enlargement of the prostate gland characterized by proliferation of cellular elements. It is common in aging men, affecting about 50% of men in their 50s and over 90% of men in their 80s. Symptoms include frequent and urgent urination, weak urine stream, and inability to fully empty the bladder. Treatment options include watchful waiting, medications to reduce symptoms, minimally invasive procedures, and surgery if other options provide inadequate relief or complications occur.

1. Benign Prostatic Hypertrophy
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2. prostate gland is a pyramidal shaped
fibromuscular and glandular organ which
surrounds the prostatic urethra.
develops in the 12th week of embryonic life
under androgens from the fetal testis.
contains a number of individual glands
composed of 30-50 lobules leading to 15-30
secretory ducts that open into the urethra
lateral to the colliculus seminalis.
Anatomy
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3.  from the bladder neck to the urogenital
diaphragm.measures about 3.5 X 2.5cm,
averages 20G.
The prostate is found in the male while its
homologous in the female, formerly
known as the paraurethral gland of skene
now named female prostate.
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6. • divided into zones
• Peripheral
• Transitional
• Central
• Pre prostactic tissue
• Non glandular fibro muscular portion
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7. The Central Zone
• Surrounds the ejaculatory duct.
• it is in contact with the urethra at the
upper end of the colliculus seminalis.
• resp for 25% of glandular tissue of
prostate
• site of 10% of Ca P
• ≠ bph

9.  Anterior lobe (or isthmus) roughly
corresponds to part of transitional zone
 Posterior lobe roughly corresponds to
peripheral zone
 Lateral lobes spans all zones
 Median lobe (or middle lobe) roughly
corresponds to part of central zone
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10. The prostatic capsule
These are normally two, pathologically three, in
number.
1. The true capsule
2. Fibrous Sheath – condensed extraperitoneal
fascia. Between layers 1 and 2 lies the prostatic
venous plexus.
3. the pathological capsule- occurs in BPH in
which the normal peripheral part of the gland
becomes compressed into a capsule .
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11. The prostate gland comprises secretory epithelium
which consists of
a. Epithelial
b. Basal
c. Neuroendocrine cells
d. Connective tissue
e. Smooth muscles
Only the epithelia1 cells secrete PSA and so cancer of
the neuroendocrine cells, connective tissue, smooth
muscle, transitional epithelium and
anaplastic cells can be present with a normal PSA
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12. smooth muscle is regulated by the
autonomic nervous system primarily; the
alpha-1A adrenergic receptors constitute
70%.
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13. The arterial blood supply of the prostate
gland arises from the middle rectal and
inferior vessical artery.
The venous drainage is into the prostati
plexus. The plexus also receives the dorsal
vein of the penis and drains into the internal
iliac veins. There are connections with no
valves between the prostatic plexus and
vertebral veins.
Hence retrogression to the vertebrae.
Blood supply
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14. Lymphatic drainage
The prostatic lymphatics drain into lymph
nodes lying alongside the internal iliac
vessels. They also have a connection with
the sacral spinal lymphatics.
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15. The prostatic fluid helps maintain the vitality
of the sperms, and contains calcium,
sodium, potassium, magnesium, chloride,
bicarbonate, zinc, spermine, citrate, lipid
cholesterol and 4 major proteins
◦ the prostatic specific antigen {PSA),
◦ prostatic acid phosphatase (PAP),
◦ the prostatic specific membrane antigen (PSMA)
and
◦ prostatic specific protein - 94(PSP-94).
functions
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16. Benign prostate hyperplasia is not always
progressive, patient must be thoroughly
investigated to rule out malignancy and
institute proper treatment.
Benign prostatic hyperplasia (BPH), also known as
benign prostatic hypertrophy, is an enlargement of the
prostate characterized by proliferation of the cellular
elements of the prostate.
Benign Prostatic Hypertrophy
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17.  Age
◦ below 40 years - 8 %,
◦ 57-60 years - 50% and
◦ 80 years -90%.
Prevalence of symptoms of BPH by International
prostatic Symptoms Score (IPSS) in men aged
 40 years is 14%,
 50-year olds is 25%,
 60-year olds 43% and
50% in 75-year olds.
epidemiology
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18. Aetiology
Age
 Positive familial and genetic factors
DHT
 increase in 5-alpha reductase activity
oestrogen imbalance
Increased epithelial cell hyperplasia
 decreased cell death of epithelial and stromal cells,
 increased activity of growth factors (GF) -
FGF,TGF,EGF,KGF, IGF, endoGF - epithelial mitogens
and non androgenic testicular substances
Race , enviroment.
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19. a fibromyoadenoma
the nodules first develop in the peri-urethral
transition zone (TZ) of the prostate
 All BPH nodules develop either in the TZ or in the
peri-urethral region
As the disease progresses, the capsule of the
prostate transmits the pressure of tissue
expansion to the urethra.which produces the
symptoms.
pathology
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20. Histological studies show increase in cell
numbers (Hyperplasia) but not
hypertrophy.
Gross appearance of hyperplastic tissue
may show lateral and/or middle lobe
enlargement and/or posterior
commissural hyperplasia
The hyperplastic nodules compress the
normal periphery of the gland which
forms the false capsule.
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21. initially response to obstruction straining,
intermittency, poor stream and incomplete
bladder emptying.
There is compensatory hypertrophy of dextrusor
smooth muscles due to increased detrusor
collage. Hence trabeculation with widening of
gaps between them to form saccules.
 With continued changes, the saccules develop
into diverticula.
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22. This leads to detrusor instability or decreased
compliance or neural detrusor response which
manifests clinically by the symptom complex of
frequency, urgency and nocturia.
Decreased detrusor contractility (atonic bladder)
leads to poor urine stream, intermittency,
incomplete bladder emptying or increased
residual urine, and hesitancy
Acute urinary retention may supervene.
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23. The nature of bph
 In patients observed with mild to
moderate symptoms prospectively up to 7
years, 55% became worse, 30% remained
stable and 15% improved.
Overall, there’s very slow progression in
most cases of BPH
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24. Symptoms
Initial recognition
◦ The early presentation of BPH is insidious and may not be
noticed by patient
 Irritative symptoms
◦ Frequency
◦ Urgency
◦ Nocturia
◦ Urge incontinence.
Obstructive symptoms
◦ Weak (poor) stream
◦ Feeling of incomplete bladder emptying
◦ Straining on micturition
◦ Intermittency.
Clinical features
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25. Others are:
◦ Difficulty of micturition associated with
◦ Hesitancy
◦ Prolong micturition
◦ Urinary retention: This may be acute/acute on
chronic or chronic.
◦ Haematuria- Microscopic/macroscopic
◦ Recurrent UTI such as cystitis, epididymo-orchitis,
pyelonephritis, bacteraemia, septicaemia etc
◦ Renal failure - This could be acute or chronic
associated with thirst, lethargy, headaches, uraemia
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26. General physical examination: may
demonstrate signs of chronic renal
impairment (anaemia, dehydration,
headaches, lethargy)
Abdominal examination: normal except for
retention (distended bladder).
Rectal examination: in BPH, posterior
surface is usually smooth, convex with a firm
consistency. Rectal mucosa moves freely
over it.
Neurological examination: to eliminate
neurological lesions.
examination
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27. INTERNATIONAL PROSTATE
SYMPTOM SCORE (IPSS)
This is a structured symptoms questionnaire
which was developed by the American Urological
Association and was adopted by the WHO in
1994.
It is used for assessment of obstructive and
irritative symptoms.
4 obstructive symptoms of BPH (when there is no
retention)
◦ Incomplete bladder emptying.
◦ Intermittency.
◦ Weak stream.
◦ Straining. Medrockets.com

28. Assessment Of 3 Irritative Symptom
◦ Frequency
◦ Urgency.
◦ Nocturia.
Each symptom is scored from 0-5 and the
maximum score is 35. The interpretation of IPSS
score values are
◦ Mild O-8.
◦ Moderate 9-19.
◦ Severe 20-35.
The Quality of Life due to BPH Urinary Symptoms
is scored from 0-6
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29. SCORING
0 – not at all in the past one month
1 – less than once in the past one month
2 – less than half the time in the past one
month
3 – about half the time in the past one month
4 – more than half of the time in the past one
month
5 – almost always in the past one month
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30. Differential Diagnosis Of
Symptoms
 Causes Of Irritative Symptoms
 UTI
 Bladder Stones
 Interstitial Cystitis
 Cancer of the Bladder
 Cancer of the Prostate
 Chronic Cystitis
 Bilharziasis
 Neurological Disorders
 CVA
 Brain Tumour
 Internal Hydrocephalus
 Parkinsonism
 Multiple Sclerosis
 Syringomyelia
 DM
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31. 2. Obstructive Symptoms
◦ Urethral stricture.
◦ Carcinoma of prostate.
◦ Bladder cancer.
◦ Bladder calculi.
◦ Phimosis
◦ paraphimosis
◦ Neurogenic bladder.
Others are :
◦ ageing, psychiatric disorders such as depression,
diuretics, chronic renal failure, polydipsia and
excessive consumption of beverages such as tea and
coffee.
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32.  diverticulitis
 infection
 calculi- mostly struvite due to urease producing
orgs (proteus, pseudomonas, pyocyanea,
klebsiella) also Ca Oxalate calculi
 hematurai
 chronic retention
 post obstructive diuresis
 post obstructive hemorrhage
 recurrent infection
Renal failure
Complications of bph
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33. INVESTIGATIONS
1. Urinalysis: check for blood, glucose, protein.
Mid steam urine for bacteriology.
2. Urine culture for infection.
3. Full Blood Count.
4. BUE, serum creatinine, urea and electrolytes
5. Serum Prostatic Specific Antigen (PSA)
6. Abdominal ultrasonography, plain abdominal X-
ray, IVU,
7. Urethrocystoscopy.
8. Urine Flowrate, Post-void Residual Urine,
Pressure Flow Urodynamics. Medrockets.com

34. – Transrectal Ultrasound of The Prostate
(TRUS) And TRUS-Guided Prostatic Biopsy
– Colour Doppler Imaging Of The Prostate
– Retrograde Urethro-Cystography
– Chest X-ray
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35. MANAGEMENT OF BPH
Watchful Waiting
Medical Therapy
Minimally Invasive Treatment
Surgery- Surgery for BPH is most commonly
performed endoscopically; however, if the
prostate gland is greater than 60g, an open
prostatectomy is performed.
◦ Transurethral incision of prostate
◦ Transurethral resection of prostate
◦ Transvesical prostatectomy
◦ Retropubic prostatectomy( millin’s) Medrockets.com

36. Watchful waiting
This option is usually offered to patients
with IPSS of 8 or less who are not much
bothered by the symptoms due to BPH.
This involves regular assessment of IPSS,
PFR, PSA and PVR, abdominal
ultrasonography and DRE
Watchful waiting can be replaced by
medical therapy or surgical treatment if
the condition changes. Medrockets.com

37. Medical Therapy For BPH
The ideal candidates are those with IPSS scores
under 19 with bothersome symptoms but with
no complications such as haematuria, stones,
retention or uraemia. They are carefully followed
up for continuation or change in therapy.
1. Alpha Adrenergic Blockers. long-acting alpha-l-
adrenergic blockers Terrazosin and doxazosin
and the selective alpha 1A tramulzosin.
◦ Side-effects are minor and reversible and include a
flu-like syndrome and dizziness..
◦ The drugs are expensive but they are effective for
medical therapy of BPH.

38. Androgen Suppression: The rationale is to reduce the
level of dihydrotestosterone and thereby shrink the
prostate volume so as to relieve the obstruction.
5-Alpha reductase inhibitors
◦ finesteride (proscar) and episteride
◦ The side-effects include loss of libido and erectile
dysfunction.
Zanoterone
◦ This is a steroid competitive androgen receptor antagonist.
◦ Its side-effects include breast pain and gynaecomastia.
 Flutamide
– It is an androgen receptor antagonist.
 Aromatase Inhibitor (Atamestame)
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39. The list include:
i) Hypoxis roopers (South African grass).
ii) Urtica spp (stinging nettle).
iii) Sabal serrulatum (dwarf palm).
iv) Serenoa repens B (American dwarf
palm).
v) Cucurbitapepo (pumpkin seed).
vi) Pygeum africannum (African plum)
phytotherapy
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40. Indications for minimally invasive surgery include
◦ patients with moderate symptoms scores (IPSS 8 -19).
◦ and patients with severe symptoms but handicapped
or unfit for surgery.
Available Minimally Invasive Techniques are
◦ High intensity focused ultrasound (HIFU).
◦ Transurethral vaporization of prostate.
◦ Transurethral laser therapy (TULIP).
◦ Hyperthermia and thermotherapy.
◦ Intra-urethral stents.
◦ Transurethral needle ablation of prostate (TUNA).
◦ Transurethral balloon dilatation.
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41. Indications For Prostatectomy
 Acute refractory urinary retention.
 Chronic urinary retention
 Recurrent episodes or severe haematuria
 Bladder stones secondary to BPH
 Recurrent UTI
 Large bladder diverticula
 Hydroureter and hydronephrosis
 Uraemia (azotaemia) due to BPH.
Others include
– Symptoms of bladder outlet obstruction due to BPH which are moderate to
severe, bothersome and interfere with the patient’s quality of life (usually
IPSS score from 19 to 35) but which are not relieved by medical therapy or
minimally invasive surgery

42. Frail elderly patients.
Patients with severe CO-morbidity such as
myocardial infarct, heart disease, liver
failure, pulmonary disease,
carcinomatosis etc
A severe bleeding tendency and patients
on anticoagulant.
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43. TURP
The standard endoscopic procedure for
BPH is a transurethral resection (TUR) of
the prostate. TUR is performed with a
nonhemolytic fluid such as 1.5% glycine. it
is the Gold standard for reducing
symptom scores.
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44. Complications of TURP
Primary haemorrhage (5-15%)
Secondary haemorrhage
Urinary incontinence
Urethral stricture
Sexual Dysfunction
 TUR syndrome
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45. Haemorrhage
Clot retention
Urinary tract infection
Epididymo-orchitis
Persistent vesico-cutaneous fistula
Wound infection
Incontinence of urine
Complications of Open
Prostatectomy
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46. Impotence (erectile dysfunction)
Retrograde ejaculaton
Infertility
Urethral strictures
Bladder neck stenosis
Damage to the ureters
Osteitis pubis
Deep vein thrombosis
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47. Management of Acute Retention
 The procedure should first be explained to the patient.
 The suprapubic, scrotal and perineal areas are shaved and washed if necessary
 diazepam 10mg given for sedation
 A sterile trolley is set up containing an antiseptic (cetrimide, povidone iodine or
chlorhexidine), sterile towels, swabs, penile clamp, syringe, catheters and a
specimen bottle for urine.
 A nurse should be on hand
 positioning the patient comfortably
 About 5-10m1 of lidocaine 1 %jelly is instilled into the urethra & massaged into
it, retained by applying pressure with the thumb and finger
 The urethra is anaesthetized in 4-5 minutes
 A suitable catheter is selected - Jacques, Foley's, Nelaton Tiemann's or
Gibbon's
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48.  A wide-bore 3-way or 2-way Foley's catheter is used
if bleeding or irrigation is anticipated and a Nelaton
catheter if not for indwelling. Otherwise a narrow
(12F) plastic Jacques catheter is selected. An
indwelling catheter should not fit tightly so that the
secretions of the paraurethral glands can drain
alongside it.
The penis is held straight and the catheter inserted
into the external meatus and gently advanced into
the urethra.
Urine is collected in a sterile bottle for culture and
sensitivity, sugar and protein tests.
The urine is then drained and the catheter removed
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49. Thank you
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