ANATOMY
BENIGN PROSTATIC HYPERPLASIA
INCIDENCE
Most prevalent Benign Tumor > 50 yr old 50% at 50 yr have histological evidence >90 % after 80 yrs
ETIOLOGY
ENDOCRINE Low Testosterone High Estrogens Sensitization of Androgen Receptors
PATHOPHYSIOLOGY
HYPERPLASIA Epithelium Stroma (Smooth muscle)
Urethra Mechanical (Prostate Enlargement) Dynamic (Smooth Muscle in Stroma) Irritable (Bladder Response to outlet reistance )
Consequences of BPH ■ No symptoms, no BOO ■ No symptoms, but urodynamic evidence of BOO ■ LUTS, no evidence of BOO ■ LUTS and BOO ■ Others (acute/chronic retention, haematuria, urinary infection and stone formation)
SYMPTOMS (LUTS)OBSTRUCTIVE SYMPTOMS IRRITATIVE SYMPTOMS
Hesitancy decreased force and caliber of
stream Sensation of incomplete bladder
emptying double voiding (urinating a
second time within 2 hours of the previous void)
straining to urinate Dribbling (post-void ) Episodes of near retention Intermittant stream
urgency, frequency Nocturia Urge incontinence enuresis
MILD 0-7 MODERATE 8-19 SEVERE 20-35
SYMPTOMS (BOO)
Ac. Retention Ch. Retention Hematuria Impaired bladder emptying
SIGNS
Digital Rectal Examination (DRE) DRE typically takes less than a minute to perform. In
this procedure, the physician inserts a lubricated, gloved finger into the patient's rectum to feel the surface of the prostate gland through the rectal wall to assess the size, shape, and consistency of the gland. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose.
INVESTIGATION
CUE PSA USG IVU CYSTOSCOPY
URODYNAMIC STUDIES < 10 ml s–1 > 80 cmH2O
DIFFERENTIAL DIAGNOSIS
UTI Ca Prostate Urethral stricture Bladder neck contracture Vesical stone
TREATMENT
WATCHFUL WAITING MEDICAL SURGICAL
Medical Alpha Blockers 5α-Reductase Inhibitors(finasteride) Combination Therapy Phytotherapy
Alpha Blockers
Non Selective-Prazocin Selective(alpha 1a)-Tamsolin
5α-reductase Inhibitors
Finasteride Epithelial component Minimum-6 months(20% reduction in size) Large prostate(40cm3)
Combination Therapy
Risk of progression Large gland High PSA
Phytotherapy
saw palmetto berry (Serenoa repens) the bark of Pygeum africanum, the roots of Echinacea purpurea and Hypoxis rooperi, pollen extract, leaves of the trembling poplar
Surgical Management
INDICATIONS refractory urinary retention (failing at least one attempt
at catheter removal), recurrent urinary tract infection recurrent gross hematuria bladder stones Ch. Retention & renal insufficiency large bladder diverticula Severe Symptoms
Surgical
CONVENTIONAL TURP TUIP Open Prostatectomy
TURP Complication
Retrograde ejaculation Impotence Incontinence TUR syndrome Bleeding Stricture\stenosis
Transurethral Incision Of Prostate
Indication Moderate-Severe Symptoms Small Prostate with post Commisure
Hyperplasia(elevated bladder neck) Procedure
5 & 7 O clock
Open Prostatectomy
Indication Glands >100 g concomitant bladder diverticulum Bladder stone dorsal lithotomy positioning is not possible.
Approaches Suprapubic Retropubic (Millon) Perineal(young)
SurgicalMINIMALLY INVASIVE Laser
TULIP Visual contact ablative laser therapy Interstitial laser therapy
Transurethral electrovaporization of the prostate Hyperthermia Transurethral needle ablation of the prostate High-intensity focused ultrasound Intraurethral stents