A short ppt on BPH and Hematuria

1. Prostatitis
Kishore SR
Oman Medical College
Chapter 14
&Hematuria

2. Contents
• Benign Prostatic Hypertrophy
▫ Introduction
▫ Case Discussion
▫ Investigation and Management
▫ Referral criteria's
• Acute and Chronic Prostatitis
• Hematuria
▫ D/Dx
▫ Management
▫ Referral Criteria's

3. Benign Prostatic Hypertrophy (BPH)
• Lower urinary tract symptoms consequent upon
bladder outlet obstruction due to benign
prostatic hyperplasia (BPH), also known as
benign prostatic enlargement (BPE). They are
predominantly due to 2 components:
• a static component related to an increase in
benign prostatic tissue narrowing the urethral
lumen and
• a dynamic component related to an increase in
prostatic smooth muscle tone mediated by
alpha-adrenergic receptors.

4. • The prevalence of histological BPH does
increase with age and affects approximately
42% of men between the ages of 51 and 60
years, and 82% of men between the ages of 71
and 80 years.
• BPH involves hyperplasia of both epithelial and
stromal prostatic components. A key
characteristic of BPH is increased stromal :
epithelial ratio

5. Case History
• A 60-year-old man presents to his primary care
physician with a 3-month history of increasing
urinary frequency without burning and nocturia 3
times each evening. He has limited his fluid
consumption and caffeine intake in the evening
without much benefit. There is no personal or
family history of prostate cancer.

6. Step-by-Step Diagnostic Approach
History
• Patient can present with either Voiding
(obstructive) symptoms or with Storage
(irritative) symptoms.
• Voiding symptoms include hesitancy,
intermittency, weak stream, straining, incomplete
emptying, and post-void dribbling.
• Storage symptoms include urinary frequency,
nocturia, dysuria and urgency

7. • Fever, pain, and dysuria can suggest of
alternative diagnosis such as prostatitis or UTI
• Hematuria increases the possibility of prostate
or bladder cancer.
• Long-standing diabetes may suggest
neurogenic bladder as a cause of lower urinary
tract symptoms (LUTS)
• Medicines such as diuretics, anticholinergics,
and adrenergic alpha-agonists may affect
urinary flow rate or affect prostate bladder tone
mimicking BPH
• Cardiovascular and renal disease may present
with polyuria or nocturia

8. Physical examination
• Abdominal examination – for distended bladder,
palpable kidneys. Examine the external genitalia
• Digital Rectal exam (DRE) – anal tone, estimate
the size, shape and consistency of the prostate
and to assess for prostate nodules or rectal
masses.

9. Investigations
1. Urine analysis
▫ To rule out UTI. M, C and S
2. MSU
▫ Dipstick for blood and glucose.
3. Serum Urea, creatinine and eGFR
▫ Renal function assessment.
4. PSA
▫ Increased PSA may suggest the presence of underlying
prostate cancer or prostatitis.
5. IPSS
6. Uroflowmetry
▫ <15mL/s is abnormal
7. Ultrasound

10. The International Prostate Symptom Score (IPSS)
• The IPSS, which is a self-administered patient
questionnaire with 8 questions (7 questions on
symptoms and 1 question on quality of life)
should be completed in the initial work-up.
• This is a reliable, accurate predictor of LUTS.
• Scores of 0 to 35 to define severity of
symptoms.
0-7 mild
8-19 moderate
20-35 severe

12. Management
• Watchful waiting: for those who have mild to
moderate symptoms at presentation with no
complications of BPH and those not troubled
severely by their symptoms. Self help can help.
• Drug Therapy:
▫ Alpha-adrenoceptor antagonists : Prazosin,
Doxazosin
 Watch for postural hypotension
▫ 5α-reductase inhibitors : Finasteride.
 For patients with bulky prostates. 6mo for effect.
Lowers the risk of urinary retention
▫ Combination therapy – reduces progression by

13. Complications
• Recurrent UTI
• Bladder stones
• Hematuria
• Acute retention of urine
• Chronic retention
• Overflow incontinence
• Obstructive nephropathy

14. When to Refer?
• Complicated BPH – Emergency admission
needed or Urgent
• Nodular or Firm prostate – Urgent
• High PSA - Urgent
• Severe symptoms – Soon
• Failure to respond to drug therapy after 3-6 mo..
of prazosin or 6-12 mo.. of fenasteride - Routine

15. Acute Bacterial Prostatitis
• The most frequent urological
diagnosis in men <50 years old.
• Commonly caused by Escherichia
coli bacteria.
• Consider in a patient with UTI
• Features include; arthralgia,
myalgia, low back pain, perineal
pain, penile pain, rectal pain
• Examination findings- DRE
reveals Swollen, tender prostate

16. • Investigate using MSU
• Management – Ciprofloxacin 500mg bd or
Ofloxacin 200mg bd
• Refer if not settling with treatment.
• Complications – Acute retention of urine, chronic
bacterial prostatitis, prostate abscess.

17. Chronic Bacterial Prostatitis
• Chronic Pelvic pain Syndrome
• Cause is unknown
• Presents with >3 mo. history of
▫ Urological pain – Low abd, pelvis/perineum, Penis
(especially tip w/t ejaculation), testis, rectum, low
back
▫ Irritative/Obstructive symptoms
• Investigations – DRE, MSU, urine cytology, STI
screening, PSA, urodynamic study
• T/t is difficult, provide info and support.
• Try doxazosin 4mg od for 6 mo..

18. Hematuria
• Macroscopic hematuria:
▫ A substantial haemorrhage into the urinary tract that
will give the urine a red or brownish tinge
• Microscopic hematuria :
▫ >5 RBCs/hpf on two microscopic urinalyses
• Significant microscopic hematuria:
▫ On microscopic examination of the urine, >5 RBCs
/hpf in spun urine or >2 RBCs /hpf in unspun urine
• Investigate all cases
• MSU, M,C & S and blood for U&E, creatinine, eGFR

19. Causes
• Kidney – Stones, Tumor,
Infection,
Glomerulonephritis
• Ureter – Stones, Tumor
• Bladder – UTI, Stones,
Tumor, Chronic
inflammation
• Prostate – Prostatitis,
Tumor
• Urethral Inflammation

20. Management
Urgent Referral
• Painless macroscopic hematuria
• Age 40 or more with recurrent/persistent UTI
asst. with hematuria
• Age 50 or more with unexplained microscopic
hematuria
• Abdominal mass that is thought to be from UT

21. Non- Urgent referral
• Patients less than 50 with microscopic
hematuria.
• If proteinuria, high serum creatinine or low
eGFR, refer to renal physician
In male patients with symptoms suggestive of UTI
and macroscopic hematuria, diagnose and treat
the infection first before referral.

22. Case Scenario
A 75 year American old male
comes to your office with a 6
month history of Nocturia,
hesitancy, a slow flow of urine
and terminal dribbling. No
other significant medical
illnesses except for diabetes
On examination, his abdomen
is normal. He has an enlarged
prostate gland which is
smooth and firm with no
nodules or irregularities.

23. Q. Before medical or surgical treatment of the
patient, which of the following should be
performed?
A. Digital Rectal Exam
B. CT
C. Colonoscopy
D. IPSS
E. Ultrasound
F. A and E
G. A and D
Q. What are the risk factors in this patient?