alexandria teaching hospital

1. BENIGN PROSTATIC
HYPERPLASIA
(BPH)

2. BPH
A widely prevailing pathology
among elderly males
BPH can cause bothersome day& night LUTS
? A negative impact on quality of life (QOL)

3. Definition Of BPH
Normal prostate:
A compound tubulo-alveolar gland
composed of 3 histological elements:
-Epithelial structure: prostatic acini&ducts
(androgen dependent) lying within a :
-fibro -
-muscular smooth m. innervated by
alpha adrenergic fibres
Stroma

4. Normal prostate is about 15 g.
in the young adult
BPH results from abnormal (proliferation) of
the 3 histological elements of the prostate:
glandular (acinar)
fibrous
muscular
in different proportions
It can be regarded as a benign tumor:
fibro-myo-adenoma

5. Aetiogy Of BPH
• Aging
• Androgens

6. PATHOLOGY OF BPH
BPH arises from
the transition zone or
the peri-urethral
zone of the gland
closely relayed to urethra &
BN
What about P Ca?

7. BPH starts as one or more
hyperplasic nodules within
the gland.. gradually
enlarging ….
may coalesce together…
compressing the intervening &
outer normal prostatic tissue
which eventually forms a
surgical capsule
around the adenoma
Pathogenesis

8. The result will be:
An elongated & compressed prostatic
Urethra
Macroscopically BPH can be:
Monolobar…middle lobe
Bilobar….. 2 lateral lobes
Trilobar… 2 lateral lobes & middle lobe

9. Pathophysiology of Urethral
Obstruction in BPH
Static component:
formed by the obstructing
prostatic mass
Dynamic component:
formed by the tone of
smooth muscle within
the stroma & capsule

10. Pathological complications of BPH
Increased intravesical pressure:
Early… bladder muscle hypertrophy
Later…. atony..
thinning out of bladder muscle
…diverticulation
The result will be:
High intra-vesical (P) …Bil hydroureteronephrosis
Outlet obstruction…significant amount of
PV residual urine….Stasis:
Rec UTI
Stone formation

11. Diagnosis of BPH
Clinical Picture
Symptoms:
Old male (over 50 ys) suffering from LUTS
Storage symptoms:
Urinary frequency
nocturia
urgency ,..urgency incontinence
Evacuation symptoms:
Straining during voiding
diminished force & calibre of the stream
bifurcated stream
interrupted stream
PV dribbling
AUR

12. Symptoms of complications
Rec. UTI
Haematuria
Bladder stone
chronic retention:
SP mass (full bladder)
overflow incontinence
renal insufficiency

13. Physical examination
• General examination
• Abdominal examination:
? Renal swelling (hydronephrosis)
? SP area ( full bladder)
Hernial orifices
• Genital examination
? associated epididymo-orchitis
• Digital rectal examination (DRE)
size , shape, symmetry, consistency
Is it suspicious of P Ca ?

14. Investigations
Lab investigations
Urinalysis
Serum creatinine
Serum PSA

15. Imaging
Abdominal ultrasonography:
size of the gland, PVR,
associated stones
? hydronephrosis,
KUB:
radio-opaque calculi
Intravenous Urography:
secretory function of the kidney
?basal smooth filling defect in
the bladder
Uroflowmetry
to document obstruction
Urethro-cystoscopy
in case of hematuria

16. Differential Diagnosis
Other causes of LUTS
Bladder & urethral calculi
Bladder cancer
BN fibrosis
Prostate cancer
Urethral stricture
Neurogenic voiding dysfunction

17. TREATMENT of BPH
Non- symptomatic BPH
Reassurance---- Follow up
Symptomatic BPH:
Conservative Treatment:
non-specific measures
* Avoid causes of prostatic congestion
* Phytotherapy

18. Specific medical treatment:
5- alpha - reductase inhibitors
prevent the conversion of testosterone
to 5-dihydro testosterone
gradual atrophy of the glandular
component of BPH
(slow effect on static component)
Alpha adrenergic blockers
Cause decrease of the smooth muscle
tone within the prostatic stroma&capsule
better urine flow
(rapid effect on dynamic component)

19. Surgical Intervention
Indications
Repeated AUR
Chronic UR
Severe obstructive symptoms
Failure of medical treatment
Haematuria
Complications:
Rec. UTI
Hydronephrosis
Bladder stones or diverticula

20. Methods of Surgical intervention
Trans-urethral resection
of the prostate (TURP)
Gold standard 90% of cases
Open surgical prostatectomy
( enucleation adenectomy)
when ?
Very large BPH
Concomitant bladder lesion that needs
open surgery
Patient limitation (limited hip joint mobility)

21. TURP

22. Conclusions
• BPH is a disease of aging males
• It can cause disabling LUTS (QOL)
• Corner stone of diagnosis
old male,.. LUTS,
DRE….. sonography
exclude cases of suspected P ca

23. Conclusions(cont.)
• Most cases ( 70 – 90 % ) can be managed
by medical treatment with reasonable pt.
satisfaction
Only a small percentage will need surgical
intervention where TURP is the standard
of care