CASE PRESENTATION

BENIGN PROSTATIC HYPERPLASIA

Created by :
Widya Amalia Swastika
1102011290
Adviser :
Dr. Herry Setya Yudha Utama, SpB, MHKes,FInaCS

KEPANITERAAN KLINIK BEDAH

FAKULTAS KEDOKTERAN UNIVERSITAS YARSI
RSUD ARJAWINANGUN
2015

Case Presentation
A. Identity
Name
Age
Gender
Tribe
Occupation
Address
In hospital since

: Mr. N
: 63 years old
: Men
: Javanese
:: Pekantingan
: august 19th 2015

B. ANAMNESIS

Main Grievance
Dysuria since 2 years ago

Historical of Present Disease

63 years old men came to RSUD Arjawinangun with painful during urination,
straining when urinating, urinary incontinence, hematuria, and night-time urination.

Fever (-), nausea (-), vomitus (-).

Historical of Past Disease
Hipertension (-)
Diabetes Melitus (-)
Historical of Family Disease
Hipertension (-)
Diabetes Melitus (-)

1. MEDICAL EXAMINATION
Present Status
General Condition
: Moderate
Awareness
: Composmantis
Blood Pressure
: 120/80
Pulse
: 82 x/minute
Breathing
: 24 x/minute
Temperature
: 36,3 C
General Status
Head
Form
: Normal, Simetrical
Hair
: Black Colour
Eye
:
Anemic
Icteric
Light

Conjungtival

-/-

Schlera

-/-

Refleks

(+)

Isocor pupil right = left

: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal

Ear
Nose
Mouth
Neck
Enlargement of lymph nodes (-)
Trachea in the middle
Thorax
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both of left and right
Palpation
: Fremitus tactile and vocal symmetrical right and left,

Percussion
Auscultation

crepitus (-), tenderness (-), rebound tenderness (-)

: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field,

ronkhi -/-, wheezing -/Heart

Inspection
: Ictus cordis is not visible
Palpation
: Ictus cordis palpable on the left midclavicula ICS line 5
Percussion
:
Upper
limit
ICS
3
linea
parasternalis
Right

limit

ICS

linea

sinistra

sternalis

dextra

Left limit ICS 5 linea midclavicula sinistra

Auscultation : Heart sound 1 2 pure regular, murmur (-), gallops (-)

Abdomen
Inspection

: flat abdomen shape, supple, not visible skin disorders

3

Palpation
Percussion
Auscultation

Ektremitas
o Superior
o Inferior
Genitalia

Lesion (-), Mass (-)

: tenderness (-), rebound tenderness (-)
: There was a whole field tympanic abdomen
: Bowel (+) Normal
: Akral warm, Edema -/-, CTR < 2
: Akral wamt, Edema -/-, CTR < 2, Lump at left ankle

: No abnormalities

2. INVESTIGATIONS
Laboratory Examination
Test
WBC
RBC
HGB
HCT
MCH
MCHC
RDW
PLT
NEUT
LYMPH
MONO
EOS
BASO
LUC

Result
9.3
4.49
12.8
35.5
28.5
36.1
14.3
324
87.7
1.7
1.0
0.8
0.2
2.7

Normal
5.2 12.4
4.2 6.1
12 18
37 52
27 31
33 37
11.5 14.5
150 450
40 74
19 48
3.4 9
0 -7
0 - 1.5
0-4

Units
10e3/uL
10e6/uL
d/dL
%
fL
g/dL
%
10e3/uL
%
%
%
%
%
%

E. DIAGNOSIS OF WORK
Benign prostatic hyperplasia (BPH)
G. MANAGEMENT PLAN
Non-medical:

Prostatektomi

medical:

Infusion RL 15 GTT / min

Keterolac 2 x 1

Cefazoline 2 x 1

LITERATURE REVIEW
Anatomi Prostat
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The prostate is a walnut-shaped gland that is part of the male reproductive system. The main
function of the prostate is to make a fluid that
goes into semen. Prostate fluid is essential for a
mans fertility. The gland surrounds the urethra
at the neck of the bladder. The bladder neck is
the area where the urethra joins the bladder. The
bladder and urethra are parts of the lower urinary
tract. The prostate has two or more lobes, or
sections, enclosed by an outer layer of tissue,
and it is in front of the rectum, just below the
bladder. The urethra is the tube that carries urine
from the bladder to the outside of the body. In
men, the urethra also carries semen out through
the penis.
Definition
Benign prostatic hyperplasia also called BPH is a condition in men in which the prostate
gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic
hypertrophy or benign prostatic obstruction.
Benign prostatic hyperplasia is a common disease with proliferation of prostatic stromal
cells and the periurethral zone (transitional zone) of the prostate, which leads to lower urinary
tract symptoms (LUTS).
The prostate goes through two main growth periods as a man ages. The first occurs early
in puberty, when the prostate doubles in size. The second phase of growth begins around age 25
and continues during most of a mans life. Benign prostatic hyperplasia often occurs with the
second growth phase. As the prostate enlarges, the gland presses against and pinches the urethra.
The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the
ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and
urinary retentionthe inability to empty the bladder completelycause many of the problems
associated with benign prostatic hyperplasia.
Epidemiologi

Some studies have suggested that African American men are at higher risk and Asian men at
lower risk for BPH than Caucasians, a 2000 study found no greater risk for African Americans
and only a slightly lower risk for Asians. Among Caucasians in the study, men of southern
European heritage were at greater risk while men of Scandinavian ancestry had a lower chance
of developing BPH.
Histologic evidence of prostate enlargement begins about the third decade of life and increases
proportionally with aging. Specifically, about 43% of men in their 40s will have evidence of
BPH, as will 50% of men in their 50s, 75% to 88% in their 80s, and nearly 100% of men
reaching the ninth decade of life.
Some evidence has reported a higher incidence of benign prostatic hyperplasia -- particularly
fast-growing BPH -- in men with obesity, heart and circulatory diseases, and type 2 diabetes.
Diabetes and hypertension, in any case, worsens urinary tract symptoms in men with BPH. In
one study, flow rates were adversely affected by diabetes, although residual urine volumes were
not significantly greater.
Etiology
The actual cause of prostate enlargement is unknown. Factors linked to aging and changes in the
cells of the testicles may have a role in the growth of the gland. Men who have had their testicles
removed at a young age (for example, as a result of testicular cancer) do not develop BPH.
Also, if the testicles are removed after a man develops BPH the prostate begins to shrink in size.
Some facts about prostate enlargement:

The likelihood of developing an enlarged prostate increases with age.

BPH is so common that it has been said all men will have an enlarged prostate if they live

long enough.
A small amount of prostate enlargement is present in many men over age 40. More than

90% of men over age 80 have the condition.

No risk factors have been identified other than having normally functioning testicles.

Patophisiology
1. Theory of dihydrotestosterone

Figure 7. The control mechanism of prostate growth by DHT

Androgen metabolite dihydrotestosterone is very important in cell growth of the prostate gland.
Formed of testosterone in prostate cells by the enzyme 5 alpha-reductase. DHT has formed binds
to the androgen receptor and protein synthesis occurs subsequent growth factor that stimulates
the growth of prostate cells.
The levels of DHT in BPH are not much different levels with normal prostate, in bph, the
activity of the enzyme 5 alpha-reductase and androgen receptor increase. This causes the cells of
the prostate in BPH are more sensitive to DHT so that replication occurs more frequently than
the normal prostate.
2. The imbalance between estrogen and testosterone
In the increasingly older age, testosterone levels decreased while estrogen is relatively fixed, so
that the ratio increases. Prostate estrogen play a role in the proliferation of cells of the prostate
gland by increasing the sensitivity of prostatic cells to androgen stimulation, increasing the
number of androgen receptors and decreasing the number of prostate cell death (apoptosis). So
even though the stimulus formation of new cells due to stimulation of testosterone decreases, but
the prostate cells that have been there have a long life so that the mass of the prostate becomes
larger.
3. The stromal-epithelial interactions

Stromal cells after stimulation of DHT

and estradiol, stromal cells synthesize a
growth factor that in turn affects the
stromal cells themselves are intrakin and
autocrine, as well as affect the epithelial
cells in a paracrine. The stimulation
causes the proliferation of epithelial cells
and stromal cells.

4. The reduction in prostate cell death

Decreasing the number of prostate cells undergoing apoptosis caused the number of prostate cells
as a whole to be increased, causing increased prostate mass. Allegedly androgen hormones play a
role in inhibiting cell death process because after the castration performed an increase in activity
of the prostate gland cell death. The growth factor TGF-beta plays a role in apoptosis.
5. Theory of stem cells
In the prostate gland known as a stem cell, the cells that have the ability to proliferate very
extensively. This cell life is very dependent on the presence of androgen hormones, so if this
hormone levels decline as happened in castration, cause apoptosis. The proliferation of cells in
BPH postulated as stem cell activity resulting in excessive production of stromal cells and
epithelial cells.
Clinical Manifestation
Lower urinary tract symptoms (LUTS) are categorized either as voiding (formerly called
obstructive) or storage (formerly called irritative) symptoms. BPH is often, but not always, the
cause of LUTS, especially the voiding symptoms. Other medical conditions, such as bladder
problems, can also cause these symptoms.

Some men with BPH may have few or no symptoms. The size of the prostate does not determine
symptom severity. An enlarged prostate may be accompanied by few symptoms, while severe
LUTS may be present with normal or even small prostates.
Voiding (Obstructive) Symptoms
Voiding symptoms can be caused by an obstruction in the urinary tract, which may be due to
BPH. (Obstruction is the most serious complication of BPH and requires medical attention.)
Voiding symptoms include:

A hesitation before urine flow starts despite the urgency to urinate

Straining when urinating
Weak or intermittent urinary stream
A sense that the bladder has not emptied completely
Dribbling at the end of urination or leakage afterward

Storage (Irritative) Symptoms

Storage symptoms, also referred to as filling symptoms, include:

An increased frequency of urination (every few hours)

An urgent need to urinate and difficulty postponing urination
Discomfort when urinating
Frequent night-time urination, or nocturia, is one of the most publicized
symptoms of BPH, but its also one of the trickiest, since many if not most cases
of nocturia are not caused by BPH but by other conditions.

Diagnosis
A health care provider diagnoses benign prostatic hyperplasia based on

a personal and family medical history

a physical exam
medical tests

A personal and family medical history

Taking a personal and family medical history is one of the first things a health care provider may
do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man
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what symptoms are present

when the symptoms began and how often they occur
whether he has a history of recurrent UTIs
what medications he takes, both prescription and over the counter
how much liquid he typically drinks each day
whether he consumes caffeine and alcohol
about his general medical history, including any significant illnesses or surgeries
The International Prostate Symptom Score (I-PSS) is based on the answers to seven
questions concerning urinary symptoms and one question concerning quality of life. Each
question concerning urinary symptoms allows the patient to choose one out of six
answers indicating increasing severity of the particular symptom. The answers are
assigned points from 0 to 5. The total score can therefore range from 0 to 35
(asymptomatic to very symptomatic)
The first seven questions of the I-PSS are identical to the questions appearing on the
American Urological Association (AUA) Symptom Index which currently categorizes
symptoms as follows:

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Physical Exam
A physical exam may help diagnose benign prostatic hyperplasia. During a physical
exam,

a health care provider most often examines a patients body, which can include checking

for
discharge from the urethra
enlarged or tender lymph nodes in the groin
a swollen or tender scrotum
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taps on specific areas of the patients body

a. performs a digital rectal exam
A digital rectal exam, or rectal exam, is a physical exam of the prostate. The exam helps
the health care provider see if the prostate is enlarged or tender or has any abnormalities
that require more testing.Many health care providers perform a rectal exam as part of a
routine physical exam for men age 40 or older, whether or not they have urinary
problems.
If the prostate is healthy, it feels smooth, while an enlarged prostate may be felt as a
bulge. If the prostate is enlarged, it will still feel smooth in the case of benign prostatic
hyperplasia (BPH) is showed palpable enlarged prostate, prostate chewy consistency as
touching the tip of the nose, flat surface, right and left lobes symmetric, not found
nodules, and protruding into the rectumbut, if cancer is present, the prostate consistency
hard or palpable nodules and between the lobes of the prostate is not symmetrical. While
on prostate stones will be palpable crepitus.. The prostate may be painful when squeezed
if it is inflamed or infected. The whole test may take around five minutes.

b. Lab
Prostate-specific

examination
antigen, or PSA, is

a protein produced

by cells

of the

prostate gland. The PSA test measures the level of PSA in a mans blood. Healthy men
have low amounts of PSA in the blood. The amount of PSA in the blood normally
increases as a man's prostate enlarges with age. PSA may increase because of
inflammation of the prostate gland (prostatitis) or prostate cancer. An injury, a digital
rectal exam, or sexual activity (ejaculation) may also briefly raise PSA levels.
c. Uroflowmetry

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To determine whether the bladder is obstructed, the speed of urine flow is measured
electronically using a test called uroflowmetry. The test cannot determine the cause of
obstruction, which can be due not only to BPH, but possibly also to abnormalities in the
urethra, weak bladder muscles, or other causes.
d. Postvoid Residual Urine
One of the important tests for urinary incontinence is the postvoid residual urine volume
(PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is
left; more than 200 mL is a definite sign of abnormalities. Measurements in between
require further tests. The most common method for measuring PVR is with a catheter, a
soft tube that is inserted into the urethra within a few minutes of urination. PVR can also
be measured using transabdominal ultrasonography.
Treatment
Treatment options for benign prostatic hyperplasia may include

lifestyle changes
medications
minimally invasive procedures
surgery

A health care provider treats benign prostatic hyperplasia based on the severity of symptoms,
how much the symptoms affect a mans daily life, and a mans preferences. Men may not need
treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their
quality of life. In these cases, instead of treatment, a urologist may recommend regular
checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk,
a urologist most often recommends treatment.

Lifestyle Changes
A health care provider may recommend lifestyle changes for men whose symptoms are mild or
slightly bothersome. Lifestyle changes can include

reducing intake of liquids, particularly before going out in public or before

periods of sleep
avoiding or reducing intake of caffeinated beverages and alcohol

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avoiding or monitoring the use of medications such as decongestants,

antihistamines, antidepressants, and diuretics

training the bladder to hold more urine for longer periods
exercising pelvic floor muscles
preventing or treating constipation

Medications
A health care provider or urologist may prescribe medications that stop the growth of or shrink
the prostate or reduce symptoms associated with benign prostatic hyperplasia:

alpha blockers
5-alpha reductase inhibitors

Alpha blockers.
These medications relax the smooth muscles of the prostate and bladder neck to improve urine
flow and reduce bladder blockage:

terazosin (Hytrin)
doxazosin (Cardura)
tamsulosin (Flomax)
alfuzosin (Uroxatral)
silodosin (Rapaflo)

5-alpha reductase inhibitors.

These medications block the production of DHT, which accumulates in the prostate and may
cause prostate growth:

finasteride (Proscar)
dutasteride (Avodart)

These medications can prevent progression of prostate growth or actually shrink the prostate in
some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful for
only moderately enlarged prostates.
Surgery
For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing
enlarged prostate tissue or making cuts in the prostate to widen the urethra.

Urologists

recommend surgery when

medications and minimally invasive procedures are ineffective

symptoms are particularly bothersome or severe
complications arise Although removing troublesome prostate tissue relieves many
benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic
hyperplasia.
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Surgery to remove enlarged prostate tissue includes

transurethral resection of the prostate (TURP)

laser surgery
open prostatectomy
transurethral incision of the prostate (TUIP)

A urologist performs these surgeries, except for open prostatectomy, using the transurethral
method. Men who have these surgical procedures require local, regional, or general anesthesia
and may need to stay in the hospital.
The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some
urologists prescribe antibiotics only when an infection occurs. Immediately after benign prostatic
hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the
opening of the penis to drain urine from the bladder into a drainage pouch.

TURP.
With TURP, a urologist inserts a resectoscope
through the urethra to reach the prostate and
cuts pieces of enlarged prostate tissue with a
wire loop.

Special fluid carries the tissue

pieces into the

bladder, and the urologist flushes them out at
the end of the procedure. TURP is the most
common

surgery

for

benign

prostatic

hyperplasia and considered the gold standard

for treating blockage of the urethra due to
benign prostatic hyperplasia.
Laser surgery.
With this surgery, a urologist uses a high-energy laser to destroy prostate tissue. The urologist
uses a cystoscope to pass a laser fiber through the urethra into the prostate. The laser destroys
the enlarged tissue. The risk of bleeding is lower than in TURP and TUIP because the laser seals
16

blood vessels as it cuts through the prostate tissue. However, laser surgery may not effectively
treat greatly enlarged prostates.
Open prostatectomy.
In an open prostatectomy, a urologist makes an incision, or cut, through the skin to reach the
prostate. The urologist can remove all or part of the prostate through the incision. This surgery
is used most often when the prostate is greatly enlarged, complications occur, or the bladder is
damaged and needs repair. Open prostatectomy requires general anesthesia, a longer hospital
stay than other surgical procedures for benign prostatic hyperplasia, and a longer rehabilitation
period.

The three open prostatectomy procedures are retropubic prostatectomy, suprapubic

prostatectomy, and perineal prostatectomy. The recovery period for open prostatectomy is
different for each man who undergoes the procedure. However, it typically takes anywhere from
3 to 6 weeks.
TUIP
A TUIP is a surgical procedure to widen the urethra. During a TUIP, the urologist inserts a
cystoscope and an instrument that uses an electric current or a laser beam through the urethra to
reach the prostate. The urologist widens the urethra by making a few small cuts in the prostate
and in the bladder neck. Some urologists believe that TUIP gives the same relief as TURP
except with less risk of side effects.
After surgery, the prostate, urethra, and surrounding tissues may be irritated and swollen, causing
urinary retention. To prevent urinary retention, a urologist inserts a Foley catheter so urine can
drain freely out of the bladder. A Foley catheter has a balloon on the end that the urologist
inserts into the bladder. Once the balloon is inside the bladder, the urologist fills it with sterile
water to keep the catheter in place. Men who undergo minimally invasive procedures may not
need a Foley catheter.
The Foley catheter most often remains in place for several days. Sometimes, the Foley catheter
causes recurring, painful, difficult-to-control bladder spasms the day after surgery. However,
these spasms will eventually stop. A urologist may prescribe medications to relax bladder
muscles and prevent bladder spasms. These medications include

oxybutynin chloride (Ditropan)

17

solifenacin (VESIcare)
darifenacin (Enablex)
tolterodine (Detrol)
hyoscyamine (Levsin)
propantheline bromide (Pro-Banthine)

Complication
The complications of benign prostatic hyperplasia may include

acute urinary retention.

chronic, or long lasting, urinary retention.

blood in the urine.

urinary tract infections (UTIs)

bladder damage.

kidney damage.

bladder stones.

Prognosis
The outlook for benign prostatic hyperplasia is good; although it can cause significant
discomfort, the condition is benign. As the prostate gland grows in size, symptoms may become
worse, warranting medication or surgery. With appropriate medical and/or surgical management,
the symptoms of an enlarged prostate gland can be treated effectively.

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Daftar pustaka
http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/benign-prostatichyperplasia-bph/Documents/ProstateEnlargement_508.pdf
http://www.aafp.org/afp/2008/0515/p1403.pdf
http://onlinelibrary.wiley.com/doi/10.1002/j.1939-4640.1991.tb00272.x/pdf
https://www.nlm.nih.gov/medlineplus/ency/article/000381.htm
http://pennstatehershey.adam.com/content.aspx?productId=10&pid=10&gid=000071

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