bph 4th yr
DESCRIPTION
lecture by Dr. Ahmed RehmanTRANSCRIPT
BLADDER OUTFLOW OBSTRUCTION
(BOO)BENIGN PROSTATIC
HYPERPLASIA(BPH)
DR AHMED REHMANFCPS ( Urology)
Assistant Professor Urology
Set induction
Learning objectives
• Define BOO
• Enlist causes of BOO
• Enlist types of prostatic enlargment
• Discuss etiology of BPH
• Enlist clinical features
• Enlist diagnostic investigations
• Enlist treatment modalities
BLADDER OUTFLOW OBSTRUCTION
A URODYNAMIC CONCEPT OF
LOW
URINARY FLOW RATE
DESPITE ABNORMALLY
HIGH
VESICAL PRESSURE
CAUSES OF BLADDER OUTFLOW OBSTRUCTION
• CONGENITAL - URETHRAL VALVES & STRICTURES
• STRUCTURAL: – Benign prostatic hyperplasia – Carcinoma of the prostate – Bladder neck stenosis – Urethral stricture
• FUNCTIONAL: – Bladder neck dyssynergia– Neurological disease - spinal cord
lesions, MS, diabetes – Drugs - anticholinergics,
antidepressants
ANATOMY and ANATOMICAL ZONES OF ANATOMY and ANATOMICAL ZONES OF PROSTATEPROSTATE
– Location– Normal weight and size
• PERIPHERAL ZONE 70%
• CENTRAL ZONE25%
• TRANSITION ZONE05%
• PERIUREHTAL GLANDS
• PREPROSTATIC SPHINCTER
PROSTATE CANCER Tumor distribution
% of glandular % of glandular tissue in tissue in prostateprostate
% of cancers% of cancersin zonein zone
10% 25% 65%
5-10% 70%20%
Oesterling J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1322-1386.
Transition zone Central zone Peripheral zone
INCIDENCE & PREVALANCE OF BPH
– Affects 50% men older than 60 years
– Affects 90% of men older than 90 years
0%
10%
20%
30%
40%
50%
60%
70%
80%
50 60's 70's 80's
AGE
ETIOLOGY
Multifactorial Genetic Predisposition Racial factors Androgens (DHT)
– Role of testosterone vs estrogen / receptors Aging / Age relationship
– Family history– ? Role of diet
PATHOLOGY
• a) Stormal Proliferation
• B) Glandular Proliferation
• Adenoma • formation
• PATHOPHYSIOLOGY OF BPH: – Size of prostate vis-a-vis BOO– Compensatory phase (detrusor hyperplasia)– Detrusor de-compensation ( PVRU)
SYMPTOMSSYMPTOMS. Etiology
• Static Obstruction (Mass related Increase in Urethral resistance).
• Dynamic Obstruction (Increased adrenergic tone in prostate)
SYMPTOMS OF BPH (LUTS)
– Obstructive• Poor flow / Decreased
force & calibre of stream
• Hesitancy / Straining• Terminal dribbling• Intermittency of stream• Sense of incomplete
evacuation of bladder• Double voiding • Post void dribbling • Retention of urine
– Acute / chronic
• IRRITATIVE SYMPTOMS:
– Urgency
– Frequency
• Day time / Night time (nocturia)
– Urge incontinence
Enuresis
• “AND KEEP CLEAN YOUR GARMENTS” QURAN
• COMPLICATIONS OF BPH:– Bladder changes
• Trabeculation / Saccules / diverticulae
– Upper tract DETERIORATION / Post obstructive renal failure (uraemia)
– RECURRENT UTI’s
– Haematuria– Acute / chronic / REFRACTORY retention of urine– Vesical stones– Manifestations of prolonged straining (intra abdominal pressure)
• Hernias• Haemorrhoids (Pics)
ASSESSMENTASSESSMENT-Essential information from patient
• LUTS (including QoL Score)
• Other Urinary symptoms (eg hematuria)
• Previous pelvic surgery (eg Ant Resection)
• Neuropathy (eg Parkinsonis, MS,CVA)
• Cardiac Problems
• Diabetes Mellitus
• Fluid Intake & out put chart.
ASSESMENTASSESMENTCLINICAL EXAMINATION
• Physical examination = may / not be NORMAL– SIGNS OF RENAL FAILURE
– Painful DISTENDED BLADDER
• EXTERNAL URINARY MEATUS
• EPIDYDIMES FOR EPIDYDIMITIS
• DREProstate (size/symmetry/consistency), Anal Tone, Rectal masses
• Focused neurological examination
INTERNATIONAL PROSTATE SYMPTOM
SCORE (AUA scoring (scoring chart)
• Symptoms Score
• i) Incomplete emptying → 1-5
• ii) Frequency → 1-5
• iii) Intermittency → 1-5
• iv) Urgency → 1-5
• v) Weak Stream → 1-5
• vi) Straining → 1-5
• vii) Nocturia → 1-5
• 0-7 = mild, 8-19 = moderate, 20-35 = Severe
• Quality of line assesment =1-6
AUA SOURCE
Urinary Symptoms (Symptom Score Criteria)
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost Always
1. Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
0 1 2 3 4 5
2. Frequency
Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
0 1 2 3 4 5
3. Intermittency
Over the past month, how often have you found you stopped and started again several times when you urinate?
0 1 2 3 4 5
4. Urgency
Over the past month, how often have you found it difficult to postpone urination?
0 1 2 3 4 5
AUA SCORE
Urinary Symptoms (Symptom Score Criteria)
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost Always
5. Weak Stream
Over the past month, how often have you had a weak urinary stream?
0 1 2 3 4 5
6. Straining
Over the past month, how often have you had to push or strain to begin urination?
0 1 2 3 4 5
None 1 time 2 times 3 times 4 times 5 or more times
7. Nocturia
Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got in the morning?
0 1 2 3 4 5
AUA Symptom Score
QUALITY OF LIFE DUE TO URINARY PROBLEMS
Delighted Pleased Mostly Satisfied
Mixed-about equally satisfied and un-satisfied
Mostly dis-satisfied
Unhappy Terrible
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
0 1 2 3 4 5 6
ASSESSMENTASSESSMENTLab & Other tests
• URINALYSIS
• CBE
• SERUM UREA & CREATININE
• U.S.G. RENAL TRACT (prostate and POST VOID URINE = PVRU)
• CXR, ECG, RBS.
• PSA ? / (Optional)
• Roll of IVU / KUB
• ? Role of Urodynamics
UROFLOWMETRY
Uroflometry - Normal curve
Peak Flow
0
Time
Flow Time
Flow rate(ml/sec)
Time to peak flow
PRESSURE FLOW URODYNAMIC STUDIES-INDICATIONS
• MULTIPLE SCLEROSIS
• PARKINSONISM
• LONG STANDING DIABETES
• CVA
• DEMENTIA
• VERY LONG (LIFE LONG) Hx FREQUENCY, URGENCY
• DOUBTFUL Hx & EQUIVOCAL FLOW RATE
• INVALID FLOW RATE (Low Volume)
BRAINSTORMING ACTIVITY
• You have a Weighing balance and seven balls all of same size.
• One of the balls is heavier then the rest which all carry equal weight.
• Using the balance only twice identify the heavy ball
DIFFERENTIAL DIAGNOSIS
• UTI / BLADDER STONE.
• URETHRAL STRICTURE
• BLADDER CARCINOMA
• PROSTATE CARCINOMA
• NEUROLOGICAL DISEASES
• MEDICATIONS SIDE EFFECTS
• POLYUREA FROM DIABETES
• TREATMENT OF BPH: Acute retention of Urine
– Urethral Catheterisation– Supra pubic puncture– Supra pubic cystostorny
– POST CATHETERIZATION DIURESIS
MILD SYMPTOMSWATCHFUL WAITING
• Decreasing total fluid intake -esp at night.
• Moderating intake of caffeine containing products.
• Timed voiding schedule.
• Avoiding constipation.
MODERATE SYMPTOMSMEDICAL TREATMENT
• ALPHA BLOCKERS – Prazosin Minipress
– Terazosin Hyterin
– Doxazosin Cardura
– Alfuzosin Xatral
– Tamsulosin Flow max
• 5 ALPHA REDUCTASE INHIBITORS– Fenesteride Proscar
• PHYTOTHERAPY (plant extracts)– Saw palmetto (acti-pro)
– β-sitosterols (pronals)
• ESTROGENS distilbesterol ( Hanovan)
Alpha adrenoceptors in BPH
• APPROXIMATELY 50% OF TOTAL URETHRAL PRESSURE IN BPH MAY BE DUE TO ALPHA ADRENOCEPTOR MEDIATED MUSCLE TONE.
(Anderson KE et al-
BPH and alpha adrenoceptors in the lower urinary tract. 4th consultation on BPH 1997. P 601-606)
ALPHA BLOCKERS- EFFECTS
• MAXIMUM URINE FLOW INCREASED.
• OVERALL SYMPTOM SCORE DECREASED.
• RESIDUAL URINE VOLUME DECREASED.
5 Alpha reductase inhibitors
•
TESTOSTERONE
DHT
FINESTERIDEDUTASTERIDE
5 AR
Definitive Indications for Indications for surgerysurgery (Patients unsuitable for medical treatment)
• Recurrent urinary retention.
• Recurrent UTI’s.
• Recurrent gross haematuria.
• Deterioration of renal function
• Associated Pathology • Bladder stone.
• Diverticulum
Conventional Surgical Procedures
• Open Prostatectomy– Transvesical– Retropubic– Perineal
TURP
Endoscopic procedures
Endoscopic procedures TUIP (BNI)
Minimal Invasive Surgery (MIS)• Trans urethral microwave therapy (TUMT).• Endoscopic LASER ablation of prostate (ELAP)• Hyperthermia • Baloon dialatation• Transurethral electroevaporation of the prostate
(TUVP / TUEVP)• Transurethral radio frequency needle ablation of the
prostate (TUNA)• Water-induced thermotherapy (WIT)• High-intensity focused ultrasound (HIFU)• Prostatic stent (stenting)
INITIAL EVALUATIONHx, CE, Lab Tests,Flow rate,
Residual urine
SYMPTOMS ASSESMENT
MILD MODERATE SEVERE
W WMEDICAL
TREATMENT
REC RETENTIONRec UTI’s
VESICAL STONESGROSS HEMATURIA
RENAL FAILURE
ADDITIONAL TESTS
SURGERY ORALTERNATIVE PROCEDURES
IF NOCONTRA INDICATION
Complications of Surgery
• a) Haemorrhage• b) Perforation• c) Sepsis• d) Incontinence• e) Retrograde ejaculation• f) Urethral Stricture• TUR Syndrome
ROLE OF INTERNIST IN MANAGEMENT OF BPH
• Diagnosis• Decision of modality chosen• Fittness for surgery and aneasthesia
– Disprin
• Blood • Post op care, -------- Irrigation • Histopath • Follow up
Summary
• Age related Benign disease
• Can affect quality of life and have bad effects on kidneys
• Treatment: medicinal and surgical, stage-wise, should be timely and prompt