Benign Prostatic Hyperplasia (BPH): Benign Prostatic Hyperplasia (BPH) Dr.B.Balagobi Lecturer Department of Surgery Faculty of Medicine UOJ What’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 BPH PowerPoint 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 symptomatic Causes 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 dyssynergia PowerPoint Presentation: 6 PowerPoint Presentation: 7 PowerPoint Presentation: 8 Surgery: Surgery 9 Urethral dilators: Urethral dilators 10 Urethral dilatation: Urethral dilatation 11 PowerPoint Presentation: 12 PowerPoint Presentation: 13 PowerPoint Presentation: 14 Introduction 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: 17 RELATIONSHIP 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 Lanka Pathogenesis of BPH: Pathogenesis of BPH Due to aging process&testosterone stimulation Proliferation of both fibrous&glandular elements. esp @median lobe/transition zone/ Periurethral zone PowerPoint Presentation: Peripheral zone Transition zone Urethra What is Benign Prostatic Hyperplasia? PowerPoint Presentation: Peripheral zone Transition zone Urethra PowerPoint Presentation: LUTS/Retention Diverticula in bladder: Diverticula in bladder Complications: Complications Clinical 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 examination Symptom 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 Cystoscopy INVESTIGATIONS 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 haematuria PowerPoint Presentation: 33 UROFLOMETRY: UROFLOMETRY Cystoscopic view of Prostatic obstruction: Cystoscopic view of Prostatic obstruction PSA(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 Bx PowerPoint 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 n Medication: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 n α 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 prostate Distribution 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 -SR 5αreductase 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 rates Regulation 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 disease PowerPoint 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 n Prostate Resectoscope and TURP: Prostate Resectoscope and TURP TURP: 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 saline Pre/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 clots Urinary Retention: Urinary Retention Acute Painful Normal renal function Precipitating event UTI Fluid overload Constipation Medication Chronic Painless Impaired renal function Large residual volume MCQ 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 zone MCQ 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 prostatitis MCQ 3: MCQ 3 Complications of TURP, Hypernatraemia Urinary Incontinence Haemolysis Secondary haemorrhage Urethral stricture Retrograde ejaculation Epididymoorchitis Confusion Clot retention Primary haemorrhage MCQ 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 BPH THANK YOU: THANK YOU ANY Q?