Luen Shaun Chew

Content Anatomical Relations

Structure

Neurovascular and lymphatics

BPH – Definition

Clinical Presentation

Complications

Investigations

Management

Anatomy Inferior to bladder

Surrounds the prostatic urethra

Conical

Weight ~20g

Length 3cm

Anatomical Relations Superior – bladder neck

Inferior – urogenital diaphragm

Anterior – pubic symphysis separated by extraperitoneal fat; puboprostatic ligaments

Posterior – rectum; fascia of Denonvilliers

Lateral – Pubococcygeal of levator ani

Structure 70% glandular 30%

fibromuscular stroma

Transition: surrounds urethra proximal to ejaculatory ducts

Central: surrounds ejaculatory ducts projects to seminal vesicles under bladder base

Peripheral: bulk of apical, posterior and lateral aspects

Anterior fibromuscular stroma

QUIZ! Which zone does BPH usually arise from?

a) Transition

b) Central

c) Peripheral

d) All/Any zones

Which zone does Prostate ca usually arise from? a) Transition

b) Central

c) Peripheral

d) All/Any zones

Neurovascular and Lymphatics Arterial: Inferior vesical and middle rectal

Venous: Prostatic venous plexus – internal iliac veins + vertebral venous plexus

Innervation:

Sympathetic (T10 – L2); 1 – andrenergic receptors

Parasympathetic (S2 – S4)

Lymphatics: Internal iliac nodes

BPH – What is it? Increase in both stromal and glandular cells

Very common, common cause of urinary retention in elderly

50% of men >50 years

Usually affects transition zone, enlargement compresses urethra and peripheral zone becomes thinner (pseudocapsule)

Aetiology: ?Local androgen imbalance between testosterone and oestrogen

BPH - Presentation Asymptomatic

Lower urinary tract symptoms (LUTS):

Voiding – hesitancy, poor stream, straining, terminal dribbling

Storage – frequency, urgency, nocturia, incontinence

Acute/Chronic urinary retention

BPH – Examination Abdominal examination – Distended, palpable

bladder, suprapubic tenderness

External genitalia – r/o urethral meatal stenosis

DIGITAL RECTAL EXAMINATION (DRE):

BPH vs Prostate ca

Faecal impaction

?Tenderness

BPH -Complications Retention

Infection

Bladder diverticula and stones

Hydronephrosis – renal impairment

BPH – Investigations Urinalysis

Bloods – FBC, u+e

PSA – if suspect cancer, need patient counselling

Uroflowmetry – need at least 100mls of urine, max flow <10ml/sec – suggestive of obstruction

Bladder scan – residual > 300mls indicates chronic urinary retention

USS Renal – r/o hydronephrosis

Urodynamics

Transrectal Ultrasound (TRUS) +/- biopsy

BPH - Management 1. Conservative:

Reassurance, once prostate ca excluded

Lifestyle changes ie decreasing fluid nocte, reduce caffeine intake

ISC, Long-term catheter

2. Medical: α-blocker – Tamsulosin, Doxazosin, Alfuzosin

5α reductase inhibitors – Finasteride, Dutasteride

3. Surgery: TURP

TUNA

Laser/Microwave ablation

Open Retropubic prostatectomy

TURP Indication:

Moderate-severe LUTS Complications of BPH Failure to medical tx Renal impairment due to LUTS

Complications: Bleeding Infection Incontinence Strictures Impotence (20%) Retrograde ejaculation (>80%) TURP syndrome

TURP syndrome Absorption of large volumes of irrigation fluid through

prostatic venous plexus

During or post-TURP

Hyponatraemia, high nitrogen load

Hypervolaemia

Cerebral oedema

Hypothermia

Management: Fluid restriction

Diuretics

Summary BPH, common cause of urinary retention in elderly

male

DRE is essential in diagnosis

BPH – transition zone, malignancy – peripheral zone

Severity of LUTS and co-morbidities determines management of BPH

Side effects of medical tx and possible complications of surgery

Thank you Any questions?