I.

Introduction

SCENARIO

 Mr. Brown 60 years old come to emergency room with chief complaint cannot voiding spontaneously since
3 hours ago and suffered from lower abdominal pain
 History of illness, he has weak of stream and strain of urination since 6 months ago.

TERM CLARIFICATION

 Can not voiding spontaneously

 Difficulty initiating the urinary stream
 Lower abdominal pain
 Pain in the suprapubic area
 Weak of stream and strain of urination
 The subjective loss of force of the urinary stream over time

PROBLEM IDENTIFICATION

 Mr. Brown, 60 years old has lower abdominal pain & weak stream & strain of urination due to inhibition of
urinating.

PROBLEM ANALYSIS

 Why can’t he void spontaneously?

 What are the structures involved in process of urination? (anatomy & physiology)

 How is the process of urination? (Physiology & biochemistry)

 What are the causes of inhibition of urinating?

 What is the patophysiology of inhibition of urinating?

 What is the patology anatomy of inhibition of urinating?

 What is the pathology clinic of inhibition of urinating?

 How is the anatomy and physiology of prostate gland?

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  How to diagnose?

 Anamnesis

 Physical examination

 Lab Exam

 Supporting Test

 What are the differential diagnoses?

 What is urinary retention?

 What is the working diagnosis?

 How is the management?

 What are the complications?

 How is the prognosis?

HYPOTHESIS

Mr. Brown, 60 years old suffered from urinary retention because of the

Benign Prostatica Hyperplasia.

II. SYNTHESIS
Structure of Urinary System

• 2 kidney (ren) → produce urine

• 2 ureter → send urine from kidney into urinary bladder

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 • 1 urinary bladder → a place where urine is collected
• 1 urethra → excrete the urine

Kidney

1. Anatomy
Kidneys are located in retroperitoneal, as high as vertebrae thorax XII, under the diaphragm. Right kidney
is located 12mm lower than left kidney. Long: 11cm, wide: 6 cm, thick: 4cm, weight: 150g.

2. Physiology
Kidneys filter 1700 L of blood to 1 L of urine per day. Excretes metabolic waste ; regulates water, salt,
pH; secrete renin, prostaglandins, erythropoietin.

Urine Formation in the Kidney:

Most of filtration of fluids free protein is occurred from glomerular capillaries to Bowman capsule. From Bowman
capsule go through tube, the fluids is changed by water and specific dissolve re-absorption to the blood circulation
or by other substances from peritubular capillaries that enter to the tube.

 Urea, creatinine, uric acid, salt uric acid → less absorption, more excretion.
 Electrolytes: sodium, chloride, bicarbonate → more absorption, less excretion.
 Amino acid and glucose → complete re-absorption from the tube.

The Process of Urination:

Blood from inferior vein cava enter to renal arteries →a. segmental →a. interlobar → a. arcuate → a. interlobular →
afferent arteriole → glomerulus → Bowman capsule → proximal tube → Henle loop → distal tube → collecting
duct → papilla → apex pyramid → calyx minor → calyx major →pelvis renal → ureter → urinary bladder →
urethra → excreted.

Efferent arteriole (peritubular capillaries & juxtamedullary nephron) → interlobular vein → arcuate vein →
interlobar vein → segmental vein → renal vein.

Ureter

Ureters are pipes, continued of pelvis renal, that connect kidney to urinary bladder to send urine. Long: 25 – 30 cm,
diameter 3mm. retroperitoneal →downwards → in front of m. psoas → oblique to posterior of urinary bladder.

Urinary Bladder (Muscular urine store)

• Anatomy:

– Position: antero-inferior pelvis minor (empty), behind the os pubis, retroperitoneal.

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 – Three-sided pyramid shape

– Cervix (collum) vesicae

• triangular

• ♂àbasis prostate gland

• ♀àcervix uteri & superior to vagina

• orificium urethra

– Tunika mukosa VU

• epitel transitional, urine-proof, able to stretch

• submukosa: longgar, inelasticàwrinkling during contraction

• rugae, except trigonum vesicae (Litaeudi)

Urethra

• Pipe from collum VU à orificium urethra externum

• Male, long: 19-20 cm; female, long: 4 cm

• Sphincter urethra externa

– at diafragma urogenital à lower abdominal muscle

– Male: at urethra membranosa

Urethra in male consists of:

– Pars prostatica : pass the prostat ±3 cm (1 ¼ inci)

– Pars membranacea : has long 2 cm (¾ inci), penetrate to sphincter externa urethra and membrana
fascia perinealis that cover the part of superficial sphincter

– Pars spongiosa : has long 15 cm (6 inci), in corpus spongiosum penis.

Prostate

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is composed of
several regions or lobes that are enclosed by an outer layer of tissue (capsule).

5 Prostate Lobes (separated by urethra & ejaculatorius duct):

1. 2 Lateral lobes. Covering urethra. Marked by posterior curve and palpated by rectal examination
2. Anterior lobes, covering urethra.
3. Middle Lobes in between urethra and ejaculatorius duct
4. Posterior lobes, behind ejaculatorius duct

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5 Prostate areas with certain histologic features:

1. Anterior zone (consistent with anterior lobes) consists of mostly fibromuscular stroma with a few glands.
2. Peripheral zone (± lateral dan posterior lobes), consists of mostly glands → the origin of (± 70%) prostate
adenocarcinoma.
3. Central zone (± mid lobes), separated from pheripheral zone by fibrous trabecular, surround ejaculatorius
duct in the way to verumontanum; is ± 25% of prostate glandular mass.
4. Transitional zone (anterior zone, central and medial pheripheral zone).
5. The fifth zone → periuretral gland, small ducts and abortive acini, spread along proximal urethra (proximal
of verumontanum) = paraprostatic glands.

Prostate function:

The prostate gland secretes a thin, milky fluid that contains calcium, citrate ion, phosphate ion, a clotting
enzyme, and a profibrinolysin. During emission, the capsule of the prostate gland contracts simultaneously with
the contractions of the vas deferens so that the thin, milky fluid of the prostate gland adds further to the bulk of
the semen. The slightly alkaline prostatic fluid helps to neutralize the acidity of the other seminal fluids during
ejaculation, and thus enhances the motility and fertility of the sperm.

MAKING DIAGNOSIS

 Anamnesis

1. Identity

Name : Mr. Brown

Age : 60 years old

2. Chief Complaint
Cannot voiding spontaneously since 3 hours ago and suffers lower abdominal pain.

3. Additional Complaint

Weak urination stream and strain since 6 month ago, sensation of incomplete bladder emptying, and
incontinence of urination.

4. International Prostate Symptom Score

a. Incomplete emptying (0-5)
b. Frequency (0-5) 0 = not at all
c. Intermittency (0-5) 1 = less than 1 time in 5
2 = less than half the time
d. Urgency (0-5)
3 = about half the time
e. Weak Stream (0-5) 4 = more than half the time
f. Straining (0-5) 5 = almost always

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 g. Nocturia (0-5)
Total Score = 0-7:mild, 8-18:moderate, 19-35:severe
IPSS for Mr. Brown: 28  severe

 Physical Examination

a. BP : 150/ 90 mmHg ® hypertension (normal: 120/90 mmHg)

b. HR : 105 bpm ® tachycardia (normal: 60-100 bpm)

c. Temp : 370C ® normal

d. Head & neck ® normal, chest ® normal

e. Abdominal :

i. Inspection : distance lower abdominal

ii. Palpation : bladder palpable 2 cm below umbillicus

f. DRE (Digital Rectal Examination)

• Sphincter tone : normal

• Prostate: enlarge

• Consistency rubbery

• No induration

 Laboratory Examination

 Creatinine : 1.0 mg/dl ® normal (0,5 – 1,5 mg/dl)

 Urine Sediment:

  RBC : 10/ HPF ® hematuria ( normal : < 1/HPF)

  WBC : 0-2 / HPF ® normal (< 5/HPF)

 Imaging/ USG : billateral mild hydronephrosis, bladder is full, prostate : 6cmx5cmx5cm ® enlargement
(normal prostate size: 4cmx3cmx2,5cm)

DIFFERENTIAL DIAGNOSIS

Signs & Symptom BPH Ca. Prostate Prostatitis Bladder Stone Urethral Stricture

Can’t voiding + + + + +
spontaneously

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 Suprapubic pain + + + colic severe pain

Inflammation - - + - +

Hesistancy + + + + +

Urine retention + + - + +

Urgency & Frequency + + + + +

Dysuria - - + + +

Prostate enlargement + + + - -

DRE: Induration - + - - -

Urine Retention

Also known as ischuria is a lack of ability to urinate. It is a common complication of benign prostatic hyperplasia.

Urinary retention is characterized by:

• Poor urinary stream with intermittence, straining, a sense of incomplete voiding and urgency.

• The bladder remains full, it may lead to incontinence.

• Nocturia (need to urinate at night).

• High frequency.

Retention is a medical emergency, as the bladder may distend (stretch) to enormous sizes and possibly tear if not
dealt with quickly. If the bladder distends enough it will begin to become painful. The water can also pass back up
the ureters and get into the kidneys, causing kidney failure.

In the longer term, obstruction of the urinary tract may cause:

 Bladder stones
 Loss of detrusor muscle tone (atonic bladder is an extreme form)
 Hydronephrosis (congestion of the kidneys)
 Hypertrophy of detrusor muscle

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  Diverticula in the bladder wall (leads to stones and infection)

Causes:

 Benign prostatic hypertrophy

 Prostate cancer and other pelvic malignancies
 Congenital urtheral valve abnormalities
 Detrusor muscle dyssynergia
 Damage to the bladder
 Obstruction in the urethra, for example a metastasis or a precipitated pseudogout crystal in the urine
 Paruresis ("shy bladder syndrome")- in extreme cases, urinary retention can result

Classification of BPH causes (Rochani,2000) :

 Supra Vesika
 Vesika
 Infra Vesikal
BENIGN PROSTATIC HYPERPLASIA

Definition

 Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that may restrict
the flow of urine from the bladder.

 BPH is a proliferative process of the cellular elements of the prostate (ie, an enlarged prostate). Cellular
accumulation and gland enlargement may be due to epithelial and stromal proliferation, impaired
preprogrammed cell death (apoptosis), or both.

Epidemiology

Prostatic Hyperplasia is an older male disease and often founded before 40 y.o. Normally, prostate of male has
increasing in size from born untill puberty slowly, and slightly increase untill 30 years old. Prevalence in Indonesia
was not known, but based on other country, was estimated since 50 y.o. 20%-30% patient need to be cured about
prostatic hyperplasia. Prevalence depend on the ages of male. Based on autopsy, microscopic changing is already
occur in 30-40 y.o., if its to be continued, it will cause pathology anatomy. For male, 50 y.o. the occurrence is about
50% and 80 y.o. Around 50% of that number will be caused clinical signs and symptoms.

Risk Factors

• Poorly understood (ageing male).

• Some study have suggested : a genetic predisposition and racial differences.

Etiology: Endocrine

Theories for the cause of BPH

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 Theory Cause Effect

Dihydrotestosteron hypothesis 5-a reductase and androgen Epithelial and stromal Hyperplasia
receptors

Oestrogen-testosteron Oestrogens Stromal hyperplasia

Imbalance (older people) ¯ Testosteron

Stromal-epithelial interactions Epidermal growth factor/ fibroblast Epithelial and stromal Hyperplasia
growth factor

¯ Transforming growth factor b

Reduced cell death Oestrogens Longevity of stroma and epithelium

Stem cell theory Stem cells Proliferation of transit cells

BPH LUTS (Lower Tract Urinary Symptoms)

Obstructive Symptoms Irritative Symptoms

Hesitancy Frequency
Straining Nocturia
Weak stream Urgency
Narrow stream Urgency incontinence
Terminal dribbling Small voided urine volume
Prolonged voiding
Overflow incontinence
Suprapubic pressure / pain
Initial hematuria

Pathophysiology

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is composed of
several regions or lobes that are enclosed by an outer layer of tissue (capsule). The different zones include the
peripheral, central, anterior fibromuscular stroma, and transition. BPH originates in the transition zone, which
surrounds the urethra. Microscopically, BPH is characterized as a hyperplastic process. The number of cells in the
gland increases with age. As the gland enlarges, it may cause increased resistance to urine flow through the urethra
over time, resulting in clinical manifestations of BPH. The prostate enlarges with age in a hormonally dependent
manner. Castrated males do not develop BPH. The traditional theory is that as the prostate enlarges, the surrounding
capsule prevents it from readily expanding, and this subsequently results in urethral compression. The notion that
clinical symptoms are simply due to mass-related increases in urethral resistance is too simplistic. Current thinking
holds that obstruction-induced bladder dysfunction contributes significantly to symptoms. The bladder wall becomes

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thickened, trabeculated, and irritable when it is forced to hypertrophy and increase its own contractile force. This
increased sensitivity (detrusor instability), even with small volumes of urine in the bladder, is believed to cause
ensuing urinary frequency and LUTS. The bladder may gradually weaken and lose the ability to empty completely,
thus leading to increased residual urine volume and, sometimes, acute or chronic urinary retention.

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 Elderly (60 y.o), male

E2 increase DHT increase

Raised estrogen level

Central (periurethral) prostate zone/ estrogen-sensitive

Sympathetic stimulated α receptor

Hyperplasia (stromal and epithelial)

Prostate enlargement

Contraction of smooth muscle (capsule prostate and bladder neck)

Pressure to urethra pars prostatica

Narrowing of
urethra lumen

Bladder distention
Disturbance of urine flow Raised miction pressure

Bladder wall hypertrophy and irritated Delay to start voiding &

hesitancy

Decrease force & caliber of stream

The contraction of detrusor muscle in bladder become weak
Congestion of superficial
veins of the prostatic urethra
and trigone
Incomplete bladder dilatation

Rapid refilling of the bladder

*Urgency &
frequency (more Incomplete emptying
frequent at night due
to the lower Bladder is full Hematuria
Rupture veins
Reflux VU -Urether
temperature) Statis urin

*Post voiding
dribbing  Bladder hidronephrosis
incontinence palpable

Hypertension

Increase renal
volume
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MANAGEMENT

Catheterization
A. Urethra Catheterization.
In male
The technique:
• Disinfection to genitalia organ.
• Insert jelly to urethra 2-3 cc. Masukkan pelicin/ jelly kedalam uretra 2-3 cc
• Insert the catheter into orificium urethra externa.
• Push the catheter slowly into bulbo-membranacea area  bladder  meatus urethra externa.
• Catheter balloon blown with 5-10 ml sterile water.
• Connected with urinbag pipe.
• Fixated with plaster in inguinal area.

B. Suprapubic Catheterization (Cystostomi)

Inserting the catheter with making a hole in the bladder through suprapubic incision.

B.1. Close Cystostomi (With Trochar)

Using the local anesthetics and trochar.
Langkah-langkah sistostomi trokar.
• Disinfection.
• Injection (infiltration) local anesthetics with lidocain 2% from the skin, subcutan, till fascia.
• Suprapubic skin incision, deep into fascia.
• Inject the trochar.
• The obturator opened and if its already reach the bladder, urine will flow through the trochar sheath.
• Obturator and sheath taken out from bladder.
• Foley catheter being injected, blown the balloon with aquadest 10 cc then connect it to urobag.
• Fixated the catheter onto the skin with silk fiber.

B.2. Open Cystostomi

Using the local anesthetic or general anesthetic.
Technique
• Disinfection.
• If not using the general anesthetic, injected the local anesthetic.
• Vertical incision in the midline ± 3,5 cm between the mid-simphisis and umbilicus.
• Deeping the incision through lipid subcutan so that linea alba can be seen.

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 • The lipid tissue and peritoneum take it to the cranial to ease bladder holding.
• Fixated to bladder.
• Explore the bladder wall to see: tumor, stone, bleeding, or bladder neck narrowed.
• Inject the Foley catheter.

1. Conservative: observation (watchful waiting) IPSS: 0 - 7

2. Medicamentose (Tx medic) IPSS: 8 – 18

Contraindication:

• Urine retention (acute or chronic)

• Renal insufficiency

• Upper urinary tract dilatation

• Frequent hematuria

• Frequent UTI

• Bladder stone/ diverticle

Alpha blocker

α-adrenergic antagonist

• First-line treatment

• 1st-generation：phenoxybenzamine

• 2nd-generation：selective long-acting (terazosin, doxazosin)、selective short-acting (prazosin)

• 3rd-generation：uroselective drug

selective α1-adrenergic antagonist

• relax prostatic smooth muscle and relieve LUTS (lower urinary tract symptoms)

• prazosin, doxazosin, terazosin

• increasing the apoptosis of epithelial and stromal cells

• do not reduce prostate size or decrease PSA

selective α1-adrenergic antagonist

1.subclasses of the α1-adrenergic antagonist

• α1A：prostate stroma, urethra

• α1B：epithelium, detrusor muscle

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 • α1D：stroma, urethra, blood vessels

2.α-adrenergic receptors is also located in the cardiovascular and central nervous systems

3. side effect：dizziness, postural hypotension, asthenia, and syncope

• adjunct agents for treating hypertension

• recommended to start with low doses administrated at bed time and titrate to relief of symptoms

Terazosin(Hytrin)

• Useful for hypertension and relieving the dynamic component of BPH

• Peak plasma concentrations are achieved within 100 minutes when administered with meals or 60minutes
without food

• Once daily

Doxazosin

• Doxazosin (Doxan, Doxazon, Dophilin)

• Male does not alter its absorption

• Long half-life permits administration daily

• Not need to be adjusted for elderly patients or those with impaired renal function

Physiological or functional selectivity

• The effect is independent of receptor blockade

• Relieve BPH symptoms while decreasing the propensity to cause adverse events associated with the
cardiovascular system ( ex. Postural hypotension, malaise, syncope, hypotension, dizzeness) or central
nervous system (ex. Dizziness, fatigue, drowsiness, and somnolence)

• Tamsulosin：pharmacological uroselectivity

• Clinically Uroselective Agents

• Receptor or pharmacologicall selectivity

• Selectivity for the α–receptor that controls prostatic or urethral smooth muscle contraction

• Reduces prostatic urethral pressure without concomitantly affecting change in blood pressure or heart rate

Tamsulosin (Harnalidge)

• Selective for a certain receptor subtype, α1A-adrenergic receptors

• 10-12 times greater affinity for prostatic receptors than the receptors in vascular and extraprostatic tissues

• Decrease intraurethral pressure without a concomitant reduction in blood pressure

• Symptom relief with tamsulosin is quicker than the 1-2 weeks needed with either terazosin or doxazosin

• Relief of obstructive symptoms begins within the first week of therapy

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 • Improvement in urine flow occurs 4-8 hours after the first dose

Drugs of choice

• α-adrenergic antagonist

• drugs of choice for relief of LUPS

• moderates sympathetic tone, relaxing the smooth muscle at the bladder neck and prostate.

• 1st-generation （ phenoxybenzamine ） are limited by significant cardiovascular side effects and are no
longer used.

• 2nd-generation (terazosin, doxazosin, prazosin) and 3rd-generation（tamsulosin）are the most widely used
and are equally efficacious.

Supresi Androgen

o 5 alfa-reduktase inhibitor

Fitoterapi

3. Intervension Therapy (spesialistic) IPSS: 19 – 35

Indication:

 BPH with severe IPSS choose this intervention therapy.

 Failed/ not effective medicamentose therapy.
 BPH with complication.

Surgery:

a. Open Prostatectomy

This procedure is now reserved for patients with very large prostates (>75 g), patients. The
procedure requires hospitalization and involves the use of general/regional anesthesia and a lower
abdominal incision. Open prostatectomy usually has an excellent outcome in terms of
improvement of urinary flow and urinary symptoms.

b. Endoscopic:

 TURP (Transurethral resection of the prostate)

TURP has long been accepted as the criterion standard for relieving BOO secondary to BPH. The
indications for surgical intervention include acute urinary retention, failed voiding trials, recurrent gross
hematuria, urinary tract infection, and renal insufficiency secondary to obstruction. TURP has long been

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 the most common method by which obstructing prostate tissue is removed through the urethra. This
procedure is performed with regional or general anesthesia and involves the placement of a working sheath
in the urethra through which a hand-held device with an attached wire loop is placed.

 TUIP (Transurethral incision of the prostate)

TUIP has actually been in use for many years and, for a long time, was the only alternative to TURP. It
may be performed with local anesthesia and sedation. TUIP is suitable for patients with small prostates and
for patients unlikely to tolerate TURP well because of other medical conditions. TUIP is associated with
less bleeding and fluid absorption compared to TURP. It is also associated with a lower incidence of
retrograde ejaculation and impotence compared to TURP.

Minimal Invasive:

 Balloon dilatation

 Stent

 Microwave (thermotherapy)

 Radiofrequency

 Laser ablation

COMPLICATIONS

Complications related to bladder outlet obstruction (BOO) secondary to BPH

o Urinary retention
o Renal insufficiency
o Recurrent urinary tract infections
o Gross hematuria
o Bladder calculi
o Renal failure or uremia (rare in current practice)

PROGNOSIS

Nice prognosis with proper management.

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For this patient, Mr. Brown 60 years old, catheterization is the proper emergency management for solving the acute
urine retention. As the IPSS score was in the severe grade, the medical therapy is not really effective. The proper
management for BPH with severe grade of IPSS is intervention therapy.

III. CONCLUSION
Mr. Brown 60 years old, based on the signs & symptoms, also from the examination results, suffered from Benign
Prostatica Hyperplasia. The management for this patient is catheterization for the emergency management and
intervention therapy.

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