i presented this when i was a resident in CMC, Bangladesh

1. Evaluation of the patient with
BPH
Presented by :
Dr. Md. Ishtiaqul Haque Mortuza (Labib)
Resident
Department of Urology
Chittagong Medical College & Hospital

2. • BPH gives rise to LUTS ( lower urinary tract
symptoms) and Obstruction of varying
degree.
• “Symptom” is what the patients are worrying
about and “Obstruction” is what the urologist
should be concerned about
• Though the majority of patients with LUTS are
due to BPH, but some patients may have LUTS
due to other causes.

3. How to evaluate a patient with BPH ?
Evaluation of a patient with BPH includes the
following steps to establish a correct diagnosis

4. History takingHistory taking

5. Pt. with BPH gives history of -
1. Obstructive symptoms:
• Hesitancy/Intermittency
• Decreased force and caliber of stream
• Sensation of incomplete bladder emptying
• Straining to urinate
• Post void dribbling
• Double voiding
2. Irritative symptoms:
• Urgency
• Frequency
• Nocturia

6. • Hesitancy- during micturation urine flow stops
and starts for several times
• Double voiding- second time voiding with in 2
hrs of last void
• Frequency- frequent micturation within a
short interval
• Urgency- difficult to postpone urination
• Nocturia- waking up from sleeping to urinate
at night

7. IPSS
(International Prostate Symptom Score)
IPSS
(International Prostate Symptom Score)
• IPSS is used to asses the severity of the
symptoms. This consist a score sheet of
obstructive & irritative symptoms mentioned
previously.
• There are some questions that will refer both
the obstructive & irritative symptoms

9. • The severity is scored from ‘none at all (0)’ to
‘almost always (5)’ giving rise to a maximum
score of 35.
IPSS score 0-7 Mild symptom
score 8-19 Moderate symptom
score 20-35 Severe symptom

10. Quality of LifeQuality of Life

11. Physical examinationPhysical examination

12. Physical examination includes:
1.DRE (Digital Rectal Examination)
2.Examination of genitourinary system
3.Focused neurological examination
4.Examination of hernial orifice
5.Related General examination including
cardiopulmonary status of the patient

13. DRE
(Digital Rectal Examination)
DRE
(Digital Rectal Examination)

14. Points to be noted in DREPoints to be noted in DRE
• Size of the prostate May be enlarged
• Surface Smooth
• Consistency Firm, elastic
• Rectal mucosa Free from prostate
• Median sulcus Obliterated
• Any rectal mass Absent
• Anal tone Normal
• Upper limit Can be reached

15. Examination of genitourinary systemExamination of genitourinary system
• External urethral meatus – normal
• Urethra – no palpable mass or cord like feeling
• Urinary bladder –
May or may not be palpable (> 200 ml)
Percussion of suprapubic region(dull on percussion)
• Kidney – usually not palpable
• Testis, Epididymis, Hydrocele, Varicocele

16. Focused Neurologic examinationFocused Neurologic examination
To exclude neurogenic bladder we have to take
history & perform examinations.
History
1. H/O stroke
2. H/O Any spinal injury
3. H/O DM
4. H/O Alteration of bowel habit (e.g. constipation)
Examinations
1. Perianal sensation
2. Bulbocavernosus reflex
3. Anal tone
4. Lower extremity function (motor & sensory)

17. Relevant investigationsRelevant investigations

18. Investigation required for the evaluation of a
patient with BPH includes:
1. Urnie analysis
2. USG of KUB ,Prostate with PVR
3. Uroflowmetry
4. Serum PSA
5. Plain X-ray KUB (A/P view)
6. Pressure flow study
7. Filling cystometry
8. Urethocystoscopy
Not recommended
routinely

19. Urine analysisUrine analysis
• Urine analysis assist in distinguishing
UTI & bladder cancer from BPH
• Components are:
1. Urine R/M/E
2. Urine for C/S
3. Urine cytology

20. Findings of urine analysisFindings of urine analysis
Urine R/M/E
1. Sugar for DM
2. Pus cell for UTI
3. RBC for UTI & other causes
Urine for C/S
• To identify any significant infection & selection of
proper antibiotic
Urine cytology
1. Should be considered in men with H/O smoking
with severe irritative symptoms
2. To exclude specially CIS

21. Pus Cells
Malignant Cell
RBC
E.choli

22. USG of KUB, Prostate with PVRUSG of KUB, Prostate with PVR
1. Size
2. Intravesical potrusion
3. Echogenicity
4. Capsule
1. Bladder wall (thickened or not)
2. Presence of any diverticulum
3. Presence of any stone
4. Any growth obstructing the
bladder neck
5. Determination of PVR
ProstateProstate BladderBladder
Following points are to be observed in USG
KidneyKidney
To see any bilateral pelvicalyceal
dilatation, which reveals any
back pressure effect of the

23. • Size of the prostate can be classified into:
1. Small prostate – < 20 gm
2. Medium prostate – 20-40 gm
3. Large prostate - > 40 gm
• Intravesical potrusion of prostate can be
graded into:
1. Grade I – 0-5 mm
2. Grade II – 6-10 mm
3. Grade III - >10 mm

24. • Echogenicity (sonographic pattern of BPH)
Mixed, heterogenous, mostly hypo echoic
parenchyma, often arranged in the form of one or
more hyperplastic nodules and sometimes
recognizable internal architecture
• Capsule
Bright echogenic structure surrounding the
prostate (in BHP it is intact)
Capsular bulging & irregularity associated with an
adjacent focal hypo echoic lesion often indicate
‘capsular invasion’ (a sign of malignancy)

25. USG image of a BPHUSG image of a BPH

26. Some important informationSome important information
• Size of the prostate correlate less well with the degree
of obstruction
• A small prostate may obstruct and a large prostate
may not obstruct. This is because of the distortion of
the “funneling effect of the bladder neck” which is
more important cause of obstruction than the
compression of the urethra.
• A small nodule sitting at the strategic position at the
outlet (such as median lobe) can cause a “ball-valve”
effect leading to significant obstruction

27. • Usually large prostate are more likely to
obstruct than the small prostate due to
compression of the urethra
• In a study it was found that :
Patients with grade I protrusion:
84% has a good flow rate > 10 ml/sec
Patients with grade III protrusion:
72% has a flow rate < 10 ml/sec

28. PVR (Post Voidal Residue)PVR (Post Voidal Residue)
• When voiding function of bladder is impaired
it will be manifested as residual urine
• Normal person with no significant obstruction
should have residual urine 0 ml
• Any patient with a persistent PVR > 100 ml
with no obvious neurogenic cause and
association with poor flow rate of 10ml/sec or
less, would be suspected to have significant
obstruction

29. UroflowmetryUroflowmetry
• Uroflowmetry is the electronic recording of
the urinary flow rate throughout the course of
micturition.
• Results of uroflowmetry are non-specific for
the causes of symptoms
• For proper uroflow test, voided volume
should be at least 150 ml.

30. Points to be noted in uroflowmetryPoints to be noted in uroflowmetry
Maximum flow rate
Average flow rate
Voiding time
Voiding volume
Pattern of voiding
curve

31. • With properly performed uroflow test:
Normal flow rate in male about 20-25 ml/sec
Normal flow rate in female about 25-30
ml/sec
• Obstruction should be suspected when
maximum flow rate is < 15 ml/sec
• definitive evidence of obstruction when
maximum flow rate < 10ml/sec

32. Plain X-ray KUBPlain X-ray KUB
• To see any stone in the
urinary bladder, vesical neck
or in the urethra, which
might be cause of LUTS
• Any metastatic lesion in the
bone
• Any calcification in Kidney,
ureter, bladder, prostate

33. Serum PSASerum PSA
• PSA is a tumor marker used for screening of Ca
prostate
• Serum PSA is considered optional, but most
physician will include it in the initial evaluation.

34. What we should know about PSA?What we should know about PSA?
 PSA is a glycoprotein enzyme(serine protease)
 It is secreted by the epithelial tissue of prostate
 It circulates in serum in free & bound form
 Its normal value is <4 ng/ml
 Its level raises with increasing age & size of prostate gland
 Real outcome of PSA test can be obtained by evaluating the
level from time to time and observing the rate of changes
 Medical opinion is divided about the usefulness of single
PSA test
 One test out of range could be caused by other problems
 Moreover PSA is not specific for Ca prostate

35. Confounding factors for PSAConfounding factors for PSA
• PSA level increases in
1. Ca prostate
2. BPH
3. Prostatitis
4. Instrumentation
5. DRE
6. Aging
7. Ejaculation
• PSA level decreases in
1. LHRH agonist
2. 5 alpha reductase inhibitors

36. Other PSA parametersOther PSA parameters
PSA velocity
• It means rate of change of PSA over time
• Man with Ca prostate has more rapidly rising serum
PSA than in man with BPH
• Serum PSA increases by .75ng/ml/yr appear to be at
increased risk of harboring cancer.
PSA density
• It is ratio of PSA to the gland volume
• PSA levels are elavated approximately .12ng/ml/gm of
BPH tissue
Thus patients with enlarged prostate due to BPH
may have elavated PSA level

37. Differential diagnosis of BPHDifferential diagnosis of BPH
• BNH
• Urethal stricture
• Ca Prostate
• Ca Bladder
• Infection (Cystitis, Prostatitis)
• Stones
• Neurogenic Bladder

38. Staging of BPHStaging of BPH

39. Stage 1
No bothersome symptom(QOL 2 or less)
No significant obstruction( Qmax >10ml/sec,PVR <100 ml)
Stage 2
With bothersome symptom(QOL 3 or more)
No significant obstruction
Stage 3
With significant obstruction irrespective of
symptoms (Qmax<10ml/sec, PVR >100ml)
Stage 4
BOO with complication

40. Treatment of BPHTreatment of BPH

41. Treatment of BPH is planned after
• Proper evaluation
• Properly informed about the disease &
various therapeutic options of BPH
So treatment can be given on the basis of
• Relative efficacy of the Rx
• Side effects

42. Rx modalities depends on
• Age of the patient
• IPSS of the patient
• DRE findings
• USCD(Ultrasound cystodynamogram)
• Uroflowmetry findings
• Serum PSA level
• Complication of BEP

43. Rx options are
• Watchful waiting
• Medical therapy
• Surgery

44. Watchful waiting
Mild symptoms (IPSS 0-7)
• No bothersome symptoms
• No significant obstruction

45. The severity & distress due to symptoms may be
improved through simple measures such as:
• Decreased fluid intake specially prior to bed time
• Reduced intake of alcohol & caffeine contaning
product
• Follow timed voiding schedules
Patient should be observed for bothering
symptoms & development of significant
obstrution

46. Medical treatment

47. Aim of medical therapy
 To decrease BOO, thereby-
• Relieving symptoms
• Improving bladder emptying
• Ameliorating detrusor instability
• Preventing future episodes of UTI & urinary
retention

48. Ideal candidate for medical Rx
• Bothersome symptoms that impact negatively on quality of
life
• No significant obstruction(Qmax>10ml/sec, PVR<100 ml)
Medical Rx should not be offered to individual
presenting with-
1. Refractory urinary retention
2. Recurrent UTI
3. Renal insufficiency
4. Bladder calculi/diverticula
5. Recurrent gross hematuria

49. Medical therapy include
1) Alpha blokers
• Non selective-phenoxybenzamine,
• Alpha 1 (short acting)- prazosin,
• Alpha 1 (long acting)- terazosin, doxazosin
• Alpha 1a selective(uroselective)-tamsulosin,
alfuzosin,silodosin
2) Androgen suppression (5 alpha reductase
inhibitor)
Finesteride, dutasteride
3) Plant extract (Phytotherapy)- popular in europe
& USA

50. Surgical therapy
A) Endoscopic method
• TURP
• TUIP
• TULIP- 1) HoLEP, 2)Free beam laser, 3)Contact laser,
4) Interstitial laser
• TUVP
• TUNA
• HIFU
• TUBD
• TUMT
• Intraurethral prostatic stent- Cobalt-Chromium stent,
Titenium nickel stent
Out of all minimally invasive technique, TURP is the gold
standered

51. B) Open method
• Retropubic prostatectomy(Millins
prostaectomy)
• Perineal prostatectomy(Youngs
prostatectomy)
• Transvesical prostatectomy
C) Laparoscopic prostatectomy
D) Robot assisted simple prostatectomy

52. Indications of TURP
Absolute indications
1. Refractory urinary retention
2. Chronic retention with renal insufficiency----
increased serum creatinine
increased blood urea level,
residual urine volume 200 ml or more,
hydroureteronephrosis in IVU
uremic manifestation.
3. BOO with complication
• Recurrent UTI
• Recurrent gross heamaturia
• Large bladder diverticula
• Stone formation

53. Relative indications
1.Severe symptoms(IPSS >20)
2.Failed medical treatment
3.Qmax <10 ml/sec
4.PVR >100ml after repeated measurement

54. Pre operative counselling
• Retrograde ejaculation
• Erectile dysfunction
• Success rate
• Risk of re-operation
• Post operative morbidity
UTI & dysuria
Incontinence
Hematuria
Dribbling
Frequency, urgency etc.

55. Complications of TURP
A) Local complication
1.Penile erection
2.TUR syndrome
3.Excessive bleeding
4.Perforation of capsule & extravasation of
urine
5.Bladder perforation, trigonal injury
6.Injury to external sphincter & urethra
Per operative complicationPer operative complication

56. B) General complication
• Myocardial infarction
• CVA
• Cardiac arrest
A)Local
• Bleeding
• Clot retention
• UTI
• Sepsis
• Failure to void
• Epidedymoorchitis
Immidiate Post operative complicationImmidiate Post operative complication

57. B) General complication
• MI
• DVT
• Pulmonary embolism
• Spinal headache
• Stricture urethra
• Bladder neck contracture
• Urinary incontinence
• Retrograde ejaculation
• impotence
Local complicationLocal complication

58. Indications of open Prostetectomy
• Large prostate > 100 gm
• Concomitant bladder condition that requires
Rx (such as symptomatic bladder
diverticulumn, large hard calculus that cant be
manage transurethally)
• Marked ankylosis of the hips that prevents
proper placement of dorsal lithotomy position
• Co-existing unilateral/bilateral inguinal hernia

59. Contraindication of open
prostatectomy
• Small fibrous prostate gland
• Previous prostatectomy
• Previous pelvic surgery
• Any type of prostate cancer