Benign Prostatic Hyperplasia (BPH)

I. Etiology, Pathophysiology, Epidemiology, and Natural History

Benign prostatic hyperplasia (BPH) is a pathologic process that contributes to, but
is not the sole cause of, lower urinary tract symptoms (LUTS) in aging men.
Histopathologically, BPH is characterized by an increased number of epithelial and
stromal cells in the periurethral area of the prostate and thus correctly referred to as
hyperplasia and not hypertrophy, a term often found in the older literature. The observed
increase in cell number may be due to epithelial and stromal proliferation or to impaired
programmed cell death leading to cellular accumulation.
Androgens, estrogens, stromal-epithelial interactions, growth factors, and
neurotransmitters may play a role, either singly or in combination, in the etiology of the
hyperplastic process.

II. Evaluation and Nonsurgical Management of Benign Prostatic Hyperplasia.

The clinical manifestations of BPH include LUTS, poor bladder emptying,

urinary retention, an overactive bladder, UTI, hematuria, and renal insufficiency. The
complex of symptoms now commonly referred to as LUTS is not specific for BPH.
Aging men with a variety of lower urinary tract pathologic processes may exhibit similar,
if not identical, symptoms.
A digital rectal examination (DRE) and a focused neurologic examination should
usually be performed. In addition, examination of the external genitalia is indicated to
exclude meatal stenosis or a palpable urethral mass and an abdominal examination is
necessary to exclude an overdistended, palpable bladder. The DRE and focused
neurologic examination are performed to detect prostate or rectal malignancy, to evaluate
anal sphincter tone, and to rule out any neurologic problems that may cause the
presenting symptoms. The presence of induration is as important a finding as the
presence of a nodule and should be correlated with a serum PSA value so that the need
for prostatic biopsy can be assessed and acted upon.
DRE establishes the approximate size of the prostate gland. Estimation of prostate
size is important to select the most appropriate pharmacologic or technical approach.
DRE provides a sufficiently accurate measurement in most cases. The size of the prostate
is not critical in deciding whether active treatment is required. Prostate size does not
correlate precisely with symptom severity, degree of urodynamic obstruction, or
treatment outcomes.
If a more accurate measurement of prostate volume is needed to determine
whether to perform open prostatectomy rather than transurethral resection of the prostate
(TURP), or some other procedure such as laser vaporization, ultrasonography
(transabdominal or transrectal) is more accurate than cystourethroscopy.
A urinalysis should be done either by using a dipstick test or microscopic
examination of the spun sediment to rule out UTI and hematuria, either of which strongly
suggest a non-BPH pathologic process as a cause of symptoms.
Although the measurement of the serum creatinine concentration was
recommended in the initial evaluation of all patients with symptoms of LUTS to exclude
renal insufficiency caused by the presence of obstructive uropathy. At the Fifth
International Consultation on BPH it was suggested that serum creatinine determination
should be optional or secondary Elevated serum creatinine levels in a patient with BPH is
an indication for imaging studies (usually ultrasonography) to evaluate the upper urinary
tract.
A PSA test and DRE increase the detection rate of prostate cancer over DRE
alone. Therefore measurement of the serum PSA value should be performed in patients in
whom the identification of cancer would clearly alter BPH management.
In the absence of prostate cancer the PSA value provides both a guide to prostate
volume and also an indication of the likelihood of response to therapy with 5-reductase
inhibitors.
The International Prostate Symptom Score (IPSS) is recommended as the
symptom scoring instrument to be used for the baseline assessment of symptom severity
in men presenting with LUTS. When the IPSS system is used, symptoms can be
classified as mild (0 to 7), moderate (8 to 19), or severe (20 to 35).
The IPSS should also be the primary determinant of treatment response or disease
progression in the follow-up period. However, the IPSS cannot be used to establish the
diagnosis of BPH. Men (and women) with a variety of lower urinary tract disorders (e.g.,
infection, tumor, neurogenic bladder disease) will have a high IPSS. Nonetheless, the
IPSS is the ideal instrument to grade baseline symptom severity, assess the response to
therapy, and detect symptom progression in those men managed by watchful waiting.
Surgery is generally recommended if the patient has refractory urinary retention
(failing at least one attempt of catheter removal) or any of the following conditions
clearly secondary to BPH: recurrent UTI, recurrent gross hematuria (resistant to 5-
reductase inhibitor therapy), bladder stones, renal insufficiency, or large bladder
Diverticula.
The goals of treatment for BPH include relieving LUTS, decreasing BOO,
improving bladder emptying, ameliorating detrusor instability, reversing renal
insufficiency, and preventing disease progression, which may include a deterioration of
symptoms, future episodes of gross hematuria, UTI, AUR, or the need for surgical
intervention.

NONSURGICAL THERAPY

Watchful Waiting or Self-Help A significant proportion of men with LUTS will

not choose medical or surgical intervention because the symptoms are not bothersome,
the complications of treatment are perceived to be greater than the inconvenience of the
symptoms, and there is a reluctance to take a daily pill owing to side effects and/or the
cost of treatment.
Medical therapies extensively investigated for BPH include -adrenergic
blockers, 5-reductase inhibitors, aromatase inhibitors, and numerous plant extracts.
Newer therapies include antimuscarinic drugs and phosphodiesterase inhibitors (PDEIs)
and several combinations of these agents.
Therapy with -Adrenergic Blockers
Rationale

The rationale for -adrenergic blockers in the treatment of BPH is based on the
hypothesis that the pathophysiology of clinical BPH is in part caused by BOO, which is mediated
by 1-adrenergic receptors associated with prostatic smooth muscle.

Androgen Manipulation
Rationale
The rationale for androgen suppression is based on the observation that the
embryonic development of the prostate is dependent on the androgen dihydrotestosterone
(DHT). Testosterone is converted to DHT by the enzyme 5-reductase.
III. Minimally Invasive and Endoscopic Management of Benign Prostatic Hyperplasia

INTRAPROSTATIC STENTS
The idea of using stents for splinting the lobes of the prostate was derived from
their original use in the cardiovascular system. Eventually it became clear that their major
role was likely to be found in the management of patients who were unfit for surgery, in
either the short or the long term, in which the alternative would have been months or,
indeed, a lifetime of indwelling urethral catheterization.
Temporary Stents
Temporary stents are tubular devices that are made of either a nonabsorbable or a
biodegradable material. They remain in the prostatic urethra for a limited period of time;
they neither become covered by the urethral epithelium nor become incorporated into the
urethral wall. The nonabsorbable stents need to be removed every 6 to 36 months,
depending on which type of material is used. They can usually be removed, and, if
necessary, replaced, without difficulty with the patient under topical anesthesia with
sedation.
Temporary stents are designed for short-term use, to relieve bladder outlet
obstruction (BOO), and to act as an alternative to an indwelling urethral or suprapubic
catheter in high-risk patients considered unfit for surgery.
TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE
Heat treatment of whatever kind to the prostate is intended to reduce outflow
resistance and the volume of the obstruction by increasing the temperature within the
prostate and inducing necrosis of prostatic tissue. The aim is to increase prostatic
temperature to in excess of 60 C.
Transurethral needle ablation of the prostate (TUNA) uses low-level
radiofrequency (RF) energy that is delivered by needles into the prostate and that
produces localized necrotic lesions in the hyperplastic tissue.
The advantage of TUNA is that it can be delivered under topical anesthesia to
patients with symptomatic BPH, causing very precise and reproducible lesions within the
prostate. The patient most likely to benefit from TUNA would be one who had lateral
lobe enlargement and a prostate of 60 g or less.
By far the most common complication reported, however, is post treatment
urinary retention, occurring at a rate between13.3% and 41.6%.
TRANSURETHRAL MICROWAVE THERAPY
The effect of TUMT on prostatic tissue has been studied widely, and a number of
different theories, none mutually exclusive, have been presented. These cover heat
changes and differential blood flow in the prostate, damage to the sympathetic nerve
endings, and induction of apoptosis. TUMT is not as effective as TURP in improving the
objective signs of outflow obstruction, in terms of either PFR or Pdet at PFR. However, it
does seem to have a measurable effect on the prostate because the elasticity of the urethra
is increased after treatment.
TRANSURETHRAL RESECTION OF THE PROSTATE
TURP, as we know it today, was developed in the United States in the 1920s and
1930s Over the years, TURP, as a treatment modality for obstructing BPH, gained
popularity throughout the world. It is now considered the gold standard for the surgical
management of BPH Transurethral surgery of the prostate is usually performed with the
use of a general or spinal anesthetic.
It is recommended that patients should be given a first-generation cephalosporin
in combination with gentamicin before the initiation of surgery. Traditionally, TURP has
been performed using monopolar technology with 1.5% glycine or mannitol as
nonhemolytic fluids for irrigation. This technique has been used for a very long time with
considerable success, but concerns about TUR syndrome have led to the introduction of
bipolar TURP.
Intraoperative Problems
Hemostasis
Transurethral Resection Syndrome
Transurethral Resection Syndrome In the AUA cooperative study (Mebust et al,
1989), TUR syndromeoccurred in 2% of the patients. The syndrome was characterized by
mental confusion, nausea, vomiting, hypertension, bradycardia, and visual disturbance.
Usually, the patients do not become symptomatic until the serum sodium concentration
reaches 125 mEq/dL. The risk is increased if the gland is larger than 45 g and the
resection time is longer than 90 minutes.
Intraoperative Priapism
During the surgical procedure a penile erection may occur, which may obviate the
surgery unless a penile urethrostomy is performed. This has usually been managed by
injecting an -adrenergic agent directly into the corpora cavernosa