Benign Prostate Hyperplasia
Benign prostatic hyperplasia (BPH) is a common condition among aging individuals, leading to troublesome lower urinary tract symptoms and a reduced quality of life. Typically, patients receive medication for relief, and surgery becomes an option for those with persistent symptoms. Transurethral resection of the prostate has long been the conventional treatment. However, there are now several minimally invasive surgical options available.
One such option is Prostatic Artery Embolization (PAE), which has been gaining recognition as an effective treatment with minimal reported side effects. It involves minimal blood loss, and most patients do not need to stay in the hospital overnight. This procedure is recommended for patients experiencing moderate to severe lower urinary tract symptoms due to bladder outlet obstruction, resulting in reduced urinary flow. Successful outcomes rely on careful patient selection and precise embolization techniques
Patho-physiology of BPH:
| Prostate Growth Phases | - Puberty: Increase in circulating androgens, leading to a doubling in size. - After 30 years: Gradual increase in size with a pathological feature of BPH. |
| BPH Proliferation Rates | - Epithelium: Approximately 9 times higher in BPH compared to normal prostate tissue. - Stroma: Approximately 37 times higher in BPH compared to normal prostate tissue. |
| Prostate Zones | - Peripheral Zone - Central Zone - Transitional Zone and Periurethral Region - Anterior Fibromuscular Stroma (Fibromuscular Zone) |
| Origin and Evolution of BPH | - Early diffuse gland growth - Small nodule proliferation - Late nodule enlargement |
| Cellular Composition in BPH | - Stromal compartment in normal prostate: 45% - Stromal-to-epithelium ratio in normal prostate: 2:1 - Stromal compartment in BPH: 66-84% - Stromal-to-epithelium ratios in BPH: 4.05:1 to 6.8:1 |
| Smooth Muscle in BPH | - Active smooth muscle tone regulated by adrenergic nervous system. - Passive smooth muscle attributed to extracellular matrix. |
| Response to Therapy | - Smooth muscle predominant nodules: Respond to α-blockers. - Epithelial nodules: May respond to 5α-reductase inhibitors. - Fibrous nodules: May respond to surgery. |
Lower Urinary Tract Symptoms:
| Storage Symptoms | 1. Frequency 2. Urgency 3. Nocturia 4. Urge Incontinence |
| Voiding Symptoms | 1. Weak Stream 2. Hesitancy 3. Straining 4. Intermittent Stream and dribbling 5. Overflow incontinence 6. Chronic urinary retention |
| Post-micturition symptoms | 1. Feeling of incomplete emptying 2. Post-voiding urinary dribbling |
| Pathology of symptoms | 1. Static component - due to increased prostate volume 2. Dynamic component - due to increased prostatic smooth muscle tone or alteration in the response of the bladder neck. |
| Differentials for LUTS | 1. Prostate cancer 2. Bladder carcinoma 3. Urethral stricture 4. Bladder neck contracture 5. Urinary tract infection 6. Prostatitis 7. Overactive bladder 8. Neurogenic bladder |
Pre-Procedural Questionnaires and Investigations:
| Questionnaires | 1. International prostate symptom score (IPSS) 2. Quality of life 3. International index of Erectile Function (IIEF-5) |
| Uroflowmetry | 1. Maximal urinary flow (Q max) rate 2. Average flow rate 3. Voided volume 4. Flow time 5. Time to maximum flow Volume voided should be > 150 ml for accurate study |
| Urodynamic studies- when Flow rate doesn't suggest obstruction, - voided volume <150 ml, - bothersome voiding symptoms with Qmax >10 ml/s; - bothersome voiding symptoms with PVR >300 ml; - bothersome voiding symptoms when invasive treatment is planned | 1. Storage and Voiding pressure measurement 2. Pelvic floor electromyographic activity |
| Measurement of post void residual urine (PVR) | PVR > 300 ml means chronic urinary retention |
| Urinalysis | Identifying issues such as urinary tract infection, diabetes mellitus, and hematuria |
| Imaging studies (USG, CT, MRI) | 1. Measurement of prostate volume (USG) 2. CT/MR angiography - determine course of internal iliac artery, prostatic artery and its anatomical variation 3. MR angiography - parenchymal vascularity, glandular volume, and malignancy |
| Prostate specific antigen (PSA) levels | > 3 ng/ml (or abnormal DRE) |
| Digital Rectal Examination (DRE) | Abnormal findings should be investigated with additional test (like Trans Rectal Ultrasound guided biopsy) |
Management for Benign Prostate Hyperplasia:
| Management | Mechanism of Action/Steps | LUTS and Prostate size | Contraindications | Dysfunctions | |
|---|---|---|---|---|---|
| First line management | 1. Lifestyle modifications such as fluid restriction for nocturia and polyuria 2. Avoidance of α-agonists | 1. Fluid restriction particularly prior to bedtime 2. Avoidance of caffeinated beverages, spicy foods 3. Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants) 4. Timed or organized voiding (bladder retraining) 5. Pelvic floor exercises 6. Avoidance or treatment of constipation | Mild symptoms or patient unbothered by symptoms | ||
| Medical Management (based on symptoms, size of the gland, PSA measurement, and patient preference) | 1. α-adrenergic blockers - (alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin) | 1. Relax smooth muscle tone in the bladder neck and prostatic stroma. 2. Don't alter the natural course of disease | Moderate to severe LUTS Irrespective of prostate size | Tamsulosin - patient planned for cataract surgery | |
| 5-α-reductase inhibitors - (dutasteride and finasteride) | 1. Shrink the prostate (~ 20 - 30%) by inhibiting conversion of testosterone to dihydrotestosterone, which results in decreased cellular proliferation. 2. Delayed onset of action (3–6 months) | Patients of LUTS without prostatic enlargement | |||
| Low-dose oral phosphodiesterase (PDE)–5 inhibitor (tadalafil) | Unknown | ||||
| Combination therapy (alpha-blockers and 5-alpha-reductase inhibitors) | Alpha blocker to be discontinued after 6-9 months of therapy | Moderate-to-severe symptoms and large prostates (>30 g or >40 g) and poor flow rates. | Reduce the disease progression and risk of sexual side effects | ||
| Surgical Management (recommended for patients with unsuccessful medical therapy, desire to stop therapy, significant PVR volume, recurrent urinary tract infections, recurrent hematuria, bladder stones, or postrenal acute kidney injury) | Open prostatectomy | Moderate to severe LUTS For prostate size larger than 80 - 100 grams | |||
| Transurethral resection of the prostate (TURP) | Gold standard for medium sized prostate. | Moderate to severe LUTS For prostate size 30 - 80 ml | Ejaculatory dysfunction in up to 66.1% cases | ||
| Other Transurethral resection methods | Photoselective vaporization (PVP) | Moderate to severe LUTS | |||
| Holmium Laser enucleation of prostate (HoLEP) | Moderate-to-severe LUTS in men with prostate size >80 ml | ||||
| Minimally invasive surgical therapies | Prostate urethral lift | Rigid cystoscope is used to place non-absorbable sutures through prostatic urethra and exiting at periphery, retracting the obstructing tissue. | For patients with prostate volume < 80 ml | Acute urinary retention or with PVR > 250 ml. | No reported ejaculatory dysfunction |
| Transurethral wave vapor thermoablative therapy | Injecting sterile water vapor into prostatic urethra with a cystoscope causing connective thermal destruction of prostate. | Moderate to severe LUTS For patients with prostate volume < 80 ml | Retained sexual function | ||
| Transurethral incision of prostate (TUIP) | Incision made with electrocautery device or laser, beginning at bladder neck and extending up to verumontanum | Moderate to severe LUTS For patients with prostate volume < 30 ml | Improved sexual function compared to TURP | ||
| Transurethral microwave therapy (TUMT) | Using Microwave to induce tissue necrosis | Less commonly performed for bothersome moderate or severe LUTS |
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| Transurethral needle ablation (TUNA) | Using radiofrequency to induce tissue necrosis | ||||
| Prostatic artery embolization | 1. For patients with prostate volume > 40 ml 2. Moderate to severe LUTS, IPSS ≥ 13-18 and quality of life ≥ 3 3. Decreased urine flow rates < 12-15 ml/sec 4. Acute urinary retention | 1. Malignancy 2. Renal insufficiency 3. Large bladder diverticula 4. Bladder stone 5. Neurogenic bladder 6. Neurological disease effecting bladder function 7. Detrusor Failure 8. Urethral stricture 9. Active urinary infection 10. Prostatitis | Retained sexual function | ||