Benign Prostatic Obstruction

Bernard S. Tjandra Bedah Urologi

Lower Urinary Tract Symptoms (LUTS)
Storage symptoms = Irritative Voiding symptoms = Obstructive


Epidemiology BPH
Common over 40 yrs of all races & cultures

Prevalence by age 60 = 50 % 70 = 70 % 80 = 90 %
From 40 – 80 : 10 % chance of undergoing prostatectomies

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Number of prostatectomies per year per 1000 men > 55 yrs Belgium USA France Denmark Japan UK 14 13 13 12 9 7 .

Prostate .

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Mc Neal 1968 (Zonal concept) Central gland : transition zone 5 % (origin bpo) periurethral (mid lobe) Peripheral gland : peripheral zone 70 % (origin cancer) central zone 25 % Fibromuscular structures : anterior (smooth muscle) longitudinal preprostatic sphincter postprostatic sphincter (striated) .

Functions of Prostatic Gland and Fluid Reproduction Citrate Glucose Antibacterial Zinc .

prostatic capsule & bladder neck The detrusor component Loss of contractile. 3.Pathophysiology 1. uninhibited 2. . The static component Hyperplastic nodule of transition zone The dynamic component Smooth muscle tone in the prostate.

2002. 89) . BJU International. both smooth muscle and connective tissue. (Chagas et al.Histology Increase in the stromal component.

Unbound testo. Dihydrotestosterone hypothesis (Testo. 1 – 3 %) formed by 5-alpha reductase isoenzymes type 1 & 2 within the prostate binds to receptors in the nucleus. Stem cell theory 6. Oestrogen – Testosterone imbalance 3. Stromal – Epithelial interaction 4. Reduced cell death 5. leads to cell replication epithelial & stromal hyperplasia 2. Bind with TBG & Albumen . Inflammation * .Pathogenesis 1.

Hypertention (20 – 30 %).Risk factors     Age Race Environment and dietary higher in men consuming milk lower in men consuming soya (phytooestrogen) Associated conditions DM. Obesity .

Classical symptoms Obstructive Weak stream Straining Hesitancy Intermittency Incomplete emptying Terminal dribbling Prolonged micturition Overflow incontinence Irritative Frequency Urgency Nocturia Urge incontinence Small voided volume .

Other symptoms        Haematuria Dysuria Haematospermia Low back pain (hydronephrosis) Nausea (uremic) Urinary retention Edema Symptoms fluctuate with time ! .

Detrusor hypertrophy  Trabeculae Residu  Diverticula Infection Stone Renal failure .

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Diverticulum .

DM. phenylpropanolamine) Provocative event (alcohol) . Tumor. HNP. MS) Pelvic surgery Instrumentation Medicine (e.g.Anamnesis  Medical history Disease (CVA.

Boyarsky (1977) .IPSS (1991) International Prostate Symptom Score AUA .Anamnesis  The severity of the problem can be quantified by asking “symptom scores” .Madsen-Iversen (1983) .

total score 46 Light Moderate Severe 0 .20 > 20 . nocturia. hesitancy. bladder emptying. voiding. incontinence Irritative : urge.8 9 . diuria Grading 0 – 4.Madsen – Iversen score Obstructive : stream. intermittency.

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straining. intermittency   Irritative : frequency. nocturia  Quality of life * Grade 0 . weak stream.5. urgency. total score 35 0.7 8 .IPSS (= AUA)  Self – assesment * Obstructive : incomplete emptying.18 > 18   Mild Moderate Severe .

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meatal stenosis . 20 grm Firm elastic / rubbery consistency as the tip of the nose .renal enlargement -bladder distention  Digital rectal examination The size of a chestnut.Physical examination  Inspection .phimosis  Abdominal palpation .

Phimosis Meatus stenosis .

Dilatator / Bougies

Paraphimosis

DRE

Grade 0 : not palpable, < 10 g
Grade 1 : whole prostate palpable < 25 g Grade 2 : enlarge, reach cranial, 25 – 60 g Grade 3 : reach the top, < 120 g Grade 4 : very big, > 120 g

Diagnosis / Investigations

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Urinalysis (ery,leuc,bact) Serum Urea, Creatinine, PSA Uroflowmetry & post-void residual urine *
X-Abdomen & USG Kidney TRUS (Transrectal Ultrasound) of the Prostate

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Pressure-flow study (optional)

IVU (cystogram) .

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Interpretation of Qmax (Uroflow) flow rate > 15 ml / sec 10 – 15 ml / sec < 10 ml / sec Interpretation normal equivocal obstructed .

Normal Uroflowmetry & BPO .

Example of obstructive flows .

Transrectale ultrasonography .

TRUS of the Prostate Intrabladder Prostate Protrution Grade 1 < 5 mm Grade 3 < 10 mm .

Residu Hydronephrosis .

Giant Prostate .

15 50 % chance of cancer biopsy !!! > 10 ng / ml .2 days) 0.Interpretation of PSA values (half – life = 2.4 ng / ml 4 .5 .10 ng / ml normal (monoclonal method) 20 % chance of cancer PSA / prostate volume = PSAD normal < 0.2 – 3.

9 X 4.1 X 53 X 57 X .Effect of prostate manipulation on PSA procedure DRE TRUS Massage Cystoscopy TURP Biopsy effect none none 1.

Treatments .

 Watchful waiting for patients with minor symptoms and no objective signs of complications .

rest .Severe haematuria .Socially disabling symptoms .Disturbance of sleep. Relative .

Chronic / recurrent infection .Overflow incontinence .Obstructive uropathy .Severely decompensated bladder .Repeated retention .Vesicle stone . Absolute .

Doxazosin .Finasteride (type 2) .Dutasteride (type 1 & 2) .Terazosin .Alfuzocin .Option for treatment  Medical therapy Alpha-1 blockers (Prostate tone) .Tamsulosine (selective) 5-alpha reductase inhibitors (Prostate volume) .

Distribution of alpha receptors Alpha 1 A prostate Alpha 1 D bladder neck Alpha 1 B vascular .

reversible impotence .discontinuation before cataract surgery !!!  Finasteride .decreases PSA by 50 % .effective 60 % .Effects of medical therapy  Alpha-1 blockers .improve flow by 2.7 ml/sec .reduced prostate volume . headaches .reduced libido .improve flow by 3-5 ml/sec .drowsiness.postural hypotention .

Phytotherapy (plant extracts)    Antiandrogenic Proapoptotic Anti-inflammatory  Serenoa repens .

mortality rate 1 % .hospital stay 10 – 12 days .Option for treatment  Surgical therapy Open prostatectomy Transvesical (Hrynchack. Freyer 1901) Retropubic subcapsule (Millin 1947) .prostate volume > 100 grm .

Retropubic subcapsule prostatectomy .

1 – 0.hospital stay 3 days .succes rate 71 % .re-treatment rate after 5 yr 8 % .mortality rate 0.2 % .Option for treatment  Surgical therapy Transurethral resection of the Prostate (= TURP) .

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Pre and Post TURP .

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3 way catheter .

Prostate  Post-operative complications Retrograde ejaculation 60 % Haemorrhage 15 % Impotence 15 % Urethra stricture 5% Bladder-neck sclerosis 5% Epididymitis 4% TUR syndrome 2% Incontinence 1% .U.R.T.

Stricture urethra Bladder neck sclerosis .

Vaporization (GreenLight laser/KTP) .Option for treatment  Technological intervention .Laser enucleation (Holmium/YAG) .

GreenLight Laser 120 -W .

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Photoselective Vaporization of the Prostate GreenLight HPS Laser 120 -W use saline or aqua .

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GreenLight Laser Prostatectomy Photoselective Vaporization Prostate       Less Bleeding Less Pain No Erectile Dysfunction No TUR Syndrome Stay one night Quick recovery Vaporization .

Advantages of GreenLight laser         Bloodless procedure Less pain No risk of water intoxication Short catheterization (< 24 hours) < 1 % cases of erectile dysfunction Rapid urine flow improvement Quick return to normal activities Definitive and long lasting treatment No pathology specimen  .

New Finding   Anti-inflammatory Antioxidants .

Differential diagnosis .

Teratoma Chordoma .

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How to insert a catheter and What you need .

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Suprapubic cystostomy .

The TUR syndrome     As result of absorption of irrigant Sodium < 120 mmol / l Widening QRS complex ST depression Mean volume of irrigant absorbed during TURP 900 ml 30 % absorbed by intravascular route (venous pressure 6 cm H20) 70 % absorbed by retroperitoneal (capsular breaches) .

Pathophysiology TUR syndrome  Circulatory distress Hypervolaemia - elevate CVP Diffusion interstitial - plasma (transient) follow „leakage‟ of water from plasma - interstitial - Hypotention Dilution of protein Lowers oncotic pressure - pulmonary oedema  .

Classic syndrome     bradycardia hypotention tachypnoea restlessness Confusion Convulsions Coma Vascuvar collapse death      .

Prevention / Management     good surgical technique avoid overfilling the bladder limit resection time (90 min.) routine administration of Furosemide   inducing diuresis (10 % Mannitol) hypertonic saline (500 ml 3 %) .

The concept of balance  The extracellular water Plasma (3 li) Interstitial-lymp (11 li) 14 li  The intracellular water 28 li ---------------------------------------------------Total body water 42 li .