Lecture: Prostate Diseases, # 71 Doctor: Rami Al-Azab, MD Done by: Mohammad Jaradat

The lecture is divided into 2 parts; BPH and Prostate Cancer. As you know, the prostate is present in an organs crowded area; anteriorly the pubic bones, posteriorly the rectum, inferiorly the external sphincter and the pelvic floor, and superiorly the bladder. The urethra passes through the prostate so many conditions in the prostate affect the urethra. In the prostatic urethra there is an area called the vermantanium through which the ejaculatory ducts opens. BPH: BPH is one of the most common diseases that affect men over the age of 40. The prevalence of the disease increases with age. The prostate enlarges during male life from just a filmy layer after birth to a size of a chestnut in adulthood. There is a poor correlation between the size of the prostate and the degree of the urethric obstruction what is more important is the direction of the prostate enlargement and the resting tone (in BPH the prostate enlarge inwardly, in cancer it enlarge outwardly). Many terms are used for this disease as Bladder Outlet Obstruction (BOO), lower urinary tract symptoms (LUTS), Benign Prostatic Enlargement, infravasical obstruction, Benign Prostatic Hyperplasia, the best one is bladder outlet obstruction because until you prove it is hyperplasia, you cant call it BPH. BPH is clinically evident in 50% of men by the age of 50 and 80% by the age of 80. Androgens play a role in prostate growth at puberty, but this process will not continue for ever; it will be remodeled by process of apoptosis. There are two components for prostate obstruction; a mechanical one caused by the hyperplasia and a dynamic one by increased smooth muscles tone. This obstruction will lead to what is called lower urinary tract symptoms (LUTS), but these symptoms arent caused only by BPH, other conditions can cause these symptoms like urethric strictures, neurogenic,, on the other hand not every obstruction gives symptoms. The adjacent figure illustrates that BPH, BOO,
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LUTS are different things that overlap. But if the growth is over years why patients comes in acute condition? It is proposed that the bladder compensation fails at one point so patients come with acute retention, studies was conducted at time of acute retentions by taking prostate biopsies that show in 80% of the cases an element of prostate infarction that lead to profuse edema causes acute retention. As you know the innervation of the Bladder is under the parasympathetic (cholinergic) system and the prostate and the bladder neck is under sympathetic (adrenergic) system. So the micturition is parasympathetic function and continence is sympathetic function as will as ejaculation, so anxiety in sex lead to faster ejaculation. This piece of information led to use of a group of drugs to treat BPH which are the antiadrenergic family, the older drugs was nonselective and led to many side effects, the newer drugs are uroselective working on the subtypes of receptors in the prostate and bladder neck. The picture shows the inside of the prostatic urethra, the inferior (whitish) structure is the vermananium with the opening of the ejaculatory duct, notice how the prostatic tissue grows inwardly in BPH (the upper darker structures). Note: it is important to see the vemantanium because, anatomically talking, the external sphincter surrounds the vermantanium, so the resection stops proximal to it; because any distal resection may injure the sphincter. Note: BPH is accompanied by neovascularization (which are weak vessels that tend to bleed), so the most common cause of hematuria in males over the age of 40 is BPH. Note: the most common cause of hematuria in female over the age of 40 is UTI. Note: the most common cause of hematuria in both sexes is transitional cell carcinoma. This figure shows the urinary flow in patient with BPH,
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Notice that the patient had hesitancy for about 20 sec Interruptancy (arrow) Second void (asterisk) The accumulative urine volume is about 300ml You cant determine if the patient strained or not. Etiology of BPH: - androgens have permissive role. - Estrogrns - Stromal-epithelial interactions: Paracrine growth factor signaling Cell proliferation and Apoptosis; they found that the stroma secrete growth factors that stimulate the glandular tissue to grow. - Inflammatory cells (chronic inflammation) in the prostate. - Smooth muscles stimulated by adrenergic nerves. - Nervous supply has a permissive role and allows for maximal growth. Clinical manifestation of BPH: BPH present itself in different ways because of the difference in growth rates, compensation of the bladder, muscular tone, Symptoms of BPH: 1. Hesitancy 2. Weakness of urinary stream 3. Intermittent urinary stream 4. A feeling of incomplete bladder emptying and need for repeat voiding 5. Bladder irritability, as manifested by urinary frequency, nocturia, and urinary urgency. These symptoms arent specific for BPH as they can be seen in other patients or even in normal people. So what is important is the AUA/IPSS system. So the approach to a patient with LUTS: 1- History: AUA (American urological association)/ IPSS (international prostate symptom score) is a system to evaluate the prostate symptoms severity over the last month. Continue the history for any other urogenital symptoms; flank pain, hematuria, and a full medical history for the patient. 2- Physical examination: Focused neurovascular exam of the lower extremities and saddle regions. For example: a patient with walking and voiding problems could have a prolapsed disk.
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 Digital rectal examination: a problem in DRE is that, it is affected by the skill of the examiner. Urinalysis: Greater than 3 RBC per high-power filed of uninfected urine requires IV urography and cystoscopy to rule out cancer of the kidney or bladder. Voiding diary: is a chart given to the patient to fill it with the time of each voiding. Note: LUTS Associated With Suspicious DRE, Hematuria, Abnormal PSA, Pain, Infection, Palpable bladder, Neurologic disease must be carefully evaluated. Other diagnostic test: Uroflowmetry. Post void residual urine volume. Pressure flow studies-urodynamic evaluation. Prostate-specific antigen (PSA) should be part of the initial workup. The most important one is the AUA/IPSS score, because it is easy to be done and with important diagnostic value. The AUA score: Over the past month, how often have you: 1. Had the sensation of not completely emptying your bladder after you finished urinating? (incomplete void) 2. Had to urinate again less than 2 hours after you finished urinating? (frequency) 3. Found that you stopped and started again several times when you urinated? (intermittency) 4. Found it difficult to postpone urination? (urgency) 5. Had a weak urinary stream? (poor stream) 6. Had to push or strain to begin urination? (straining) 7. Had to get up to urinate from the time you went to bed at night until you got up in the morning? (nocturia) The point scale for AUA/IPSS: 0 = Not at all 1 = Less than once in 5 times you have urinated 2 = Less than half the time 3 = About half the time 4 = More than half the time 5 = Almost always

Score 0-7 8-21 20-35

Severity Mild Moderate Severe

To say that a patient is improving, a change of 4 or more on AUA score should happen. An increase in the AUA score means a failure of the medical treatment, and a surgical intervention should be considered.

Complication of BPH: Urinary retention. Renal impairment. Urinary tract infection. Gross hematuria. Bladder stones. Bladder decompensation. Overflow incontinence as a result of retention. The most common is gross hematuria and the rare is renal impairment. Impact of Prostate Volume on treatment options: If the patient has a PSA more than 1.5 ng/mL, this means the prostate is enlarging (not only a dynamic obstruction). If the prostate size more than 30 cc, the patient need maximum treatment. Treatment of BPH: The treatment options for patients with BPH include watchful waiting, medical therapy, and surgical therapy. Therapy choices depend on symptomology. Patients with low symptom scores and a normal PSA are considered ideal candidates for observation and reassurance. These patients are seen on a yearly basis. Symptom scores should be checked over time; patients with increasing symptom scores will progress to more aggressive treatments. In patients with moderate symptoms, medical therapy, minimally invasive therapy, and observation are all accepted options. In those with severe symptomology, medical therapy, MIT, and open surgery comprise the choices for treatment. (The slides). The only thing the doctor said about treatment is: The mainstay of medical treatment are 5-reductase inhibitors and -blockers, if the medical treatment failed we go into other treatment modalities such as Minimally invasive therapy (MIT, such as laser, microwaves, thermotherapy), TURP, Open surgery. Here the doctor stopped talking about BPH escaping about 80 slides, and start talking about prostate cancers, he was reading the slides only with few notes. Prostate cancer: this entity will be transcribed by Radwan Al-Okour Insha2allah.