K21-BPH

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Benign prostate hyperplasia

Dr. Syah Mirsya Warli, SpU

Div. of Urology, Dept. Surgery Medical Faculty,

University of Sumatera Utara

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Ref :

• Clinical Manual of Urology, (Philip M.

Hanno et al eds), McGraw-Hill Int ed, 3rd

ed, 2001

• Smith’s General Urology (Tanagho &

McAninch eds), Lange Medical Books, 17th

ed, 2008

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Definition

• Regional nodular growth of varying

combinations of glandular and stromalproliferation that occurs in almost all men

who have testes and who live long enough

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TERMINOLOGY

BPH (Benign Prostatic Hyperplasia):histopathologic diagnosis

BPE (Benign Prostatic Enlargement) :

anatomic diagnosis

BOO (Bladder Outlet Obstruction):anatomic diagnosis

BPO (Benign Prostatic Obstruction):BOO caused by BPE

LUTS (Lower Urinary TractSymptoms): clinical manifestation of

lower urinary tract obstruction

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Introduction

• Common non-neoplastic lesion.

• Involves peri urethral zone.• BPH is common as men age.

• 25% by 50y, but 90% By 80y..!

• About 10% are symptomatic.

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Prevalence

The Most Frequent Benign Tumor in Men

• 70 % of men above 60 years.*

• 90 % of men above 80 years.**

• 30 – 40 % of men above 70 years

• Indonesia : The Second after Stone

• Disease in Urology Clinic ***

* Berry SJ et all J Urol 1984 ;132:474-79

** Carter HB , Coffey DS. Prostate 1990;16 : 39-48

*** Rahardjo D,Birowo P,Pakasi LSMed . J of Ind 1999 ; 8(4) : 260 - 63

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Impact of ageing population

• With life expectancy approaching 80 years inmany countries 88% chance developinghistological BPH

• in life expectancy significantly thenumber of men affected by BPH

• The number of men presenting with BPHsymptoms will ± 45% in the next 10 years

and further in the following decade

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Prevalence of histological BPH with age

11%

29%

48%

77% 87%

92%

0

20

40

60

80

100

31 – 40 41 – 50 51 – 60 61 – 70 71 – 80 80+

Berry SJ et al. J Urol 1984; 132: 474 –9

Prevalence (%)

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Anatomy

• N weight about 20 g

• Classification of Lowsley : 5 lobes : anterior,

posterior, median, right lateral, left lateral• According to Mc Neal :

- peripheral zone

- central zone

- transitional zone- an anterior segment

- a preprostatic sphincter zone

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Causes

- Many theories

- The actual cause still not clear

- Factors are known to be important:

1. Male sex

2. Aging

3. Testosterone

4. Growth Factors (EGF, FGF, IGF II)

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Pathophysiology

• Nodular hyperplasia of glands and stroma.

• Normal 20 to 30 50 to 100 gm.• Press upon the prostatic urethra.

• Obstruction - difficulty on urination

• Dysuria, retention, dribbling, nocturia• Infections, hydronephrosis, renal failure.

• Not a premalignant condition*

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Prostate growth

Increased urethral resistance

Decompensation

Flow

Bladder emptying ,

hesitancy, intermittency

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Mechanism

• Hormonal imbalance with ageing.

• Estrogen sensitive peri-urethral glands.• Accumulation of DHT in the prostate and its

growth-promoting androgenic effect

• Some Drugs (Finasteride) inhibit DHT diminishes prostatic enlargement.

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Symptoms LUTS

• Weaker, smaller

stream

• Hesitancy

• Intermittent /

interrupted flow

• Feeling of incomplete

emptying or retention• Terminal dribbling

• Nocturia

• Frequency

• Urgency

• dysuria

• Symptoms may

worsen with alcohol

and caffeine, coldremedies

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How to Assess the Patient?

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Diagnosis

• Anamnesis

Cardinal symptoms:

Weak Stream

Frequency

Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS

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1. KENCING TIDAK LAMPIASDalam sebulan ini berapa sering anda merasakan sensasi tidak lampias

saat kencing (terasa belum habis) ?

2. Sering Kencing

Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam

2 jam setelah anda Kencing

3.KENCING TERPUTUS PUTUSDalam sebulan ini berapa sering kencing anda terhenti sejenak, lalu mulai

lagi ( Terputus putus)

4.TIDAK DAPAT MENUNDA KENCING

Dalam Sebulan ini Berapa sering anda merasa kesuli tan untuk menunda

Kencing

5.PANCARAN KENCING YANG LEMAHDalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah

6. MENGEDAN SAAT KENCING

Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing

7.KENCING DI MALAM HARI

Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk

Kencing

Gejala Tidak Pernah < 20 % < 50 % =50% > 50 % Hampir Selalu

0 1 2 3 4 5

0 1 2 3

0 1 2 3

2 3

4 5

4 5

0 1

0 1

4 5

4 5

1 2 3

2 3

BPH SYMPTOM SCORE (by :AUA)

4 5

Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4 5kali, =5

0

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.

• IPSS (International Prostate ScoringSystem ).

0 – 7 : Mild

8 - 19 : Moderate20 – 35 : Severe

7 : Watchful & Waiting 7 : Medical treatment

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Diagnosis

Physical

examination:DRE

Prostate:

1. Size2. Nodule

3. Consistency

4. Tenderness

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DRE

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Diagnosis

Uroflowmetry Qmax

Voided volume

Residual urine TAUS

Catheter

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Diagnostic for BPH

• Uroflowmetry :

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Lab test

• Blood Count

• Serum Electrolyte

• Serum Creatinine• Serum PSA

• Urine :

ProteinuriaSediment

Culture

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IMAGING

• TRUS

• Transabdominal Ultrasound

• With Indication :

IVP

Cystography

CT-Scan

MRI

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Trans Rectal Ultra Sonography :

• Volumometry

• Identification of hypoechoic lesions

• Calcification

• Periprostatic vein

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Urethral stricture

Bladder neck contracture Small bladder stone

Locally advanced prostate ca

Poor bladder contractility

Differential diagnosis

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Effects of benign prostatic obstruction

• Irreversible bladder changes

• Thickening of the bladder wall

• Recurrent haematuria

• Bladder diverticulum formation• Repeat urinary tract infections

• Bladder stone formation

• Upper tract dilatation

• Renal impairment

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Complications

• Increased risk of UTI due to urinary retention

• Calculi due to alkalinization of residual urine

• Hematuria due to overstretched blood

vessels

• Pyelonephritis

• Renal failure

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Indication for treatment

• Absolute or near absolute :

- refractory or repeated urinary retention

- azotemia due to BPH

- recurrent gross hematuria- recurrent or residual infection due to BPH

- bladder calculi

- large residual urine

- overflow incontinence

- large bladder diverticula due to BPH

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Treatment

• Watchful waiting

• Medical therapies

• Intervention therapies

• Minimally invasive therapies• Surgical therapies

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Watchful waiting

Altering modifiable factor such as:

– Concomitant drug

– Regulation of fluid intake especially in the evening

– Life style change (avoid sedentary life)

– Dietary advice (avoid excessive intake of alcohol, and

highly seasoned or irritative foods)

Evaluation/ monitoring : after 6 months/ 1 year IPSS, uroflowmetry, post-void

residual urine volume

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Medical therapy

• I.P.S.S. > 7

• Flow > 5 ml/s• Residual urine < 100 ml

• No hard nodule

• PSA < 4 ng/dl

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Medical therapy

• Reducing smooth muscle tone (dynamiccomponent) : α-1 adrenergic blocker

• Short acting : prazosin, afluzosin

• Long acting : doxasosin, terazosin, tamsulosin

• Reducing prostatic mass (static component):5α redutase inhibitor (finasteride, epristeride)

estrogen aromatase inhibitor

LHRH agonist / antagonist GF inhibitor

antiandrogens

• Unknown

phytotherapy

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Adrenergic stimuli

• Alpha adrenergicstimuli increasestonus of smoothmuscle cell in the

trigonum, bladder neck and prostate

• Location of alphareceptor: – Bladder

– Trigonum

– Prostate gland

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Mode of action alpha blocking

agent

• Alpha adrenergic blocking agent blocks

adrenergic stimuli relaxation of the

smooth muscle cell:

– intra urethral pressure

– Improvement of urine flow

R ti l f 5Al h d t i hibit

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Sintesis Protein

Reseptor Inti

+

Transkripsi DNA

T DHT

5-α reductase

Hipotalamus

LHRH

ACTH

DHT

Rationale of 5Alpha reductase inhibitor

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Invasive Treatment for BPH

Absolute indication:

• Chronic Retention

• With Hematuria

• Concomitant Bladder stone• Intractable UTI

• Deteriorating kidney function

Relative indication:

• Huge PVR due to obstruction or low Qmax

• Refuse medical treatment

• Failure in medical treatment

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Intervention therapy

• Minimally invasive therapy – Thermotherapy

• TUNA (Trans Urethral Needle Ablation)

• HIFU (High Intensity Focused Ultrasound)

• TUMT (Trans Urethral Microwave Theraphy)

• Laser

– Stent

• Surgical therapy• TUIP (Trans Urethral Incision of the Prostate)

• TURP (Trans Urethral Resection of Prostate)

• Open prostatectomy

• TUVP (Transurethral Vaporization of the Prostat)

• Laser

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Invasive Treatment for BPH

• TURP (gold standar)

• Laser resection (Hol Yag Laser)

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TURP

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JARINGAN PROSTAT

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TUIP

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ADENOCARCINOMA OF

THE PROSTATE

Dr. Syah Mirsya Warli, SpU Div. of Urology, Dept. Surgery

Medical Faculty,

University of Sumatera Utara

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Ref :

• Clinical Manual of Urology, (Philip M.

Hanno et al eds), McGraw-Hill Int ed, 3

rd

ed, 2001

• Smith’s General Urology (Tanagho &

McAninch eds), Lange Medical Books, 15th

ed, 2000

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• The most common cancer in men

• 2nd most common cause of cancer related death after lung ca

• The choice of th/ for localized disease

must be based on many factors :- grade & stage

- personal preference

- age- performance status

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• Prostate tumors are generally androgen

sensitive and advanced disease is most

often treated by single or combinedandrogen ablation

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Etiology

• Risk factor :

- age > 50

- family history

- ethnic origin African American >>

- androgens

- diet (>> animal fat)- environmental exposure

- insulin-like growth factors

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pathology

• Benign cystadenoma

• Prostatic intraepithelial neoplasia (PIN)

- high grade (2 & 3) 30 – 40% chance of

developing prostat Ca need repeat biopsies• Malignant

- conventional adenocarcinoma

- transitional cell carcinoma

- sarcoma

- metastatic tumour

- hematologic malignancies

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Conventional adenocarcinoma

(small acinar carcinoma)

• Vast majority (95 – 97%) is adenoCa from

acinar epith• Majority lesion in peripheral zone, 20 –

25% from the transitional zone

• Classically discovered after TURP

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Patterns of spread

• Direct extension into the seminal

vesicles & extracapsularly through the

periprostatic nerve routes• Direct extension into the rectum is

uncommon

• Ureteral obstruction 10 – 35%

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• Lymphatic spread is not uncommon

hypogastric, obturator, external iliac,

presacral, common iliac

• 90% distant metastate osseous

• Visceral meta (lung, liver, adrenal) less

common

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Grading & Staging

• Gleason grade based on the degree of

glandular diff and growth pattern

• Mostofi grade based on the degree of nuclear irregularity. The lesion are graded as well,

moderately and poorly differentiated

• Staging systems The American Joint

Committee on Cancer , modified TNM system

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Signs & symptoms

• A prostatic nodule or induration of the gland

hallmark sign

• Consist of :

- symptom of bladder outflow obstruction

- symptom resulting from local extension

- symptom from distant metastase (bonepain, low back pain, weight loss)

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diagnosis

• Digital rectal examination (DRE) any

palpable irregularity 50% chance

• TRUS very sensitive but non specific• Serum marker PSA

• Prostate needle biopsy

• Bone scan

• CT & MRI

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DRE findings that may indicate cancer :

• Asymmetry of the gland

• A nodule within one lobe of the gland

• Induration of part or all of the prostate

• Lack of mobility due to adhesion to surrounding

tissue

• Palpable seminal vesicles

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Treatment for localized disease

• Radical or complete prostatectomy

• Radiation th/ :

- external beam radiation th/

- interstitial brachyth/

• Follow up after treatment for localized disease

- serum PSA single most important parameter

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Treatment for advanced disease

• Prostate Ca is an androgen-sensitive tumor

• Methods of androgen ablation :

bilateral simple orchiectomydiethylstilbesterol

DHT receptor blockade (flutamide, bicalutamide

LHRH agonist (leuprolide)aminoglutethimide

ketoconazole

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• Castration

- easily accomplished, relatively inexpensive,well-tolerated, almost free of complication

- side effects : vasomotor instability, loss of

libido, ED

• LHRH agonist

- long term effects of bone mineralization

- as effective as castration with similar side

effects, administered subcutaneously

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• Antiandrogens- act by blocking DHT receptor

- not as effective as castration or LHRH th/

- do not lower the serum testosterone level do not cause impotence or decreased libido

- side effects : diarrhea & liver function abN

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K21-BPH