Treatments for Benign Conditions of the Prostate Gland

Abstract

Histologically, the prostate is comprised of a network of branched tubuloalveolar glands that are surrounded by a richly innervated, well-vascularized fi bromuscular stroma. Benign prostatic hyperplasia (BPH) is often referred to as the most common benign neoplasm in the aging male. It is a distinct histopathologic entity that is characterized by cellular proliferation of both components of the prostate: the glandular and stromal elements [ 1 , 2 ]. From a clinical standpoint, this may be associated with age-dependent, bothersome, and progressive voiding symptoms.The burden of BPH on society is enormous. It accounts for over 8 million outpatient physician visits annually in the United States, signifi cantly impacts the quality of life of our aging population, and carries a price tag of more than 1.1 billion dollars in direct medical costs [ 3 ]. Defi nitionsThe term BPH should be used exclusively to describe the specifi c histological fi ndings of glandulo-stromal hyperplasia, seen within the transition zone (periurethral region) of the prostate ( Fig. 16.1 ) [ 4 ]. While it is often used in the context of describing the constellation of voiding symptoms that occur in aging males, this should be discouraged. As we will see later, the very symptoms that are often attributable to BPH are not specifi c for BPH; they may occur even in its absence.Lower urinary tract symptoms , or LUTS, is the accepted terminology used to describe the symptoms which are often associated with BPH and benign prostatic enlargement (BPE) [ 4 , 5 ]. They refl ect not only a direct (static) component of prostatic growth and obstruction but also a dynamic component of obstruction as well [ 6 ]. It is the static component of obstruction that results from an increase in number and volume of epithelial and smooth muscle cells, as well as connective tissue within the prostatic stroma. The dynamic component of obstruction results from an increase in the smooth muscle tone and resistance from the enlarging gland. Finally factoring into the LUTS perceived by the patient is the bladder response to obstruction, aging, and other less obvious infl uences [ 7 ]. This bladder component results in a spectrum of responses, varying from detrusor underactivity to detrusor overactivity.LUTS can be broadly classifi ed into one of three, often overlapping categories ( Fig. 16.2 ) [ 8 ]. As mentioned above, none of the voiding symptoms under these categories are specifi c to BPH. In fact, cross-sectional studies performed in the United States and Europe have shown that the prevalence of LUTS in women is equivalent to that of men, suggesting that the pathophysiology of LUTS is much more complex than a simple obstructive process, as described above [ 9 , 10 ]. However, under the right circumstances, in a male 45 years or older, in the absence of other potential non-BPH causes for LUTs, clinicians may safely attribute LUTs to BPH and BPE [ 6 ]. When confi rmed by the presence of low fl ow and high voiding pressures on urodynamic studies, benign prostatic obstructio...