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1. BENIGN PROSTATIC
HYPERPLASIA
(BPH)
ERICK L. NGOSSO
2024

2. FORMAT
•Definition
•Surgical anatomy
•Epidemiology
•Etiology
•Pathophysiology
•Clinical presentation
•Workup
•Treatment
•Complications

3. DEFINITION
•BPH is a non-cancerous enlargement of the prostate gland that may restrict
the flow of urine from the urinary bladder
•It is the most common cause of bladder outlet obstruction (obstructive
uropathy) in the male geriatric population

4. SURGICA ANATOMY

5. Position
•The prostate gland forms
part of the male
reproductive system
•It is located in front of the
rectum and just below the
urinary bladder

6. Structure
•The prostate is a walnut-sized gland weighing 15-20g
•Composed of:-
•The capsule-surrounds the gland
•The parenchyma-composed of:-
•Fibrous tissue
•Smooth muscles-mediated by -adrenergic receptors
•Glandular tissue
•Divided anatomically into 4 zones and 5 lobes

7. Prostatic zones
•Peripheral zone
•Central zone
•Transition zone
•Anterior fibro-muscular zone

9. Peripheral zone
•Comprises of 70% of the normal prostate gland
•More than 70% of prostatic cancers originate from this portion of the gland

10. Central zone
•Comprises approximately 25% of the normal prostate gland
•This zone surrounds the ejaculatory ducts
•Central zone tumors account for more than 25% of all prostate cancers

11. Transition zone
•Contributes apprx 5% of the prostate weight
•The transition zone surrounds the prostatic urethra
•is the region of the prostate gland which grows throughout life
•It is responsible for the benign prostatic enlargement (BPH)

12. Anterior fibro-muscular zone
•Accounts for approximately 5% of the prostatic weight
•This zone is usually devoid of glandular components, and composed only of
muscle and fibrous tissue

14. Prostatic lobes
•Anterior lobe
•Posterior lobe
•2 Lateral lobes
•Median lobe

15. Functions of the Prostate gland
•Produces alkaline fluids that comprises 70% of seminal volume
•It is a conduit for semen to pass
•Prevents retrograde ejaculation by closing off the bladder neck during
sexual climax
•Produces alkaline fluids that help to neutralize the acidic vaginal
environment
•Provides carbohydrates and nutrients for the sperm

16. ETIOLOGY
•Is unclear. Multifactorial.
•Factors related to development of disease are:-
i) age ii) hormonal status (DHT).
•Normal part of aging process in men.
•Is homonallydependent on testosterone and dihydro-testosterone.
Castrated males do not develop BPH.

17. PATHOPHYSIOLOGY
•Need to understand the following:-
•Site of BPH formation
•What is the effect of enlarged prostate gland?
•What is the effect of bladder outlet obstruction

18. Site of BPH formation
•BPH develops in the periurethral transition zone of the prostate gland
involving both stromal and epithelial elements of the gland

19. What is the effect of enlarged prostate ?
•As the prostate gland enlarges, the surrounding capsule prevents it from
readily expanding prostatic urethral compression
•Prostatic urethral compression causes bladder outlet obstruction
•Bladder Outlet Obstruction occurs as a result of both
•Static factors [mechanical enlargement of the gland]
•Dynamic factor [increased prostatic smooth muscle tone, mediated by -adrenergic
receptors]

20. What is the effect of BOO
•Bladder outlet obstruction causes hypertrophy of the detrusor muscleand
thickening of the bladder walldue to increasing workload against the outflow
resistance
•Bladder wall thickening causes:-
•detrusor contractilityforce of the urinary stream, hesitancy, intermittency,
increased residual urine e.t.c. (obstructive symptoms)
•Detrusor instability [compliance]frequency, nocturia, urgency e.t.c. (irritative
symptoms)

21. Pathophysiology cont’d
•Bladder wall thickening also causes increased oxygen
demand tissue ischemia trabeculation, saccule and
diverticulum formation in the bladder BLADDER WALL
THINNING
•When the obstruction is not relieved, hydronephrosis,
hydroureter and renal failure can occur
•As a result of increased residual urine, stasis can lead to
infection and stone formation in the bladder

24. CLINICAL PRESENTATION
•History
•Physical Examination

25. History
•Lower urinary tract symptoms
•Symptoms related to complications

26. Lower urinary tract symptoms
•Obstructive symptoms (voiding /emptying related symptoms)
•Irritative symptoms (retention/filling / storage related symptoms)

27. Obstructive symptoms
•Difficulty in passing urine
•Hesitancy
•A sensation of incomplete emptying
•Terminal dribbling
•Urinary retention

28. Difficulty in passing urine
•Characterized by:-
•Progressive loss of force and calibre of urinary stream (weak and narrow
stream)
•Interrupted urinary flow
•Worse on straining
•Not related to change in posture

29. Hesitancy
•Delay in starting the act of micturation i.e. the patient has to wait for a
while before starting the act of micturation

30. A sensation of incomplete
emptying
•A feeling of incomplete emptying

31. Terminal dribbling
•The patient continue to dribble at the end of urination

32. Urinary retention
•Acute urinary retention
•Is sudden inability to void
•It is a painful condition and the patient cries in agony
•Chronic urinary retention
•Is gradual accumulation of urine in the bladder due to inability of the patient to
empty the urinary bladder completely
•Painless, can progress to renal failure

33. Irritative symptoms
•Day time frequency
•Nocturia
•Urgency
•Urge incontinence
•Dysuria

34. Day time frequency
•The patient present with increased urinary steam during day time
•This is due to inadequate emptying of the bladder and due to presence of
sensitive prostatic mucosa membrane of the intravesical enlargement of
prostate gland

35. Nocturia
•The patient present with increased urinary frequency during night hours
•The patient gets up in the middle of night twice or thrice to pass urine

36. Urgency
•Intense desire to pass urine (void)

37. Urge incontinence
•When the patient feels urgency to pass urine and if it is not possible a few
drops may come out

38. Dysuria
•Painful micturation

39. Symptoms related to complications
•Haematuria
•Loin pain
•Hernias
•Haemorrhoids
•Etc

40. History
cont………..
•Take detailed history including neurologic history, medications,
sexual history, previous attempted treatments.
•Quantification of the symptoms by IPSS= International Prostate
Symptom Severity score.
•Symptoms: onset, duration, severity, how they affect quality of life.

41. IPSS
IPSS; 7 questions symptom severity scale 0-5.
Total score = 0-7 mildly symptomatic, 8-19 moderately
symptomatic,
20-35 severely symptomatic.
IPSS ; 8
th
question bother score scale 0-6.

42. Physical Examination
•Digital rectal examination

43. Digital rectal examination (DRE)
•Position
•Dorsal
•Knee-chest position
•Left lateral
•Look for
•The size of the gland
•Grade 0: prostate gland not enlarged
•Grade I: able to reach the upper limit of the gland easily
•Grade II: able to reach the upper limit of the gland with difficulty
•Grade III: not able to reach the upper limit of the gland
•Consistency-firm
•Surface -smooth
•Median sulcus –not obliterated
•Mobility of the rectal mucosa-free
•Examining finger –usually stained with normal stool

44. WORK UP
•Laboratory investigations
•Imaging investigations
•Endoscopic investigations
•Histopathological investigations

45. Laboratory investigations
•Full blood picture
•Grouping and cross-matching
•Serum creatinine & urea
•Serum electrolytes
•Urinalysis
•Mid Stream Urine for Culture & Sensitivity
•Serum PSA levels (Prostatic specific antigen)********
oBPH IS NOT prostate cancer.
oLarge prostates have SLIGHTLYhigher PSA levels.

46. Imaging investigations
•Plain KUB xrays
•Urological ultrasound
•Trans-rectal ultrasound (TRUS)

47. Plain KUB x-rays
•To rule out radio-opaque stones in the urinary tract system

48. Urological ultrasound
Demonstrates the whole urinary tract system –renal, ureters, urinary
bladder& prostate gland
In case of BPH-it assesses the size (in grams) and the volume of residual
urine

49. Trans-rectal ultrasound (TRUS)
•To demonstrate enlargement and allow estimation of the volume of prostatic
tissue
•It does not assess the whole Urinary Tract System

50. Endoscopic investigations
•Cystoscopy

51. Cystoscopy
•To assess the state of the urinary bladder e.g. presence of stones,
trabeculation, saccule, tumors etc

52. Histopathological investigations
•To confirm diagnosis and to rule out malignancy

53. TREATMENT
•Classified as:-
•Emergency treatment
•Elective treatment

54. Emergency treatment
•Aim: to relieve urinary retention
•Achieved through:
•Urethral catheterization
•Suprapubic cystostomy (SPC)

55. Elective treatment
•Watchful treatment
•Medical treatment
REFER
•Surgical treatment

56. Watchful treatment
•Patients with only mild symptoms with little impact on quality of life and
with no evidence of complications can be managed conservatively
•Education, Reassuarnce, Periodic monitoring.
•Life-style modifications
o–avoidance∕ moderation of
o-caffeine & alcohol.
o-use relaxed & double voiding techniques.
o-bladder re-training
o-review patients medications.
o-treat constipation.

57. Medical treatment
•Medical treatment is a suitable for patients with moderate LUTS
•It is also indicated to patients who are younger in age (<50 years) who are
not happy with the potential consequences of surgical treatment e.g.
impotence, retrograde ejaculation…… etc
•Agents:
•Alpha-Adrenergic Antagonists
•5-αReductase Inhibitors

58. Alpha-Adrenergic Antagonists
•Contraction of the prostatic smooth muscle occurs due to activation of the
NA alpha-1 receptors
•Inhibiting these receptors relaxes the smooth muscle and decreases urinary
outflow resistance, thereby improving symptoms
•Agents: Prazosin, Phenoxybenzamine
•Response to treatment occurs with 2 weeks of treatment

59. 5-αReductase Inhibitors
•Testosterone is converted to DHT by the enzyme 5-alpha reductase within
the prostate cell
•DHT induces BPH by acting on the prostate tissue
•5-alpha reductase inhibitors decrease the production of DHT and thereby
arrest prostatic hyperplasia
•Agents: Finasteride

60. Pharmacological treatment according to; STANDARD TREATMENT
GUIDELINES AND NATIONAL ESSENTIAL MEDICINES LIST FOR TANZANIA
MAINLAND SIXTH EDITION 2021

61. Surgical treatment
•Remain the gold standard for symptomatic BPH
•Goals of treatment include
•Symptomatic improvement
•Enhancement of bladder emptying and flow dynamics
•Preservation of bladder and upper tract function
•Resolution of haematuria if present

62. Indications for surgical treatment
•Recurrent haematuria
•Renal impairment or hydronephrosis
•Recurrent urinary tract infections
•Large residual urine (>200 ml)
•Associated conditions requiring surgery eg vesical calculus
•No improvement on medical treatment

63. Types of surgeries
•Transurethral resection of the prostate (transurethral
prostatectomy, TURP)
•Open prostatectomy
•Transvesical prostatectomy (Freyer’s prostatectomy(1901)
•Retropubic prostatectomy
•Transperineal prostatectomy-has been abandoned
•Laser ablation technique
•Thermotherapy (microwave treatment)
•Intra-prostatic stents
•Balloon dilatation

64. Complications of BPH
•Local complications
•Systemic complications

65. Local complications
•Renal complications
•Ureteric complications
•Vesical complications
•Urethral complications

66. Renal complications
•Hydronephrosis
•Ascending pyelonephritis
•Renal stones

67. Ureteric complications
•Hydroureter
•Ureteric stones

68. Vesical complications
•Vesical calculus
•Cystitis
•Diverticulum
•Trabeculation
•

69. Urethral complications
•Compression of prostatic urethral into an A-P slit

70. Systemic complications
•Hypertension
•Renal insufficiency renal failure
•Anemia

71. DIFFERENTIAL DIAGNOSIS.
•Urethral stricture -trauma, STD.
•Neurogenic bladder.
•Carcinoma of urinary bladder.
•Cystitis.
•Bladder stones.
•Prostatitis, prostatic abscess.
•Carcinoma of prostate.
•UTI.
•Dettrusorsphincter dysynergia.

72. ASSIGNMENT
•OUTLINE PREVENTION OF BPH

73. THANK YOU