BENIGN BENIGN PROSTATIC PROSTATIC

HYPERPLASIAHYPERPLASIA

This disease is described by ancient physicians such as Avicenna, Paracelsus and others

Location and function Location and function of the prostateof the prostate

The prostate is a small gland The prostate is a small gland

present only in men which is about present only in men which is about the size of a chestnut.the size of a chestnut.

Location and function of Location and function of the prostatethe prostate

The prostate produces a fluid which The prostate produces a fluid which forms a part of the semen.forms a part of the semen.

During sexual intercourse, sperm During sexual intercourse, sperm pass from the seminal vesicles into pass from the seminal vesicles into the urethra and are carried through the urethra and are carried through the urethra in fluid squeezed out from the urethra in fluid squeezed out from the prostate gland during orgasm.the prostate gland during orgasm.

Enlargement of the Enlargement of the BPHBPH

In many, indeed, most men, the In many, indeed, most men, the prostate progressively enlarges as prostate progressively enlarges as they get older.they get older.

More than 50% of men over the age More than 50% of men over the age of 60 and 80% of men over the age of 60 and 80% of men over the age of 80 have benign (i.e. not of 80 have benign (i.e. not cancerous) enlarged prostates.cancerous) enlarged prostates.

Doctors call this enlargement of the Doctors call this enlargement of the prostate 'benign prostatic prostate 'benign prostatic hyperplasia' or 'BPH' for short.hyperplasia' or 'BPH' for short.

Enlargement of the BPHEnlargement of the BPH

The prevalence of symptomatic BPH increases with age.The prevalence of symptomatic BPH increases with age. Beyond the age of 60 years, more than 40% of men are affected and Beyond the age of 60 years, more than 40% of men are affected and

almost half of these have significant impairment in quality of life.almost half of these have significant impairment in quality of life.

Enlargement of the Enlargement of the prostate glandprostate gland

As the prostate enlarges, it presses on As the prostate enlarges, it presses on the urethra, which is the tube that the urethra, which is the tube that carries the urine and semen out of the carries the urine and semen out of the body. body.

This causes obstruction, making it This causes obstruction, making it difficult to pass urine. It may also make difficult to pass urine. It may also make you want to go to the toilet more often you want to go to the toilet more often and empty the bladder incompletely. and empty the bladder incompletely.

Enlargement of the prostate glandEnlargement of the prostate gland

SymptomsSymptoms of BPH

BPHBPH

BPH complicationsBPH complications

UTI UTI (5-10%) (5-10%) Acute urine retentionAcute urine retention (0.4-6%) (0.4-6%) HematuriaHematuria (2-3%) (2-3%) Chronic kidney insuffiencyChronic kidney insuffiency Bladder stonesBladder stones Upper urinary tract dilatationUpper urinary tract dilatation

Acute retentionAcute retention

Bladder problemsBladder problems

• Distension of the ureters and back pressure on the kidneys may produce tiredness and loss of appetite.

• Because of the high pressures in the bladder, 'pouches' called diverticula may form at weak points in the bladder wall. This may result in the need to pass urine twice in rapid succession.

BPH stagesBPH stages

I. I. CompensationCompensation II. II. SubcompensationSubcompensation III. III. DecompensationDecompensation

Quantification of symptoms

Symptoms should be quantified by using the International Prostate Symptom Score (I-PSS) and Quality of Life Assessment.

The scores derived allow this tentative classification of symptoms as shown in Table .

Symptom scores.Symptom scores.

0-7 mildly symptomatic

8- 19 moderately symptomatic

20 - 35 severely symptomatic

Digital rectal examination (DRE)

This procedure should be performed to evaluate the prostate gland with regard to approximate size, consistency, shape, and abnormalities suggestive of prostate cancer.

Physical examinationPhysical examination should assess:- Suprapubic area to rule out significant bladder tone- Sphincter toneBulbocavernosus reflex plus brief assessment of motor and sensory function in lower body

Interpreting results of Interpreting results of DREDRE

BPH and prostate cancer are two distinct diseases, although they may coexist in the same patient. Patients should be advised that no clear evidence exists that BPH predisposes to development of cancer.

Urinalysis

It is used to determine if the patient has

- Haematuria

- Proteinuria

- Pyuria

Renal-function assessment

- Should be determined by serum creatinine test

Uroflowmetry

Uroflowmetry, an non-invasive technique, is recommended in the initial diagnostic assessment and whenever appropriate during and after treatment to determine response .

Maximal urinary flow rate (Qmax) is the best single measure, but a low Qmax does not distinguish between obstruction and decreased bladder contractility.

Ultrasonography

Residual urine The determination of residual urine is

recommended in the initial diagnostic assessment of the patient during and after treatment to determine response.

Ultrasonography

Prostate specific antigen

PSA is an important indicator of prostate cancer because it is a protein secreted exclusively by prostatic epithelial cells and is elevated in the serum of most patients with BPH or prostate cancer.

X-Ray ExaminationX-Ray Examination

Excretory urographyExcretory urography Retrograde cystographyRetrograde cystography Retrograde urethrography gives only indirect information on the Retrograde urethrography gives only indirect information on the

effect of benign prostatic enlargement (BPE) on adjacent structures. effect of benign prostatic enlargement (BPE) on adjacent structures.

««Fish-hookFish-hook»» symptom symptom

CystoscopyCystoscopy

The standard endoscopic procedure for diagnostic evaluation of the lower The standard endoscopic procedure for diagnostic evaluation of the lower urinary tract (urethra, prostate, bladder neck and bladder) is a urinary tract (urethra, prostate, bladder neck and bladder) is a urethrocystoscopy.urethrocystoscopy.

This investigation can confirm causes of outflow obstruction while This investigation can confirm causes of outflow obstruction while eliminating intravesical abnormalities. eliminating intravesical abnormalities.

CT MRICT MRI

Differential DiagnosticsDifferential Diagnostics

Differential DiagnosticsDifferential Diagnostics

Treatment of BPHTreatment of BPH

Most treatments for prostate enlargement aim to reduce the size of the prostate and its restrictive effect on the urethra.

This may be done either with drugs or by surgery.

Those with only minor symptoms need no treatment. This is sometimes called 'watchful waiting'.

Treatment ofTreatment of

BPHBPH

Treatment of prostate enlargementTreatment of prostate enlargement

In general, if symptoms are mild or moderate, either no treatment or treatment with tablets will be tried at first.

The risk of side-effects with tablets is small and they usually disappear if treatment is stopped.

Contraindications to medical treatment of Contraindications to medical treatment of BPHBPH

Acute urinary retentionAcute urinary retention Palpable bladder, large volume of post-void Palpable bladder, large volume of post-void

residual urine (>300ml)residual urine (>300ml) Renal insufficiencyRenal insufficiency Recurrent haematuriaRecurrent haematuria Recurrent urinary tract infections secondary Recurrent urinary tract infections secondary

to BPHto BPH Bladder stones or diverticulaBladder stones or diverticula Evidence of prostate cancerEvidence of prostate cancer

Non-invasive methodsNon-invasive methods

Transurethral Laser Interstitial AblationTransurethral Laser Interstitial Ablation

Transurethral Laser Needle AblationTransurethral Laser Needle Ablation

Transurethral Microwave thermotherapyTransurethral Microwave thermotherapy

High Intensity Focused UltrasoundHigh Intensity Focused Ultrasound

Intraprostatic stentsIntraprostatic stents

Operative treatmentOperative treatment

IndicationsIndications:: Medication is Medication is ineffective ineffective Residual urineResidual urine Repetitive urine retentionRepetitive urine retention Upper urinary way dilatationUpper urinary way dilatation HematuriaHematuria Recurrent UTIRecurrent UTI

TURP – transurethral prostatectomy(“gold standart”)TURP – transurethral prostatectomy(“gold standart”) TUIP –Transurethral incision of prostateTUIP –Transurethral incision of prostate

Open operationOpen operation

Transurethral incision of the prostate

(TUIP) Transurethral incision of the prostate

(TUIP) is not the most common prostate operation, but may be the most suitable procedure when the prostate is still quite small, and is becoming increasingly popular with urologists.

Transurethral resection of the prostate (TURP)

TURP is the most frequently performed operation for BPH.

It is carried out under a general anaesthetic and usually takes about 30-60 minutes. TURP involves passing an instrument up the urethra and cutting away the middle of the enlarged prostate.

Transurethral resection of the prostate (TURP)

Retropubic prostatectomy (RP)

Retropubic prostatectomy (RP) is an operation that is usually performed only if the prostate is very large by means of a cut through the skin.

Prostatic stents

Stents are small metal coils that are inserted into the urethra to hold the walls open.

Two types of stent are available - temporary and permanent.

Transrectal hyperthermia

Transrectal hyperthermia uses microwave energy to destroy some of the prostate tissue by heat.

The procedure is carried out without anaesthesia and takes about 60 minutes;

Transurethral thermotherapy

Transurethral thermotherapy uses microwave energy to destroy some of the prostate tissue by heat.

The procedure is carried out under local anaesthesia, which means that you will be awake throughout the operation, which takes about 60 minutes.

Transurethral thermotherapy

Laser therapy

Laser energy is used to destroy some of the prostate tissue by intense local heat. The procedure is carried out under a general anaesthetic and takes about 20 minutes.

High intensity focused ultrasound therapy

High intensity focused ultrasound is a very new technique that is used to destroy some of the prostate tissue by heat.

Cancer ProstateCancer Prostate

Prostate Cancer is n 'fifth place in the disease in men after 45 years

prostate cancerprostate cancer

In 1995, were approximately 244 000 new cases and 44 000 deaths from In 1995, were approximately 244 000 new cases and 44 000 deaths from prostate cancer (PC)-numbers that will continue to rise as the population prostate cancer (PC)-numbers that will continue to rise as the population ages . Ninety-five percent of prostate cancer is diagnosed in men between ages . Ninety-five percent of prostate cancer is diagnosed in men between 45 and 89 years of age with a median age of diagnosis of 72 years.45 and 89 years of age with a median age of diagnosis of 72 years.

CClassification of CaPlassification of CaP

T Primary tumour T Primary tumour Tx Primary tumour can not be Tx Primary tumour can not be

assessed assessed T0 No evidence of primary tumour T0 No evidence of primary tumour T1 Clinically inapparent tumour not T1 Clinically inapparent tumour not

palpable or visible by imaging palpable or visible by imaging T1a Tumour incidental histological in T1a Tumour incidental histological in

5% or less of tissue resected 5% or less of tissue resected T1b Tumour incidental histological T1b Tumour incidental histological

finding in more than 5% of tissue finding in more than 5% of tissue resected resected

T1c Tumour identified by needle T1c Tumour identified by needle biopsy because of prostate specific biopsy because of prostate specific antigenantigen

T2 Tumour confined within the T2 Tumour confined within the prostate prostate

T2a Tumours involves one lobeT2a Tumours involves one lobe T2b Tumour involves both lobesT2b Tumour involves both lobes

T3T3 Tumours extends through the Tumours extends through the prostatic capsule prostatic capsule

T3a Extracapsular extension (uni- or T3a Extracapsular extension (uni- or bilateral) bilateral)

T3b Tumour invade Seminal vescile(s) T3b Tumour invade Seminal vescile(s) T4 Tumour is fixed or invades adjacent T4 Tumour is fixed or invades adjacent

structures other than seminal vesicles: structures other than seminal vesicles: bladder neck, external sphincter, bladder neck, external sphincter, rectum, levator ani and/or pelvic wallrectum, levator ani and/or pelvic wall

Digital rectal examinationDigital rectal examination

Ultrasound imagingUltrasound imaging

CT MRICT MRI

MRIMRI

PSAPSA

Total PSA (Prostate Specific Antigen) is used in the Tumour Marker Lab Total PSA (Prostate Specific Antigen) is used in the Tumour Marker Lab primarily in the management of prostate cancer. It is used as a diagnostic primarily in the management of prostate cancer. It is used as a diagnostic test, along with Free PSA and the Free vs.Total PSA Ratiotest, along with Free PSA and the Free vs.Total PSA Ratio

Age related Reference Ranges:Age related Reference Ranges: <50 years = <2.5 µg/L<50 years = <2.5 µg/L 50-60 years = <3.5 µg/L50-60 years = <3.5 µg/L 60-70 years = <4.5 µg/L60-70 years = <4.5 µg/L >70 years = <6.5 µg/L>70 years = <6.5 µg/L

TTreatmentreatment