Methodological Instructions for Students
Theme: Benign prostatic hyperplasia.
Aim: How to diagnose specific clinical findings of benign prostatic hyperplasia, teach plan
of investigation of patient and form diagnosis and differential diagnosis benign prostatic
hyperplasia, form plan of treatment.
In observation of men older than 50 years benign prostatic hyperplasia is noted in every
one of two men. Till now benign prostatic hyperplasia is 10% in glands.
1. Anatomy, physiology of prostate and urinary bladder.
2. To know how to collect anamnesis (life history). and should know to do physical
methods of investigation.
3. X-ray, functional, innstrumental, laboratory, endoscopial, morphological methods of
investigation to diagnose of benign prostatic hyperplasia.
4. You should know the usage of hormones in the treatment of benign prostatic
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Prevalence of BPH.
Benign prostatic hyperplasia is present in more than 50% of men aged over 60 years.
Between 15% and 30% of these men have lower urinary tract symptoms (LUTS), but crucially,
not all such symptoms are caused by the hyperplasia, and many are attributable to various types
of dysfunction of smooth muscle (detrusor) in the bladder. Previously, many such men have not
sought advice, accepting LUTS as part of ageing, but because of increased publicity about men’s
health, a raised awareness of prostate cancer, and new medical treatments, more men are seeking
help than did so previously. Benign prostatic hyperplasia can cause serious medical
complications. In England and Wales, up to 25% of men undergo prostatectomy because of
acute urinary retention, which doubles the risk of death and morbidity compared with elective
surgery. Moreover, chronic urinary retention can lead to renal failure, and is responsible for 15%
of prostatectomies (England and Wales). Other complications include recurrent urinary tract
infection, bladder calculi, and hematuria.
2. Aetiology and pathogenesis of benign prostatic hyperplasia.
BPH primarily affects three anatomic structures: the prostate, urethra and bladder. Of the
three zones that comprise the prostate (peripheral, transition and central) the transition zone in
the central part of the organ is the area affected in BPH. Stromal nodules appear in the
periurethral area of that zone as glandular hyperplasia develops. In contrast, prostate cancer
generally develops in the peripheral zone of the organ.
In the normal prostate, cell growth is regulated by a balance between cell death (apoptosis)
and cell growth (proliferation). Investigators examining prostate tissue at the cellular level have
found a substantial decrease in the total number of both glandular and basal epithelial cells dying
in hyperplastic tissue compared with normal tissue. This suggests a deregulation of apoptotic
cell death mechanisms in prostate tissue that results in a growth imbalance in favour of cell
proliferation in the presence of BPH.
The bladder obstruction that occurs with BPH has both static and dynamic components. In
the early stages of disease, normal prostatic tissue is compressed by hyperplastic tissue, which
impinges on the prostatic urethra, creating the static component. The bladder detrusor muscle
responds to this obstruction of urine flow with smooth muscle hypertrophy and changes in the
composition of the extracellular matrix. This results in the increased voiding pressure, decreased
bladder compliance, and involuntary bladder contractions that comprise the dynamic component
of obstruction. Untreated, advanced disease that involves prolonged obstruction may cause
chronic urinary retention. The classic obstructive symptoms include hesitancy, weak urine
stream, straining, prolonged micturition, feeling of incomplete bladder emptying, urgency,
frequency, nocturia, and urge incontinence.
3. Classification of benign prostatic hyperplasia.
BPH may be classified on three stages:
1. Stage with dysuria only (pollakiuria, nocturia, urgency, week stream).
2. Stage with dysuria and residual urine (more than 100 ml).
3. Stage than residual urine increased that leads to upper urinary tract deterioration
with pyelonephritis, renal insufficiency, urolithiasis.
4. Main clinical symptoms.
The initial evaluative step is to quantify symptoms and quality of life to establish a
baseline for severity and frequency of symptoms and to employ as a monitor of progress with or
without treatment. The American Urological Association (AUA) has developed, tested, and
validated a four-part index that rates symptoms of urinary problems (eg, urgency, frequency,
nocturia), the degree to which these symptoms are a problem to the patient, the impact of the
symptoms on the patient's life (eg, physical discomfort, worry, bother), and the overall quality of
the patient's life. A more widely used evaluation based on that developed by the AUA is the
International Prostate Symptom Score (IPSS). This simplified, easily administered form assesses
symptoms and general quality of life.
5. Diagnosis of benign prostatic hyperplasia.
Diagnosis of LUTS, benign prostatic hyperplasia and benign enlargement of the prostate is
based on history, physical examination, rectal examination, simple investigations to exclude
urinary tract infection and renal damage, and urinary flow measurement. No specific symptoms
reliably indicate benign prostatic obstruction, and there is no correlation between size and LUTS,
or between symptoms and objective data from urodynamics. Frequency volume charts
([http://image.thelancet.com/extras/02art8339webappendix2.pdf]), symptom scores (IPSS), free
flow rates, and pressure flow studies (urodynamics) measure different aspects, and should be
viewed separately in the assessment of patients with LUTS.
A careful digital rectal examination can exclude locally advanced, but not early, prostate
cancer. The size of the gland is important when counselling the patient on the type of surgery that
might be offered. The DRE is especially important in assessing the size, consistency, and
anatomic limits of the prostate; findings may be especially helpful in differentiating BPH from
prostatic cancer. The prostate that contains a nodule or that is diffusely hardened and asymmetric
may indicate cancer in contrast to the smooth, symmetric, and elastic consistency of a benign
Uroflowmetry is recommended as a diagnostic assessment in the workup of patients with
LUTS and an obligatory test prior to patients receiving surgical treatment. It is a simple, noninvasive test that can reveal abnormal voiding. Flow rate machinery provides information on
voided volume, maximum flow (Qmax), average flow (Qave) and time to Qmax, and this
information should be interpreted by the physician to exclude artefacts. Flow rates are useful to
monitor changes over time, both for watchful waiting, and for the follow-up of both medical and
surgical therapy. Before men are advised to undergo surgery, they must be counselled on the
probable success rate, even those patients with straightforward symptoms. Success rates are
highest in men with urodynamically proven obstruction of the outlet, so that such investigation
provides the best information to advise men. Measurement of flow rates before treatment is
therefore strongly recommended. In most units, most men will undergo urodynamics before
surgically invasive treatments, especially if there is an indication that the symptoms are related to
underlying detrusor overactivity, or causes other than benign prostatic hyperplasia.
Urinalysis via dipstick testing or microscopic examination of sediment is employed both to
differentiate BPH from urinary tract infection or bladder cancer and to prompt the use of
additional tests if findings are pathologic. Such optional tests might include upper urinary tract
imaging or endoscopy. Renal function is assessed via measurement of serum creatinine. Renal
function should be assessed by measurement of creatinine, but many urologists do not take
images of the upper urinary tract routinely, because tumours and kidney stones are not more
frequent in men with benign prostatic hyperplasia than in healthy men.If the creatinine is
elevated, indicating compromised renal function, ultrasonography is the appropriate follow-up
Prostate specific antigen testing. PSA, used as a marker for prostate cancer, is also
produced by benign prostatic epithelial cells and many patients presenting with benign prostatic
hyperplasia and LUTS will have a raised PSA. Conversely, many men with early prostate cancer
have PSAs in the normal range. Serum PSA increases with prostate size and age (by 3·2% per
year). There is no evidence that benign prostatic hyperplasia is associated with prostate cancer,
but there is uncertainty whether men in their 50s and 60s should be screened for prostate cancer.
PSA testing might be appropriate in those with a clinically benign gland and LUTS provided that
that the patient is counselled about the implications and subsequent actions that might be needed
after such a test. Men should be aware that a negative PSA test is no guarantee that prostate
cancer is absent. However, men in this age range with very low PSA values (<1 _g/L) have low
risks of developing clinically significant prostate cancer.PSA has been suggested as a screening
tool for prostatic cancer, but the antigen is produced by normal, hyperplastic, and cancerous
tissue, which can limit its diagnostic usefulness as a single test. However, the patient should be
told that there is a good possibility of a false-positive or false-negative result that might require
the use oftransrectal ultrasonographic (TRUS)-guided biopsy to confirm or refute the diagnosis
Urethrocystoscopy may be appropriate as a guideline when surgical treatment is planned to
rule out pathology and to assess the size and shape of the prostate. This form of endoscopy can
provide visual documentation of an enlarged prostate that is obstructing the urethra and bladder
neck, obstruction of the bladder neck by a high posterior lip, muscular hypertrophy of the
detrusor muscle (indicated by muscular trabeculation and formation of cellules and diverticula),
formation of bladder stones, and retention of urine in the bladder.
6. Medical therapy of benign prostatic hyperplasia.
Inhibit 5-alpha reductase, the enzyme that converts testosterone to dihydrotesterone
(DHT). DHT is a key component involved in control of prostate growth, so inhibition of its
formation can limit prostate hyperplasia and, in fact, reverse its development. Thus, these drugs
address the mechanical component of obstruction in BPH. The primary agent in this class is
finasteride. Clinical studies have shown that it can reduce the volume of the prostate by about
20%. The use of alpha blockers in treatment of BPH is based on the finding of a high density of
adrenergic nerves in the urogenital system and, particularly, a high density of alpha 1
adrenoceptors in the smooth muscle cells of the prostate, urethra, and bladder neck. The alpha,
adrenoceptor is activated when an agonist such as norepinephrine attaches to it; such activation
can cause smooth muscle contraction. Alpha blockers compete with the agonists in occupying
the adrenoceptor and, thus, prevent smooth muscle contraction in the prostate. Thus, these agents
address the dynamic component of obstruction in BPH. Natural compounds have been used for
many years in Europe in the treatment of BPH. Many of these compounds are undergoing critical
clinical evaluation in an effort to determine their mechanism of action and efficacy. Four
compounds have received the most intensive in vitro and clinical examination: pollen extract,
Sabal Serrulata, Serenoa Repens, and Pygeum Africanum.
7. Operative treatment of benign prostatic hyperplasia.
Transurethral prostatectomy (TURP) is the most commonly performed surgical approach
to BPH, although, as noted earlier, the frequency with which this procedure is performed has
decreased in the past few years as less invasive medical therapies have become more available.
Absolute indications for the procedure include BPH leading to bladder stones or obstruction of
the upper urinary tract with uremia. Because of their potential for serious consequences,
recurrent urinary retention or urinary tract infections suggest the need for surgical treatment.
Open prostatectomy is the most invasive of the surgical procedures and is indicated when the
prostate is >70 g resectable weight. Laser prostatectomy can be performed at low-power density,
which results in tissue coagulation, or high-power density, which causes vaporization of tissue.
Transurethral electrovaporization of the prostate (TVP) is a modification of TURP that combines
electrosurgical vaporization with dessication to remove hyperplastic tissue.
II. Tests and Assignments for Self-assessment
1. Main characteristic symptom of benign prostatic hyperplasia in excretory urography is:
A. Chain shaped urinary canal
B. Structure of ureter.
C. Bent urinary tract in 1/3 part
D. Symptom «fishhook».
E. Symptom «lion's face».
2. For III stage of benign prostatic hyperplasia main characteristic is:
A. Aseptical pyuria.
C. Chronic obstruction of urine.
D. Paradoxical ishuria.
E. Acute obstruction of urine.
Choose the correct answer/statement:
Real life situation to be solved:
1. Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with
out sensation of urinary secretion, thirst and weakness. Objective: above the lap when the
percussive sound is dumb and when touched it is painful. Symptom of. Pastematzkiy is doubling
in two sides, prostate is bulged 6/6,5 cm, elastic, between two doles it is smooth. What is your
diagnose? What should we do to the patient to confirm diagnosis and tactics in treatment?
2. During cystoscopy patient M., at the age of 72, complains of frequent, hard, urine
excretion, night 2-3 times noted: urine 180 ml, positive symptom of «curtain». Rectal. prostate
5/5/4 cm is elastic. What is the clinical diagnose? What are the tactics of treatment?
Answers to the Self-assessment.
The correct answers to the tests:
The correct answers to the real life situations:
1 benign prostatic hyperplasia we should put a permanent catheter if the patient is doing
well, we should do prostatectomy.
2. benign prostatic hyperplasia of II stage, chronic obstruction of urine, we should do
Visual Aids and Material Tools:
a) retrograde cystoscopy;
b) excretory urography.
2. X-ray photographs.
a) excretory urography (symptom of «fishhook»).
b) retrograde cystoscopy (deffect in the region of urinary bladder).
3. Tables (symptom of «curtain», a good quality prostatic hyperplasia and stone in urinary
Students' Practical Activities:
Students must know:
1. Classification of benign prostatic hyperplasia in stages.
2. Symptomatology of benign prostatic hyperplasia.
3. Clinical sings of benign prostatic hyperplasia.
4. Diagnose of benign prostatic hyperplasia.
5. Differential diagnosis of benign prostatic hyperplasia.
6. Treatment of benign prostatic hyperplasia.
Students should be able to:
1. know main symptoms of benign prostatic hyperplasia.
2. make differential diagnosis of benign prostatic hyperplasia of prostatic glands with
cancer of urinary bladder, cancer prostate, acute and chronic prostatitis, tuberculosis of prostatic
glands, structure ofurether.
3; To diagnose different stages of benign prostatic hyperplasia, to form diagnosis.
4. know tactics of treatment of benign prostatic hyperplasia in different stages.
5. provide palpation of prostatic glands, to do catheterization of urinary bladder with
elastic catheter and percussion of urinary bladder.