Benign prostatic

hyperplasia (BPH)
 Introduction
• Noncancerous enlargement of the prostate gland
• Is a proliferative process of cellular elements
(stromal & epithelial cell proliferation)
• Occurs primarily in transion zone of the prostate
• Increase with age
• Hormonally dependent (testosterone & DHT)
• Not all men with BPH have LUTS or not all men
with LUTS have BPH the same can be said for
Boo
 Anatomy
• Wal nut –sized gland
• Part of reproductive system
• Has 3 lobes & 4 zones
• The transion zone surrounds the urethra
• Located in front of the rectum ,below the bladder
• Blood supply from inferior vesical, mid
hemorroidal, & internal pudendal arteries
• Venous drain (to pelvic plexus & bastone veins)
Anatomy
 Functions
• Produce alkaline fluid for liquefaction of
the semen ,comprises~ 70% of seminal
volume, provides nutrients for the sperm
• Conduit for semen to pass
• Prevent retrograde ejaculation by closing
the bladder neck during sexual climax
 Definition & epidemiology
• Enlargement of the prostate glands due to
an increased number of epithelial &
stromal cell in periurethral area
 Epidemiology
• In U.S.A 14 million have symptoms of BPH
• Worldwide about 30 million
• Common in male older than 50ys
• By age of 60 = 60% & by age of 80=90%
• Sexual activity (increase fibro muscular stromal cell)
& increase the risk of BPH
• Alcohol( decrease plasma testosterone & increase of
testosterone clearance & decrease the risk of BPH
• Smoking increase testosterone & estrogen level & it
has positive & inductive effect of on development of
BPH
 Etiology
 Unknown
 Aging
 Hormonal effects
Androgen is important for both normal & abnormal
growth of the prostate
90% of prostatic androgen is in the form of DHT
(from testicular androgen & 10% from adrenal
androgen)
Stromal – epithelial cells interaction produce growth
factors (epidermal GF, insulin like GF, fibroblast GF
Increased estrogen increase the expression of AR
in aging prostate & increase prostate size
 Pathogenesis
(Gland Enlargement)
 Occurs as results of increased Number of
epithelial & stromal cell (increased cell
proliferation)
 Disruption of equilibrium b/n cell death &
cell proliferation (decreased in cell death)
 Androgen requiring during development,
puberty & aging
 Castrated men or no androgen results no
BPH
 Common symptoms
(symtomatology)
 Prostatism =LUTS

 Classified in to
 Obstructive Irritative
 Weak urine stream • Frequency
 Difficulty starting urination • Urgency
 Dribbling
 Needing to urinate several • Urge incontinency
times • Enuresis
 Straining
 Sensation poor bladder
emptying
 Effects of BPH
Initially bladder becomes hypertrophied
Increase postvoidal residuals, poor
contractility
LUTS & BOO
Urinary retention
Hematuria, urinary infection
Stone formation, trabeculation
Bladder irritability, renal insufficiency
 DDX of BOO
• BPH
• Bladder stone
• Bladder tumor
• Urethral stricture
• Prostatic cancer
• Neurogenic bladder
 Diagnosis of BPH
• To pathologist is microscopic Dx (cellular
proliferation of stromal & epithelial elements)
• To radiologist makes the Dx in presence of
bladder neck elevation of cystogram phase of
IVP or enlarged prostate
• To urodynamist
– Elevated voiding pressure
– Low urinary rate
• To practicing urologist is constellation of sign &
symptom
 Diagnosis…..
• Hx
– Onset of the symptoms
– Age
– Hx of STD
• Determine which symptoms are predominant
(irritative or obstructive)
• Hx of hematuria, UTI, diabetis, NS disease,
urinary retention, surgery of LUT( Lower urinary
tract)
 Diagnosis…..
• P/E
 General assessment (chest, cvs, anemia,
external genitalia)
 Abdominal examination
Bladder distention
Dullness
Tenderness
 Diagnosis….
• DRE (digital rectal examination)
– Prostate size,consistance,noduls
– Prostate size does not correlate with symptoms
severity & degree of urodynamic obstruction & Rx
outcome
• Prostate is large, smooth, convex, elastic, firm,
mucosa moves over the prostate
• Ns examination (R/o caudaequina lesions)
 Investigations
U/A – dipstick & /or via centrifuged sediment for blood,
bact, prot, glucos …
Cytology for severe irritable symptom
Urine culture
PSA to R/o prostatic Ca which can coexist with
BPH
• Large BPH may have slightly elevated PSA
• PSA value >4ng/ml or DRE induration or nodularity
needs transrectal US & multiple biopsy
• PSA & DRE increase the detection rate of prostate Ca
over DRE alone
 Investigations….
Serum creatinine to R/o renal insufficiency
Occurs in 13% of case
 Help to evaluate the pt. with occult & progressive
renal damage secondary to silent prostatism
Postvoidal residual urine
Obtained after voiding of urine with a catheter or
transabdominal US
 Investigations….
Pressure flow studies
Done to distinguish b/n low pressure flow rate
secondary to BOO & decompensated bladder
Reliable if BOO not Dxed by flow rate, initial
evaluation
Uroflometry
Electrical recording of the urine flow rate
Noninvasive urodynimic test
Quantifies strength of urine stream
2 to 3 voids with voided volume 150 to 200ml
in flow rate clinic
 Investigations ….
Imaging studies
IVP/US/KUB
Determine bladder & prostate size
Degree of hydronephrosis
Not indicated for initial evaluation of LUTS
 Indications
UTI
Hematuria
Hx of urolithiasis
Hx of urinary tract surgery
 Investigations…..
Upper tract imaging is indicated
Concomitant hematuria
Hx of urolithiasis
Elevated creatinine
Increased post voidal residual & Hx of UUTI
Urethroscopy
Indications
Hematuria
Urethral stricture
Bladder Ca
Prior LUT surgery
 Investigations…..
Advantage
Prostate enlargement
Bladder stone
Diverticula's
Voidal obstruction of urethra or bladder neck
 TREATMENT
 Aim of Rx
Relieving LUTS
Decreasing BOO
Improving bladder emptying
Reversing renal insufficiency
Preventing feature episodes of hematuria, UTI &
urinary retention
 The treatment includes
Medical therapy
Minimally invasive
Operative therapy
 Medical therapy
Alpha adrenergic blocker drugs
Terazosin (long acting)
Doxazosin (long acting)
Tamsulosin (alpha 1a selective)
The tension of prostate smooth muscle is
mediated by alpha1 adrenoreceptor
98% of alpha1 AR located in prostate
By blocking this receptors
Decrease the resistance along bladder neck,
prostate, & urethra (relaxing of smooth muscle)
Relieve dynamic component of the obstruction
 Minimally invasive Mx of BPH
 Intraprostatic stents
• Tubular device left in the urethra
(absorbable or nonabsorbable)
• An alternative for indwelling catheter for
pts. unfit for surgery
• Success rate is from 50 to 90%
• The insertion is endoscopicaly (us guided)
• Temporally or permanent (after radical
prostatectomy with incontinence)
 Minimally invasive Mx…
 Transurethral microwave therapy
 Deliver heat to the prostate via urethral catheter
or transrectal route
 Damaging to sympatatic nerve ending &
induction of apoptosis → ↓se prostate size
 Takes one hour as out pt with LA
 Less complication (like impotence)
 Does not cure BPH – reduce urinary frequency,
urgency & intermittent flow
 Minimally invasive…..
 Lasers delivered heat
 Causes destruction of the prostate tissue
(coagulation necrosis or vaporization of prostate
tissue)
 Destroyed tissue then contract → ↓prostate size
 Increase flow rate = 9 to15ml/sec
 Decrease bleeding, fluid absorption, length of
hospital stay
 ↓se the incidence of retrograde ejaculation &
impotence compared with TURP
 Prostatectomies
 Types
 TURP
 RP
 TVP
 Success
 AUR & CUR = 100%
 sever symptoms & urodynamically proven BOO = 90%
 Mild symptoms = 65
 Prostatectomies….
Pre-op preparation
Two unit of blood
Counseling
Obtain consent
Inform the pt about benefit & risk
– Retrograde ejaculation
– Erectile dysfunction
– Urinary incontinence
– UTI & urethral stricture
 Prostatectomies
 TURP
 Developed in 1920 & 30s in USA
 Used endoscopy (fibroptic lighting together with
the Hopkins, rod lens wide angle system for
visualization)
 High energy electrical current is used, entire
device attached to video camera
 Gold standard (90% of prostatectomy)
 Solution used for TURP → 5% DW, 1.5%
glycine, cystol
 TURP……
 Under regional or GA with lithotomy position
 Through resectoscope the prostate is
removed
 MAX flow rate improve 9 to 18 ml/sec
 Indications
 AUR
 Recurrent infection
 Recurrent hematuria
 Renal insufficiency
 Upper urinary tract dilatation
 Gland size <40gm
 Open prostatectomy
 Indications
 Large prostate >80gm with concomitant bladder
stone
 Ankylosis of the hip & other orthopedic condition
 Sever symptoms unresponsive to medical Rx
 All other indications for TURP
 Urethral stricture or previous hypospadias repair
 Associated inguinal hernia
 Open prostatectomy….
General
preparation of 1-2 unit of blood
counseling (inform the risks)
Incontinence
Retrograde ejaculation
Impotence
UTI, Urethral stricture
Needs of blood transfusion
Untoward effects (DVT, pul.embolism)
 Open Prostatectomy ….
Anesthesia
Spinal or epidural (standard)
GA
The resection could be retropubic or
suprapubic approach
 Open prostatectomy….
Contraindications
 Small fibrous gland
 The presence of prostate cancer
 Previous prostatectomy
 Pelvic surgery that obliterate access to the
prostate gland
 Prostatectomy…..
Post-op Mx
 Measure output input
 Bladder irrigation
 Effective pain mx
 1st post op day fluid diet, ambulation, deflate
balloon (10ml↓) & irrigate residual clot
 2nd post op day regular diet
 3rd post op day remove retro pubic drainage
 4th post op day discharge with catheter
 5-7 post op day remove catheter
 Prostatectomy…..
Complications
Bleeding
Urethral catheter traction with 50ml of saline to
compress the bladder neck & prostatic fossa
Bladder irrigation to prevent clot formation
The inflow through urethral catheter & out flow
through the suprapubic tube
If the bleeding persist cystoscopic inspection of the
prostatic fossa & bladder neck
If marked bleeding continue to persist → open re-
exploration
 Complications……
 Perforation of the bladder & prostatic capsule (In
TURP)
 Incontinency (if damaged external sphincter
mechanism)
 Retrograde ejaculetion (80-90%) & impotence (3-6%
due to damage of the nerves associated with erection)
 Bladder neck contracture
 Urethral stricture
 Sepsis
 Death (0.2 to 0.3%)
 Complications….
TUR-syndrome
In 2% of all TURP
Due to absorption irrigating fluid through
cut open veins
Characterized by (hyponatremia →
↓Na+, HPT, nauesa & vomiting,
bradicardia, visual disturbance, mental
confusion)
RX diuretics & correct electrolytes
 Urethral stricture
 Arise from varies causes
 Can occur secondary to inflammation or ischemic
process leading scar tissue formation → scar
tissue contract & ↓the calibre of urethral lumen →
resistance to ante grade flow of urine → common
in male (longer urethral)
 Anterior urethral stricture is secondary to scaring
in spongy erectile tissue of the corpus
spongiosum (more common)
 The posterior urethral stricture is due to a fibrotic
process
 Etiology
Inflammatory → post. Gonorrheal
(common), Tbc, schstosomiasis
Traumatic → external injury to pelvis area
Instrumental → long term use of urethral
catheter or cystoscopy
Post. op → open prostatectomy &
amputation of penis
congenital
 Clinical manifestation
Obstructive voiding symptoms
Decrease force of stream
Incomplete emptying of the bladder
Terminal dribbling
Urinary intermitency
Urinary retention
 Diagnosis
HX (previous op, trauma, STD)
P/E (suprapubic & genital area)
Urethroscopy → to detect the degree of
narrowing of the urethra
Retrograde urogram → site, degree,
number & length of stricture (failure to
pass the medium beyond the tightness)
 Treatment
 Accurate diagnosis & assessment of location & length
of the stricture is important for the Rx
 Temporarily or short term Rx (pt with acute pain or
sever blocking of the urine flow)
• Suprapubic catheter
• Nephrostomy tube (inserted in pt. back to drain
directly from kidney)
• Dilation
• Gradually open the urethra
• Used different size buggies
• The goal is to stretch the fibrotic tissue without
producing more scar
 Treatment ….
Endoscopic internal urethrotomy
 For short to medium stricture at the external end of
the urethra
 Under direct vision the stricture is cut open with
knife, laser or electrocautory
 Release of scared tissue
 Leave small catheter for 3-5 days (oppose wound
contraction & allow epithelazation)
 Success rate → 50% permanent cure of simple
stricture
 Treatment …..
Complications
Bleeding
Infection
Recurrence of the stricture
Advantages
Is minimally invasive
More rapid recovery
Minimal scaring
Less risk of infection from surgery
 Treatment …..
Open urethral reconstruction
Most common effective Rx
Used for longer stricture (length 1-2cm)
Extensive mobilization of the corpus sponiosum
Involves complete excision of the fibrotic (stenosed)
segment with reanastomosis of the spatulated cut
end (tension free & widely patent)
Some times need replacement of strictured urethra
(free-fulthicknes or pediculated skin graft) →
myocuyaneous patch of Perianal skin & dartus
muscle, bucal mucosa, penile skin
 Treatment ….
Permanent catheter or implant stent
For the pt. who chooses no to undergo
surgery or who has sever stricture
Provide a patent lumen
Most successful in short length stricture in
the bulbous urethra
If all else fails → urinary diversion
(appendico-vesicostomy)
 Complications
Retention of urine
Urethral diverticulum → excision & repair
Periurethral abscess → drain, antibiotics &
suprapubic catheter
Urethral fistula
 Bladder calculus
Primary bladder calculus
Are developed in sterile urine often originated
in the kidney
Pass down to the ureter then to bladder &
enlarges
Secondary bladder calculi
Occurs in presence of infections, Boo, foreign
body
 Bladder calculi. ….
 Risk factors
• Male (8x than female)
• ↑se age
• Poor fluid intake
• Incomplete emptying of the bladder
• Recurrent urinary infection
• Foreign body (nonabsorbable suture, metal
staples, stents & catheter fragments)
 Clinical features
 Male 8x than female
 Asymptomatic
 Frequency → the earliest symptom common during
day time
 Sensation of incomplete bladder emptying
 Pain
– At the time of micturation
– Referred to the tip of penis & labia majora aggravated by
movement. Screaming & puling the penis with the hand
at the end of urination
 Clinical feature….
 Hematuria ▬ bright red blood at the end of
micturation
 Interruption of urinary stream
 Pyuria (rare)
 Symptoms of urinary infection
 P/E
 Suprapubic area
 Rectal or vaginal examination (large calculi is
palpable in female)
 Investigations
♣ U/A (for blood, pus, crystals typical of calculi)
♣ CBC
• Plain abdominal x-ray – radiopaque calculus seen
♣ US
♣ IVU--- filling defect in case of radiolucent calculus
♣ Cystoscopy – to examine the inside of the bladder
 Treatment
♠ Medical Rx
 Alkalization of urine for dilution of the uric acid stone
 Analgesic
 Antibiotics
♠ Surgical Rx --Indications
 Failed medical Rx
 Recurrent infection
 Suprapubic pain & AUR
 Gross hematuria
 Treatment ….
▲Cystolitholapxy ▬ through cystoscope
lithotrite the calculus is broken. fragments
are crushed in to small pieces then
removed
▲Suprapubic lithotomy ▬ the calculus
evacuated through suprapubic incision
▲Suprapubic cystolitholapxy
▲ECSWL
 Bladder neck contracture
 Causes BOO
 Muscular hypertrophy
 Stenosis of the tissue at the neck following
TURP or dense fibrotic stenosis as result
of over use of diathermy (coagulating
diathermy)
 Treatment
 Alpha adrenergic blocker drugs cause
relaxation bladder neck →→ improve
urinary flow
 Transurethral incision of the fibrotic tissue
of bladder neck is an operative option
 Neurogenic bladder
The lower urinary tract mechanism regulated by
biomechanics of bladder & urethral muscle &
controlled by NS
Causes of neurologic bladder dysfunction
 Trauma to spinal cord →→ disrupts normal
supraspinal circuit that control the urine storage
& release
 Stroke
 Herniated intervertebral disc
 Degenerative neurological disease (multiple
sclerosis), diabetes, syphilis, acute infection
 Symptoms
Similar as other causes of LUTS
Diagnosis
 Hx →which feature suggestive of an
underlying neurological disease
 Symptoms & signs
 P/E –rectal examination (↓perianal
sensation, poor anal sphincter tone &
absence of bulb cavernous reflex)
 Lower abdominal examination
 Investigations
 U/A
 CBC
 RFT
 U/S
 IVP
 Urodynamic studies (urine flow rate, cystometry &
postvoidal residual)
 Complications
 Urinary leakage & urinary retention
 Damage to tiny blood vessels of kidney
 Infections of the bladder & urethra
 Formation of kidney stone
 Management
Goals
 Prevention of upper tract damage
 Urinary continence
 Effective bladder emptying
Essential to ensure low pressure urine
storage, low pressure voiding & adequate
bladder drainage with elimination of UTI &
stone formation
 Management ….
 Conservative Rx
 Catheterization (urethral or suprapubic)
 Avoid long term urethral catheterization to
prevent urethral injury
 Suprapubic catheter can avoid urethral erosion,
inflammation & dilation
 Prophylactic antibiotic to reduce the incidence of
infection
 Artificial sphincter around the neck of the
bladder to prevent urinary incontinence
 Medical management
Aim
 ↑ing intravesical pressure or ↓ in outflow
resistant →↑bladder emptying
Parasympatomimetic drugs (bethanechol)
stimulate muscarinic cholinergic ▬
↑intravesical pressure
 Facilitating urine storage by reducing bladder
contractility or ↑ing outflow resistance
Anticholinergic drugs (propantheline) is
effective in suppressing detrusor contractility
 Surgical Mx
For impeding or existing danger to UUT or
intractable urinary incontinence (reduced
bladder compliance, a high leak point pressure
& detrusor dyssynergia )
Bladder augmentation → ileocystoplasty
commonly used, the bladder is bivalved in
coronal or sagital plane
Bladder substitution → in pt. with contracted
high pressure bladder
 Surgical Mx…..
Urinary diversion can be either incontinent
(urine pass through an open conduit in to
external collecting system) or continent (urine is
drained from bowel reservoir via a
catheterizable stoma ) classical incontinent
urinary diversion is the ileal conduit
Indian pouch == used cecum, ascending colon
& the proximal third of transverse colon to
construct the pouch & terminal ileum brought
out as a continent stoma
THANK U