Prostate diseases are common among aging men. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate that leads to urinary symptoms. BPH prevalence increases with age, affecting 20% of men aged 41-50 and over 80% of men aged 81-90. Treatment options for BPH include lifestyle changes, watchful waiting, medical therapy with alpha blockers or 5-alpha-reductase inhibitors, and surgical procedures like TURP. Prostate cancer is the second most common cancer in men. Screening includes a PSA test and digital rectal exam. Treatment depends on cancer risk and may include active surveillance, surgery, radiation, or hormone therapy.
7. Definition
• BPH is a nonmalignant enlargement of the prostate gland caused by
cellular hyperplasia of both glandular and stromal elements that leads
to troublesome lower urinary tract symptoms (LUTS) in some men
• It is the most common benign tumor in men and is not a
precancerous condition
7
8. Prevalence of BPH
• In men 20 to 30 years of age, the prostate weighs about 20 g;
• However, the mean prostatic weight increases after the age of 50.
• 20% of men age 41-50
• 50% of men age 51-60
• 65% of men age 61-70
• 80% of men age 71-80
• 90% of men age 81-90
lower urinary tract symptoms associated with BPH increase with age
8
10. Berry SJ, et al. J Urol. 1984;132:474-479.
CDC. 2003 National Diabetes Fact Sheet.
Available at http://www.cdc.gov/diabetes/pubs/estimates.htm. Accessed May 16, 2003.
CDC. 1998 Forecasted State-Specific Estimates of Self-Reported Asthma Prevalence.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00055803.htm. Accessed January 8, 2003.
Prevalence of BPH Versus Other Common
Conditions
10
BPH
(Men Ages 61 to 72)
Diabetes
(Adults Over 65)
Asthma
(Entire Population)
0 25 50 75
14. Digital rectal exam
• “If you don’t put your finger in,
you might put your foot in it”
15. Digital rectal exam
• R/O Ca: nodules, asymmetry, hardened ridges, induration;
• R/O prostatitis: tenderness, bogginess;
• R/O anal malignancy and detect undiagnosed neurologic conditions
by evaluating the sphincter tone and perianal sensation
16. Approach to a patient with BPH
• Urinalysis- by dipstick and routine microscopy, urine culture and
sensitivity to R/O infections and hematuria
• Serum PSA-optional to R/O Prostate Cancer
16
17. Serum PSA and Prostate Volume Increases
Correlate with Age
17
Roehrborn CG et al. J Urol. 2000;163:13-20.
18. Approach to a Patient with BPH Contd…
Upper tract imaging (IVP,CT, U/S) only in presence of concomitant urinary tract
disease or complications-hematuria, UTI, renal insufficiency, Hx of stone disease
18
20. Cystoscopy
• Cystoscopy- only for patients
who don’t respond to medical
Trx to determine the need for
surgical approach
21. Treatment of BPH
• Lifestyle modification
• Watchful Waiting
• Medical Therapy
• Phytotherapy (alternative)
• Surgical Treatment : Conventional Surgical or Minimally Invasive Treatment
21
22. Lifestyle Changes
• Enriched diet with ample
amounts of fresh fish, fruits and
vegetables.
• Reduce stress.
• Exercise on a regular basis.
• Weight within normal limits.
• Limit fluid intake, decrease
bladder irritants-caffeine,
alcohol;
• Avoid anticholinergic drugs,
narcotics and skeletal muscle
relaxants.
22
23. Watchful Waiting
• The risk of progression or complications is uncertain
• In men with symptomatic BPH, progression is not inevitable and some men
undergo spontaneous improvement or resolution of their symptoms
• Men with moderate or severe symptoms can also be managed in this
fashion if they so choose
• Neither the optimal interval for follow-up nor specific endpoints for
intervention have been defined
23
25. Medical Treatment : Alpha blockers Contd…
• Side Effects: dizziness, postural hypotension, fatigue, retrograde ejaculation,
rhinitis, and headaches. May potentiate other antihypertensive medications
25
26. Silodosin
• Preferred for
• Initial management
• Patients with cardiovascular co-morbidities
• Effective in Nocturia
• Patients on Phosphodiesterase type 5 inhibitors
26
Int J Clin Pract. 2013 Jun;67(6):544-51
28. Guidelines
28
• No bothersome symptoms : Watchful waiting
• Bothersome symptoms and prostate volume <30 cc: 2nd and 3rd
generation alpha 1 receptor antagonist
• Significant bothersome and prostate >30 cc: 5-ARI
• Combination of 5ARI and alpha 1 receptor antagonist : recommended
• PDE-5: not recommended
29. Guidelines
29
• Men with enlarged prostates >40 ml: 5α-reductase inhibitors (5-ARIs)
• Phosphodiesterase type 5 inhibitor Tadalafil :
• Reduce LUTS to a similar extent as α1-blockers
• Improves erectile dysfunction
30. Transurethral Resection of the Prostate
(TURP): Overview
Advantages
• Availability of long-term outcomes data
• Good clinical results
• Treats prostates <150 g
• Low retreatment rate
• Low mortality
30
Borth CS et al. Urology. 2001;57:1082-1086.
Mebust WK et al. J Urol. 1989;141:243-247.
Wagner JR et al. Semin Surg Oncol. 2000;18:216-228.
31. Transurethral Resection of the Prostate
(TURP): Overview
Disadvantages
• Retrograde ejaculation
• Bleeding
• TUR Syndrome
• Catheter time
• Hospital Stay
31
32. TURP: Efficacy
• Symptom improvement in 88% of patients
• 82% decrease in AUA Symptom Score
• 125% improvement in peak flow rate (Qmax)
• Re-op rate approx. 1.5%/yr
32
Jepsen JV et al. Urology. 1998;51(suppl 4A):23-31.
35. Surgical Treatment : Conventional Surgical
Treatment
Open Prostatectomy
• Not done routinely
• When prostate too large for TURP (>100mL)
• Concomitant conditions - bladder diverticulum or
bladder stone present, recurrent or persistent urinary
tract infections, acute urinary distention, bladder
outlet obstructions, recurrent gross hematuria of
prostate origin, pathological changes in the bladder,
ureters, or kidneys due to prostate obstruction
35
39. INTRODUCTION
• Prostatitis is an inflammation of the prostate gland, that is
caused by infectious agents(bacteria, fungi and
mycoplasma) or other conditions including urethral
stricture, prostatic hyperplasia.
• Overall prevalence in men is 5
%
• Higher risk age 20-50 years
42. Chronic Prostatitis causes ……
• A primary voiding dysfunction problem, either structural or
functional .
• E coli is responsible for 75-80% of chronic bacterial prostatitis cases.
• Enterococci
• Pseudomonas
• C trachomatis,
• Ureaplasma species,
• Uncommon organisms, such as M tuberculosis and
• Histoplasma, and Candida species , must also be considered.
43. • Tuberculous prostatitis may be
found in patients with………
• Renal tuberculosis
• Human immunodeficiency virus
• Cytomegalovirus
• Inflammatory conditions (eg,
sarcoidosis)
• Asymptomatic inflammatory
prostatitis is usually diagnosed in
individuals who have no
symptom, but are found to have
an inflammatory process in the
prostate.
44. DIAGNOSTIC EVALUATION
• History collection and physical
examination
• Culture of the prostate fluid or
tissue and occasionally histological
examination of the tissue
• Urine analysis and culture
• CBC
• MRI and transabdominal
ultrasound
46. Complications
• Bladder outlet obstruction/urinary retention
• Abscess - Typically in immunocompromised patients
• Infertility due to scarring of the urethra or ejaculatory ducts
• Recurrent cystitis
• Pyelonephritis
• Renal damage
• Sepsis
49. Epidemiology
• It’s the second most common cause of death from cancer in men
(following lung cancer)
• Nearly 3,00,000 men die every year from prostate cancer
• More than 12,00,000 men are diagnosed every year
• Average annual cancer incidence rate for prostate cancer in India
ranged 5.0-9.1 per 1,00,000/year
55. 55
PSA(ng/ml) DRE RISK OF CA
(%)PROSTATE
NORMAL NORMAL 15
NORMAL ABNORMAL 20
4-10 +/- 30
>10 +/- 60-70
Prostate Cancer Detection as a Function of
Serum Prostate-Specific Antigen (PSA) Level
and Digital Rectal Examination (DRE)
56. • In summary, both PSA and DRE are used to assess the risk that
prostate cancer is present.
• The addition of PSAto DRE increases both the detection rate of
prostate cancer and the detection of cancers with a more favourable
prognosis.
59. Estimated Effect Number of Men
Men invited to screen 1,000
Men diagnosed with prostate CA 100
Men who ultimately undergo radical prostatectomy or radiation
treatment
80
Men who develop sexual dysfunction 50
Men who develop urinary incontinence 15
Men who die of prostate cancer despite screening, diagnosis,
and treatment
5
Men who avoid dying of prostate cancer 1.3
Men who avoid metastatic prostate cancer 3
61. Prostate Imaging-Reporting and Data System
(PI-RADS)
• PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)
• PI-RADS 2: low (clinically significant cancer is unlikely to be present)
• PI-RADS 3: intermediate (the presence of clinically significant cancer is
equivocal)
• PI-RADS 4: high (clinically significant cancer is likely to be present)
• PI-RADS 5: very high (clinically significant cancer is highly likely to be present)
62. Prostate Biopsy
• > 1,20,00,000 prostate biopsies are performed yearly in the US
• Elevated PSA most frequently triggers biopsy
• 30% of men referred for biopsy are diagnosed with prostate cancer
• Relies on random sampling – 12 core biopsy
63. Indications
• Abnormal serum prostate-specific antigen (PSA) level.
• Abnormal digital rectal examination (DRE) include the presence of
nodules, induration, or asymmetry.
87. CRPC
• Hormone-refractory prostate cancer is defined as
2-3 consecutive rises in prostate-specific antigen (PSA)
• levels obtained at intervals of > 2 weeks
• and/or
• Documented disease progression based on:
Findings from PET CT scan or bone scan.
Bone pain.
Obstructive voiding symptoms.
With castration levels of Testosterone: ( < 50 ng/dl)
90. In Summary
• BPH (Benign prostatic hyperplasia) becomes increasingly common as men age
• Many men with BPH are asymptomatic or have only mild symptoms, and may not require therapy
• Alpha-adrenergic antagonists provide immediate therapeutic benefits and are first line treatment
for smaller prostates <40mL and mild symptoms
• 5-alpha-reductase inhibitors require long-term treatment for efficacy and are beneficial for larger
prostates >40 mL mild to moderate symptoms
• TURP is the GOLD STANDARD for men who require an invasive procedure and are in good health
• Routine bacterial prostatitis can be treated as an Outpatient
91. In Summary
• Lack of prostate cancer awareness & education about the disease/detection
• No symptoms until disease is advanced
• Once diagnosed, there’s no single “best” treatment
• Every treatment has side effects
• If detected early, it can be cured… There IS a cure for cancer – under the right circumstances!
• It is possible to lower the risk by limiting high-fat foods, increasing the intake of vegetables and
fruits and performing more exercise
93. • 50 year old male presented to you with incidental finding of 50 cc
prostatomegaly on U/S
• What next?
• P/R?
• Refer to a Urologist?
• Serum PSA?
94. • 53 year old diabetic male presented to you with LUTS with history of
fever
• Serum PSA?
• U/S abdomen?
• Refer to a Urologist?
95. • 46 year old male with family history of prostate cancer
• Serum PSA?
• P/R
• Refer to a Urologist?
96. • 90 year old male who is bedridden comes to your OPD on a stretcher
with chief complaints of urinary incontinence
• Serum PSA?
• P/R?
• U/S abdomen?
• Refer to a Urologist?
97. • 66 year old male presented to your opd for second opinion whether
to continue tamsulosin + dutasteride (taking since 3 years) for LUTS
prescribed by another physician. His U/S shows 80 cc prostatomegaly,
PSA – 3 ng/dl
• P/R - Hard
• Refer to a Urologist?