2. • 71 yrs old man has been referred to the urology outpatient clinic with a history of poor
urine stream, urinary frequency, nocturia and some post micturition dribbling. He has
occasional urgency. He suffer with osteoarthritis of his left hip and uses a walking stick.
He has angina, HTN and hypercholesteremia. He is an ex-smoker and lives with his
wife. His younger brother had prostate cancer and underwent a radical prostatectomy
at the age of 65yrs. He is anxious to get his PSA test as he is concerned about prostate
cancer.
• On examination, abdominal examination is unremarkable. The bladder is not palpable
and the genitalia are normal. DRE confirms a moderately enlarged firm prostate gland.
in any case of urological disease think about differential diagnosis by :
Lower urinary tract
symptoms (LUTS) :
• Voiding symptoms :
- Poor flow, intermittency,
straining, hesitancy and
terminal dribble.
• Storage symptoms :
- urgency, frequency,
incontinence and
nocturia.
Hematuria :
• Painless or painful
hematuria.
• Visible and clot
formation
Pain :
• Flank and loin pain in
kidney and ureter.
• Supra-pubic pain in urinary
bladder.
• Perianal pain in prostate.
• Scrotum pain in testis
3. • Usually associated
with pain +/-
hematuria and
dysuria as in UTI
and pyelonephritis.
Painless hematuria
and cause dull pain in
case of locally
advanced as in
bladder and kidney
tumors.
Could cause mixed
voiding and storage
symptoms in case
of bladder outlet
obstruction like
BPH.
• In case of
stones, will
cause painful
hematuria.
• In case of
urethral
stricture, will
cause storage
symptoms.
4. Benign prostatic hyperplasia
• Benign condition caused by Hyperplasia of the glandular tissue which
more common among elderly.
Prostate enlargement :
• Enlargement of
prostate occur by
aging process.
• Asymptomatic
presentation only
detect by DRE or
imaging.
Bladder prostatic
obstruction:
• Enlargement of
prostate in which
cause obstruction of
neck of bladder and
urethra.
• Patient present with
mixed voiding and
storage symptoms.
Benign prostatic
hyperplasia :
• Enlargement of
prostate which could
be symptomatic or
not.
• Consider histologic
diagnosis as need
biopsy to diagnose.
Etiology of BPH :
There are multiple theory of etiology including :
• High level of dihydrotestosterone (DHT) as converted from testosterone by 5 α-
reductase enzyme which lead to increase the growth and enlargement.
• increase in the estrogen/androgen ratio in prostatic tissue.
• Decrease cell death regulation (apoptosis) of prostatic cell.
6. Clinical manifestation :
Early manifestation :
• The patients are asymptomatic in early stage as enlargement of prostate not cause
urethra obstruction.
• As BPH cause urethra and bladder neck compression, will cause :
- Storage symptoms with Increased daytime frequency, nocturia, urgency, and urinary
incontinence.
- Voiding symptoms with Slow urinary stream, splitting or spraying of the urinary stream,
intermittent urinary stream, hesitancy, straining to void, and terminal dribbling.
- Microscopic or gross Hematuria.
Late manifestation as complication :
• Acute and chronic urinary retention.
• Overflow incontinence.
• Hydro-ureter and hydro-nephrosis.
• Recurrent UTI
• Renal failure
• Urinary bladder stones
8. Full history and clinical examination including DRE.
• 71 yrs old man has been referred to the urology outpatient clinic with a history of poor
urine stream, urinary frequency, nocturia and some post micturition dribbling. He has
occasional urgency. He suffer with osteoarthritis of his left hip and uses a walking stick.
He has angina, HTN and hypercholesteremia. He is an ex-smoker and lives with his
wife. His younger brother had prostate cancer and underwent a radical prostatectomy
at the age of 65yrs. He is anxious to get his PSA test as he is concerned about prostate
cancer.
Some points need to cover during history :
• the presence of storage, voiding, and irritative urinary symptoms.
• general health (diabetes mellitus is a BPH risk factor, family history of BPH or prostate
cancer.
• History of urethral trauma, urethritis, or urethral instrumentation that could lead to
urethral stricture.
• Gross hematuria or pain in the bladder region, which may be suggestive of a bladder
calculi or cancer.
• Underlying neurologic disease, which might indicate a neurogenic bladder.
• Cigarette smoking, which is a risk factor for bladder cancer.
• Treatment with drugs that can impair bladder contractility (eg, anticholinergic agents) or
increase outflow resistance (eg, sympathomimetic agents).
9. ProstatitisProstate CABPHNormalDRE finding
SameSame or
increase
increase20gSize
FirmHard/nodularfirmfirmConsistency
Well defined
smooth
irregularWell defined
smooth
Well defined
smooth
Surface
PalpableNot palpablePalpable or notpalpableMedial sulcus
tenderNon-tenderNon-tenderNon-tendertenderness
Differential diagnosis during DRE :
10. Laboratory test include :
• Urinalysis :
- Present of RBC or UTI features.
- Morphology appearance of RBC.
• Urine culture if suspected UTI.
• RFT to assess the kidney.
• Prostate specific antigen (PSA) test
• Other test as baseline including CBC, LFT.
• Urine cytology might done if suspected bladder
cancer.
Imaging studies :
• KUB x-ray to exclude other causes.
• genitourinary US might done.
Other test use in selected
patient if symptomatic,
inconclusive previous
results and not benefit
from medical therapy
PSA :
• PSA is proteolytic enzyme secreted
from prostate gland to liquefied the
semen.
• Normally 0-4 ng/ml in serum PSA. If
high indicate overactivity of prostate
gland.
• Its raise in normally with age,
prostate cancer, BPH, prostatitis, DRE
and previous instrumental through
urethral as catheterization.
• If PSA level exceed 100 ng/ml, think
about metastatic prostate cancer.
11. Urodynamic study (uroflowmetry) :
• Use to assess bladder outlet obstruction by the following information: volume voided,
peak and mean flow rates, and a graph of flow in mL/sec as a function of time.
• Maximal urinary flow rates >15 mL/sec are thought to exclude clinically important
bladder outlet obstruction.
• Maximal flow rates <15 mL/sec are compatible with obstruction from prostatic or
urethral disease
Post –void residual urine volume :
• useful in men with evidence of urinary obstruction.
• Residual urine volume can be determined by in-out ultrasonography or bladder scan.
• Done by apply pelvic US before and after emptying the urine to check residual urine
• Normal men have less than 12 mL of residual urine.
Urodynamic study (uroflowmetry)
12. Tran-rectal US guided biopsy of prostate :
• Done only if suspected of prostate cancer by very high level of PSA .
• Patient still not benefit from medical or surgical treatment.
13. Management
General measures :
• Avoid patient factors including Excess work, worry, weather (cold),
wine, women, withholding urine in bladder, spices, constipation
• α -blockers: e.g.
Tamsulosin, Alfuzosin .
block α -receptors in the
urethra → ↓its tone.
• 5α -reductase inhibitors:
e.g. Finasteride (proscar)
14. Surgical Transurethral resection of the prostate (TURP)
reduce the amount of prostate tissue are performed via the urethra using a special
cystoscope (ie, resectoscope) . The prostatic tissue can be removed (ie, resected).
There is two type of TURP techniques :
Monopolar TURP :
• Old technique using monopolar electrocautery
done under neuraxial anesthesia (spinal,
epidural), or regional nerve block. The
procedure takes approximately 60 to 90
minutes to perform and generally requires a
24 hour postoperative observation.
• Continuous irrigation using a nonconductive
solution (eg, 1.5% glycine in sterile water)
which increase the risk of TURP syndrome.
Bipolar TURP :
• uses bipolar electrocautery with
saline can be used as an irrigant
(also known as TUR in saline),
eliminating the risk of hyponatremia
(ie, postprostatectomy syndrome).
Complication of TURP :
• Bleeding
• Clot retention (reduce by continue irrigation post-OP).
• Infection (UTI).
• TURP syndrome as use glycine irrigation lead to dilutional hyponatremia and its
symptoms as cerebral edema.
• Sexual dysfunction as erectile dysfunction and retrograde ejaculation.
• Urethral stricture and urinary incontinence.
