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Benign Prostatic Hypertrophy With Outflow Obstruction

What Causes Benign Prostatic Hyperplasia

Summary on Lecture 10) Bladder Outflow Obstruction

The cause of benign prostatic hyperplasia is not well understood however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.

Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.

Another theory focuses on dihydrotestosterone , a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.

Medical Treatment Of Bph

Medical treatment is suitable for patients with moderate to severe symptoms of BPH. If you have urinary retention or complications of BPH, such as bladder stones or damage to the kidneys, doctors may suggest surgical options.

Medical management of BPH involves 1-blockers and/or 5-reductase inhibitors.

  • 1-blockers, such as doxazosin, tamsulosin and alfuzosin:
  • Produce a rapid and sustainable improvement in lower urinary tract symptoms and urine flow – but only in around 60% of patients.
  • Do not stop BPH neither do they prevent the eventual need for surgery.
  • Symptoms usually improve within 2-3 weeks and these drugs can be used as a long-term option.
  • Main side-effects, which affect 10-15% of patients, include tiredness, headaches and dizziness.
  • 5-reductase inhibitors, including finasteride and dutasteride:
  • Improve symptom scores and urine flow rates.
  • Capable of reversing the course of BPH.
  • Works best in patients with large prostates and elevated PSA levels.
  • The main clinical effects of 5-reductase inhibitors take 3-6 months to become apparent and PSA levels are reduced by approximately 50% after 6-12 months.
  • Side-effects include reduced libido and weak erections in 3-5% of men, which return to normal after treatment is stopped. About 1% of men develop breast tenderness.
  • Women who are or who might be pregnant should avoid touching crushed or broken tablets.
  • Pathophysiology & Clinical Presentation

    Benign Prostatic Hyperplasia is a common disorder characterized by the enlargement of the prostate gland over a prolonged period of time. Benign hyperplasia of the prostate develops in men around the age of 40-45 and slowly progresses until death .

    The actual pathophysiology of BPH and how it develops is complex and focuses on the following:

    1. Levels and ratios of endocrine factors such as :

    • Androgens
    • Gonadotropins
    • Prolactin

    2. Alterations in the balance of autocrine/paracrine growth-stimulatory and growth inhibitory factors such as :

    • Insulin-like growth factors
    • IGF binding proteins
    • Transforming growth factor-beta

    Aging along with circulating androgens, have potential to disrupt the balance of growth factor signaling pathways and stromal/epithelial interactions creating a growth-promoting and tissue remodeling microenvironment. This process can contribute to prostatic enlargement and the development of BPH .

    Testosterone is the primary circulating androgen in men. Testosterone has the potential to be metabolized through CYP19/aromatase into the potent estrogen, estradiaol-17. The prostate is an estrogen target tissue and estrogens can affect the growth and differentiation of the prostate. Estrogens along with selective estrogen receptor modulators have been shown to impact prostate proliferation demonstrating a potential role in the development of BPH .

    These interactions and changes that occur can lead to an increase in prostate volume by:

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    When Is Bph Treatment Necessary

    The course of BPH in any individual is not predictable. Symptoms, as well as objective measurements of urethral obstruction, can remain stable for many years and may even improve over time for as many as one-third of men, according to some studies. In a study from the Mayo Clinic, urinary symptoms did not worsen over a 3.5-year period in 73% of men with mild BPH. A progressive decrease in the size and force of the urinary stream and the feeling of incomplete bladder emptying are the symptoms most correlated with the eventual need for treatment. Although nocturia is one of the most annoying BPH symptoms, it does not predict the need for future intervention.

    If worsening urethral obstruction is left untreated, possible complications are a thickened, irritable bladder with reduced capacity for urine infected residual urine or bladder stones and a backup of pressure that damages the kidneys.

    • Inadequate bladder emptying resulting in damage to the kidneys
    • Complete inability to urinate after acute urinary retention
    • Incontinence due to overfilling or increased sensitivity of the bladder
    • Bladder stones
    • Recurrent severe hematuria
    • Symptoms that trouble the patient enough to diminish his quality of life

    Find a Location

    Currently, the main options to address BPH are:

    • Watchful waiting
    • Medication
    • Surgery

    What Are The Symptoms Of Benign Prostatic Hyperplasia

    Bph 4th yr

    Since the prostate gland surrounds the urethra , it is easy to understand that enlargement of the prostate can lead to blockage of the tube. Therefore, you may develop:

    • Slowness or dribbling of your urinary stream.
    • Hesitancy or difficulty starting to urinate.
    • Frequent urination.
    • Feeling of urgency .
    • Need to get up at night to urinate.
    • Pain after ejaculation or while urinating.
    • Urine that looks or smells “funny” .

    The enlargement of the prostate can lead to blockage of the urethra.

    As symptoms get worse, you may develop:

    • Damage to your kidneys from back pressure caused by retaining large amounts of extra urine in the bladder.

    If you have any of these symptoms, see your doctor right away:

    • Pain in the area of the lower abdomen or genitals while urinating.
    • Cant urinate at all.
    • Pain, fever and/or chills while urinating.
    • Blood in the urine.

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    Benign Prostatic Hyperplasia With Lower Urinary Tract Symptoms

      20162017 – Revised Code20182019202020212022Billable/Specific CodeAdult Dx Male Dx
    • N40.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
    • Short description: Benign prostatic hyperplasia with lower urinary tract symp
    • The 2022 edition of ICD-10-CM N40.1 became effective on October 1, 2021.
    • This is the American ICD-10-CM version of N40.1 – other international versions of ICD-10 N40.1 may differ.
    • N40.1 is applicable to adult patients aged 15 – 124 years inclusive.
    • N40.1 is applicable to male patients.

    “use additional code”

  • code for associated symptoms, when specified:
  • How Is Benign Prostatic Hyperplasia Treated

    Patients who have mild symptoms may not require treatment other than continued observation to make sure their condition doesn’t get worse. This approach is sometimes called “watchful waiting” or surveillance. There are a number of treatment options available if your symptoms are severe.


    Finasteride and dutasteride work by decreasing the production of the hormone dihydrotestosterone , which affects the growth of the prostate gland. These appear to be most beneficial for men with larger prostates.

    Drugs that relax the muscle in the prostate are more commonly used. These include terazosin , doxazosin , tamsulosin , alfuzosin , and silodosin . The most common side effects are lightheadedness, weakness and retrograde ejaculation.

    Medications are sometimes combined to help treat symptoms and improve the flow of urine. One such medication is dutasteride and tamsulosin .


    Several different types of surgery can be used to remove the prostate tissue that blocks the flow of urine, including:

    Minimally invasive treatments

    Minimally invasive treatments include:

    Last reviewed by a Cleveland Clinic medical professional on 03/10/2020.


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    Benign Prostatic Hypertrophy With Outflow Obstruction

    You always take care of your body, but after some age, body changes is a natural process, and we can not control it.

    For men, one of those body changes is the prostate gland gets bigger.

    This gland becomes large as it becomes difficult to urinate. This problem is usually found only after 60 years, i.e., in older men.

    Lower Urinary Tract Symptoms


    Lower urinary tract symptoms refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. Although LUTS is a preferred term for prostatism, and is more commonly applied to men, lower urinary tract symptoms also affect women.

    LUTS affect approximately 40% of older men.

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    Benign Prostatic Hypertrophy Symptoms

    Benign prostatic hypertrophy refers to benign adenoma-like hyperplasia of the prostate around the urethra, leading to varying degrees of bladder outflow tract obstruction. The main difficulty in determining the prevalence of benign prostatic hyperplasia is the lack of a common definition, according to autopsy, histologically diagnosed as benign prostatic hyperplasia prevalence in men aged 31 to 40 years 8%, 51 to 60 years old male To 40% to 50%, age> 80 years old male incidence rate of more than 80%. According to clinical criteria, that is, prostate volume> 30ml and the international prostate symptom score is high, 55 ~ 74 years old without prostate cancer in men benign prostatic hyperplasia prevalence rate of 19%, and if the prostate volume> 30ml, the highest score, the largest Urine flow rate of 50ml as a standard, the incidence rate of only 4%.

    Benign prostatic hyperplasia does not smoke alcoholism: prostate hyperplasia, fear of alcohol stimulation, otherwise it is easy to lead to autonomic disorders, causing urinary retention, smoking more of the same. Do not eat irritating food: due to irritation, such as spicy food will stimulate the prostate swelling increased, leading to increased or increased prostate hyperplasia. To maintain a good attitude: because after the angry can occur in varying degrees of urination inconvenience. So benign prostatichyperplasia for the daily life must maintain a good attitude, do not angry.

    Urodynamic Assessments Of Bladder Outflow Obstruction Associated With Benign Prostatic Hyperplasia

    • Kun Dou1

    1physician in the Department of Urology at Kunming General Hospital in Kunming, P.R. China

    2surgeon in the Department of Urology at Kunming General Hospital in Kunming, P.R. China

    3surgeon in the Department of Urology at Kunming General Hospital in Kunming, P.R. China

    4surgeon in the Department of Urology at Kunming General Hospital in Kunming, P.R. China

    5surgeon in the Department of Urology at Kunming General Hospital in Kunming, P.R. China

    DOI:10.31083/jomh.v11i6.18Vol.11,Issue 6,December 2015 pp.29-34

    07 December 2015

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    Benign Prostate Hypertrophy In Men

    BPH is a benign histologic process of hyperplasia that contributes to, but it not solely responsible, for lower urinary tract symptoms in the aging male. Previously, LUTS in older men were considered to be completely a result of increased prostate mass and elevated urethral resistance. These symptoms were known as âprostatism.â However, we now understand that LUTS in the aging male are only partially due to BPH and are also caused by age-related detrusor dysfunction as well as bladder outlet obstruction-related detrusor dysfunction, and detrusor overactivity.12 A significant proportion of men with symptoms of BPH also have symptoms of OAB . The linkage between BPH and OAB symptoms is not well understood.13

    Figure 39.4. Relationship between LUTS, BPH, and OAB

    Who Is Most Likely To Be Affected

    Benign Prostatic Hyperplasia

    The precise cause of BPH remains poorly understood despite ongoing research. That said, a number of contributors and risk factors have been identified, including the following.

    • Males only
    • Age: This is the most significant risk factor for BPH. It is almost unheard-of in young men, while post-mortem studies suggest more than 80 percent of men over 80 years old have at least some BPH.
    • Hormones: Particularly androgens such as testosterone and dihydrotestosterone are known to contribute to BPH development and progression. This is based on the knowledge that blocking these hormones can treat BPH while supplementing them can worsen BPH or even trigger it. However, these hormones are also part of normal biology and most men with BPH have normal hormone levels.
    • Race: This may play a role in BPH risk, though the evidence for this is somewhat unclear. Some studies have found that black men are more likely to need surgery for BPH than white men, while Asian men are less likely than either group to require prostate surgery.

    Various other possible risk factors such as obesity have been proposed, though evidence for these is conflicted.

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    Importance Of Smooth Muscle

    Regardless of the exact proportion of epithelial to stromal cells in the hyperplastic prostate, there is no question that prostatic smooth muscle represents a significant volume of the gland. Although the smooth muscle cells in the prostate have not been extensively characterized, presumably their contractile properties are similar to those seen in other smooth muscle organs. The spatial arrangement of smooth muscle cells in the prostate is not optimal for force generation however, there is no question that both passive and active forces in prostatic tissue play a major role in the pathophysiology of BPH. Stimulation of the adrenergic nervous system clearly results in a dynamic increase in prostatic urethral resistance. Blockade of this stimulation by α-receptor blockers clearly diminishes this response.

    Autonomic nervous system overactivity may contribute to LUTS in men with BPH., The activity of the autonomic nervous system, as measured by a standard set of physiologic tests, plasma and urinary catecholamines correlates positively with symptom score and other BPH measures.

    What Is The Prostate

    The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a mans fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

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    Others Forms Of Diagnosis

    If the IPSS diagnosis appears inconclusive or suggests a possible problem, your doctor may recommend one of several other diagnostic procedures, including:

    • Digital rectal examination – used to assess the size and shape of the prostate gland.
    • An abdominal examination to check whether the bladder can be felt .
    • Urine and blood tests – checking for infection or unusual cells.
    • A prostate-specific antigen test. Increased levels of PSA often suggests prostate damage. A high PSA can indicate the presence of prostate cancer or BPH.
    • Urine flow tests . Several different tests designed to measure urine flow. Peak flow rate, for example, tests for a flow rate of less than 15 ml/second. This often suggests an obstruction. However, urine flow measurements may also be affected by the bladder being unable to contract or shrink properly.
    • Post-voidal residual urine measurement. This involves using ultrasound equipment to check the volume of urine left in your bladder after you have urinated. In general, volumes of 200ml or more suggest a problem and may prompt doctors to consider less conservative therapies.
    • Trans-rectal ultrasound. This allows an accurate measurement of the volume of the prostate and may guide the physician in choosing the correct therapy.

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    How Is Bph Managed And Treated

    #23298 Prostate size and flowrate can predict absence of outflow obstruction.

    Before a doctor decides on the best treatment for your situation, he or she will consider:

    • What your symptoms are and how serious they are.
    • How much the symptoms affect your quality of life.
    • The extent of urine flow reduction and if there is any urine remaining in the bladder after you have been to the toilet.

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    Does Having Benign Prostatic Hyperplasia Increase The Risk Of Prostate Cancer

    Based on research to date, having BPH does not seem to increase the risk of developing prostate cancer. However, BPH and prostate cancer have similar symptoms, and a man who has BPH may have undetected cancer at the same time.

    To help detect prostate cancer in its early stages, the American Urological Association and the American Cancer Society recommend a prostate screening every year for men ages 55 to 69. They also recommend that men who are at high risk such as African-American men and men who have a family history of prostate cancer begin screening at age 40. Screening tests for prostate cancer include a blood test for a substance called prostate-specific antigen and the digital rectal exam .

    Personal And Family Medical History

    Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man

    • what symptoms are present
    • when the symptoms began and how often they occur
    • whether he has a history of recurrent UTIs
    • what medications he takes, both prescription and over the counter
    • how much liquid he typically drinks each day
    • whether he consumes caffeine and alcohol
    • about his general medical history, including any significant illnesses or surgeries

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    The Bladder’s Response To Obstruction

    Current evidence suggests that the bladder’s response to obstruction is largely an adaptive one. However, it is also clear that many lower tract symptoms in men with BPH or prostate enlargement are related to obstruction-induced changes in bladder function rather than to outflow obstruction directly. Approximately one third of men continue to have a significant irritative or storage symptoms after surgical relief of obstruction. Obstruction-induced changes in the bladder are of two basic types. First, the changes that lead to âdetrusor instabilityâ or decreased âcomplianceâ are clinically associated with symptoms of frequency and urgency. Second, the changes associated with decreased âdetrusor contractilityâ are associated with further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine and detrusor failure. Acute urinary retention should not be viewed as an inevitable result of this process. Many patients presenting with acute urinary retention have more than adequate detrusor function, with evidence of a precipitating event leading to the obstruction. Independent of obstruction, aging produces some of the same changes in bladder function, histology and cellular function. There is a suggestive evidence from animal models that atherosclerosis and the resultant chronic bladder ischemia or hypoxia induced by other mechanisms may contribute to bladder pathology.,


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