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BPH- Pathology & Investigations

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BPH- Pathology & Investigations

  1. 1. Pathology & Investigation Benign Prostatic Hyperplasia Presented by Dr. Ankur Agarwal Surgical Resident
  2. 2.  Introduction  Etiology  Pathology  Clinical findings  Investigation  MCQ  References Scheme of Presentation
  3. 3.  It is a histologic diagnosis characterised by proliferation of the cellular elements of the prostate.  In men 20 to 30 years of age, the prostate weighs about 20 gm and generally weighs more after 50. It is a common problem among older men, aged > 50 however, it is an infrequent cause of death.  BPH is considered to be the most common benign internal neoplasm of the adult male. Introduction
  4. 4.  The prevalence of histologically diagnosed prostatic hyperplasia increases from  8 percent in men aged 31 to 40,  40 to 50 percent in men aged 51 to 60,  >80 percent in men older than age 80
  5. 5.  BPH is considered a normal part ageing process in men, serum testosterone level decreases slowly but the level of oestrogenic steroids is not decreased equally.  According to theory, this increased levels of oestrogenic steroids  cause for prostate enlargement.  The secretion of intermediate peptide growth factors also plays a part in the development of BPH. Etiology
  6. 6.  Androgens are necessary for both normal and abnormal development of the prostate.  Testosterone is converted to a more potent androgen, dihydrotestosterone (DHT), by the enzyme 5-α reductase type 2. The type 1 form of the enzyme is present in liver and skin.
  7. 7.  Men who congenitally lack 5-α reductase type 2 enzyme have normal serum testosterone levels but lack dihydrotestosterone.  Those with this disorder have a rudimentary prostate throughout life but rarely experience bladder outlet obstruction secondary to BPH.  These findings suggest that the active androgen, DHT, is important in promoting growth of prostate that would eventually lead to symptomatic BPH.
  8. 8.  Prostatic hyperplasia increases urethral resistance causing compensatory changes in bladder function.  Obstruction induced changes in detrusor function, compounded by age related changes in both bladder and nervous system function lead to  Urinary frequency  Urgency  Nocturia Pathophysiology
  9. 9.  McNeal demonstrated that BPH first develops in the peri-urethral transition zone of the prostate.  BPH affects both glandular epithelium and connective tissue stroma. Pathology
  10. 10. Transitional zone surrounds the urethra proximal to the ejaculatory ducts. Central zone surrounds the ejaculatory ducts and projects under the bladder base.
  11. 11. Peripheral zone constitutes the bulk of the apical, posterior, and lateral aspects of the prostate. Anterior fibromuscular stroma extends from the bladder neck to the striated urethral sphincter
  12. 12.  The zonal anatomy of the prostate is clinically important because most carcinomas arise in the peripheral zone, whereas BPH affects the transitional zone, which may grow to form the bulk of the prostate.  BPH begins as micronodules in the transitional zone which grow and coalesce to form macronodules around the inferior margin of the pre-prostatic urethra, just above the verumontanum.
  13. 13.  Macronodules in turn compress the surrounding normal tissue of the peripheral zone postero-inferiorly, creating a ‘false capsule' around the hyperplastic tissue which coincidentally provides a plane of cleavage for its surgical enucleation.
  14. 14. Well-defined nodules compress the urethra (arrowheads) into a slit-like lumen.
  15. 15.  As the transitional zone grows, it produces the appearance of ‘lobes' on either side of the urethra. In due course, these lobes may compress or distort the preprostatic and prostatic parts of the urethra and produce symptoms.  The central zone surrounding the ejaculatory ducts is rarely involved in any disease.
  16. 16.  BPH typically affects the submucous group of glands in the transitional zone, forming a nodular enlargement.  This overgrowth compresses the PZ glands into a false capsule and causes the appearance of the typical ‘lateral’ lobe.
  17. 17.  The unique feature of human prostate is the presence of prostatic capsule- plays an important role in the development of Lower urinary tract symptoms.  The capsule transmits the “pressure” of tissue expansion to the urethra and leads to an increase in urethral resistance.
  18. 18. In the Late Stage of BPH • When BPH affects the Central Zone glands, a ‘middle’ lobe develops that projects up into the bladder within the internal sphincter
  19. 19.  The relationship between anatomical prostatic enlargement, lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outflow obstruction (BOO) is complex Effects of BPH
  20. 20.  Diagram showing the relationship between histologic hyperplasia of the prostate (BPH), lower urinary tract symptoms (LUTS), benign prostate enlargement (BPE), and bladder outlet obstruction (BOO). The size of the circles does not represent actual proportions but rather illustrates the partial overlap between the different disease definitions.
  21. 21.  The pathophysiology of benign prostatic hyperplasia (BPH) involves complex interactions between urethral obstruction, detrusor function and dysfunction, and urine production.
  22. 22.  Prostatic hyperplasia increases urethral resistance, resulting in compensatory changes in bladder function.  However, the elevated detrusor pressure required to maintain urinary flow in the presence of increased outflow resistance occurs at the expense of normal bladder storage function.
  23. 23.  Chronic bladder outlet obstruction (BOO) secondary to BPH leads to  Urinary retention  Renal insufficiency  Recurrent UTI  Bladder wall thinning and loss of function due to constant distension  Haematuria  Vesical calculi
  24. 24.  The prostatic urethra is lengthened (twice its normal length), but it is not narrowed anatomically.  The normal posterior curve may be so exaggerated- requires a curved catheter to negotiate it.  When only one lateral lobe is enlarged, distortion of the prostatic urethra occurs. Effects of BPH on the Urethra
  25. 25.  If BPH causes BOO, the musculature of the bladder hypertrophies to overcome the obstruction and appears trabeculated .  BPH is associated with increased blood flow, and the resultant veins at the base of the bladder causes haematuria. Effects of BPH on the Urinary Bladder
  26. 26.  Not all symptoms of disturbed voiding in ageing men should therefore be attributed to BPH causing BOO.  Pathophysiologically, BOO may be caused in part by increased smooth muscle tone, which is under the control of a-adrenergic agonists Lower Urinary Tract Symptoms (LUTS)
  27. 27.  The following conditions can coexist with BOO: oIdiopathic detrusor overactivity. oNeuropathic bladder dysfunction as a result of diabetes, strokes, Alzheimer’s disease or Parkinson’s disease. oDegeneration of bladder smooth muscle giving rise to impaired voiding and detrusor instability; oBOO due to BPH.
  28. 28.  Hesitancy (worsened if the bladder is very full)  Poor flow (unimproved by straining)  Intermittent stream – stops and starts  Dribbling (including after micturition)  Sensation of poor bladder emptying  Episodes of near retention Voiding symptoms
  29. 29.  Frequency  Nocturia  Urgency  Urge incontinence  Nocturnal incontinence (enuresis) Storage symptoms-Overactive Bladder Syndrome
  30. 30.  This is a urodynamic concept based on the combination of low flow rates in the presence of high voiding pressures.  Diagnosed definitively only by pressure-flow studies. Bladder Outflow Obstruction
  31. 31.  Flow rates provide a useful guide for everyday clinical management.  Urodynamically proven BOO may result from:  BPH  Bladder neck stenosis  Bladder neck hypertrophy  Prostate cancer  Urethral strictures  Functional obstruction due to neuropathic conditions
  32. 32. Effects of BOO on the Bladder Decrease in urinary flow rates : For a voided volume > 200 ml, a peak flow rate of > 15 ml/s is normal, 10–15 ml/s is equivocal and < 10 ml/s is low.
  33. 33.  Increase in voiding pressures :  Pressures > 80 cmH2O are high, pressures between 60 and 80 cmH2O are equivocal and pressures < 60 cm H2O are normal.
  34. 34.  Acute retention of urine  Chronic retention  Impaired emptying of bladder  Haematuria Complications of BOO
  35. 35.  Other than pain from retention, pain is not a symptom of BOO  Its presence should prompt the exclusion of acute retention, urinary infection, stones, carcinoma of the prostate and carcinoma in situ of the bladder
  36. 36.  It is critical to exclude causes of LUTS other than BPH before medical or surgical treatment.  The differential diagnosis of lower urinary tract symptoms in addition to BPH includes the following:  Urethral stricture  Bladder neck contracture  Carcinoma of the prostate  Carcinoma of the bladder  Bladder calculi  Urinary tract infection and prostatitis  Neurogenic bladder
  37. 37.  History:  Symptom assessment:  The International Prostate Symptom Score (IPSS) is recommended scoring system for the baseline assessment of symptom, severity in men presenting with LUTS Assessment of the Patient with LUTS
  38. 38.  Generally WNL  Chronic retention- distended bladder  Loss of the transverse supra pubic skin crease  Examination of the external urethral meatus is done to exclude stenosis or a palpable urethral mass  Epididymides are palpated for signs of inflammation Abdominal Examination
  39. 39.  The posterior surface of the prostate is smooth, convex and firm in consistency.  The rectal mucosa can be made to move over the prostate.  Residual urine may be felt as a fluctuating swelling above the prostate.  Considerable amount of residual urine if present, pushes the prostate downwards, making it appear larger than it is. Digital Rectal Examination
  40. 40.  To eliminate neurological conditions like diabetes mellitus, tabes dorsalis, disseminated sclerosis, cervical spondylosis, Parkinson’s disease may mimic prostatic obstruction.  Examination of perianal sensation and anal tone is useful in detection of an S2 to S4 cauda equina lesion. Nervous System
  41. 41.  A urinalysis should be done either by using a dipstick test or microscopic examination of the spun sediment to rule out UTI and haematuria, either of which strongly suggest a non-BPH pathologic process as a cause of symptoms.  Urine cytology should always be requested in men with severe irritable symptoms and dysuria, especially if they have a smoking history. Carcinoma in-situ of the bladder is a diagnosis that may have serious consequences if overlooked. Urinalysis
  42. 42.  Postvoid residual urine volume is the amount of fluid remaining in the bladder immediately after the completion of micturition.  Studies indicate that PVR urine volume normally ranges from 0.09 to 2.24 mL, with the mean being 0.53 mL (Hinman and Cox, 1967).  Seventy-eight percent of normal men have PVR volumes of less than 5 mL, and 100% have volumes of less than 12 mL(DiMare et al, 1963). USG & Postvoid Residual Urine Volume
  43. 43.  Traditionally, urologists have assumed that increasing amounts of PVR urine denote BPH progression and are thus an “indication” for surgery.
  44. 44.  Normally present in Serum but if > 2.5–4 nmol/L, then transrectal ultrasound scanning (TRUS) plus multiple transrectal biopsies (10 biopsies) should be considered. Serum Prostate – Specific Antigen
  45. 45.  Special flow rate clinic.  Coupled with ultrasound measurement of post-void residual urine Flow Rate Measurement
  46. 46. A, Normal cystoscopic appearance of the prostate in a young man. B, Moderate BPH, viewed cystoscopically
  47. 47. Q- In which zone of the prostate does hypertrophy begin A) Peripheral zone B) Central zone C) Transitional zone D) Fibromuscular Stroma MCQ  Answer- C) Transitional zone  Reference- Bailey & Love’s Short Practice of Surgery, 26th edition, page #1342.
  48. 48.  Bailey and Love’s Short Practice of Surgery, 26th Edition  Sabiston Textbook of Surgery, 19th Edition  Campbell – Walsh Urology, 10th Edition  Robbins Basic Pathology, 9th Edition  Gray’s Anatomy, 40th Edition References
  49. 49. Thank You