BPH: Benign Prostatic Hyperplasia PDF

Benign Prostatic Hyperplasia Cevdet Kaya, MD Professor of Urology Medical School in Istinye University  Learning Outcomes  Able to describe benign prostate hyperlasia (BPH)  Able to analyze the risk factors and the developmental period f...

Benign Prostatic Hyperplasia Cevdet Kaya, MD Professor of Urology Medical School in Istinye University  Learning Outcomes  Able to describe benign prostate hyperlasia (BPH)  Able to analyze the risk factors and the developmental period for BPH  Able to describe lower urinary tract symptoms  Able to evaluate of a patient with BPH  List the names of medical therapy  List the surgical management types  What is “BPH”?  “Prostatism” and “BPH”  Benign Prostatic Hyperplasia is a histological diagnosis  BPH-Histological diagnosis  BPE-Enlargement due to benign growth (can be without obstruction)  BPO-Urodynamically proven BOO (static/dynamic components)  LUTS  Symptoms attributable to lower urinary tract dysfunction  storage (irritative) symptoms  emptying (obstructive) symptoms  may be associated with BPH, BPE, and BPO, but not exclusive to these  Differential Diagnosis  Urethral stricture  Neurogenic bladder  Bladder neck  Inflammatory prostatitis contracture  Medications  Bladder stones  Carcinoma of the prostate  Urinary tract infection  Carcinoma in situ of the bladder  Interstitial cystitis Prevalence of Histologic BPH 100 90 80 70 Prevalence (%) 60 50 40 30 20 10 0 20–29 30–39 40–49 50–59 60–69 70–79 80–89 Age Pradhan 1975 Swyer 1944 Franks 1954 Moore 1943 Harbitz 1972 Holund 1980 Baron 1941 Fang-Liu 1991 Karube 1961 Old paradigm  Subsequent paradigm Normal prostatee Small prostate with -receptors Small prostate with -receptors Enlarged prostatee  New paradigm Normal prostatee Small prostate with -receptors Small prostate with -receptors Brain/ Spinal column/ Enlarged prostatee Prostate BPH/LUTS Pathophysiology  Initial Evaluation  Detailed medical history  Physical exam including DRE and neurologic exam  Urinalysis  Serum creatinine no longer mandatory  PSA*  Symptom assessment (AUA-SS)  Initial evaluation History DRE & focused exam Urinalysis PSA1 Objective Symptom Assessment Mild Moderate to severe IPSS 7 IPSS 8 Offer treatment alternatives Watchful Medical Minimally invasive Surgery waiting therapy therapies Cystoscopy, if important in planning operative approach  PSA… It’s not just for cancer  Serine protease produced by epithelial cells  Dissolves semen coagulum  Most bound to antiproteases ACT  Increased with-  Malignancy  Hyperplasia  Infection/Inflammation  Clinical & Anatomical and Pathophysiologic Changes  BPH All Men >50 y  Histologic: stromoglandular hyperplasia  Clinical: presence of Histologic bothersome LUTS BPH  Anatomic: enlargement of the gland (BPE = Benign Prostatic Enlargement)  Pathophysiologic: compression of urethra and compromise of urinary flow (BOO = Bladder Outlet Obstruction) LU Bo TS/ the r BPE em en t arg En l ` BOO Obstruction  Goals of Therapy for BPH BPH Treatment Success measured by:  ↓ symptoms (IPSS/AUA)  ↓ bother (bother score) and ↑ QOL  ↓ prostate size or arrest further growth  ↑Increase in peak flow rate / Relieve obstruction  Prevention of long-term outcomes/complications  Acceptable adverse events profile  Medical Treatments for BPH, LUTS, BOO  -adrenergic blockers  Dynamic component  5 -reductase inhibitors  Anatomic component  Anticholinergic Therapy  Storage Sx’s  Role of -Adrenoreceptors 1-ARs and Human LUTS Prostate Spinal cord Detrusor Vessels Smooth muscle Lumbosacral Instability Resistance contraction Irritative vessels 1A 1D symptoms 1A 1D> 1A Aging effects 1B> 1A  Dihydrotestosterone (DHT) Action  Testosterone is converted to DHT by two 5 -reductase isoenzymes  The target for DHT is the androgen receptor  DHT has approximately 5 times greater affinity for the androgen receptor than testosterone  The greater affinity makes DHT a more potent androgenic steroid at physiologic concentrations  The DHT/androgen receptor complex alters gene expression  Rationale for Combination Therapy Alpha- 5 -Reductase Blockers: Inhibitors: Relieve Arrest Disease Progression Symptoms Rapidly Combination Therapy: Arrest Disease Progression and Rapidly Relieve Symptoms Doxazosin/Finasteride/Combination  MTOPS (Medical Treatment of Prostatic Symptoms) & Combination Therapy (Doxazosin/Finasteride/Combination)  In selected patients, combination therapy is most effective in  Reducing risk of clinical progression  Improving AUA symptom score  Improving maximum urinary flow rate  Monotherapy significantly reduces risk of clinical progression of BPH  Finasteride (5ARI) and combination therapy significantly reduce the risk of AUR and invasive therapy  Doxazosin ( -adrenergic blocker) prolongs time to progression of AUR and invasive therapy, but does not  Combination Treatment with -Blocker Plus An Anticholinergic for Bladder Outlet Obstruction Detrol® and Tamsulosin Combination Therapy in Men With BOO and OAB  Improved QoL  Increased bladder capacity, no acute urinary retention  Did not affect quality of urinary flow and postvoid residual urine volume  “The proposed combination of Detrol® and tamsulosin appears to be an effective and relatively safe treatment option in patients with bladder outlet obstruction and detrusor overactivity”  Surgical Therapy Electrosurgical TURP, TUVP, Gyrus, TUIP Laser,PVP, HoLAP,HoLEP,ILC, CLAP,VLAP Open Suprapubic Retropubic Perineal Minimally-Invasive, TUMT, TUNA, WIT, TEAP, Botox, ILC  Transurethral Resection of the Prostate (TURP) Advantages Availability of long-term outcomes data Good clinical results Treats prostates 1A Aging effects 1B> 1A  Prevalence of BPH Versus Other Common Conditions BPH (Men Ages 61 to 72) Diabetes (Adults Over 65) Asthma (Entire Population) 0 25 50 75 Natural History of BPH: Prostate Volume Increases