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Dr Soumar Dutta Guwahati Refinery Hospital

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The prostate is an accessory gland of the male reproductive system. The secretions of this gland add bulk to the seminal fluid. Shape: Inverted cone Apex, base & 4 surfaces Size: 4cm X 3cm X 2cm Weight: 8 Gm Consistency: Firm Lobes: 5 Histological 3 zones outer /peripheral middle/transitional inner/central

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<ul><ul><li>(I) Hormonal Theory </li></ul></ul><ul><ul><li>(II) Neoplastic Theory </li></ul></ul>Pathogenesis : Hyperplasia of both glandular epithelium and connective tissue stroma forming one or more nodules. May involve any part of the gland with the exception of ant. and post. lobes. May compress the rest of the gland forming a false/surgical capsule.

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Changes in the urethra : enlargement of the prostatic urethra exaggeration of the normal posterior curvature of the prostatic urethra urethra compressed laterally reducing it to an A-P slit Changes in the urinary Bladder: Compensatory hypertrophy of the vesical detrussor Trabeculation of bladder wall. Hypertrophy of the trigone. Formation of diverticula Formation of pool of residual urine- cystitis,calculus[triple PO4] Changes in ureters and kidney: Hydroureter and Hydronephrosis Vesicoureteric reflux- Ac. & Chr. Pyelonephritis

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CLINICAL FEATURES <ul><li>BEP seldom causes symptoms before 50 yrs of age </li></ul><ul><li>No direct relation between the degree of enlargement and severity of symptoms. </li></ul><ul><li>Earlier prostatism term now replaced by “LUTS”. </li></ul><ul><li>OBSTRUCTIVE IRRITATIVE . Hesitancy . Frequency </li></ul><ul><li>. Poor flow . Nocturia </li></ul><ul><li>. Intermittent stream . Urgency </li></ul><ul><li>. Dribbling . Urge Incontinence </li></ul><ul><li>. Sense of incomplete evacuation . Nocturnal enuresis </li></ul><ul><li>. Episodes of near retention </li></ul>

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Assessment Of A Patient With Prostatism/LUTS <ul><li>General examination : to exclude renal insufficiency-raised BP, anemia </li></ul><ul><li>Local examination : palpable mass: distended bladder; hydronephrotic kidney. </li></ul><ul><li>External urethral meatus. </li></ul><ul><li>DRE (Digital Rectal Examination) </li></ul><ul><li>surface </li></ul><ul><li>consistency </li></ul><ul><li>overlying mucosa. </li></ul><ul><li>midline sulcus </li></ul><ul><li>Examination of nervous system . </li></ul>

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<ul><li>Serum PSA : non specific </li></ul><ul><li>Flow rate measurement : lowered in BEP </li></ul><ul><li>Volm 150-200 ml </li></ul><ul><li>Q max >15 ml/s NORMAL </li></ul><ul><li>10-15 EQUIVOCAL </li></ul><ul><li>< 10 LOW </li></ul><ul><li>Voiding pressure: increased in BEP. </li></ul><ul><li>> 80 cm H 2 O HIGH </li></ul><ul><li>60-80 EQUIVOCAL </li></ul><ul><li><60 NORMAL </li></ul><ul><li>USG (KUB) more sensitive TRUS </li></ul><ul><li>size, ecotecture, Post-void residue, Hydronephrosis,Hydroureter </li></ul><ul><li>Grading: Gr. I > 25 cm3 </li></ul><ul><li> Gr. II >50 cm3 </li></ul><ul><li> Gr. III > 75 cm3 </li></ul>

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Cystoscopy: Indications: Haematuria Urethral stricture or H/O urethritis. Prior TURP / Open Prostatectomy IVP: Determines f(x) of kidneys Hydronephrosis / Hydroureter Diverticula of Bladder

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Management of a patient with BPH/BOO <ul><li>Pt may present with features of : </li></ul><ul><li>Acute retention </li></ul><ul><li>Chronic retention with features of incontinence,hydronephrosis,hydroureter. </li></ul><ul><li>Haemorhage </li></ul><ul><li>Renal impairement </li></ul><ul><li>Complications of BOO: stone,infection,diverticula formation. </li></ul><ul><li>Severe symptoms of LUTS </li></ul><ul><li>Conservative medical treatment : </li></ul><ul><li>strategies: </li></ul><ul><li>Smooth muscle relaxation </li></ul><ul><li>Androgen Supression </li></ul><ul><li>Estrogen Supression </li></ul>

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Alpha- blockers : Relaxes smooth muscles -> decrease urethral resistance . Non selective : phenoxybenzamine Selective alpha 1 : Prazosine, Terazocin, Doxazocin. Selective alpha 1a : Tamsulosin and Alfuzosin Androgen suppression : Involution of Epithelial Component, decreasing Volm. Anti-androgens : Flutamide 5 Alpha Reductase Inhibitors : Finestride; Dutasteride Estrogen suppression : Atamastane

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Surgery: Procedure: Prostatectomy Approach: Transurethral- TURP Retropubic Transvesical Perineal Complications: Haemorrhage Perforation of UB and prostatic capsule. Incontinence Urethral strictures Retrograde ejaculation and impotency Bladder neck Contractures Urethral strictures Reoperation TUR Syndrome: water intoxication --> dilution hyponatraemia.

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