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Evaluation of the patient with BPH

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Evaluation of the patient with BPH

  1. 1. Evaluation of the patient with BPH Presented by : Dr. Md. Ishtiaqul Haque Mortuza (Labib) Resident Department of Urology Chittagong Medical College & Hospital
  2. 2. • BPH gives rise to LUTS ( lower urinary tract symptoms) and Obstruction of varying degree. • “Symptom” is what the patients are worrying about and “Obstruction” is what the urologist should be concerned about • Though the majority of patients with LUTS are due to BPH, but some patients may have LUTS due to other causes.
  3. 3. How to evaluate a patient with BPH ? Evaluation of a patient with BPH includes the following steps to establish a correct diagnosis
  4. 4. History takingHistory taking
  5. 5. Pt. with BPH gives history of - 1. Obstructive symptoms: • Hesitancy/Intermittency • Decreased force and caliber of stream • Sensation of incomplete bladder emptying • Straining to urinate • Post void dribbling • Double voiding 2. Irritative symptoms: • Urgency • Frequency • Nocturia
  6. 6. • Hesitancy- during micturation urine flow stops and starts for several times • Double voiding- second time voiding with in 2 hrs of last void • Frequency- frequent micturation within a short interval • Urgency- difficult to postpone urination • Nocturia- waking up from sleeping to urinate at night
  7. 7. IPSS (International Prostate Symptom Score) IPSS (International Prostate Symptom Score) • IPSS is used to asses the severity of the symptoms. This consist a score sheet of obstructive & irritative symptoms mentioned previously. • There are some questions that will refer both the obstructive & irritative symptoms
  8. 8. • The severity is scored from ‘none at all (0)’ to ‘almost always (5)’ giving rise to a maximum score of 35. IPSS score 0-7 Mild symptom score 8-19 Moderate symptom score 20-35 Severe symptom
  9. 9. Quality of LifeQuality of Life
  10. 10. Physical examinationPhysical examination
  11. 11. Physical examination includes: 1.DRE (Digital Rectal Examination) 2.Examination of genitourinary system 3.Focused neurological examination 4.Examination of hernial orifice 5.Related General examination including cardiopulmonary status of the patient
  12. 12. DRE (Digital Rectal Examination) DRE (Digital Rectal Examination)
  13. 13. Points to be noted in DREPoints to be noted in DRE • Size of the prostate May be enlarged • Surface Smooth • Consistency Firm, elastic • Rectal mucosa Free from prostate • Median sulcus Obliterated • Any rectal mass Absent • Anal tone Normal • Upper limit Can be reached
  14. 14. Examination of genitourinary systemExamination of genitourinary system • External urethral meatus – normal • Urethra – no palpable mass or cord like feeling • Urinary bladder – May or may not be palpable (> 200 ml) Percussion of suprapubic region(dull on percussion) • Kidney – usually not palpable • Testis, Epididymis, Hydrocele, Varicocele
  15. 15. Focused Neurologic examinationFocused Neurologic examination To exclude neurogenic bladder we have to take history & perform examinations. History 1. H/O stroke 2. H/O Any spinal injury 3. H/O DM 4. H/O Alteration of bowel habit (e.g. constipation) Examinations 1. Perianal sensation 2. Bulbocavernosus reflex 3. Anal tone 4. Lower extremity function (motor & sensory)
  16. 16. Relevant investigationsRelevant investigations
  17. 17. Investigation required for the evaluation of a patient with BPH includes: 1. Urnie analysis 2. USG of KUB ,Prostate with PVR 3. Uroflowmetry 4. Serum PSA 5. Plain X-ray KUB (A/P view) 6. Pressure flow study 7. Filling cystometry 8. Urethocystoscopy Not recommended routinely
  18. 18. Urine analysisUrine analysis • Urine analysis assist in distinguishing UTI & bladder cancer from BPH • Components are: 1. Urine R/M/E 2. Urine for C/S 3. Urine cytology
  19. 19. Findings of urine analysisFindings of urine analysis Urine R/M/E 1. Sugar for DM 2. Pus cell for UTI 3. RBC for UTI & other causes Urine for C/S • To identify any significant infection & selection of proper antibiotic Urine cytology 1. Should be considered in men with H/O smoking with severe irritative symptoms 2. To exclude specially CIS
  20. 20. Pus Cells Malignant Cell RBC E.choli
  21. 21. USG of KUB, Prostate with PVRUSG of KUB, Prostate with PVR 1. Size 2. Intravesical potrusion 3. Echogenicity 4. Capsule 1. Bladder wall (thickened or not) 2. Presence of any diverticulum 3. Presence of any stone 4. Any growth obstructing the bladder neck 5. Determination of PVR ProstateProstate BladderBladder Following points are to be observed in USG KidneyKidney To see any bilateral pelvicalyceal dilatation, which reveals any back pressure effect of the
  22. 22. • Size of the prostate can be classified into: 1. Small prostate – < 20 gm 2. Medium prostate – 20-40 gm 3. Large prostate - > 40 gm • Intravesical potrusion of prostate can be graded into: 1. Grade I – 0-5 mm 2. Grade II – 6-10 mm 3. Grade III - >10 mm
  23. 23. • Echogenicity (sonographic pattern of BPH) Mixed, heterogenous, mostly hypo echoic parenchyma, often arranged in the form of one or more hyperplastic nodules and sometimes recognizable internal architecture • Capsule Bright echogenic structure surrounding the prostate (in BHP it is intact) Capsular bulging & irregularity associated with an adjacent focal hypo echoic lesion often indicate ‘capsular invasion’ (a sign of malignancy)
  24. 24. USG image of a BPHUSG image of a BPH
  25. 25. Some important informationSome important information • Size of the prostate correlate less well with the degree of obstruction • A small prostate may obstruct and a large prostate may not obstruct. This is because of the distortion of the “funneling effect of the bladder neck” which is more important cause of obstruction than the compression of the urethra. • A small nodule sitting at the strategic position at the outlet (such as median lobe) can cause a “ball-valve” effect leading to significant obstruction
  26. 26. • Usually large prostate are more likely to obstruct than the small prostate due to compression of the urethra • In a study it was found that : Patients with grade I protrusion: 84% has a good flow rate > 10 ml/sec Patients with grade III protrusion: 72% has a flow rate < 10 ml/sec
  27. 27. PVR (Post Voidal Residue)PVR (Post Voidal Residue) • When voiding function of bladder is impaired it will be manifested as residual urine • Normal person with no significant obstruction should have residual urine 0 ml • Any patient with a persistent PVR > 100 ml with no obvious neurogenic cause and association with poor flow rate of 10ml/sec or less, would be suspected to have significant obstruction
  28. 28. UroflowmetryUroflowmetry • Uroflowmetry is the electronic recording of the urinary flow rate throughout the course of micturition. • Results of uroflowmetry are non-specific for the causes of symptoms • For proper uroflow test, voided volume should be at least 150 ml.
  29. 29. Points to be noted in uroflowmetryPoints to be noted in uroflowmetry Maximum flow rate Average flow rate Voiding time Voiding volume Pattern of voiding curve
  30. 30. • With properly performed uroflow test: Normal flow rate in male about 20-25 ml/sec Normal flow rate in female about 25-30 ml/sec • Obstruction should be suspected when maximum flow rate is < 15 ml/sec • definitive evidence of obstruction when maximum flow rate < 10ml/sec
  31. 31. Plain X-ray KUBPlain X-ray KUB • To see any stone in the urinary bladder, vesical neck or in the urethra, which might be cause of LUTS • Any metastatic lesion in the bone • Any calcification in Kidney, ureter, bladder, prostate
  32. 32. Serum PSASerum PSA • PSA is a tumor marker used for screening of Ca prostate • Serum PSA is considered optional, but most physician will include it in the initial evaluation.
  33. 33. What we should know about PSA?What we should know about PSA?  PSA is a glycoprotein enzyme(serine protease)  It is secreted by the epithelial tissue of prostate  It circulates in serum in free & bound form  Its normal value is <4 ng/ml  Its level raises with increasing age & size of prostate gland  Real outcome of PSA test can be obtained by evaluating the level from time to time and observing the rate of changes  Medical opinion is divided about the usefulness of single PSA test  One test out of range could be caused by other problems  Moreover PSA is not specific for Ca prostate
  34. 34. Confounding factors for PSAConfounding factors for PSA • PSA level increases in 1. Ca prostate 2. BPH 3. Prostatitis 4. Instrumentation 5. DRE 6. Aging 7. Ejaculation • PSA level decreases in 1. LHRH agonist 2. 5 alpha reductase inhibitors
  35. 35. Other PSA parametersOther PSA parameters PSA velocity • It means rate of change of PSA over time • Man with Ca prostate has more rapidly rising serum PSA than in man with BPH • Serum PSA increases by .75ng/ml/yr appear to be at increased risk of harboring cancer. PSA density • It is ratio of PSA to the gland volume • PSA levels are elavated approximately .12ng/ml/gm of BPH tissue Thus patients with enlarged prostate due to BPH may have elavated PSA level
  36. 36. Differential diagnosis of BPHDifferential diagnosis of BPH • BNH • Urethal stricture • Ca Prostate • Ca Bladder • Infection (Cystitis, Prostatitis) • Stones • Neurogenic Bladder
  37. 37. Staging of BPHStaging of BPH
  38. 38. Stage 1 No bothersome symptom(QOL 2 or less) No significant obstruction( Qmax >10ml/sec,PVR <100 ml) Stage 2 With bothersome symptom(QOL 3 or more) No significant obstruction Stage 3 With significant obstruction irrespective of symptoms (Qmax<10ml/sec, PVR >100ml) Stage 4 BOO with complication
  39. 39. Treatment of BPHTreatment of BPH
  40. 40. Treatment of BPH is planned after • Proper evaluation • Properly informed about the disease & various therapeutic options of BPH So treatment can be given on the basis of • Relative efficacy of the Rx • Side effects
  41. 41. Rx modalities depends on • Age of the patient • IPSS of the patient • DRE findings • USCD(Ultrasound cystodynamogram) • Uroflowmetry findings • Serum PSA level • Complication of BEP
  42. 42. Rx options are • Watchful waiting • Medical therapy • Surgery
  43. 43. Watchful waiting Mild symptoms (IPSS 0-7) • No bothersome symptoms • No significant obstruction
  44. 44. The severity & distress due to symptoms may be improved through simple measures such as: • Decreased fluid intake specially prior to bed time • Reduced intake of alcohol & caffeine contaning product • Follow timed voiding schedules Patient should be observed for bothering symptoms & development of significant obstrution
  45. 45. Medical treatment
  46. 46. Aim of medical therapy  To decrease BOO, thereby- • Relieving symptoms • Improving bladder emptying • Ameliorating detrusor instability • Preventing future episodes of UTI & urinary retention
  47. 47. Ideal candidate for medical Rx • Bothersome symptoms that impact negatively on quality of life • No significant obstruction(Qmax>10ml/sec, PVR<100 ml) Medical Rx should not be offered to individual presenting with- 1. Refractory urinary retention 2. Recurrent UTI 3. Renal insufficiency 4. Bladder calculi/diverticula 5. Recurrent gross hematuria
  48. 48. Medical therapy include 1) Alpha blokers • Non selective-phenoxybenzamine, • Alpha 1 (short acting)- prazosin, • Alpha 1 (long acting)- terazosin, doxazosin • Alpha 1a selective(uroselective)-tamsulosin, alfuzosin,silodosin 2) Androgen suppression (5 alpha reductase inhibitor) Finesteride, dutasteride 3) Plant extract (Phytotherapy)- popular in europe & USA
  49. 49. Surgical therapy A) Endoscopic method • TURP • TUIP • TULIP- 1) HoLEP, 2)Free beam laser, 3)Contact laser, 4) Interstitial laser • TUVP • TUNA • HIFU • TUBD • TUMT • Intraurethral prostatic stent- Cobalt-Chromium stent, Titenium nickel stent Out of all minimally invasive technique, TURP is the gold standered
  50. 50. B) Open method • Retropubic prostatectomy(Millins prostaectomy) • Perineal prostatectomy(Youngs prostatectomy) • Transvesical prostatectomy C) Laparoscopic prostatectomy D) Robot assisted simple prostatectomy
  51. 51. Indications of TURP Absolute indications 1. Refractory urinary retention 2. Chronic retention with renal insufficiency---- increased serum creatinine increased blood urea level, residual urine volume 200 ml or more, hydroureteronephrosis in IVU uremic manifestation. 3. BOO with complication • Recurrent UTI • Recurrent gross heamaturia • Large bladder diverticula • Stone formation
  52. 52. Relative indications 1.Severe symptoms(IPSS >20) 2.Failed medical treatment 3.Qmax <10 ml/sec 4.PVR >100ml after repeated measurement
  53. 53. Pre operative counselling • Retrograde ejaculation • Erectile dysfunction • Success rate • Risk of re-operation • Post operative morbidity UTI & dysuria Incontinence Hematuria Dribbling Frequency, urgency etc.
  54. 54. Complications of TURP A) Local complication 1.Penile erection 2.TUR syndrome 3.Excessive bleeding 4.Perforation of capsule & extravasation of urine 5.Bladder perforation, trigonal injury 6.Injury to external sphincter & urethra Per operative complicationPer operative complication
  55. 55. B) General complication • Myocardial infarction • CVA • Cardiac arrest A)Local • Bleeding • Clot retention • UTI • Sepsis • Failure to void • Epidedymoorchitis Immidiate Post operative complicationImmidiate Post operative complication
  56. 56. B) General complication • MI • DVT • Pulmonary embolism • Spinal headache • Stricture urethra • Bladder neck contracture • Urinary incontinence • Retrograde ejaculation • impotence Local complicationLocal complication
  57. 57. Indications of open Prostetectomy • Large prostate > 100 gm • Concomitant bladder condition that requires Rx (such as symptomatic bladder diverticulumn, large hard calculus that cant be manage transurethally) • Marked ankylosis of the hips that prevents proper placement of dorsal lithotomy position • Co-existing unilateral/bilateral inguinal hernia
  58. 58. Contraindication of open prostatectomy • Small fibrous prostate gland • Previous prostatectomy • Previous pelvic surgery • Any type of prostate cancer