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Bph..ibrahim hakami

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  1. 1. Benign Prostatic Hyperplasia Presented by Dr. IBRAHIM HAKAMI
  2. 2. Objectives : 01 02 03 04 05 Anatomy of the prostatic gland What’s Benign Prostatic Hyperplasia ? Approach to patient with BPH. History, Examination, Investigation, Management. Indications For Referral. Prevalence of BPH
  3. 3. Anatomy of The Prostatic Gland
  4. 4. About Prostatic Gland Male sex gland Pear-shape, weight 7-16 gm Size of walnut Help to control urine outflow. 01 02 03 04 05 06 Produces fluid component of the semen. Produces prostate specific antigen (PSA)
  5. 5. The prostate gland is made up of differe nt types of cells: - gland cells that produce the fluid portion of semen. -muscle cells ( epithelial ) control urine flow and ejaculation. -fibrous cells ( stromal )provide the supportive structure of gland. Prostatic Gland
  6. 6. Benign Prostatic Hyperplasia
  7. 7. What’s Benign Prostatic Hyperplasia ? Benign prostatic hyperplasia (BPH) refers to neoplastic, non- malignant proliferation of the prostatic tissue surrounding the urethra. BPH is a condition that occurs in aging men as the prostate gland undergoes exposure to androgenic and estro- genic stimulation over time. Other names include: • Benign prostatic hypertrophy. • Enlarged prostate. • BPH.
  10. 10. Prevalence of BPH Male in their 30s 8% Male in their 50s 50% Male in their 80s 80%
  11. 11. RISK FACTORS • Age. • Family Hx. • Black Men. • Use Of Beta-blockers. • Lack Of Physical Exercise. • Obesity. BPH does not predispose to the development of prostate cancer.
  12. 12. Approach to patient with BPH
  13. 13. Clinical Manifestations. (LUTS) Voiding Symptoms Straining Dribbling At The End Of Urination Decrease In The Urinary Stream Hesitancy Burning During Urination Feeling Of Incomplete Bladder E mptying. Irritative Symptoms Frequency Urgency Dysuria Nocturia Incontinence
  14. 14. Differential Diagnosis • Urethral stricture • Bladder neck contracture • Carcinoma of the prostate • Carcinoma of the bladder • Bladder calculi • Urinary tract infection and prostatitis • Neurogenic bladder
  15. 15. Complete Hx Taking. • The goals of the history are to clarify symptoms consistent with BPH and exclude conditions that mimic BPH. • Important point for pt. with symptoms of BPH. 1. Onset and duration of symptoms. 2. Urethral or bladder trauma (including instrumentation). 3. STDs 4. Fever, dysuria, gross hematuria, pain suggestive of stones.
  16. 16. Important Hx. point for pt. with symptoms of BPH. 5. Medication use is helpful because medications account for 10% of LUTS in men. 6. DM, tobacco use, intake of bladder irritants (e.g., Caffeine), 7. Sexual dysfunction, or conditions resulting in neurologic impairm ent (e.g., Neurogenic bladder), 8. Family history of prostate or bladder cancer.
  17. 17. Physical examination The examination for suspected BPH focuses on the: ABDOMEN Genital area RECTUM
  18. 18. Digital rectal examination (DRE) • A digital rectal examination is recommended by the American Urological Association (AUA). • Performed to assess the size, consistency, and shape of the prostate . • Nodularity, and asymmetry, which may raise suspicion for malignancy.
  19. 19. Investigation Urinalysis. Serum prostate-specific antigen (PSA). U/S of the prostate. Serum Cr. is not indicated. because the incidence of baseline renal in sufficiency in men with BPH is similar to th at in the general population.
  20. 20. Investigation (optional) Post-void residual urine should be performed if history and physical examination suggest urinary retention. Uroflowmetry Urine cytology
  21. 21. Uroflowmetry
  22. 22. Management of BPH
  23. 23. Management : 02 03 04 05 06 Behavioral modification Pharmacological treatment Herbal therapy Surgical or invasive management Indications of referral 01 Severity Guide Management
  24. 24. AUA symptom score # Used to : -assess the severity of symptoms of BPH. -measure the outcome of BPH treatments. # It consists of 7 questions: 1-Frequency 2-nocturia 3-weak urinary stream 4-hesitancy 5-incomplete emptying 5-intermittence 7-urgency
  25. 25. Severity Guide Management. 0-7 8-19 20+ Mild Moderate Severe
  26. 26. Behavioral modification Mild to moderate symptoms with little ”bother” Manage with watchful waiting & lifestyle modification : • Losing weight. • Decreasing evening fluid intake. • Avoiding excess alcohol, caffeine, or highly seasoned foods • Limiting medications that cause lower urinary tract symptoms. • Double voiding to empty the bladder more completely.
  27. 27. Pharmacological Treatment Alpha blockers.  5-alpha-reductase inhibitors.  Anticholinergic agents.
  28. 28. Alpha blockers. Tamsulosin Prazosin Terazosin Alfuzosin Doxazosin
  29. 29. Alpha blockers. Mild to moderate symptoms of BPH whose symptoms have a sufficient effect on quality of life we suggest initial treatment with Alpha blockers. (Grade 2A). MOA: Relaxing smooth muscle in the bladder neck,prostate capsul e, and prostatic urethra. Side effects: • Hypotension, dizziness. • Ejaculatory Dysfunction. • Interaction with phosphodiesterase-5 inhibitors The AUA recommends avoidance of all alpha blockers in men with planned catara ct surgery because of the risk of intraoperative floppy iris syndrome. 2 to 4 weeks after initiation
  30. 30. 5-alpha-reductase inhibitors. Finasteride Dutasteride
  31. 31. 5-alpha-reductase inhibitors. MOA: block the conversion of testosterone to dihydrotestosterone, resulting in a gradual decr ease in prostatic volume. The combination of alpha blockers and 5-alpha reductase inhibitors is eff ective for long-term management of BPH and demonstrated large prostate s. Side effects. • Ejaculation Disorder, Decreased Libido. • Erectile Dysfunction Decrease PSA About 50% 3 to 6 months
  32. 32. Anticholinergic agents. Tolterodine Oxybutynin Darifenacin Trospium Solifenacin
  33. 33. Anticholinergic agents. MOA: Anticholinergic agents block the effects of acetylcholine on muscarinic rece ptors in the bladder, resulting in decreased bladder contractions. Side effects. • Dry mouth and eyes. • constipation.
  34. 34. Herbal therapy. Data of herbal therapies for BPH are confl icting. Commonly used in Europe. Until additional studies of herbals are perfo rmed, we do not suggest using these f or the treatment of BPH. No herbal therapies have been approved by the FDA for BPH.
  35. 35. Surgical Or Invasive Management. Out-patient based therapies: • Transurethral microwave therapy (TUMT) • Transurethral needle ablation (TUNA) OR based therapies: • Open simple prostatectomy. • Transurethral Resection Of The Prostate TURP. • Transurethral incision of the prostate. • Laser photoselective vaporization of the prostate (PVP). • Laser Prostatectomy.
  36. 36. Surgical Or Invasive Management. Is considered the gold-standard surgical tr eatment for BPH. Transurethral Resection Of The Prostate (TURP)
  37. 37. Postoperative guidelines for the patient  There may be urgency even to the point of incontinence for a few days.  Bleeding can occur intermittently for 3 weeks, so increase fluid i ntake.  Avoid intercourse for 3 weeks.  Orgasms continue but there is usually no emission with ejaculati on. The semen is ejaculated back into the bladder.
  38. 38. Indications For Referral.  Complications of Bladder outflow Obstruction : -upper tract (hydronephrosis , renal insufficiency) -lower tract (urinary retention, recurrent UTI ) - bladder decompensation  Symptoms following invasive treatment of the urethra or prostate.  Abnormality on prostate exam (nodule, induration, asymmetry)  Hematuria.  Bladder calculi.
  39. 39. References
  40. 40. THANK YOU

Notas do Editor

  • In addition to onset and duration of symptoms, any history of fever, dysuria, gross hematuria, pain suggestive of stones, or previous urethral instrumentation should be obtained. Identification of medication use is helpful because medications account for 10% of lower urinary tract symptoms in men.4 Other key information includes history of diabetes mellitus, tobacco use, intake of bladder irritants (e.g., caffeine), sexual dysfunction, or conditions resulting in neurologic impairment (e.g., neurogenic bladder), and a personal or family history of prostate or bladder cancer.2,5 Assessing overall health can guide eligibility for future medical and surgical interventions.2
  • Digital rectal examination (DRE) is performed to assess the size, consistency, and shape of the prostate.
  • Transurethral microwave therapy TUMT :A device delivers heat transurethrally to destroy prostatic tissue.
    Transurethral needle ablation (TUNA) :A needle delivers radio frequency energy to ablate the prostate
    Office treatments
    Local anesthesia
    Minimally invasive
    High retreatment rate
    Increased dysuria, and urinary retention compared with TURP
    Lack of large, high-quality studies with long-term outcomes

    Laser photoselective vaporization of the prostate (PVP). :A high-power potassium titanyl phosphate (KTP) laser vaporizes prostate tissue