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Welcome to the teaching session on benign prostatic hyperplasia, also known as B PH. This is one in a series given by medical students for medical students and is based on the MLA content map. Today, we'll cover key points about BPH including presentation, diagnosis and management. Let's start off with a case presentation. So you have a 60 year old man presenting to his general practitioner with three months of urinary frequency and nocturia. He reports no burning with this. The patient has tried limiting his fluid and caffeine intake with no real relief. He reports no family history or personal history of prostate cancer. On examination, you yield no suprapubic mass or tenderness. And digital rectal examination shows a normal rectal tone with a moderately enlarged prostate, no nodules or tenderness are noted. Benign prostatic hyperplasia, also known as BPH is defined as the proliferation of smooth muscle and epithelial cells in the transition zone. On the diagram below. In this slide, you can note that the regions of the prostate, the transitional zone in cases of urethra making it easy to understand why BH presents with urinary voiding symptoms such as frequency weak, a weak stream dribbling and the inability to fully empty the bladder BPH is incredibly common. As noted here with almost half of the male population in their fifties being afflicted and 82% of men in their seventies. The main risk factor is age as men age the cells of the prostate proliferate in response to the presence of a hormone called dihydrotestosterone, which accumulates as men grow older. This causes prostate to grow in size, resulting in an enlarged prostate. There are other factors, increasing risks such as metabolic and race related risks, but these are less impactful than age. Symptoms of BPH are separated into urinary storage and voiding symptoms. Storage related features are frequency, urgency, nocturia and incontinence. While voiding symptoms include poor stream hesitancy, dribbling and incomplete emptying. There are a number of differentials to consider. The first is an overactive bladder. Hence the frequency. This is due to malfunctioning nerves which contract while the bladder is filling. Uti is another common differential. It would also present with frequency and urge. However, it would be more likely to present with dysuria with the patient potentially having blood or debris in their urine. The last and arguably most important differential to consider is prostate cancer. This presents very similarly. However, on D you would likely feel a nodular prostate while BPH would be a smooth enlargement with preservation of the median sulcus. However, this is a very important differential to keep in mind and patients should be referred if there is any suspicion of prostate cancer helpful in quantifying lower urinary tract symptoms and in identifying which type of symptoms are predominant. However, they are not disease, gender or age specific. The I PSS, the international Prostate Symptom score is commonly used in general practice to aid in making a primary assessment. A voiding diary may be kept by the patient to establish an understanding of when they are experiencing their symptoms. This can help to differentiate between an obstructive or an irritative pathology. Your analysis is typically normal in an uncomplicated benign prostatic hyperplasia. So it is more used for the exclusion of other conditions. High urea may indicate uti hematuria may indicate cancer. The psa is a blood test with a good predictive value which can predict prostate growth. However, it is not specific and may be increased by recent vigorous exercise, ejaculation, rectal examination or prostatitis. Dynamic studies include uroflowmetry, which is a noninvasive technique used to measure the volume of urine accumulation or the more invasive pressure flow studies which are typically offered if conservative and medical treatments have failed imaging. Regarding BPH used to be a transrectal ultrasound. However, due to having complications such as infection, bleeding and pain, a multiparametric MRI is now recommended. The main goal of therapy for patients with BPH is to improve lower urinary tract symptoms with voiding and storage to improve quality of life for men with mild to moderate uncomplicated symptoms. What waiting may be an appropriate approach with lifestyle modification, caffeine and alcohol can have a diuretic in effect. Therefore, they will increase fluid output and enhance frequency urgency and nocturia. For BPH. There are a number of options, alpha blockers such as doxazosin or tamsulosin work by relaxing the smooth muscles of bladder, neck and prostatic urethra. These are typically the first line treatments for most patients, patients should be warned that partial hypertension is a common side effect. Five alpha reductase inhibitors such as Finasteride or steroid work by reducing the prostate size and decreasing circulating psa levels. There are two types of five alpha reductase in the body. Type. One is predominantly expressed in the skin and the liver and type two is expressed in the prostate finasteride only inhibits five alpha reductase type two. Whereas due to steroid inhibits both types, an indirect comparison and one direct comparative trial over 12 months indicated that they are equally effective in the treatment of lower urinary tract symptoms. These medications should be used in men with moderate to severe symptoms and an increased risk of disease progression. Antimuscarinics su such as oxybutynin will block muscarinic receptors on the smooth muscle cells which cause relaxation. The the detrusor muscle is innervated by parasympathetic nerves. This main main neurotransmitter is acetylcholine which stimulates muscarinic receptors on the smooth muscle cells blocking this receptor causes smooth muscle relaxation. Phosphodiesterase five inhibitors reduce smooth muscle tone of the prostate and urethra and should be used in men with moderate to low, moderate to severe lower urinary tract symptoms. They should be used with caution in patients with existing cardiovascular disease. Beta three agonists such as Mirabegron will induce tru or relaxation and should be used in men with moderate to severe symptoms that might mainly affect storage if patients symptoms are not controlled on monotherapy. There are various combinations of gel therapy that they can try. There are also a number of surgical management options. The standard procedure is a terp transurethral resection of prostate for men with 30 to 18 old prostate sizes and bothersome symptoms. Enucleation is an alternative to this and involves removing the core prostate tissue while leaving the outside room intact. Vaporization is another alternative which removes excess prostate tissue with a laser. Due to the bloodless nature of this procedure, it may be suitable for patients on blood thinners or with coagulation disorders. Alternative ablative therapies include aqua ablation and prostate artery embolization which we shall talk about in the following slides. Nonablative procedures may be done for patients with prostate sizes of less than 70 mil with no middle lobes and interested in preserving ejaculatory function. Prostate artery embolization is a type of ablative procedure which can be performed as a day case. This is done under local anesthesia through with access to the femoral or radial arteries. Arterial anatomy is visualized and embolic agents are injected into appropriate arterial supply to selectively embolize it. This causes an ischemic necrosis of the gland which is followed by shrinkage and reduction in the patient's symptoms. Prostate artery embolization is less effective at TERP procedures at improving symptoms and urodynamic parameters. Procedural time is longer compared to turp. However, blood loss catheterization and hospitalization time favorite. The panel was unable to find substantial evidence to recommend pa over more widely available, minimally invasive therapies for the routine treatment of lower urinary tract symptoms. However, there is evidence showing a short term benefit of pa compared to observation in a very select patient population. It's a very technically demanding procedure averaging fluoroscopy times up to 50 minutes and procedure times up to two hours attainment of proficiency involves a challenging learning curve for physicians who while changing the performance of endovascular interventions may be less familiar with core concepts of BPH pathophysiology, diagnosis, treatment and follow up, which is why the panel recommends that these procedures are only formed by physicians specifically trained in this technique technique. The panel recommends continued investigation of pe through trials involving multidisciplinary teams of urologists and radiologists who are focused on further defining specific indications including but not limited to gross hematuria for each session. Today, we have talked about h and all the key points surrounding this key presentation points include frequency, urgency, dribbling and intermittency in urine passing. We have talked about various investigations and what they are best at showing. We've talked about management including life, cell modification, medical management and surgical options. Thank you. All for attending and listening to our talk today.