Benign Prostatic Hyperplasia

BENIGN PROSTATIC HYPERPLASIA
- is an enlarged prostate gland
> it squeezes or partly blocks the
urethra causing problems with
urinating.
Reference:
‘BPH (Enlarged Prostate) Causes, Symptoms, Treatments, and More’ (no date). WebMD.
Available at:
http://www.webmd.com/men/prostate-enlargement-bph/benign-prostatic-hyperplasia-bph-topic-overview
(Accessed: 1 April 2015).

BENIGN PROSTATIC HYPERPLASIA
- also known as benign prostatic hypertrophy
characterized by proliferation of the cellular
elements of the prostate
- there is a Chronic bladder outlet obstruction (BOO)
secondary to BPH
- may lead to:
urinary retention
renal insufficiency
recurrent urinary tract infections
gross hematuria
bladder calculiReference:
Benign Prostatic Hypertrophy (no date). Available at:
http://emedicine.medscape.com/article/437359-overview

THE PROSTATE GLAND
- a small gland (organ) in the male reproductive system
- it makes fluid that protects and feeds sperm,
- it makes about one third of the fluid that is
ejaculated from the penis at orgasm
- Size:
> young men: about the size of a walnut, but
it gets bigger with age
- Location:
> It sits underneath the bladder
> surrounds the top part of the urethra
Reference:
‘Prostate enlargement or BPH’ (no date). Andrology Australia. Available at:
https://www.andrologyaustralia.org/prostate-problems/prostate-enlargement-or-bph/

THE PROSTATE GLAND
Testosterone and the size of the prostate:
- Male sex hormone, made in the testes, that makes
the prostate grow in size
- As men get older, the prostate grows larger.
- It starts to increase its level during puberty, making
the prostate grow to about eight times its size
- Prostate doubles in size between the ages of 21
and 50 years
- almost doubles again in size between the ages of
50 and 80 years
Reference:
‘Prostate enlargement or BPH’ (no date). Andrology Australia. Available at:
https://www.andrologyaustralia.org/prostate-problems/prostate-enlargement-or-bph/

EPIDEMIOLOGY
BPH occurs in almost all men as they age.
About half of all men older than 75 have some
symptoms.
It is probably a normal part of the aging process
In men
> caused by changes in hormone balance and
in cell growth.
Reference:
‘BPH (Enlarged Prostate) Causes, Symptoms, Treatments, and More’ (no date). WebMD. Available at:
http://www.webmd.com/men/prostate-enlargement-bph/benign-prostatic-hyperplasia-bph-topic-overview

CAUSES
- is not well understood
- common in older men
- it does not occur in men whose testicles are
removed before puberty
- factors are believed to be related to aging
and the testicles may cause BPH
Reference:
Kidney, T. N. N. and Clearinghouse, U. D. I. (no date) Prostate Enlargement: Benign Prostatic Hyperplasia.
Available at: http://kidney.niddk.nih.gov/KUDiseases/pubs/prostateenlargement/#3

CAUSES
Theories:
- The amount of testosterone level in the blood decreases as
men age leaving a higher proportion of estrogen (a female
hormone) which increases the activity of substances that
promote prostate cell growth
> a male hormone dihydrotestosterone (DHT), plays a role
in prostate development and growth. Scientists noted
that men do not develop BPH when they do not
produce DHT. Older men continue to produce and
accumulate high levels of DHT in the prostate, even if
testosterone production is reduced as they age,
which may encourage continues cell growth in the
prostate.Reference:

CAUSES
Theories:
- The amount of testosterone level in the
blood decreases as men age leaving a
higher proportion of oestrogen (a female
hormone) which increases the activity of
substances that promote prostate
cell growth
Reference:

RISK FACTORS
- age 40 years and older
- family history of BPH
- obesity,
- cardiovascular diseases,
- type 2 diabetes
- Sedentary Lifestyle
- erectile dysfunction
Reference:
Kidney, T. N. N. and Clearinghouse, U. D. I. (no date) Prostate Enlargement: Benign Prostatic Hyperplasia. Available at:
http://kidney.niddk.nih.gov/KUDiseases/pubs/prostateenlargement/#3

PATHOPHYSIOLOGY
- There is the development of Multiple
fibroadenomatous nodules in the
periurethral region of the prostate.
- There is narrowing and lengthening of the
lumen of the prostatic urethra progressively
obstructing urine flow
Reference:
Benign Prostatic Hyperplasia (BPH): Benign Prostate Disease: Merck Manual Professional (no date). Available
at:
http://www.merckmanuals.com/professional/genitourinary_disorders/benign_prostate_disease/benign_pros
tatic_hyperplasia_bph.html

PATHOPHYSIOLOGY
- There is a progression to hypertrophy of the
bladder detrusor, trabeculation, cellule
formation, and diverticula
> due to Increased pressure associated
with micturition and bladder distention
- Incomplete bladder emptying causes stasis
> predisposes to calculus formation and
infection
> hydronephrosis may happen secondary
to prolonged obstruction, even if
incomplete,and it compromises renal
functionReference:
Benign Prostatic Hyperplasia (BPH): Benign Prostate Disease: Merck Manual Professional (no date). Available
at:
http://www.merckmanuals.com/professional/genitourinary_disorders/benign_prostate_disease/benign_pros
tatic_hyperplasia_bph.html

SIGNS AND SYMPTOMS
- Urinary frequency
- Urinary urgency
- Hesitancy (Difficulty initiating the urinary stream;
interrupted, weak stream)
- Straining
> The need to push (Valsalva maneuver) in
order to fully evacuate the bladder
- Weak stream of urine
Reference:
Benign Prostatic Hypertrophy (no date). Available at: http://emedicine.medscape.com/article/437359-
overview

SIGNS AND SYMPTOMS
- Often feels the urge to urinate
> may even wake you up at night.
- A sense that the bladder is not completely empty
after urinating
- Can not urinate or extremely hard to urinate
> Blocked bladder secondary to BPH
> leads to bladder infections or stone formations,
or kidney damage
Note:
BPH does not cause prostate cancer
does not affect a man's ability to father children
does not cause erection problemsReference:
‘BPH (Enlarged Prostate) Causes, Symptoms, Treatments, and More’ (no date). WebMD. Available at:
http://www.webmd.com/men/prostate-enlargement-bph/benign-prostatic-hyperplasia-bph-topic-
overview

SIGNS AND SYMPTOMS
Complications:
- chronic, or long lasting, urinary retention
- Hematuria (blood in the urine)
- acute urinary retention
- UTI
- bladder damage
- kidney damage
- bladder stones
Reference:

TESTS AND DIAGNOSIS
Digital rectal exam (DRE)
Urinalysis (to help rule out an infection)
Blood test. (it can indicate kidney problems)
Reference:
Staff, M. C. (2014) ‘Benign prostatic hyperplasia (BPH) Tests and diagnosis’. MayoClinic. Available at:
http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/tests-diagnosis/con-
20030812

TESTS AND DIAGNOSIS
Prostate-specific antigen (PSA) blood test
- PSA, a substance produced in the prostate,
levels increase with enlarged prostate.
- elevated PSA levels can also be
secondary to infection, surgery or
Prostate cancer.
Neurological exam
- can help identify causes of urinary
problems other than BPHReference:
20030812

TESTS AND DIAGNOSIS
To help confirm an enlarged prostate and to
rule out other conditions:
Urinary flow test
- urinating into a receptacle connnected to
a machine
> measures the strength and amount of
urine flow as it determines if it gets
worse over timeReference:
20030812

TESTS AND DIAGNOSIS
Post-void residual volume test.
- measuring if bladder emptying is complete.
> by the use of ultrasound or by insertion
of a catheter into the bladder after
urination to measure how much urine
is left in the bladder.Reference:
20030812

TESTS AND DIAGNOSIS
24-hour voiding diary.
- a record of the frequency and amount
of urine
> especially helpful if more than
one-third of daily urinary output occurs
at night.Reference:
20030812

TESTS AND DIAGNOSIS
In a more complex condition:
Transrectal ultrasound.
- insertion of ultrasound probe into your
rectum to measure and evaluate the
prostate.
Prostate biopsy
- to rule out a prostate cancer
> needles are inserted guided by
transrectal ultrasound to take tissue
samples (biopsies) of the prostate.Reference:
20030812

TESTS AND DIAGNOSIS
Urodynamic and pressure flow studies
- to measure bladder pressure and to
determine how well the bladder muscles
are working
> A catheter is threaded through the
urethra into the bladder where water
(or air) is injected slowly into the bladder.
Reference:
20030812

TESTS AND DIAGNOSIS
Cystoscopy.
- to visualize the bladder and urethra
> a lighted, flexible cystoscope is
inserted into your urethra, a local
anesthetic is given before this test.
Reference:
20030812

TESTS AND DIAGNOSIS
Intravenous pyelogram or CT urogram
- to detect urinary tract stones, tumors, or
blockages above the bladder
> a tracer is injected into a vein. X-rays
or CT scans are then taken of the
kidneys, bladder and the tubes that
connect the kidneys to the
bladder (ureters).Reference:
20030812

MANAGEMENT
Minimally invasive or surgical therapy might
be recommended for patients with:
- moderate to severe symptoms
- Medication that failed to relieve symptoms
- urinary tract obstruction, bladder stones,
hematuria or kidney problems
Reference:
Staff, M. C. (2014) ‘Benign prostatic hyperplasia (BPH) Treatments and drugs’. MayoClinic. Available at:
http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/treatment/con-
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Minimally invasive or surgical therapy might
not be an option ito patients with:
- untreated urinary tract infection
- Urethral stricture disease
- A history of prostate radiation therapy or
urinary tract surgery
- A neurological disorder, such as Parkinson's
disease or multiple sclerosisReference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Possible complications depending on the
type of prostate procedure:
- Retrograde Ejaculation (semen goes back into
the bladder instead of out the tip of the penis)
- Temporary difficulty with urination
- Urinary tract infection
- Bleeding
- Erectile dysfunction
- Urinary Incontinence (loss of bladder control)
> a very rare caseReference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Types of minimally invasive or surgical therapy
TURP
- Transurethral resection of the prostate
> A lighted scope is inserted into the urethra,
and the surgeon removes all but the outer
part of the prostate
- relieves symptoms quickly
> post-TURP, the patyient might temporarily
need a catheter to drain the bladder,
> the patient is advised to do only light
activity until healed.Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
TUIP
- Transurethral Incision Of The Prostate
> A lighted scope is inserted into the urethra,
and the surgeon makes one or two small cuts
in the prostate gland making urine to pass
through the urethra easily.
> an option for small or moderately enlarged
prostate gland, especially for patients with
health problems that make other surgeries
too risky.Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
TUMI
- Transurethral Microwave ThermoTherapy
> a special electrode is inserted through the
urethra into the prostate area.
> the inner portion of the enlarged prostate
glands are destroyed and shrink by the
microwave energy from the electrode.
This eases the urine flow.
- generally suggested only on small prostates in
special circumstances
> re-treatment might be necessary.Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
TUNA
- Transurethral Needle Ablation
- an outpatient procedure
> a scope is passed into your urethra, needles are
placed into the prostate gland, radio waves
pass through the needles
> excess prostate tissues blocking the flow of urine are
heated and destroyed.
- a good choice for patient that bleeds easily or have certain
other health problems.
- It might only partially relieve symptoms
- it might take some time before results are noticed
Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Laser Therapy
- use of high-energy laser
- destroys or removes overgrown prostate tissue
- generally relieves symptoms right away
- has a lower risk of side effects than does
non-laser surgery
- for men who did not have other prostate
procedures because they take blood-thinning
medications.
Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
The options for laser therapy include:
Ablative procedures
- it vaporizes obstructive prostate tissue thus
increasing urine flow
- Examples:
photoselective vaporization of the prostate (PVP)
holmium laser ablation of the prostate (HoLAP).
- causes irritating urinary symptoms post-surgery
resection procedure might be done if
necessary (rare case)Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
The options for laser therapy include:
Enucleative procedures
- Removal of all the prostate tissue that blocks
urine flow
- Prevents tissue regrowth
- Similar to open prostatectomy
- removed tissue can be examined for prostate can
- Example:
holmium laser enucleation of the prostate (HoLEP)
Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Prostate Lift
- an experimental transurethral procedure
> to increase the flow of urine, compression
of the sides of the prostate through
the use of special tags are done.
Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Embolization
- an experimental procedure
- selectively blocking the blood supply to or from
the prostate causing the prostate to decrease
in size
Reference:
20030812 (Accessed: 3 April 2015).

MANAGEMENT
Open or Robot-assisted Prostatectomy
- an incision in the lower abdomen is performed
to remove tissue of the prostate
- generally for patients with a very large prostate,
bladder damage or other complicating factors.
- requires a hospital confinement for a short period
- the patient might be at risk of needing a
blood transfusion.
Reference:
20030812 (Accessed: 3 April 2015).

MEDICATIONS
For mild to moderate symptoms BPH:
Alpha blockers
- to relax bladder neck muscles and muscle fibers in the
prostate making urination easier
- alfuzosin (Uroxatral),
doxazosin (Cardura),
tamsulosin (Flomax),
silodosin (Rapaflo)
- works quickly in men with relatively small prostates
- Side effects:
> dizziness
> Retrograde Ejaculation (semen goes back into the
bladder instead of out the tip of the penis, it is harmless)Reference:
20030812 (Accessed: 3 April 2015).

MEDICATIONS
5-alpha reductase inhibitors.
- to shrink prostate by preventing hormonal changes that
cause prostate growth
- finasteride (Proscar)
dutasteride (Avodart)
- might take up to six months to be effective
- Side effect: retrograde ejaculation.
Reference:
20030812 (Accessed: 3 April 2015).

MEDICATIONS
Combination drug therapy
- alpha blocker and 5-alpha reductase inhibitor
is given at the same time if either medication
alone isn't effective.
Reference:
20030812 (Accessed: 3 April 2015).

MEDICATIONS
Tadalafil (Cialis)
- Studies suggest that this medication can also
treat prostate enlargement and is generally
prescribed to men who also experience
erectile dysfunction.
Reference:
20030812 (Accessed: 3 April 2015).

Benign Prostatic Hyperplasia

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