Or BPH (Benign Prostatic Hyperplasia) and now a days clinicians only say it Benign Prostatic Enlargement (BPE), Hyperplasia or Hypertrophy commented after Biopsy report.

Let’s start our Learning adventure……….

Now what is BHP …….it’s the Benign Hyperplasia/Hypertrophy of Prostate, well thank God for the self explanatory name, so

Its Benign ……….and in fact it is the most common benign tumor in men, and it is not a precancerous condition.

BPH is a nonmalignant enlargement of the Prostate gland caused by cellular hyperplasia of both glandular and stromal elements that can leads to….

• Hesitancy (It’s the trouble starting to urinate or Delay in initiating urination)

• Intermittency (Urinary stream that is not continuous)

• Incomplete voiding (I think you know that one…)

• Weak urinary stream

• Prolonged micturition

• Increased frequency of urination

•Nocturia (It is the condition where patient have to wake up during night to urinate…more often, of course)

•Urgency (compelling need to void that can not be deferred)

Do you know that healthy human prostate is slightly larger than a walnut (4cm by 3cm)…….. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam.

Now the problem in urination in BPH is due to two components

(a) Static component: That problem in urination is due to increase in size of gland, and the enlargement depends on DHT (DiHydroTestosterone). DHT is an Androgen, a sex hormone. Testosterone is converted to DHT with help of an enzyme ( 5 α reductase )

(b) Dynamic component : the problem in urination is due to increase in tone of smooth muscles of the bladder neck, trigone and urethra. The increased tone of these smooth muscle is due to α-1 receptors, and to be specific we can say α-1 A receptors (Recall what you have studied during ANS section about adrenergic receptors α and β)

Now we know the problem……….and the next step is to solve it…..

So the Immediate relief (and by immediate i mean one to two weeks), can be gained by relaxing the smooth muscles of the bladder neck, trigone and urethra and this action is achieved by blocking the α-1 receptors by the drugs (i.e. Alpha 1 Blockers like Prazosin) but we prefer longer acting brothers of Prazosin like Alfuzosin, Doxazosin, Terazosin due to convenience of once daily dosing.

The problem with blocking α-1 receptors is that they are present on blood vessels also (remember α-1 Constricts and β-2 Dilates) and blocking α 1 receptors can cause the decreased blood pressure and postural hypotension and tachycardia also and don’t forget about another important side effect of the Alfa blockers i.e. Inhibition of ejaculation.

And that’s why in normotensive patients we prefer α-1 A selective blockers (as this subtype is more prominent in the prostate and urethral pathway) which are Tamsulosin and Silodosin.

And they does not cause the effect on the blood vessels and so no significant change in BP (which is mediated by the subtype α-1 B)

So we can conclude easily that ………

The drug of choice in BPH patient with Hypertension is Prazosin or Doxazosin (Alpha 1 Blockers).

The drug of choice in BPH patient without Hypertension is Tamsulosin or Silodosin (Alpha 1 A Blockers)

So, the α-1 blockers relaxes the urine pathway and facilitate the urine flow but the main problem of increased size of prostate (static component) is still unaddressed.

As i stated earlier the enlargement in size depends on DHT (DiHydroTestosterone).

This DHT (DiHydroTestosterone) is formed by the Testosterone with help of enzyme 5 α reductase

Testosterone ——-Enzyme 5 α reductase ——– DHT (DiHydroTestosterone)

And the formation of DHT is blocked by inhibiting the enzyme 5 α reductase

And that’s why 5 α reductase inhibitors like Finasteride and Dutasteride are used and they respond by Decreased prostate size and increased urinary flow in most patients.

Though this beneficial effect can take upto six month for maximum response.

The Combination of Tamsulosin (0.4 mg) + Finasteride (5 mg) is also available, the combination will act on both static and dynamic components and the cost of this combination is nearly 400 rs /15 capsules.

And if the problem is not resolved by the drugs then the surgery is the main option (Transurethral resection of the Prostate)

Hope, you enjoyed the presentation.

Happy learning……..