ETIOLOGI DAN

PATHOPHYSIOLOGI
PEMBESARAN PROSTAT JINAK

Dr. Rochani
 Prostate anatomy – urethral division of gland

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Clinical importance of prostatic zonal anatomy

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Functions of prostatic gland and
fluid

Reproduction

Antibacterial

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Composition of normal ejaculate

Total volume 3 - 3.5 mls

Semifinal vesicles 50% volume

Prostate 15 - 30% volume
Cowper’s glands and 5% volume
urethral glands

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Constituents of prostatic fluid

Polyamines (spermine)
Plasminogen activator
Citrate
Seminal neutral protease (seminin)
Cholesterol, lipids
Lactate dehydrogenase
Prostatic acid phosphatase (PAP)
Prostatic - specific antigen (PSA)
Electrolytes (K+, Na+, etc.)
Zinc (prostatic antibacterial factor)
Glucose
Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
 Prostatic secretory products -
actions

Zinc Antibacterial factor

Citrate Sperm transport
Spermine Cell proliferation
Odor of semen
Cholesterol / lipids Sperm protection
Plasminogen activator Semen liquefaction
Seminin Semen liquefaction

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Prostate weight versus age

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
 Etiological factors in BPH

C Lee et All, 5th International Consultation on BPH, Paris 2000

 Role of androgens in BPH

Castration or antiandrogen drugs cause

shrinkage of prostate
Castration before puberty prevents BPH
Genetic diseases, e.g., 5α – reductase
deficiency, are associated with
nonpalpable prostates
Androgen levels (T, DHT) in prostate are high
in elderly men

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 The hypothalamus – pituitary – testes – prostate
hormonal axis

T = testosterone
LH = luteinizing hormone
LH – RH = luteinizing
hormone – releasing
hormone
DHT = dihydrotestosterone

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Conversion of testosterone to dihydrotestosterone by the
enzyme 5α – reductase in the prostatic epithelial cell

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Prostatic growth factors – Putative roles in BPH

Periurethral stromal cells

Basic fibroblast growth factor (bFGF)

Transforming growth
? ß1 (TGF ß-1)

Stromal hyperplasia Epithelial hyperplasia

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

The growth factors EGF and FGF activate proto-
oncogenes and thus stimulate cell growth

C. Lee et All, 5th International Consultation on BPH, Paris 2000

The role of estrogen in prostatic growth

C. Lee et All, 5th International Consultation on BPH, Paris 2000

A Simple summary of the influence
of the extrinsic factors

C. Lee et All, 5th International Consultation on BPH, Paris 2000

BPH – hyperplastic tissue surrounds urethra,
forming “pseudo” or “surgical” capsule

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

BPH – Mechanism of Obstruction

Dynamic – Determined primarily by the tone of

the prostate smooth muscle

Static / mechanical – Related to the obstruction

caused by the enlarging prostate adenoma

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

Andersson K.E et All, 5th International Consultation on BPH, Paris 2000
Andersson K.E et All, 5th International Consultation on BPH, Paris 2000
Determinants of symptoms in BPH

Smooth
Prostate Bladder
muscle

Histologic BPH Muscle tone Prostate

Size Muscle contractility Bladder neck

Symptomatic BPH
Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
Pathophysiology of the urinary bladder
in obstruction

J. Nordling et All, 5th International Consultation on BPH, Paris 2000

Effects of BPH – trabuculated bladder with multiple
diverticula and dilated ureters

Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993

 Effects of bladder outlet obstruction

Infection
Large post-void residual volumes
Calculi
Bladder trabeculation
and diverticula

Ureteral dilatation

Obstructive uropathy
Azotemia
Renal damage
Renal failure
Edwin M. Meares Jr, MD, Differential Diagnosis of Prostate Disorders, 1993
 DIAGNOSIS
PEMBESARAN PROSTAT
JINAK

Dr. Rochani
Subbagian Urologi FKUI- RSCM Jakarta
 ANAMNESIS
 ANAMNESA
 PROSES & LAMANYA GGN BERKEMIH
 RIWAYAT OPERASI SEBELUMNYA
 KESEHATAN UMUM & FUNGSI SEKS
 TOLERANSI PADA TERAPI
 OBAT-OBATAN YANG DIMINUM
 Anticholinergic ( mengurangi kontraksi buli-buli)
  simpatomimetik ( meningkatkan resistensi outflow)

(Cockett et all 1993, McConnell et all 1994)

 ANAMNESIS
 SISTIM SKORING
 I-PSS (International Prostat Symtom Score)
 Menilai sendiri ( tingkat pendidikan)
 Ringan = 0–7
 Sedang = 8 – 19
 Berat = 20 - 35

 BS (Bother Score)
 Lebih mudah, pilihan terapi & follow up
 0–6
 Seandainya anda harus menghabiskan sisa hidup anda dengan
kondisi berkemih seperti saat ini bagaimana perasaan anda ?
SELAMA 1BULAN TERAHIR SEBERAPA SERING
Tidak Kurang dari Kurang Kadang Lebih Hampir
pernah sekali dari 5 dari kadang dari selalu
kali berkemih setengah (50%) setengah
1.Tidak lampias saat 0 1 2 3 4 5
selesai berkemih ?
2. Harus kembali 0 1 2 3 4 5
kencing dalam waktu
< 2jam
3. Kencing terputus 0 1 2 3 4 5
putus
4. Sulir menahan 0 1 2 3 4 5
kencing
5. Pancaran kencing 0 1 2 3 4 5
lemah
6. Mengedan untuk 0 1 2 3 4 5
mulai berkemih

7.Bangun untuk Tidak 1 kali 2 kali 3 kali 4 kali 5 kali /

berkemih malam hari ada lebih
0
 ANAMNESIS
 Madsen Iversen
 Lebih mudah
 Interpretasi oleh dokter

 Masih dipakai di UROLOGI FKUI – RSCM.

Obstructive Irritative

Stream Urge
Voiding Nocturia
Hesitancy Diuria
Intermitency
Incontinence
 PEMERIKSAAN FISIK
UMUM  SUPRA SIMPISIS
–MOTORIK & SENSORIK  RETENSIO URIN

 COLOK DUBUR
 TONUS SFINGTER ANI 
 PROSTAT
 UKURAN ( obstruksi) 
 KONSISTENSI
 NODUL
 NYERI TEKAN
 Masa di rectum
 (Cockett et all 1993, McConnell et all 1994)
 (Donkervoort dkk 1975, Bissada dkk 1976, Roehrborn dkk 1986, Meyhoff dkk 1981)
 LABORATORIUM
 URINALISA
 HEMATURI,
 PYURI,
 PROTEINURI (?),
 GLUKOSURIA.
(Cockett et all 1993, McConnell et all 1994)

 UREUM / KREATININ
 13,6% (0,3 – 30%) BPH + insufisiensi renal
(McConnell et all 1994)
 LABORATORIUM

 PSA
 Dihasilkan oleh Jaringan Prostat Jinak dan Ganas.
 Terdapat False (+) / (-).
 Nilai normal (< 4 ng/dl).
 Biopsi :
1. > 10ng/dl
2. 4 – 10 ng/dl bila PSAD (PSA/Vol prostat) > 0,15
 Pasien Harus Dirujuk
1. Kecurigaan ganas (colok dubur)
2. Hematuria
3. PSA abnormal
4. Nyeri
5. Infeksi
6. Buli-buli teraba
7. Kelainan Neurologis

(5th International Consultation on BPH 2000, WHO)

UROFLOWMETRI
UROFLOWMETRI
 Tidak infasif (nyaman)

 Q MAX (MAX. FLOW RATE)

 NORMAL ( 15 – 25 CC/DET)
 Ringan (12 – 14 cc/det)
 Sedang ( 8 – 12cc/det)
 Buruk ( <8 cc/det)

 Jumlah kencing
 >150cc
 UROFLOWMETRI
Studi Adam - Griffith dari 180 kasus

Q max > 10 ml Qmax 10-15 ml Qmax >15 ml

Obstruksi 88% 45% 24%

Tidak 12% 46% 76%

obstruksi
 RESIDU URIN
 RESIDU URIN (USG trans abdominal)
 Normal (78% < 5cc)
(100% < 12 cc) (Di Mare et all 1963)
 Minimal (< 50cc)
 Sedang (50 – 100cc)
 Banyak (>100cc)
 Pemeriksaan Tambahan
 BNO – IVP
 USG ( GINJAL & Sal Kemih)
1. Infeksi saluran kemih berulang
2. Hematuria
3. Riwayat Batu Saluran Kemih
4. Gangguan fungsi Ginjal

(McConnell et all 1994)

 TERAPI BPH FKUI - RSCM

Parameter Terapi Medik Operasi

Medsen score < 10 > 10

Flow rate > 10 ml/det < 10 ml/det

Residu < 100 ml > 100 ml

 KELEMAHAN
 SKOR ANAMNESA
 Terdiri dari : Obstuktif
Iritatif
 PANCARAN KENCING
 Mengedan
 RESIDU URIN
 Kontraktilitas otot Buli-buli

Obyektif : URODYNAMIC
PRESSURE FLOW STUDY
 URODINAMIK

• Menilai proses fisiologi berkemih

• Tekanan intra vesika
• Kontraksi otot abdomen
• Pancaran urin
• Residu urin
• Suteja PMK, Rochani, 2000, Riwayat retensio urin, setelah
Aff catheter dapat BAK spontan, pada evaluasi urodinamik 90%
(44 dari 49 kasus ) tekanan intra vesika >55cm H2O
(OBSTRUKSI) dilakukan TUR Prostat.
URODINAMIK
 TRUS (Trans Rectal Ultrasound)
 BENTUK & UKURAN PROSTAT
 Rekomendasi Terapi :
 Hipertermi
 Stents

 TUIP

 GUIDE NEEDLE BIOPSY

 BIOPSI SEXTAN ( 6 TEMPAT)
 AREA TERTENTU
TRUS (Trans Rectal Ultrasound)
 TRUS

•USG TRANSREKTAL

•BIOPSI PROSTAT
SEKIAN TERIMA
KASIH