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