11- BPH

Benign Prostatic Hyperplasia (BPH)

• BPH is a histological diagnosis
• BPH is enlargement due to benign growth (can include obstruction)
• BPH is often associated with "prostatism" and/or lower urinary tract symptoms (LUTS)
• Risk factors for BPH increase with age
• Symptoms include irritative (storage) and obstructive symptoms common in LUTS, such as nocturia and urgency.

Learning Outcomes

• Able to describe BPH
• Able to analyze risk factors and developmental period for BPH
• Able to describe lower urinary tract symptoms
• Able to evaluate a patient with BPH
• List medical therapies
• List surgical management types

What is BPH?

• BPH is a histological diagnosis.
• Prostate enlargement can occur without obstruction.
• Bladder outlet obstruction (BOO) may be present and can be static or dynamic (components).

LUTS

• Lower urinary tract dysfunction symptoms (LUTS) involve both storage and emptying symptoms.
• Symptoms may include nocturia, urgency, and difficulty urinating, related to BPH, but not exclusive to it.
• LUTS are frequently included in patient evaluations.

Differential Diagnosis

• Urethral stricture is a possible differential diagnosis.
• Bladder neck contracture is a possible differential diagnosis.
• Bladder stones are a possible differential diagnosis.
• Urinary tract infection is a possible differential diagnosis.
• Interstitial cystitis is a possible differential diagnosis.
• Neurogenic bladder is a possible differential diagnosis.
• Inflammatory prostatitis is a possible differential diagnosis.
• Medications are a possible differential diagnosis.
• Carcinoma of the prostate is a possible differential diagnosis.
• Carcinoma in situ of the bladder is a possible differential diagnosis.

Prevalence of Histologic BPH

• Prevalence of BPH increases with age.
• Relevant data points from various studies are presented graphically, showing prevalence rates across different age groups.

Old Paradigm Versus Subsequent Paradigm

• Old paradigm viewed BPH as simple enlargement.
• Subsequent paradigm recognized that a prostate might be small with receptors.
• A subsequent view includes the enlarged prostate with a different set of possible diagnostic markers and clinical considerations.

BPH/LUTS Pathophysiology

• Prostate hyperplasia initiates a chain of events.
• BOO occurs as a result of obstruction.
• Aging effects may affect the detrusor response.
• Primary bladder disease may be present.
• Polyuria can occur as a result of any of the conditions linked.

Initial Evaluation

• Detailed medical history is important.
• Physical exam, including DRE and neurologic exam, is needed.
• Urinalysis is part of the evaluation.
• Serum creatinine is no longer mandatory but may be important in some cases.
• PSA is a marker for prostate cancer and is usually evaluated.
• Symptom assessment using the AUA-SS score is essential.

PSA

• PSA is produced by epithelial cells.
• It cleaves semen.
• PSA is often bound to other proteins (ACT).
• Elevated PSA can be due to malignancy, hyperplasia, or infection/inflammation.

Clinical & Anatomical and Pathophysiologic Changes

• Histological changes in the prostate gland, such as stromoglandular hyperplasia, occur.
• Clinical symptoms such as bothersome LUTS can be part of the clinical evaluation.
• Anatomical enlargement (BPE) may occur as a result of the histological changes.
• Pathophysiological compression of the urethra can result in BOO.

Goals of Therapy for BPH

• Reduce symptoms (IPSS/AUA scores).
• Improve quality of life (QOL).
• Prevent further prostate growth.
• Increase maximum urinary flow rate and relieve obstruction.
• Prevent long-term complications related to BPH.
• Acceptable adverse events profile.

Medical Treatments for BPH, LUTS, BOO

• Alpha-adrenergic blockers affect the dynamic component, while 5-alpha-reductase inhibitors impact the anatomic component.
• Anticholinergic therapy is effective in reducing storage symptoms often associated with BPH.

Role of α-Adrenoreceptors

• Alpha-1 (α-1) adrenoreceptors are involved in smooth muscle contraction in the prostate.
• Alpha-1 receptors in the spinal cord influence the detrusor response.
• Different alpha subtypes in the urinary tract and prostate can have various effects which can be affected by therapies.

Dihydrotestosterone (DHT) Action

• Testosterone is converted to DHT by 5-alpha-reductase.
• DHT binds to the androgen receptor.
• DHT has a higher affinity than testosterone.
• DHT modulates gene expression in a significant way.

Rationale for Combination Therapy

• 5-alpha reductase inhibitors arrest disease progression, while alpha-blockers rapidly relieve symptoms.
• Combination therapy is most effective for preventing clinical progression in specific or selected patients.

Doxazosin/Finasteride/Combination

• MTOPS (Medical Treatment of Prostatic Symptoms) studied a combination of doxazosin and finasteride.
• The method significantly reduces clinical BPH progression.
• This approach can reduce the risk of AUR and other invasive therapies.

Combination Treatment with-Blocker Plus Anticholinergic for Bladder Outlet Obstruction

• The proposed combination of Detrol® and Tamsulosin for bladder outlet obstruction (BOO) and overactive detrusor (OAB) has a positive impact on quality of life.
• Outcomes include increased bladder capacity, no acute urinary retention, no significant impact on urinary flow or post-void residual urine, and a safe treatment option.

Surgical Therapy

• Common surgical therapies, such as TURP, TUVP, Gyrus, TUIP surgeries etc.
• Laser procedures, open procedures, such as suprapubic, retropubic, perineal and minimally-invasive procedures including TUMT, TUNA, WIT, TEAP, Botox, and ILC are also options.

Transurethral Resection of the Prostate (TURP)

• Advantages include availability of long-term outcome data, good clinical results, treating smaller prostates, low retreatment rate, and low mortality.
• Disadvantages include retrograde ejaculation and bleeding, including potential TUR Syndrome.

BPH and Erectile Dysfunction

• LUTS and erectile dysfunction (ED) are common in older men.
• Sexual function declines with age.
• ED is often associated with chronic diseases such as diabetes and hypertension.
• A possible link exists between LUTS and ED.
• Possible underlying mechanisms for co-existence of ED and BPH, such as diminished quality of life, increased sympathetic tone, ischemia/endothelial dysfunction, or alteration of NO pathways.

Take Home Messages

• Aging increases the prevalence of BPH.
• Not all men with LUTS have BPH.
• Not all men with BPH have LUTS.
• Consider combination therapy in specific cases.
• Quality of life is a significant factor in treatment decisions.

Additional Information

• Presented data show the response to various treatments over time.