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Benign Prostate Hyperplasia

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Benign Prostate Hyperplasia

  1. 1. ProstateEnlargement Presented by: Marwan Adnan Zuaiter
  2. 2. Introduction • Prostate(‫ة‬َ‫ث‬‫و‬ُ‫م‬‫:)ال‬ is a single, fibromuscular glandular organ, and the largest accessory sex gland in men (about 2 × 3 × 4 cm). • The prostate secretes a milky fluid which contains: 1. Citric acid 2. Proteolytic enzymes 3. Acid phosphatase • The prostatic secretion is alkaline and helps neutralize the acidity in the vagina. • Prostatic secretions enter the prostatic urethra via many prostatic ducts, which makes up about 25% of the volume of semen and contribute to sperm motility and viability.
  3. 3. Embryologically
  4. 4. Embryology 1. fetal testosterone stimulates urogenital sinus mesenchyme through androgen receptors. 2. urogenital sinus mesenchyme acts on the overlying epithelium to stimulate cell proliferation. 3. urogenital sinus epithelium then forms prostate ductal progenitor, the prostatic buds. 4. prostatic buds then grow into the urogenital sinus mesenchyme.
  5. 5. • Macroscopically the prostrate can be divided into lobes. 1. peripheral zone 2. internal zone 3. innermost zone • In good histological sections it is possible to distinguish three concentric zones • *excretory ducts
  6. 6. Anatomy
  7. 7. Anatomy • It is about the size of a chestnut (about 2 × 3 × 4 cm) and somewhat conical in shape. The base is directed upward, and is applied to the inferior surface of the bladder, the apex is directed downward, and is in contact with the superior fascia of the urogenital diaphragm. • The prostate is a firm, partly glandular and partly muscular body, which is placed in the pelvic cavity. Immediately below the internal urethral orifice, posterior to the lower part of the symphysis pubis, above the superior fascia of the urogenital diaphragm, in front of the rectum, and surrounding the prostatic urethra.
  8. 8. Anatomy
  9. 9. Anatomy • Arteries: inferior vesical artery > prostatic artery > urethral and capsular branches, middle hemorroidal and internal pudendal arteries>minor branches. • Veins: prostatic venous plexus > internal iliac vein • Lymph drainage: internal iliac nodes. • Nerve supply: inferior hypogastric plexuses and the sympathetic nerves stimulate the prostatic smooth muscle during ejaculation.
  10. 10. Prostate Enlargement • The prostate slowly increases in size from birth to puberty, and then it expands rapidly. The size attained by age 30 typically remains stable until about age 45, when further enlargement may occur. • Enlargement of the prostate to 2 to 4 times its normal size occurs approximately 1/3 of all males over age 60. • Generally a healthy adult prostate weighs about 20–25 grams.
  11. 11. Prostate Enlargement • Benign prostate hyperplasia (BPH). • Prostatitis. • Prostatic cancer.
  12. 12. BPH • It is not cancer, and it does not raise your risk for prostate cancer. • Disease of elderly men (average age is 60-65 years); prostate gradually enlarges, creating symptoms of urinary outflow obstruction. • The actual cause of prostate enlargement is unknown. • Factors linked to aging, testosterone levels. • Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH. Also, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size.
  13. 13. •Absent malignancy, most tissues in the body shrink as we age. Why does the prostate expand as men grow old?
  14. 14. Absent malignancy, most tissues in the body shrink as we age. Why does the prostate expand as men grow old? • equilibrium between cell division and cell death • androgens not only are required for normal prostatic cell proliferation BUT • also actively inhibit cell death • progression of normal prostatic cells to terminally differentiated cells IS BLOCKED • thereby reduces the overall rate of cell death • This leads to increasing gland size.
  15. 15. BPH • BPH mainly occur periurethrally. (Note: prostate cancer occurs in the periphery of the gland)
  16. 16. BPH symptoms (Obstructive-type symptoms) • Hesitancy. • Weak stream. • Nocturia. • Intermittency. • UTI/recurrent UtI. • Urinary retention. • Dribbling at the end of urinating. • Straining to urinate. • Strong and sudden urge to urinate. • Incomplete emptying of your bladder.
  17. 17. BPH Diagnosis • Digital Rectal Exam (DRE) • Urinalysis • Urine culture • Prostate-specific antigen • BUN and CR • Cystoscopy • Post-void residual urine • Urethrometry • US
  18. 18. Diagnostic guidelines for BPH • History:- • prior and current illnesses • prior surgery and trauma • Current medication, including over-the-counter drugs • Physical examination:- • including DRE • Urinalysis:- • Routine and microscopic, culture and sensitivity. To rule out diagnoses other than BPH that may cause LUTS and may require additional diagnostic tests. • prostate-specific antigen (PSA):- • Should be offered to patients who have at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management. Among patients without prostate cancer, serum PSA may also be a useful surrogate marker of prostate size and may also predict risk of BPH progression.
  19. 19. *NOTE* IPSS or AUA Symptom Score International Prostate Symptom Score or American Urologic Association system score are recommended for an objective assessment of symptoms at initial contact, for follow-up of symptom evolution for those on watchful waiting and for evaluation of response to treatment.
  20. 20. Diagnostic guidelines for BPH • In cases where the physician feels it is indicated, it is reasonable to proceed with one or more of the following: 1. Post-void residual urine 2. Urethrometry 3. Voiding diary 4. BUN and CR 5. Sexual function questionnaire
  21. 21. Diagnostic guidelines for BPH • The following diagnostic modalities are not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS. BUT may be required in patients with a definite indication, such as hematuria, uncertain diagnosis, DRE abnormalities, poor response to medical therapy or for surgical planning. 1. Cystoscopy 2. Cytology 3. Urodynamics 4. Radiological evaluation of upper urinary tract 5. Prostate ultrasound 6. Prostate biopsy
  22. 22. Treatment guidelines for BPH • How bad your symptoms are and how much they bother you? • lifestyle modification ? • MEDICINES? • SURGERY?
  23. 23. Treatment guidelines for BPH Soooooo How tell whether the patient needs lifestyle modification or medications or surgery?
  24. 24. Remember IPSS ?
  25. 25. Treatment guidelines for BPH • IPSS < 7: MILD symptoms >Combination of lifestyle modification and watchful waiting< • IPSS 8 – 18: MODERATE symptoms • IPSS 19 – 35: SEVERE symptoms >Watchful waiting/lifestyle modification, as well as medical, minimally invasive or surgical therapies<
  26. 26. Lifestyle modifications with watchful waiting? • Patients on watchful waiting should have periodic physician-monitored visits. • Fluid restriction particularly prior to bedtime. Avoid drinking fluids within 2 hours of bedtime. • DO NOT drink a lot of fluid all at once. • Timed or organized voiding. Go to the bathroom on a timed schedule, even if you don't feel a need to urinate. • Pelvic floor exercises regularly. Kegel exercises. • Avoidance of caffeinated beverages, spicy foods. • Reduce stress, avoidance or treatment of constipation. Nervousness and tension can lead to more frequent urination. • Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants).
  27. 27. Kegel exercises
  28. 28. Kegel exercises
  29. 29. Medical treatment • Alpha-1 blockers: relax the muscles of the bladder neck and prostate capsule. (within 3 to 7 days). • Terazosin (Hytrin®): are appropriate treatment options for LUTS secondary to BPH. They do not alter the natural progression of the disease. • Finasteride (Proscar®): 5-alpha-reductase inhibitor. Several studies have demonstrated that in addition to improving symptoms, the natural history of BPH can be altered through a reduction in the risk of acute urinary retention (AUR) and the need for surgical intervention. • Hormonal: Antiandrogens
  30. 30. Surgical Intervention • Indications for surgical intervention:- 1. Sever symptoms. 2. Failure of treatment. 3. Patient do not want medical therapy. 4. Urinary retention. 5. Hydronephrosis. 6. Recurrent UTIs. 7. Recurrent blood in the urine. 8. Decreasing kidney function. 9. Bladder stones. 10.Hernias (inguinal).
  31. 31. Surgical Intervention • Transurethral Resection of Prostate (TURP): This is the most common and most proven surgical treatment for BPH (gold standard treatment). TURP is performed by inserting a scope through the penis and removing the prostate piece by piece.
  32. 32. Complications of TURP • Failure to void. • Erectile dysfunction. • Bleeding. • Clot retention. • UTIs. • Incontinence.
  33. 33. Other Surgical Intervention • Transurethral Incision of Prostate (TUIP): is appropriate surgical therapy for men with prostate gland volumes less than 30 grams. • Laser prostatectomy: Greenlight laser or photoselective vaporization prostatectomy (PVP). • Open prostatectomy : indicated for men whose prostates are too large for TURP for fear of incomplete resection, significant bleeding or the risk of dilutional hyponatremia (TURP syndrome).
  34. 34. TURP syndrome (BRIEFLY) • Is a rare but potentially life-threatening complication of a TURP procedure. • It occurs as a consequence of the absorption into the prostatic venous sinuses of the fluids used to irrigate the bladder during the operation. Symptoms and signs are varied and unpredictable. • Fluid overload: The average rate of absorption is 20ml/min, and therefore length of surgery may have an effect on the total volume absorbed.
  35. 35. TURP syndrome (BRIEFLY) The clinician must have a high index of suspicion for diagnosing TURP syndrome in a patient who becomes unwell following a TURP procedure.
  36. 36. TURP syndrome diagnosis (BRIEFLY) • Acutely unwell, confused patient with a reduced Glasgow coma scale score. • Hyponatremia: Na < 120 mmol/L • Hyperkalemia: K > 6.0mml/L • Hyperglycemia. • Hypothermia. • Hyperammonemia. • Intra-vascular hemolysis, disseminated intravascular coagulation (reduced platelet count, increased fibrin degradation products)
  37. 37. Management of TURP syndrome The treatment of TURP syndrome is mainly supportive, and is most successful where diagnosis is made early and interventions are instituted before systemic complications occur. The patient should preferably be transferred to a high dependency unit and be attached to continuous monitoring.
  38. 38. Thank you