logging in or signing up Benign Prostatic Hyperplasia (BPH) Balagobi Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 1793 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: December 03, 2012 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Benign Prostatic Hyperplasia (BPH): Benign Prostatic Hyperplasia (BPH) Dr.B.Balagobi Lecturer Department of Surgery Faculty of Medicine UOJWhat’s LUTS?: What’s LUTS? Voiding (obstructive) symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incomplete bladder emptying Urinary retention(Acute/Chronic) Storage ( irritative or filling) symptoms Urgency Urge incontinence Frequency Nocturia Nocturnal enuresis LUTS is not specific to BPHPowerPoint Presentation: 3 Bladder Outflow Obstruction (BOO) Syn: Prostatism : Bladder Outflow Obstruction (BOO) Syn : Prostatism Obstructive Symptoms Irritative Symptoms Emergency - Acute urinary retention(ARU) - Retention with overflow Elective - Weak stream - Incomplete emptying - Intermittency - Hesitancy/Straining - Prolonged micturition Terminal dribbling Urgency Urge incontinence Frequency - Nocturia Nocturnal enuresis International Prostate Symposium Score (IPSS) 0 – 7 = Mildly symptomatic, 8 -19 = Moderately symptomatic, 20 – 35 = Severely symptomaticCauses of Bladder Outlet obstruction: Causes of Bladder Outlet obstruction Prostate:BPH,Ca prostate,Prostatitis Urethral stricture Post traumatic(Trauma/Instrumentation/post TURP) Post inflammatory( STD:Chlamydia,Gonococcal ) Ix:Asending urethrogram Rx:Urethral dilatation,Urethroplasty Bladder calculi Phimosis (BXO),Urethral meatal stenosis Bladder neck stenosis Sphincter dyssynergiaPowerPoint Presentation: 6PowerPoint Presentation: 7PowerPoint Presentation: 8Surgery: Surgery 9Urethral dilators: Urethral dilators 10Urethral dilatation: Urethral dilatation 11PowerPoint Presentation: 12PowerPoint Presentation: 13PowerPoint Presentation: 14Introduction to BPH: Introduction to BPH BPH is a common problem affects 1/3 of men older than 50 years . Pathological process of BPH starts at thirties. Histologically identifiable BPH 70%@70 years,90%@90 yrs. But only 10%present with symptoms. Severity of the symptoms not correlated with the size of the prostate.PowerPoint Presentation: 17RELATIONSHIP OF PROSTATE VOLUME AND PSA LEVELS IN SRI LANKAN MEN WITH BPH: RELATIONSHIP OF PROSTATE VOLUME AND PSA LEVELS IN SRI LANKAN MEN WITH BPH B Balagobi ,WTT de Silva ,SK Chandrasekera , K Sutharshan , S Prathapan , AWeerakkodi University Surgical Unit, Colombo South Teaching Hospital,Kalubowila , Sri LankaPathogenesis of BPH: Pathogenesis of BPH Due to aging process&testosterone stimulation Proliferation of both fibrous&glandular elements. esp @median lobe/transition zone/ Periurethral zonePowerPoint Presentation: Peripheral zone Transition zone Urethra What is Benign Prostatic Hyperplasia?PowerPoint Presentation: Peripheral zone Transition zone UrethraPowerPoint Presentation: LUTS/RetentionDiverticula in bladder: Diverticula in bladderComplications: ComplicationsClinical features: Clinical features LUTS Complications CRF(obstructive uropathy ) UTI Bladder stone Haematuria Acute retention( Painful,Urine volume < 700ml) Chronic retention(Painless)Examination: Examination Palpable bladder Palpate the scrotum:epididymo orchitis Signs of CRF,Pallor Digital Rectal Examination(DRE) Smooth,symmetrical enlargement median sulci + Firm in consistency Mobility of rectal mucosa + inaccurate for size detection Relevent Neurological examinationSymptom assessment : Symptom assessment The International Prostate Symptom Score ( IPSS )/AUA Score is recommended as it is used worldwide IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). It contains: seven questions about the severity of symptoms. Total score 0–7 (mild), 8–19 (moderate), 20–35 (severe)INVESTIGATIONS FOR LUTS: INVESTIGATIONS FOR LUTS Basic Ix: UFR,S.Cr,FBC Urine culture + ABST Xray KUB : calculi,prostatic Ca Bone mets + USS/KUB Uroflometry PSA(prostate specific antigen) Flexible CystoscopyINVESTIGATIONS FOR LUTS: INVESTIGATIONS FOR LUTS USS/KUB size of the prostate(>20cm 3 :abnormal) post micturition residual volume(>50-100ml), hydroureter,hydronephrosis,?CRF Uroflometry Flow rate(Q max >15ml/sec is normal) voiding time,volume of voided urine,voiding pattern Flexible Cystoscopy if evidence of haematuriaPowerPoint Presentation: 33UROFLOMETRY: UROFLOMETRYCystoscopic view of Prostatic obstruction: Cystoscopic view of Prostatic obstructionPSA(prostate specific antigen) : PSA(prostate specific antigen) normal<4ng/dl Not disease specific Also ↑ in BPH,prostatitis,PR Ex,catheterization Never do Serum PSA within 2 weeks of catheterization. >10ng/dl: ? Prostate ca > 20 ng /dl: ? Bone mets + High PSA → Trans rectal trucut BxPowerPoint Presentation: Watchful waiting Medical management Surgical approaches Minimal invasive TURP Invasive “open” procedures Treatment options“watchful waiting”: “ watchful waiting ” For mild symptoms. follow up1 to 2 times yearly Offer suggestions that help reduce symptoms Avoid caffeine and alcohol Alteration of timing,volume of fluid intake n n n nMedication:Two major types: : Medication: Two major types: α 1 adrenergic blockers Relax the smooth muscle of prostate and provide a larger urethral opening 5 α reductase inhibitor Shrink the prostate gland nα blockers(relaxants) : α b lockers(relaxants) Eg:prazosin,terazosin,Tamsulosin Prostatic specific α 1 adrenergic blockers → less S/E S/E postural hypotension(First dose effect with Prozosin,Terazosin ) Retrograde ejaculation with Tamsulosin Relax the smooth muscle of the prostate,proximal urethra Early action. ↑ urinary flow in men with mild moderate symptoms awaiting for surgery Drugs don’t alter the size of the prostateDistribution of 1-Adrenergic Receptors : Distribution of 1 -Adrenergic Receptors-Blockers: -Blockers Nonselective Phenoxybenzamine Short-acting selective a 1 -blocker Prazosin , Alfuzosin Long-acting selective a 1 -blockers Terazosin Doxazosin Long-acting selective a 1A -subtype Tamsulosin Alfuzosin -SR5αreductase inhibitors(shrinkers)(5ARI): 5 α reductase inhibitors( shrinkers )(5ARI) Eg:finasteride Testosterone -- Dihydrotestosterone (DHT) (Active molecule) 5 α reductase 5ARI( antiandrogens ) S/E Impotence, ↓ Lipido,Ejaculatory disorders,Gynaecomastia ↓ PSA,Use condom while sex → y?Drug excreted at semen. Slow action,Taken orally as once daily dose as long term basis atleast 6months. ↓ The size of the prostate &the flow ratesRegulation of cell growth in the prostate in BPH: Regulation of cell growth in the prostate in BPH DHT-androgen receptor complex Growth factors Unbalanced DHT T 5AR (1 and 2) Serum testosterone (T) Prostate cell Increased Cell growth Cell death Serum D i h ydro t estosterone (DHT)Medical management: Medical management Combination therapy gives better outcome( Medical treatment of prostate symptoms study ) Anticholinergics can be combined if patients have bothersome storage symptoms.INDICATION FOR SURGERY: INDICATION FOR SURGERY Complicated BPH Renal dysfunction(obstructive uropathy ) Recurrent attacks of acute retention of urine Chronic retention of urine Recurrent UTI Haematuria Calculi Patient dissatisfaction with medical management(QOL)BPH :SURGICAL OPTIONS: BPH :SURGICAL OPTIONS Bladder neck incision(For smaller prostate) TURP is still Gold standard Prostate ablative procedures Laser prostatectomies:Holmium,K + green light Plasma vaporisation of prostate(PVP) Minimally invasive:TUNA,TUMT Open prostatectomy( Retropubic / Transvesical )INDICATIONS FOR OPEN PROSTATECTOMY: INDICATIONS FOR OPEN PROSTATECTOMY Large prostate(>100ml) Co existing bladder pathology eg:bladder calculi,Bladder diverticula . Situations where patient can not be placed on lithotomy position eg:Hip joint diseasePowerPoint Presentation: TURP “ Gold Standard ” of care for BPH Uses an electrical “knife” to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow (transurethral resection of the prostate) n n nProstate Resectoscope and TURP: Prostate Resectoscope and TURPTURP: TURP “Gold standard” of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.2%Complication of TURP: Complication of TURP Immediate complication bleeding capsular perforation with fluid extravasation TURP syndrome clot retention sepsis Late complication urethral stricture /bladder neck contracture (BNC) Retrograde ejaculation(90%): due to damage to internal urethral sphincter Impotence (5-10%) incontinence (0.1%)TURP SYNDROME: TURP SYNDROME Absorbtion Irrigation fluid(boiled cooled water/ glycine ) into the open prostatic vein Fluid overload Pulmonary oedema,cerebral oedema Haemodilution Hyponatraemia,haemolysis Rx: StopSx IVfrusemide Hypertonic salinePre/Post op Mx: Pre/Post op Mx Pre-operative Mx if UTI → Rx If uraemia + → Rx with catheter drainage. Stop aspirin,clopidogrel 10days before surgery Post-op: Continuous bladder irrigation with N.Saline until urine clear of clotsUrinary Retention: Urinary Retention Acute Painful Normal renal function Precipitating event UTI Fluid overload Constipation Medication Chronic Painless Impaired renal function Large residual volumeMCQ 1: MCQ 1 Benign prostatic hyperplasia Leads to chronic renal failure Can be treated medically Always need surgical treatment Cause rise in prostate specific antigen(PSA) Occurs in the transition zoneMCQ 2: MCQ 2 Causes for acute retention of urine Phimosis Epidural anaesthesia Enlarged prostate After haemorrhoidectomy Bladder calculi Tricyclic anti depressants Prostatic Ca Beta blockers Acute prostatitisMCQ 3: MCQ 3 Complications of TURP, Hypernatraemia Urinary Incontinence Haemolysis Secondary haemorrhage Urethral stricture Retrograde ejaculation Epididymoorchitis Confusion Clot retention Primary haemorrhageMCQ 4: MCQ 4 Bladder outflow obstruction in men Is associated with large post voidal volume in USS/ Abd . Is likely to be present in a man with a flow rate of<10ml.s. Can be caused by spinal cord injury Can be caused by ureteric stricture. Always managed with surgical intervention.MCQ 5: MCQ 5 T/F regarding prostate specific antigen(PSA) Is always elevated in adeno carcinoma of the prostate. Rise significantly in the serum following digital rectum examination Is a hormone that regulates the growth of the prostate Is a serum protease involved in the liquefaction of the semen A serum PSA level>10ng/dl supports the diagnosis of BPHTHANK YOU: THANK YOU ANY Q? You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Benign Prostatic Hyperplasia (BPH) Balagobi Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 1793 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: December 03, 2012 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Benign Prostatic Hyperplasia (BPH): Benign Prostatic Hyperplasia (BPH) Dr.B.Balagobi Lecturer Department of Surgery Faculty of Medicine UOJWhat’s LUTS?: What’s LUTS? Voiding (obstructive) symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incomplete bladder emptying Urinary retention(Acute/Chronic) Storage ( irritative or filling) symptoms Urgency Urge incontinence Frequency Nocturia Nocturnal enuresis LUTS is not specific to BPHPowerPoint Presentation: 3 Bladder Outflow Obstruction (BOO) Syn: Prostatism : Bladder Outflow Obstruction (BOO) Syn : Prostatism Obstructive Symptoms Irritative Symptoms Emergency - Acute urinary retention(ARU) - Retention with overflow Elective - Weak stream - Incomplete emptying - Intermittency - Hesitancy/Straining - Prolonged micturition Terminal dribbling Urgency Urge incontinence Frequency - Nocturia Nocturnal enuresis International Prostate Symposium Score (IPSS) 0 – 7 = Mildly symptomatic, 8 -19 = Moderately symptomatic, 20 – 35 = Severely symptomaticCauses of Bladder Outlet obstruction: Causes of Bladder Outlet obstruction Prostate:BPH,Ca prostate,Prostatitis Urethral stricture Post traumatic(Trauma/Instrumentation/post TURP) Post inflammatory( STD:Chlamydia,Gonococcal ) Ix:Asending urethrogram Rx:Urethral dilatation,Urethroplasty Bladder calculi Phimosis (BXO),Urethral meatal stenosis Bladder neck stenosis Sphincter dyssynergiaPowerPoint Presentation: 6PowerPoint Presentation: 7PowerPoint Presentation: 8Surgery: Surgery 9Urethral dilators: Urethral dilators 10Urethral dilatation: Urethral dilatation 11PowerPoint Presentation: 12PowerPoint Presentation: 13PowerPoint Presentation: 14Introduction to BPH: Introduction to BPH BPH is a common problem affects 1/3 of men older than 50 years . Pathological process of BPH starts at thirties. Histologically identifiable BPH 70%@70 years,90%@90 yrs. But only 10%present with symptoms. Severity of the symptoms not correlated with the size of the prostate.PowerPoint Presentation: 17RELATIONSHIP OF PROSTATE VOLUME AND PSA LEVELS IN SRI LANKAN MEN WITH BPH: RELATIONSHIP OF PROSTATE VOLUME AND PSA LEVELS IN SRI LANKAN MEN WITH BPH B Balagobi ,WTT de Silva ,SK Chandrasekera , K Sutharshan , S Prathapan , AWeerakkodi University Surgical Unit, Colombo South Teaching Hospital,Kalubowila , Sri LankaPathogenesis of BPH: Pathogenesis of BPH Due to aging process&testosterone stimulation Proliferation of both fibrous&glandular elements. esp @median lobe/transition zone/ Periurethral zonePowerPoint Presentation: Peripheral zone Transition zone Urethra What is Benign Prostatic Hyperplasia?PowerPoint Presentation: Peripheral zone Transition zone UrethraPowerPoint Presentation: LUTS/RetentionDiverticula in bladder: Diverticula in bladderComplications: ComplicationsClinical features: Clinical features LUTS Complications CRF(obstructive uropathy ) UTI Bladder stone Haematuria Acute retention( Painful,Urine volume < 700ml) Chronic retention(Painless)Examination: Examination Palpable bladder Palpate the scrotum:epididymo orchitis Signs of CRF,Pallor Digital Rectal Examination(DRE) Smooth,symmetrical enlargement median sulci + Firm in consistency Mobility of rectal mucosa + inaccurate for size detection Relevent Neurological examinationSymptom assessment : Symptom assessment The International Prostate Symptom Score ( IPSS )/AUA Score is recommended as it is used worldwide IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). It contains: seven questions about the severity of symptoms. Total score 0–7 (mild), 8–19 (moderate), 20–35 (severe)INVESTIGATIONS FOR LUTS: INVESTIGATIONS FOR LUTS Basic Ix: UFR,S.Cr,FBC Urine culture + ABST Xray KUB : calculi,prostatic Ca Bone mets + USS/KUB Uroflometry PSA(prostate specific antigen) Flexible CystoscopyINVESTIGATIONS FOR LUTS: INVESTIGATIONS FOR LUTS USS/KUB size of the prostate(>20cm 3 :abnormal) post micturition residual volume(>50-100ml), hydroureter,hydronephrosis,?CRF Uroflometry Flow rate(Q max >15ml/sec is normal) voiding time,volume of voided urine,voiding pattern Flexible Cystoscopy if evidence of haematuriaPowerPoint Presentation: 33UROFLOMETRY: UROFLOMETRYCystoscopic view of Prostatic obstruction: Cystoscopic view of Prostatic obstructionPSA(prostate specific antigen) : PSA(prostate specific antigen) normal<4ng/dl Not disease specific Also ↑ in BPH,prostatitis,PR Ex,catheterization Never do Serum PSA within 2 weeks of catheterization. >10ng/dl: ? Prostate ca > 20 ng /dl: ? Bone mets + High PSA → Trans rectal trucut BxPowerPoint Presentation: Watchful waiting Medical management Surgical approaches Minimal invasive TURP Invasive “open” procedures Treatment options“watchful waiting”: “ watchful waiting ” For mild symptoms. follow up1 to 2 times yearly Offer suggestions that help reduce symptoms Avoid caffeine and alcohol Alteration of timing,volume of fluid intake n n n nMedication:Two major types: : Medication: Two major types: α 1 adrenergic blockers Relax the smooth muscle of prostate and provide a larger urethral opening 5 α reductase inhibitor Shrink the prostate gland nα blockers(relaxants) : α b lockers(relaxants) Eg:prazosin,terazosin,Tamsulosin Prostatic specific α 1 adrenergic blockers → less S/E S/E postural hypotension(First dose effect with Prozosin,Terazosin ) Retrograde ejaculation with Tamsulosin Relax the smooth muscle of the prostate,proximal urethra Early action. ↑ urinary flow in men with mild moderate symptoms awaiting for surgery Drugs don’t alter the size of the prostateDistribution of 1-Adrenergic Receptors : Distribution of 1 -Adrenergic Receptors-Blockers: -Blockers Nonselective Phenoxybenzamine Short-acting selective a 1 -blocker Prazosin , Alfuzosin Long-acting selective a 1 -blockers Terazosin Doxazosin Long-acting selective a 1A -subtype Tamsulosin Alfuzosin -SR5αreductase inhibitors(shrinkers)(5ARI): 5 α reductase inhibitors( shrinkers )(5ARI) Eg:finasteride Testosterone -- Dihydrotestosterone (DHT) (Active molecule) 5 α reductase 5ARI( antiandrogens ) S/E Impotence, ↓ Lipido,Ejaculatory disorders,Gynaecomastia ↓ PSA,Use condom while sex → y?Drug excreted at semen. Slow action,Taken orally as once daily dose as long term basis atleast 6months. ↓ The size of the prostate &the flow ratesRegulation of cell growth in the prostate in BPH: Regulation of cell growth in the prostate in BPH DHT-androgen receptor complex Growth factors Unbalanced DHT T 5AR (1 and 2) Serum testosterone (T) Prostate cell Increased Cell growth Cell death Serum D i h ydro t estosterone (DHT)Medical management: Medical management Combination therapy gives better outcome( Medical treatment of prostate symptoms study ) Anticholinergics can be combined if patients have bothersome storage symptoms.INDICATION FOR SURGERY: INDICATION FOR SURGERY Complicated BPH Renal dysfunction(obstructive uropathy ) Recurrent attacks of acute retention of urine Chronic retention of urine Recurrent UTI Haematuria Calculi Patient dissatisfaction with medical management(QOL)BPH :SURGICAL OPTIONS: BPH :SURGICAL OPTIONS Bladder neck incision(For smaller prostate) TURP is still Gold standard Prostate ablative procedures Laser prostatectomies:Holmium,K + green light Plasma vaporisation of prostate(PVP) Minimally invasive:TUNA,TUMT Open prostatectomy( Retropubic / Transvesical )INDICATIONS FOR OPEN PROSTATECTOMY: INDICATIONS FOR OPEN PROSTATECTOMY Large prostate(>100ml) Co existing bladder pathology eg:bladder calculi,Bladder diverticula . Situations where patient can not be placed on lithotomy position eg:Hip joint diseasePowerPoint Presentation: TURP “ Gold Standard ” of care for BPH Uses an electrical “knife” to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow (transurethral resection of the prostate) n n nProstate Resectoscope and TURP: Prostate Resectoscope and TURPTURP: TURP “Gold standard” of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.2%Complication of TURP: Complication of TURP Immediate complication bleeding capsular perforation with fluid extravasation TURP syndrome clot retention sepsis Late complication urethral stricture /bladder neck contracture (BNC) Retrograde ejaculation(90%): due to damage to internal urethral sphincter Impotence (5-10%) incontinence (0.1%)TURP SYNDROME: TURP SYNDROME Absorbtion Irrigation fluid(boiled cooled water/ glycine ) into the open prostatic vein Fluid overload Pulmonary oedema,cerebral oedema Haemodilution Hyponatraemia,haemolysis Rx: StopSx IVfrusemide Hypertonic salinePre/Post op Mx: Pre/Post op Mx Pre-operative Mx if UTI → Rx If uraemia + → Rx with catheter drainage. Stop aspirin,clopidogrel 10days before surgery Post-op: Continuous bladder irrigation with N.Saline until urine clear of clotsUrinary Retention: Urinary Retention Acute Painful Normal renal function Precipitating event UTI Fluid overload Constipation Medication Chronic Painless Impaired renal function Large residual volumeMCQ 1: MCQ 1 Benign prostatic hyperplasia Leads to chronic renal failure Can be treated medically Always need surgical treatment Cause rise in prostate specific antigen(PSA) Occurs in the transition zoneMCQ 2: MCQ 2 Causes for acute retention of urine Phimosis Epidural anaesthesia Enlarged prostate After haemorrhoidectomy Bladder calculi Tricyclic anti depressants Prostatic Ca Beta blockers Acute prostatitisMCQ 3: MCQ 3 Complications of TURP, Hypernatraemia Urinary Incontinence Haemolysis Secondary haemorrhage Urethral stricture Retrograde ejaculation Epididymoorchitis Confusion Clot retention Primary haemorrhageMCQ 4: MCQ 4 Bladder outflow obstruction in men Is associated with large post voidal volume in USS/ Abd . Is likely to be present in a man with a flow rate of<10ml.s. Can be caused by spinal cord injury Can be caused by ureteric stricture. Always managed with surgical intervention.MCQ 5: MCQ 5 T/F regarding prostate specific antigen(PSA) Is always elevated in adeno carcinoma of the prostate. Rise significantly in the serum following digital rectum examination Is a hormone that regulates the growth of the prostate Is a serum protease involved in the liquefaction of the semen A serum PSA level>10ng/dl supports the diagnosis of BPHTHANK YOU: THANK YOU ANY Q?