Prostate enlargement

1. ProstateEnlargement
Presented by: Marwan Adnan Zuaiter

2. Introduction
• Prostate(‫ة‬َ‫ث‬‫و‬ُ‫م‬‫:)ال‬ is a single, fibromuscular glandular organ, and the largest
accessory sex gland in men (about 2 × 3 × 4 cm).
• The prostate secretes a milky fluid which contains:
1. Citric acid
2. Proteolytic enzymes
3. Acid phosphatase
• The prostatic secretion is alkaline and helps neutralize the acidity in the
vagina.
• Prostatic secretions enter the prostatic urethra via many prostatic ducts,
which makes up about 25% of the volume of semen and contribute to
sperm motility and viability.

3. Embryologically

4. Embryology
1. fetal testosterone stimulates urogenital sinus mesenchyme through
androgen receptors.
2. urogenital sinus mesenchyme acts on the overlying epithelium to
stimulate cell proliferation.
3. urogenital sinus epithelium then forms prostate ductal progenitor,
the prostatic buds.
4. prostatic buds then grow into the urogenital sinus mesenchyme.

6. • Macroscopically the prostrate can be divided into lobes.
1. peripheral zone
2. internal zone
3. innermost zone
• In good histological sections it is possible to distinguish three
concentric zones
• *excretory ducts

7. Anatomy

8. Anatomy
• It is about the size of a chestnut (about 2 × 3 × 4 cm) and somewhat
conical in shape. The base is directed upward, and is applied to the
inferior surface of the bladder, the apex is directed downward, and is
in contact with the superior fascia of the urogenital diaphragm.
• The prostate is a firm, partly glandular and partly muscular body,
which is placed in the pelvic cavity. Immediately below the internal
urethral orifice, posterior to the lower part of the symphysis pubis,
above the superior fascia of the urogenital diaphragm, in front of the
rectum, and surrounding the prostatic urethra.

9. Anatomy

11. Anatomy
• Arteries: inferior vesical artery > prostatic artery > urethral and capsular
branches, middle hemorroidal and internal pudendal arteries>minor
branches.
• Veins: prostatic venous plexus > internal iliac vein
• Lymph drainage: internal iliac nodes.
• Nerve supply: inferior hypogastric plexuses and the sympathetic nerves
stimulate the prostatic smooth muscle during ejaculation.

12. Prostate Enlargement
• The prostate slowly increases in size from birth to puberty, and then it
expands rapidly. The size attained by age 30 typically remains stable
until about age 45, when further enlargement may occur.
• Enlargement of the prostate to 2 to 4 times its normal size occurs
approximately 1/3 of all males over age 60.
• Generally a healthy adult prostate weighs about 20–25 grams.

13. Prostate Enlargement
• Benign prostate hyperplasia (BPH).
• Prostatitis.
• Prostatic cancer.

14. BPH
• It is not cancer, and it does not raise your risk for prostate cancer.
• Disease of elderly men (average age is 60-65 years); prostate
gradually enlarges, creating symptoms of urinary outflow obstruction.
• The actual cause of prostate enlargement is unknown.
• Factors linked to aging, testosterone levels.
• Men who have had their testicles removed at a young age (for
example, as a result of testicular cancer) do not develop BPH. Also, if
the testicles are removed after a man develops BPH, the prostate
begins to shrink in size.

15. •Absent malignancy, most tissues in the body
shrink as we age. Why does the prostate
expand as men grow old?

16. Absent malignancy, most tissues in the body
shrink as we age. Why does the prostate expand
as men grow old?
• equilibrium between cell division and cell death
• androgens not only are required for normal prostatic cell proliferation
BUT
• also actively inhibit cell death
• progression of normal prostatic cells to terminally differentiated cells
IS BLOCKED
• thereby reduces the overall rate of cell death
• This leads to increasing gland size.

17. BPH
• BPH mainly occur periurethrally. (Note: prostate cancer occurs in the
periphery of the gland)

18. BPH symptoms
(Obstructive-type symptoms)
• Hesitancy.
• Weak stream.
• Nocturia.
• Intermittency.
• UTI/recurrent UtI.
• Urinary retention.
• Dribbling at the end of urinating.
• Straining to urinate.
• Strong and sudden urge to
urinate.
• Incomplete emptying of your
bladder.

19. BPH Diagnosis
• Digital Rectal Exam (DRE)
• Urinalysis
• Urine culture
• Prostate-specific antigen
• BUN and CR
• Cystoscopy
• Post-void residual urine
• Urethrometry
• US

20. Diagnostic guidelines for BPH
• History:-
• prior and current illnesses
• prior surgery and trauma
• Current medication, including over-the-counter drugs
• Physical examination:-
• including DRE
• Urinalysis:-
• Routine and microscopic, culture and sensitivity. To rule out diagnoses other than BPH that
may cause LUTS and may require additional diagnostic tests.
• prostate-specific antigen (PSA):-
• Should be offered to patients who have at least a 10-year life expectancy and for whom
knowledge of the presence of prostate cancer would change management. Among patients
without prostate cancer, serum PSA may also be a useful surrogate marker of prostate size
and may also predict risk of BPH progression.

21. *NOTE*
IPSS or AUA Symptom Score
International Prostate Symptom Score or American Urologic
Association system score are recommended for an objective
assessment of symptoms at initial contact, for follow-up of symptom
evolution for those on watchful waiting and for evaluation of response
to treatment.

22. Diagnostic guidelines for BPH
• In cases where the physician feels it is indicated, it is reasonable to
proceed with one or more of the following:
1. Post-void residual urine
2. Urethrometry
3. Voiding diary
4. BUN and CR
5. Sexual function questionnaire

23. Diagnostic guidelines for BPH
• The following diagnostic modalities are not recommended in the routine
initial evaluation of a typical patient with BPH-associated LUTS. BUT may
be required in patients with a definite indication, such as hematuria,
uncertain diagnosis, DRE abnormalities, poor response to medical therapy
or for surgical planning.
1. Cystoscopy
2. Cytology
3. Urodynamics
4. Radiological evaluation of upper urinary tract
5. Prostate ultrasound
6. Prostate biopsy

24. Treatment guidelines for BPH
• How bad your symptoms are and how much they bother you?
• lifestyle modification ?
• MEDICINES?
• SURGERY?

25. Treatment guidelines for BPH
Soooooo
How tell whether the patient needs lifestyle modification or
medications or surgery?

26. Remember IPSS ?

27. Treatment guidelines for BPH
• IPSS < 7: MILD symptoms
>Combination of lifestyle modification and watchful waiting<
• IPSS 8 – 18: MODERATE symptoms
• IPSS 19 – 35: SEVERE symptoms
>Watchful waiting/lifestyle modification, as well as medical, minimally
invasive or surgical therapies<

28. Lifestyle modifications with watchful waiting?
• Patients on watchful waiting should have periodic physician-monitored visits.
• Fluid restriction particularly prior to bedtime. Avoid drinking fluids within 2 hours
of bedtime.
• DO NOT drink a lot of fluid all at once.
• Timed or organized voiding. Go to the bathroom on a timed schedule, even if you
don't feel a need to urinate.
• Pelvic floor exercises regularly. Kegel exercises.
• Avoidance of caffeinated beverages, spicy foods.
• Reduce stress, avoidance or treatment of constipation. Nervousness and tension
can lead to more frequent urination.
• Avoidance/monitoring of some drugs (e.g., diuretics, decongestants,
antihistamines, antidepressants).

29. Kegel exercises

30. Kegel exercises

31. Medical treatment
• Alpha-1 blockers: relax the muscles of the bladder neck and prostate
capsule. (within 3 to 7 days).
• Terazosin (Hytrin®): are appropriate treatment options for LUTS
secondary to BPH. They do not alter the natural progression of the
disease.
• Finasteride (Proscar®): 5-alpha-reductase inhibitor. Several studies
have demonstrated that in addition to improving symptoms, the
natural history of BPH can be altered through a reduction in the risk
of acute urinary retention (AUR) and the need for surgical
intervention.
• Hormonal: Antiandrogens

32. Surgical Intervention
• Indications for surgical intervention:-
1. Sever symptoms.
2. Failure of treatment.
3. Patient do not want medical therapy.
4. Urinary retention.
5. Hydronephrosis.
6. Recurrent UTIs.
7. Recurrent blood in the urine.
8. Decreasing kidney function.
9. Bladder stones.
10.Hernias (inguinal).

33. Surgical Intervention
• Transurethral Resection of Prostate (TURP): This is the most common
and most proven surgical treatment for BPH (gold standard
treatment). TURP is performed by inserting a scope through the penis
and removing the prostate piece by piece.

34. Complications of TURP
• Failure to void.
• Erectile dysfunction.
• Bleeding.
• Clot retention.
• UTIs.
• Incontinence.

36. Other Surgical Intervention
• Transurethral Incision of Prostate (TUIP): is appropriate surgical
therapy for men with prostate gland volumes less than 30 grams.
• Laser prostatectomy: Greenlight laser or photoselective vaporization
prostatectomy (PVP).
• Open prostatectomy : indicated for men whose prostates are too
large for TURP for fear of incomplete resection, significant bleeding or
the risk of dilutional hyponatremia (TURP syndrome).

37. TURP syndrome (BRIEFLY)
• Is a rare but potentially life-threatening complication of a TURP
procedure.
• It occurs as a consequence of the absorption into the prostatic
venous sinuses of the fluids used to irrigate the bladder during the
operation. Symptoms and signs are varied and unpredictable.
• Fluid overload: The average rate of absorption is 20ml/min, and
therefore length of surgery may have an effect on the total volume
absorbed.

38. TURP syndrome (BRIEFLY)
The clinician must have a high index of suspicion for diagnosing TURP
syndrome in a patient who becomes unwell following a TURP
procedure.

39. TURP syndrome diagnosis (BRIEFLY)
• Acutely unwell, confused patient with a reduced Glasgow coma
scale score.
• Hyponatremia: Na < 120 mmol/L
• Hyperkalemia: K > 6.0mml/L
• Hyperglycemia.
• Hypothermia.
• Hyperammonemia.
• Intra-vascular hemolysis, disseminated intravascular coagulation
(reduced platelet count, increased fibrin degradation products)

40. Management of TURP syndrome
The treatment of TURP syndrome is mainly supportive, and is most
successful where diagnosis is made early and interventions are
instituted before systemic complications occur.
The patient should preferably be transferred to a high dependency unit
and be attached to continuous monitoring.

42. Thank you