Benign Prostatic Hyperplasia by Artjola Puja

Benign Prostatic Hyperplasia

Artjola Puja

All rights reserved. No part of this publication may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations em- bodied in critical articles or reviews.

For information contact; e-mail : artjolapuja97@outlook.com September 2018

CONTENTS

CONTENTS.....................................................III PROSTATE GLAND...........................................1 BENIGN PROSTATIC HYPERPLASIA..................5 EPIDEMIOLOGY...............................................5 CAUSES & RISK FACTORS...............................6 HORMONAL & MICROSCOPIC PATHOPHYSIOLOGY.........................................7 SYMPTOMS...................................................10 POTENTIAL COMPLICATIONS.........................11 DIAGNOSIS...................................................12 TREATMENT..................................................18 PROGNOSIS..................................................26 QUESTIONNAIRE...........................................28

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INTRODUCTION Prostate Gland

What is the prostate? The prostate is a small gland that is part of the male reproductive system. It has usually the size and shape of a walnut and grows bigger as men get older. It sits underneath the bladder and surrounds the urethra, which is the tube men urinate and ejaculate through.

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What does the prostate do? The prostate only appears in males. It secretes a fluid that nourishes and protects sperm. It contains a number of ingredients, including enzymes, zinc, and citric acid. During ejaculation, the prostate squeezes this fluid into the urethra, and itâ&#x20AC;&#x2122;s expelled with sperm as semen. One of the enzymes found in prostatic fluid is prostate-specific antigen (PSA); after ejaculation, PSA makes thickened semen runnier, helping sperm travel through urethra more easily, increasing their likelihood of successfully fertilizing an egg. To function properly, the prostate needs androgens (male hormones), such as testosterone and dihydrotestosterone (DHT).

Prostate Conditions Prostatitis: Inflammation or infection of the prostate and is diagnosed as one of three types: acute bacterial prostatitis, chronic bacterial prostatitis, or chronic non-bacterial prostatitis/chronic pelvic pain syndrome.In some cases, it is treated with antibiotics. Enlarged prostate: Called benign prostatic hypertrophy or BPH, prostate growth affects virtually all men over 50. Symptoms of difficult urination tend to increase with age. Medicines or surgery can treat BPH. Prostate cancer: Itâ&#x20AC;&#x2122;s the most common form of cancer in men (besides skin cancer), but only one in 35 men die from prostate cancer. Prostate cancer usually causes no symptoms unless it has spread outside the prostate. Surgery, radiation, hormone therapy, and chemotherapy can be used to treat prostate cancer.

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What changes should I look out for? Most people urinate up to eight times each day, depending on how much they drink, and their bladder can usually hold around 300 to 400 ml. But everyone is different. If the bladder is working normally, one should know when your bladder is full and have enough time to find a toilet. It is recommended to empty it completely every time people urinate and shouldnâ&#x20AC;&#x2122;t leak urine. Our body makes more urine in the evening than during the day. In some individuals, the fluid we take in during the day pools into our lower extremities, and when we lie down, some of that fluid gets back into circulation. The heart and the kidneys recognize that there is extra fluid and that you need to eliminate it. Most people can sleep for six to eight hours without having to urinate more than once. This will be affected by how much and how recently they had a drink before going to sleep. As men get older, they will probably need to urinate more often. They may wake up to urinate once in the early morning â&#x20AC;&#x201C; this is common in older men.

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Possible changes when men urinate or have any urinary problems, they could be a sign of a problem in prostate. Urinary problems are common in older men and are not always a sign of a prostate problem. They can also be caused by an infection, another health problem such as diabetes, or some medicines. The lifestyle can also affect the way you urinate. For example, drinking too much will make you urinate more often, while alcohol, caffeine and fizzy drinks can make some urinary problems worse. In the older male, symptoms may be the result of a blockage in the tubes due to a benign (non-cancerous) enlargement of the prostate gland (benign prostatic hyperplasia â&#x20AC;&#x201C; BPH).

BENIGN PROSTATIC HYPERPLASIA

Benign prostatic hyperplasia Benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland, is the most common benign tumor found in men. Histologically, BPH describes a proliferative process of both the stromal and epithelial elements of the prostate gland. An enlarged prostate is very common in men over the age of about 50. As the prostate grows, it can press on the outside of the urethra (the tube you urinate through) and slow down or stop the flow of urine. Having an enlarged prostate doesnâ&#x20AC;&#x2122;t increase your risk of getting prostate cancer. But itâ&#x20AC;&#x2122;s possible to have an enlarged prostate and prostate cancer at the same time.

Epidemiology Global differences in epidemiology statistics depend somewhat on how BPH is defined. Study parameters used to determine prevalence may include prostate volume, an International Prostate Symptom Score, maximum flow rate, and presence of postvoid residual volume. BPH occurs more often in the West compared to Eastern countries, such as Japan and China, and may be more common among blacks. Not long ago, a study found a possible genetic link for BPH in men younger than age 65

ARTJOLA PUJA who have a very enlarged prostate: Their male relatives were four times more likely than other men to need BPH surgery at some point in their lives, and their brothers had a six-fold increase in risk. Enlarged prostate is fairly common in older men and more likely to develop with advancing age, particularly after age 40. The prevalence of BPH is about 10 percent for men in their thirties, and 20 percent for men in their forties, according to a 2005 report for the USA. It rises as high as 60 percent for men in their sixties, and up to 80 to 90 percent for men in their seventies and eighties. In 2010, BPH affected 210 million men worldwide, or about 6 percent of the male population. The number of people with BPH is expected to increase significantly in the next few decades because of the growing elderly population and increasing life expectancy across the globe.

Causes and risk factors It is not clear what causes BPH, but the condition may be the result of hormonal changes that are part of our natural aging process. Males produce the hormones testosterone and estrogen throughout their lives, but the relative amount of these hormones vary over the time. As a man ages, the amount of active testosterone in his bloodstream drops relative to his estrogen levels, which may affect certain substances that influence prostate cell growth. BPH may also be related to the male hormone dihydrotestosterone, which plays a role in prostate development and growth and continues to accumulate in old age despite the drop in testosterone. As with estrogen, dihydrotestosterone may encourage prostate cell growth.

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Various factors may raise your risk of developing BPH, including: 

Being over age 40



A family history of BPH



Obesity



Lack of physical activity or exercise



Erectile dysfunction (ED)



Heart and cardiovascular diseases



Type 2 diabetes

Hormonal and Microscopic Pathophysiology Despite the fact that reasons for the development of benign prostatic hyperplasia are not fully understood, the impact of hormones on the disease is well documented. While men produce large amounts of male hormones called testosterone throughout their lives and small amounts of female hormones, estrogen, as they get old, the production of testosterone decreases, creating an impairment and resulting in BPH. This explains why the only group of men who do not develop BPH are those who have had the testicles removed due to a cancer or any other disease.

ARTJOLA PUJA Simultaneously, dihydrostestosterone (DHT) accumulates in the prostate due to a process during which type II 5-alpha-reductase metabolizes, circulating testosterone into DHT. DHT and androgen receptors connect to each other in the cell nuclei and end up resulting in benign prostatic hyperplasia. Based on this fact, researchers have focused on the blockage of alpha-1-adrenergic receptors in the smooth muscle of stroma and capsule of the prostate and in the bladder neck, which has been proven effective in relaxing the muscles and relief the symptoms of the disease.

The microscopic pathophysiology of benign prostatic hyperplasia demonstrated the hyperplastic process that occurs in the gland. The hyperplasia is a result of the swollen prostate, which blocks the normal flow of urine from the bladder through the urethra to be expelled. The prostate enlargement is faced as a normal part of male aging, while the most typical explanation for the disease focus on the fact that the swollen gland cannot radially expand due to the surrounding capsule, but it can

BENIGN PROSTATIC HYPERPLASIA compress the urethra. But researchers also note the importance of obstruction-induced bladder dysfunction in the development of symptoms. In addition, analyzing microscopically the features of benign prostatic hyperplasia reveal that there is an increased sensitivity known as detrusor overactivity in the bladder that contribute for both urinary frequency and BPH symptoms, even if there is little urine in the bladder. Throughout time, the walls of the bladder become weaker and the organ may lose the ability to fully empty during urination. Bladder obstruction also results in smooth-muscle-cell hypertrophy.

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Symptoms The lower urinary tract symptoms of BPH can be categorized as wither obstructive (related to pressure or blockage) or irritative.

Obstructive symptoms include: 

Trouble starting to urinate, despite a strong urge to go



Straining when urinating



Weak urine flow



Urinating for a long time



Urinary retention (inability to completely empty the bladder)



Overflow incontinence (involuntary loss of urine from an overly full bladder, often when there is no urge to urinate)

BENIGN PROSTATIC HYPERPLASIA 

Dribbling at the end of urinating

Irritative symptoms include: 

Having to urinate frequently



A strong urge to urinate, sometimes resulting in incontinence (involuntary loss of urine)



Needing to urinate frequently while sleeping



Painful urination



Pain after ejaculation



Ability to urinate only in small amounts



Urine with an unusual color or smell

In the most severe cases, BPH may prevent urination completely — a serious medical problem. But some men only have mild symptoms that aren't bothersome enough to make them seek medical attention.

Potential Complications Complications from BPH can develop if the condition is not treated. The following table includes the potential complications appearing over time in untreated or mistreated patients with BPH:

ARTJOLA PUJA COMPLICATION

TIMEFRAME

LIKELIHOOD

BPH Progression

short term

low

Urinary tract infection

short term

low

Renal insufficiency Bladder stones Hematuria Sexual dysfunction

short term short term short term short term

low low low low

Acute urinary retention

long term

low

Overactive bladder

long term

low

Diagnosis If a man experiences symptoms of BPH, he should see a doctor. Seeking treatment early may prevent complications and damage to the bladder or kidneys. Seeing a doctor also helps rule out other causes. Prostate cancer, inflammation of the prostate and kidney stones can cause similar symptoms in men. Diagnosis should include a careful history and directed physical exam. Men with the following features should be referred urgently to a urologist: ď&#x201A;ˇ

Microscopic or macroscopic hematuria: increases the possibility of prostate or bladder cancer

ď&#x201A;ˇ

Neurologic disease (such as long-standing diabetes): may suggest neurogenic bladder

BENIGN PROSTATIC HYPERPLASIA 

History of prior urologic surgeries and urethral stricture



History of recurrent infection



Palpable bladder



Abnormal digital rectal exam suggesting prostate cancer



Abnormal prostate-specific antigen (PSA) levels.

History History and suggestive symptoms of BPH include possible voiding and storage symptoms. Voiding symptoms include hesitancy, intermittency, weak stream, straining, incomplete emptying and postvoid dribbling. Storage symptoms include urinary frequency, nocturia and urgency. There are many other factors and diseases that appear with similar symptoms as the BPH, which should take into consideration as potential causes. Medication such as diuretics, anticholinergics, and adrenergic alpha-agonists may affect urinary flow rate or affect prostate bladder tone mimicking BPH. Cardiovascular and renal disease may present with polyuria or nocturia. Sexual dysfunction including erectile dysfunction co-exists frequently in patients with lower urinary tract symptoms (LUTS).

Physical Examination

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A digital rectal exam should be done to asses anal sphincter tone and estimate the size of the prostate and to assess for prostate nodules or rectal masses. Bladder palpation and inspection of the external meatus should be performed. A neurologic exam may be necessary depending on the patient's history.

Voiding diary If the patient has significant nocturia, completion of a frequency/volume chart voiding diary for a few days should be documented and reviewed, as this can be a useful tool to objectify symptoms and detect polyuria (>3 liters of urine in 24 hours).

Laboratory evaluation Initial workup should include a urinalysis and may include a prostatespecific antigen (PSA) blood test, which checks for high levels of a

BENIGN PROSTATIC HYPERPLASIA prostatic protein. PSA is a good predictor of prostate volume and prostate growth. However, it should be used in appropriate circumstances. An alternative laboratory indicator of BPH is the serum creatinine, but it is recommended if renal insufficiency is suspected secondary to comorbidities or in anticipation of surgical intervention.

Urodynamics Uroflowmetry is a noninvasive measure of peak urinary flow rate and is considered optional testing in patients with moderate to severe BPH. It is used to evaluate how well the urinary tract stores and releases urine.

Imaging Urinary tract imaging with ultrasound or computed tomography is not recommended unless the patient has one of the following: chronic

ARTJOLA PUJA retention, recurrent UTI/hematuria, renal insufficiency, urolithiasis, or a history of prior urinary tract surgery. ď&#x201A;ˇ

Cystoscopy, a procedure to look inside the urethra and bladder

ď&#x201A;ˇ

Transrectal ultrasound, in which a probe is inserted in the rectum to create images of the prostate. It is used to assess if the bladder is emptying completely and to examine your kidneys

Biopsy Biopsy is commonly used to rule out the potential risk of prostate cancer in patients with suspicious symptoms. The most common type of prostate biopsy is a core needle biopsy.

For this procedure, the doctor puts a thin, hollow needle into the prostate gland. When the needle is pulled out it removes a small cylinder of prostate tissue called a core. This is often repeated several times to sample different areas of the prostate.

AUA symptom score

BENIGN PROSTATIC HYPERPLASIA The AUA symptom score, which is similar to the International Prostate Symptom Score, is a self-administered patient questionnaire with 7 questions that should be completed in the initial workup. It is a reliable, accurate predictor of lower urinary tract symptoms (LUTS). At the end of the book, you will find the questionnaire and related scores to evaluate the symptoms of LUTS and the potential risk of BPH.

Treatment

ARTJOLA PUJA The main goal of therapy for patients with BPH is to improve lower urinary tract symptoms (LUTS), both voiding and storage, in order to improve quality of life. All patients should be advised on self-directed behavioral management programs such as limitation of fluids, bladder training focused on timed and complete voiding, and treatment of constipation, which may help patients regulate urinary symptoms. Similarly, a review of the patient's medication list will help identify opportunities to modify or avoid medications that may impact symptoms of BPH.

Watchful waiting Patients who present with mild symptoms and whose symptoms are not bothersome may be managed with watchful waiting. This implies both self-monitoring of symptoms progression by the patient and periodic

(yearly) follow-up by the physician to reassess the condition. Patients in this category may also be substantially aided by behavioral modification techniques such as fluid avoidance after dinner, limitation of caffeinated beverages, and avoidance of diuretics or medications that increase urinary retention.

The following table demonstrates some of the foods, a patient suffering from BPH should avoid. 18

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FOODS EFFECTS OF FOOD TO AVOID Meat elevates levels of arachidonic acid in your body, and that, in turn, increases inflammation, the very Red meat thing your enlarged prostate does not need. Choosing alternatives such as lean meat and fish is a better option. Egg yolks have high levels of arachidonic acid, which Eggs and causes inflammation. Try eating only the egg white, as poultry this is a good source of protein. Processed These kind of foods increase inflammation in your foods & system. sugar Avoiding or limiting the caffeine intake including coffee, tea and fizzy drinks can make a big difference to your urinary health. Caffeine has a diuretic effect, which means it increases your urge to go to the toilet. Instead, try drinking chamomile tea which has antiCaffeine inflammatory properties, green tea which had antioxidant benefits. An important drink for the prostate is water. It is vital to stay well hydrated, but remember to try not to drink anything at least 2 hours before bedtime. Curries, chili, hot sauces can make tasty meals but men with enlarged prostate need to be wary of spicy Spicy foods foods like these, as they can irritate the bladder and prostate, causing urinary symptoms associated with BPH. Dairy

A low fat diet is a recommended way to help relieve BPH symptoms. As diary is typically high in saturated fats, it is best to limit the intake of this food type. However, it does not mean that you have to avoid them 19

Alcohol

ARTJOLA PUJA totally, just try to get the low fat versions instead. Alcohol acts as an irritant in the bladder and prostate, resulting in the need to urinate frequently.

Medical therapy For patients with bothersome symptoms of BPH, who do not require surgery, initial management should be pharmacotherapy.A variety of drugs are available, which are all appropriate for first-line treatment based on patient characteristics or symptoms. Drug therapy and response should be reassessed every 6 to 12 months. 

Alpha-blockers are efficacious within a matter of a few days and usually well tolerated. These drugs include: Hytrin (terazosin), Flomax (tamsulosin), Uroxatral (alfuzosin), Cadura (doxazosin).However, men exposed to prostate-specific alphablockers have been shown to have significantly increased risks of falling and fracture, as well as increased risk of hypotension and head trauma.



5-alpha-reductase inhibitors are used as an initial therapy in patients with larger prostates over 30 grams. This group of drugs includes: Proscar (finasteride), Avodart (dutasteride). They block production of the hormone dihydrotestosterone (DHT), which is involved in prostate cell growth. These drugs are effective at reducing prostate size, decreasing the short-term risk for acute urinary retention and invasive surgery. They require several months of use to improve symptoms. 5-alpha-reductase inhibitors can also be added to alpha-blocker therapy for patients with symptom progression on monotherapy.



Phosphodiesterase-5 (PDE-5) inhibitors, such as Cialis (tadalafil) and Viagra (sildenafil), may improve LUTS, erectile function, and quality of life, and may be considered for patients

BENIGN PROSTATIC HYPERPLASIA with comorbid BPH and erectile dysfunction. PDE-5 inhibitors improve LUTS and erectile function with a negligible change in flow rate. PDE-5 inhibitors in combination with alpha-blockers improved flow rate compared with alpha-blockers alone.

Surgical therapy Patients should be referred to a urologist for therapeutic invasive therapy if they have: 

Chosen surgical therapy as primary treatment



Refractory responses to medication



Complications attributed to BPH, such as renal insufficiency, bladder stones, recurrent hematuria or UTIs, or refractory urinary retention.

There are a variety of procedures that can be performed, and the decision of procedure type is best done in collaboration between the patient and urologist with respect to risk/benefit of each procedure and patient comorbidities.

Invasive therapy if prostate volume <80 grams: 

Minimally invasive therapies include transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA). These procedures can be performed as a day-case, but efficacy

ARTJOLA PUJA and durability are not comparable to transurethral resection of the prostate (TURP).

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ď&#x201A;ˇ

Moderately invasive procedures are TURP and transurethral vaporization of the prostate (TUVP). TURP and TUVP are more invasive and entail more risk, but can improve symptoms to a greater degree. TURP is the standard surgical procedure for men with prostate sizes less than 80 grams and bothersome lower urinary symptoms due to BPH.

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ď&#x201A;ˇ

Laser vaporization may also be used to resect or ablate prostate tissue. Photoselective vaporization (PVP), holmium laser enucleation (HoLEP), or thulium laser enucleation (ThuLEP) techniques can be done under local anesthesia on an outpatient basis. These procedures have fewer bleeding complications when compared to TURP. Laser prostate vaporization or enucleation may be preferred in patients on anticoagulation because of their hemostatic effect on prostate tissue.

BENIGN PROSTATIC HYPERPLASIA Invasive therapy if prostate volume ≥80 grams: Open prostatectomy has become less common for LUTS as other techniques have continued to gain acceptance. It is generally only recommended for patients who are good surgical candidates and have significantly enlarged prostates (typically ≥80 grams). Prostatectomy means removal of the prostate gland. This surgery can be done in two ways: a radical prostatectomy, and an open simple prostatectomy. 

In a radical prostatectomy, your surgeon will remove the entire prostate gland along with surrounding tissue, including lymph nodes. This procedure is commonly done in men with prostate cancer.



In an open simple prostatectomy, your surgeon will remove only the problematic part of the prostate, not the entire gland. This procedure is usually recommended for men who suffer from an enlarged prostate.

The table below presents some data on the need to have a repeat operation for BPH within 24 months after a first procedure. This provides one indicator of how effective the procedures are. The given information is based on the federal Medicare data, a national health insurance program in the USA, for 2013.

PERCENTAGE OF MEN WHO REQUIRED PROCEDURE ANOTHER OPERATION WITHIN 24 MONTHS TURP 2.2% TUMT 11.9% 25

ARTJOLA PUJA TUNA PVP laser

14% 2.05%

Prognosis The majority of patients with BPH can expect at least moderate improvement of their symptoms with a decreased bother score and improved quality of life. Lower urinary tract symptoms (LUTS), secondary to BPH, may affect sexual wellbeing including erectile function. Medical therapy for BPH may also affect sexual function, beneficially and harmfully, so this must be considered on an individual basis. Some studies suggest that patients with a low risk for progression may be able to discontinue first-line therapy with alpha-blockers after several months of therapy. However, the majority of patients will require ongoing therapy.

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Questionnaire Prostate Symptom Score In Past Month have you had the under mentioned symptoms ? 1. Have you felt like your bladder is not completely empty after urination in the past month ? o

None (0 points)

Less than once every 5 times (1 point)

Less than once every 2 times (2 points) 27

ARTJOLA PUJA o

About once every 2 times (3 points)

More than once every 2 times (4 points)

Almost always (5 points)

2. Have you had to go to the toilet within 2 hours of doing so in the past month ? o o o o o o

None (0 points) Less than once every 5 times (1 point) Less than once every 2 times (2 points) About once every 2 times (3 points) More than once every 2 times (4 points) Almost always (5 points)

3. Have you had disrupted urination in the past month? o o o o o o 4.

None (0 points) Less than once every 5 times (1 point) Less than once every 2 times (2 points) About once every 2 times (3 points) More than once every 2 times (4 points) Almost always (5 points) Have you found it hard to control urine in the past month ? o

None (0 points)

Less than once every 5 times (1 point)

Less than once every 2 times (2 points)

About once every 2 times (3 points)

More than once every 2 times (4 points)

Almost always (5 points)

5. Have you had a case of weak urination in the past month ? o

None (0 points)

Less than once every 5 times (1 point) 28

BENIGN PROSTATIC HYPERPLASIA o

Less than once every 2 times (2 points)

About once every 2 times (3 points)

More than once every 2 times (4 points)

Almost always (5 points)

6. Have you had to strain to initiate urination in the past month ? o

None (0 points)

Less than once every 5 times (1 point)

Less than once every 2 times (2 points)

About once every 2 times (3 points)

More than once every 2 times (4 points)

Almost always (5 points)

7. How many times do you on the average get up to urinate at night after going to bed in the past month ? o

None (0 points)

Once (1 point)

Twice (2 points)

3 Times (3 points)

4 Times (4 points)

5 times or more (5 points)

Total Criteria Point Count: 29

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Table of evaluation: 0 to 7 Points: 8 to 19 Points: 20 to 35 Points:

Minimal symptoms Moderate Symptoms Severe symptoms

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