Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

1. Definition:

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy or prostate enlargement, is a common condition in older men that progresses slowly and causes urinary problems ranging from mild to severe.

– Approximately 60% of men over 50 experience BPH, with the incidence rising with age, reaching 88% in those over 90.

– 13%-56% of men over 70 experience urinary problems due to BPH.

2. Pathophysiology:

The exact cause of BPH is unknown, but age and hormonal imbalances play a significant role.

– Testosterone plays a key role in the pathogenesis of BPH:

– Testosterone is converted into Dihydrotestosterone (DHT) by the enzyme 5 alpha-reductase.

– DHT directly affects the growth and proliferation of the prostate gland.

– In older men, testosterone levels decrease, estrogen levels increase, leading to an increased ratio of androgen receptors. Additionally, fibroblast growth factors (FGFs) also play a critical role in the cause of BPH.

3. Stages of the Disease:

BPH goes through 3 stages:

– Microscopic Stage:

– Corresponds to the term “BPH (Benign prostatic hyperplasia),” diagnosed through pathological examination showing hyperplasia of muscle cells, connective tissue, and/or glandular cells.

– Macroscopic Stage:

– Lesions grow from the microscopic to macroscopic stage.

– The prostate gland enlarges in volume, exceeding 20 cm3.

– Corresponds to the term “Benign prostatic enlargement (BPE).”

– Symptomatic Stage with Urinary Disturbances:

– Corresponds to the term “BPO (Benign prostatic obstruction).”

– The prostate gland compresses the urethra due to BPH or BPE.

4. Characteristics of BPH Lesions:

– The prostate gland consists of: smooth muscle fibers, collagen, and glandular tissue.

– The smooth muscle fibers in the prostate gland/bladder neck are controlled by:

– The adrenergic system, especially alpha 1-adrenergic.

– The cholinergic system.

– Changes in the ratio between smooth muscle fibers, collagen, and glandular tissue can cause:

– Stimulation of the adrenergic sympathetic nervous system -> Muscle contraction -> Dynamic obstruction hindering the outflow of the urethra and bladder neck.

– The late stage leads to urinary problems and complications.

5. Common Diagnostic Examinations:

– International Prostate Symptom Score (IPSS): Used to track changes in symptoms over time or after intervention. Valuable for treatment indication, prognosis, and monitoring response to treatment.

– Quality of Life (QoL) Score with Urinary Symptoms.

– Digital Rectal Examination (DRE):

– The simplest, fastest, and least expensive option.

– Normal: Prostate gland 3×4 cm, with a clear middle groove, firm texture, smooth surface, non-tender to palpation.

– Suspicion of cancer when: The prostate gland is asymmetrical, firmer than normal.

– DRE is mandatory to assess the characteristics of the prostate: size, surface, texture, boundaries with surrounding areas.

– Prostate-Specific Antigen (PSA):

– A marker protein secreted by prostate epithelial cells.

– PSA is elevated in: cancer, BPH, prostatitis, after procedures: cystoscopy, urethral catheterization, prostate massage, after prostate biopsy within 4 weeks, after ejaculation within 48 hours,…

– Decreased by approximately 50% when using 5 alpha-reductase inhibitors with continuous use for over 6 months.

– Serum PSA ? 4 ng/ml is considered normal.

– Free PSA / Total PSA ? 20%: suspicion of cancer.

– Prostate Ultrasound and Residual Urine Volume Measurement:

– Evaluates size, shape, and visualization of prostate tissue.

– Formula for calculating prostate volume: Prostate volume (cm3) = thickness x width x height x 0.52;

– 1 cm3 volume is equivalent to 1 gram of the gland.

– Prognosis of treatment outcome and suggestion for treatment methods.

– Residual urine volume on ultrasound:

+ Simple, accurate, non-invasive.

+ Residual urine volume on ultrasound < 30 ml: normal.

+ Large residual urine volume (> 200 ml):

– Bladder dysfunction

– Predicts unfavorable response to treatment.

– Computed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI):

– Determines prostate volume, assesses associated pathologies.

– Screening for prostate cancer and guiding repeated biopsies.

– Expensive, not all hospitals are equipped with it.

– Uroflowmetry and Urodynamic Studies:

– Diagnoses obstruction: urine volume per void ? 150 ml.

– Peak flow rate (Qmax):

+ > 15 ml/second: no obstruction

+ 10-15 ml/second: moderate obstruction

+ < 10 ml/second: severe obstruction

– Peak flow rate measurement cannot distinguish between obstruction of the urethra or weak bladder neck function.

– Other Examinations:

– Blood urea and creatinine: Assess kidney function.

– Urinalysis: Detects urinary tract infection.

– Intravenous urography (IVU).

– Urethroscopy and cystoscopy.

6. Definitive Diagnosis of BPH:

– Presence of urinary tract symptoms:

– Obstructive symptoms.

– Irritative symptoms.

– Symptoms: urinary frequency, frequent urination both day and night, hesitancy, weak stream, intermittent urination, incomplete bladder emptying, dribbling, straining to initiate urination.

– Prostate symptom score from moderate to severe: IPSS score ? 8 points, QoL score ? 3 points.

– Digital rectal examination: Prostate gland larger than normal, middle groove blurred or absent, firm and homogeneous texture, smooth surface, clear boundaries; no signs of suspicion of acute or malignant pathologies of the prostate.

– Uroflowmetry (Qmax) shows evidence of urinary tract obstruction: <15 ml/second.

– Ultrasound:

– Prostate volume > 25 cm3.

– No images suggestive of acute or malignant lesions.

– Serum PSA level ? 4 ng/ml.

– When PSA is 4-10 ng/ml, free PSA/total PSA ratio ? 20%.

– Prostate biopsy:

– DRE reveals a hard nodule suspicious of prostate cancer along with abnormal findings on transrectal ultrasound or MRI.

– PSA > 10 ng/ml.

– PSA 4-10 ng/ml but free PSA/total PSA ratio < 20% and/or PSA density ? 0.15ng/ml/g and/or PSA velocity > 0.75 ng/ml/year.

– Transrectal biopsy of 12 samples, 6 samples per lobe in specific locations.

7. Staging of BPH:

– Stage 1:

– No physical lesions.

– Urinary frequency both day and night, residual urine volume ? 50 ml.

– Treatment: Medical management and lifestyle modifications.

– Stage 2:

– Physical lesions present, bladder begins to dilate.

– Residual urine volume increases > 100 ml.

– Urinary symptoms worsen.

– Complications of urinary tract infection.

– Urinary retention multiple times.

– Surgical intervention is necessary.

– Stage 3: Stage of decompensation, clear physical lesions.

– Affects kidney function, renal failure, bladder atony.

– Urine retention > 300 ml.

– Significant infection.

– Hesitancy, dribbling, only 15-20 ml per void, frequent urination, some patients void up to 100 times/day, severe cases can cause continuous dribbling both day and night.

– Systemic symptoms of renal failure due to lower urinary tract obstruction appear abruptly: anemia, poor appetite, fatigue, drowsiness, edema, hypertension.

– Early diagnosis and appropriate treatment can lead to improvement back to Stage 2.

– Without treatment, BPH at this stage can gradually lead to bladder dysfunction and eventually to acute urinary retention, sepsis, and ultimately death.

8. Complications of BPH:

– Urinary retention (complete, incomplete, acute).

– Bladder diverticula.

– Bladder stones.

– Hematuria, pyuria.

– Urinary tract infection.

– Sepsis.

– Renal failure.

– Ureteral dilatation.

9. Treatment of BPH:

– Watchful Waiting:

– Patients with mild to moderate lower urinary tract symptoms, no severe obstruction.

– Lifestyle modifications:

+ Avoid alcohol and coffee.

+ Drink small sips of water multiple times, avoid drinking large amounts of water before bedtime.

+ Avoid using nasal decongestants and antihistamines.

+ Relax, avoid stress.

+ Exercise regularly.

– Medical Management:

– 5-alpha-reductase inhibitors: Reduce Dihydrotestosterone levels, decrease prostate volume. Slow effect.

– Alpha 1-adrenergic blockers:

+ Relaxes smooth muscles in the prostate and bladder neck.

+ Drugs have an early effect.

+ No effect on gland size reduction.

– Anti-muscarinic drugs:

+ Block M3 cholinergic receptors on the surface of bladder neck cells.

– Helps reduce irritative urinary symptoms.

– No effect in improving obstructive symptoms, can even worsen obstruction, contraindicated when residual urine volume > 100 ml.

– Phosphodiesterase inhibitors:

+ Increase the concentration and prolong the duration of cGMP activity.

+ Reduce smooth muscle tone in the bladder, prostate, and urethra.

– Herbal remedies.

– Surgery:

– Indications:

– Stage 1 with intractable urinary retention.

– Stage 2, Stage 3.

– Patients with complications: recurrent hematuria, recurrent UTIs, recurrent urinary retention.

– Patients with systemic diseases: hypertension, COPD, heart failure,… that have been stabilized.

– Methods:

– Open surgery: used in cases of excessively large prostate volume (>80 grams) and/or concomitant: bladder diverticula,…

– Transurethral resection of the prostate (TURP): “gold standard” in surgical treatment, the most prevalent, less complications than open surgery, for BPH with prostate volume ? 80 grams.

– Some minimally invasive interventional techniques:

– Placement of a urethral prostate stent.

– Prostate artery embolization.

– Prostate urethral dilation with a balloon.

– TUNA (Transurethral needle ablation): a method of prostate ablation using a needle through the urethra.

– Laser energy-based intervention: safe, fewer complications.

10. Multiple Choice Questions:

– Prostatic adenoma is a tumor that arises in:

– A. Periurethral region below the seminal vesicle

– B. Periurethral region above the seminal vesicle

– C. Principal portion of the prostate gland around the middle groove

– D. Principal portion of the prostate gland close to the capsule

– The histopathological characteristics of prostatic adenoma:

– A. Fibrous tissue occupies an insignificant proportion

– B. No glandular tissue

– C. Only fibrous tissue, hence the name prostatic adenoma

– D. Fibrous tissue occupies the majority

– Obstruction due to prostatic adenoma depends on:

– A. Size of the adenoma

– B. Hardness of the adenoma

– C. Compensation by increased bladder contraction

– D. Stage of development of the adenoma

– To make a definitive diagnosis of prostatic adenoma, it is necessary to:

– A. Find bladder stones

– B. Acid phosphatase test

– C. X-ray of the urinary tract

– D. Cystoscopy

– Common symptoms of prostatic adenoma are:

– A. Dysuria

– B. Polyuria

– C. Urinary retention

– D. Dysuria

Note:

This text is for general informational purposes only and does not substitute for medical advice. If you have any health concerns, please consult a doctor for appropriate advice and treatment.