BPH

• Benign prostatic hyperplasia (BPH) refers to a regional nodular growth of varying combinations of glandular and stromal proliferation that occurs in almost all men who have testes and who live long enough.
• BPH can be defined in a number of ways
• Microscopic BPH refers to the histologic evidence of cellular proliferation
  • Histopathologically BPH is characterized by an increased number of epithelial and stromal cells in the periurethral area of the prostate
    • The molecular etiology of is uncertain.
    • The incidence of histologic or microscopic BPH is far greater than that of clinical or macroscopic BPH.
• Macroscopic BPH refers to organ enlargement due to the cellular changes
• Clinical BPH refers to the lower urinary tract symptoms thought due to benign prostatic obstruction.
• BPH synonyms:
  • Hyperplasia
  • Benign prostatic hypertrophy
  • Adenomatous hypertrophy
  • Glandular hyperplasia
  • Stromal hyperplasia.

Male LUTS

The micturition cycle:

• Filling/Storage
• Emptying

• At a low intravesical pressure (compliance)
• With appropriate sensation

• Hyperreflexia
• Instability
• Uninhibited contraction
• Reflex contraction
• Detrusor over activity

Urine Emptying Requirements:
Reservoir requirements:
Coordinated bladder contraction of adequate magnitude (or other increase in pressure)…or not

Outlet requirements:

• Absence of anatomic obstruction
• Concomitant lowering of resistance at the level of:
• Smooth muscle of bladder neck and proximal urethra
• Striated muscle that surrounds urethra

• Failures of Fill/Store which can be due to:
• Bladder
• Urethra/outlet
• Both
• Failure of Emptying which can be due to:
• Bladder
• Urethra/outlet
• Both

References

• Abrams P: In support of pressure-flow studies for evaluating men with lower urinary tract symptoms. Urology 44:153-155, 1994.
• Ball AJ, Fenely RCL, Abrams PH: The natural history of untreated "prostatism " Br J Urol 53:613-616, 1981.
• Barry MJ: Epidemiology of benign prostatic hyperplasia. AUA Update Series 16:274-279, 1997.
• Barry MJ, Fowler FJ, Bin L, et al: The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. J Urol 157:10-15, 1997.
• Barry MJ, Fowler FJ, Jr., O'Leary MP, and the Measurement Committee of the AUA: The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 148:1549-1557, 1992.
• Barry MJ, Williford WO, Chang Y, et al: Benign prostatic hyperplasia specific health status measures in clinical research: How much change in the AUA symptom index and the BPH impact index is perceptible to patients? J Urol 154:1770-1774, 1995.
• Blaivas J: The bladder is an unreliable witness. Neurourol Urodyn 15:443-445, 1996.
• Denis L, Griffiths K, Khoury S, et al, eds. 4th International Consultation on Benign Prostatic Hyperplasia (BPH). Plymouth, United Kingdom, Plymbridge Distributors, Ltd., 1998.

  Chapter 3: Regulation of prostatic growth. Cockett ATK, Coffey D, DiSant Agnese A, et al.
  Chapter 5: Initial evaluation of LUTS. Artibani W, Correa R, Desgranchamps F, et al.
  Chapter 6: Quantification of symptoms, quality of life and sexuality. Adolfsson J, Barry M, Batista JE, et al.
  Chapter 7: The urodynamics of LUTS. Abrams P, Buzelin JM, Griffiths D, et al.
  Chapter 10: Interventional therapy. Altwein J, Baba S, Blute M, et al. Chapter 11: Endocrine treatment. Akaza H, Bartsch G, Calais daSilva F, et al. Chapter 12: Alpha-blocker therapy. AldoBono V, Andersson KE, Chapple C, et al.
  Chapter 15: BPH 1997-New treatment strategy. ElHilali M, Kirby R, McConnell J.
  Lepor H, Williford WO, Barry MJ, et al: The efficacy of terazosin, finasteride, or both in BPH. N Engl J Med 335:533-539, 1996.

• McConnell J: Why pressure flow studies should be optional and not mandatory for evaluating men with benign prostatic hyperplasia. Urology 44:156-158, 1994.
• McConnell JD, Barry MJ, Bruskewitz R, et al: Benign prostatic hyperplasia: Diagnosis and treatment. Clinical Practice Guideline, no. 8, AHCPR publication No. 94-0582, Rockville, Md., Agency for Health Care Policy Research, Public Health Service, US Dept. Of Health and Human Services, 1994.
• Walsh PC, Retik AB, Vaughan ED Jr., Wein AJ, eds: Campbell's Urology, 7th ed. Philadelphia, Saunders Company, 1998. Chapter 45: The molecular biology, endocrinology, and physiology of the prostate and seminal vesicles. Partin AW, Coffey DS.

  Chapter 46: Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. McConnell JD.
  Chapter 47: Natural history, evaluation, and nonsurgical management of benign prostatic hyperplasia. Lepor H.
  Chapter 48: Minimally invasive treatment of benign prostatic hyperplasia. McCullough DL.
  Chapter 49: Transurethral surgery. Mebust WK.

• Wasson JH, Reda DJ, Bruskewitz RC, et al: A comparison of transurethral surgery with watchful waiting for moderate symptoms of BPH. N Engl J Med 332:75-79,1995.
• Wein AJ: Criteria for assessing outcome following intervention for benign prostatic hyperplasia. In: Lepor H, ed. Prostatic Diseases. Philadelpha, Saunders, 1999, pp 210-231.

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