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Benign prostatic hypertrophy

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Benign prostatic hypertrophy

  1. 1. Benign Prostatic Hypertrophy Medrockets.com
  2. 2. prostate gland is a pyramidal shaped fibromuscular and glandular organ which surrounds the prostatic urethra. develops in the 12th week of embryonic life under androgens from the fetal testis. contains a number of individual glands composed of 30-50 lobules leading to 15-30 secretory ducts that open into the urethra lateral to the colliculus seminalis. Anatomy Medrockets.com
  3. 3.  from the bladder neck to the urogenital diaphragm.measures about 3.5 X 2.5cm, averages 20G. The prostate is found in the male while its homologous in the female, formerly known as the paraurethral gland of skene now named female prostate. Medrockets.com
  4. 4. • divided into zones • Peripheral • Transitional • Central • Pre prostactic tissue • Non glandular fibro muscular portion Medrockets.com
  5. 5. The Central Zone • Surrounds the ejaculatory duct. • it is in contact with the urethra at the upper end of the colliculus seminalis. • resp for 25% of glandular tissue of prostate • site of 10% of Ca P • ≠ bph
  6. 6.  Anterior lobe (or isthmus) roughly corresponds to part of transitional zone  Posterior lobe roughly corresponds to peripheral zone  Lateral lobes spans all zones  Median lobe (or middle lobe) roughly corresponds to part of central zone Medrockets.com
  7. 7. The prostatic capsule These are normally two, pathologically three, in number. 1. The true capsule 2. Fibrous Sheath – condensed extraperitoneal fascia. Between layers 1 and 2 lies the prostatic venous plexus. 3. the pathological capsule- occurs in BPH in which the normal peripheral part of the gland becomes compressed into a capsule . Medrockets.com
  8. 8. The prostate gland comprises secretory epithelium which consists of a. Epithelial b. Basal c. Neuroendocrine cells d. Connective tissue e. Smooth muscles Only the epithelia1 cells secrete PSA and so cancer of the neuroendocrine cells, connective tissue, smooth muscle, transitional epithelium and anaplastic cells can be present with a normal PSA Medrockets.com
  9. 9. smooth muscle is regulated by the autonomic nervous system primarily; the alpha-1A adrenergic receptors constitute 70%. Medrockets.com
  10. 10. The arterial blood supply of the prostate gland arises from the middle rectal and inferior vessical artery. The venous drainage is into the prostati plexus. The plexus also receives the dorsal vein of the penis and drains into the internal iliac veins. There are connections with no valves between the prostatic plexus and vertebral veins. Hence retrogression to the vertebrae. Blood supply Medrockets.com
  11. 11. Lymphatic drainage The prostatic lymphatics drain into lymph nodes lying alongside the internal iliac vessels. They also have a connection with the sacral spinal lymphatics. Medrockets.com
  12. 12. The prostatic fluid helps maintain the vitality of the sperms, and contains calcium, sodium, potassium, magnesium, chloride, bicarbonate, zinc, spermine, citrate, lipid cholesterol and 4 major proteins ◦ the prostatic specific antigen {PSA), ◦ prostatic acid phosphatase (PAP), ◦ the prostatic specific membrane antigen (PSMA) and ◦ prostatic specific protein - 94(PSP-94). functions Medrockets.com
  13. 13. Benign prostate hyperplasia is not always progressive, patient must be thoroughly investigated to rule out malignancy and institute proper treatment. Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is an enlargement of the prostate characterized by proliferation of the cellular elements of the prostate. Benign Prostatic Hypertrophy Medrockets.com
  14. 14.  Age ◦ below 40 years - 8 %, ◦ 57-60 years - 50% and ◦ 80 years -90%. Prevalence of symptoms of BPH by International prostatic Symptoms Score (IPSS) in men aged  40 years is 14%,  50-year olds is 25%,  60-year olds 43% and 50% in 75-year olds. epidemiology Medrockets.com
  15. 15. Aetiology Age  Positive familial and genetic factors DHT  increase in 5-alpha reductase activity oestrogen imbalance Increased epithelial cell hyperplasia  decreased cell death of epithelial and stromal cells,  increased activity of growth factors (GF) - FGF,TGF,EGF,KGF, IGF, endoGF - epithelial mitogens and non androgenic testicular substances Race , enviroment. Medrockets.com
  16. 16. a fibromyoadenoma the nodules first develop in the peri-urethral transition zone (TZ) of the prostate  All BPH nodules develop either in the TZ or in the peri-urethral region As the disease progresses, the capsule of the prostate transmits the pressure of tissue expansion to the urethra.which produces the symptoms. pathology Medrockets.com
  17. 17. Histological studies show increase in cell numbers (Hyperplasia) but not hypertrophy. Gross appearance of hyperplastic tissue may show lateral and/or middle lobe enlargement and/or posterior commissural hyperplasia The hyperplastic nodules compress the normal periphery of the gland which forms the false capsule. Medrockets.com
  18. 18. initially response to obstruction straining, intermittency, poor stream and incomplete bladder emptying. There is compensatory hypertrophy of dextrusor smooth muscles due to increased detrusor collage. Hence trabeculation with widening of gaps between them to form saccules.  With continued changes, the saccules develop into diverticula. Medrockets.com
  19. 19. This leads to detrusor instability or decreased compliance or neural detrusor response which manifests clinically by the symptom complex of frequency, urgency and nocturia. Decreased detrusor contractility (atonic bladder) leads to poor urine stream, intermittency, incomplete bladder emptying or increased residual urine, and hesitancy Acute urinary retention may supervene. Medrockets.com
  20. 20. The nature of bph  In patients observed with mild to moderate symptoms prospectively up to 7 years, 55% became worse, 30% remained stable and 15% improved. Overall, there’s very slow progression in most cases of BPH Medrockets.com
  21. 21. Symptoms Initial recognition ◦ The early presentation of BPH is insidious and may not be noticed by patient  Irritative symptoms ◦ Frequency ◦ Urgency ◦ Nocturia ◦ Urge incontinence. Obstructive symptoms ◦ Weak (poor) stream ◦ Feeling of incomplete bladder emptying ◦ Straining on micturition ◦ Intermittency. Clinical features Medrockets.com
  22. 22. Others are: ◦ Difficulty of micturition associated with ◦ Hesitancy ◦ Prolong micturition ◦ Urinary retention: This may be acute/acute on chronic or chronic. ◦ Haematuria- Microscopic/macroscopic ◦ Recurrent UTI such as cystitis, epididymo-orchitis, pyelonephritis, bacteraemia, septicaemia etc ◦ Renal failure - This could be acute or chronic associated with thirst, lethargy, headaches, uraemia Medrockets.com
  23. 23. General physical examination: may demonstrate signs of chronic renal impairment (anaemia, dehydration, headaches, lethargy) Abdominal examination: normal except for retention (distended bladder). Rectal examination: in BPH, posterior surface is usually smooth, convex with a firm consistency. Rectal mucosa moves freely over it. Neurological examination: to eliminate neurological lesions. examination Medrockets.com
  24. 24. INTERNATIONAL PROSTATE SYMPTOM SCORE (IPSS) This is a structured symptoms questionnaire which was developed by the American Urological Association and was adopted by the WHO in 1994. It is used for assessment of obstructive and irritative symptoms. 4 obstructive symptoms of BPH (when there is no retention) ◦ Incomplete bladder emptying. ◦ Intermittency. ◦ Weak stream. ◦ Straining. Medrockets.com
  25. 25. Assessment Of 3 Irritative Symptom ◦ Frequency ◦ Urgency. ◦ Nocturia. Each symptom is scored from 0-5 and the maximum score is 35. The interpretation of IPSS score values are ◦ Mild O-8. ◦ Moderate 9-19. ◦ Severe 20-35. The Quality of Life due to BPH Urinary Symptoms is scored from 0-6 Medrockets.com
  26. 26. SCORING 0 – not at all in the past one month 1 – less than once in the past one month 2 – less than half the time in the past one month 3 – about half the time in the past one month 4 – more than half of the time in the past one month 5 – almost always in the past one month Medrockets.com
  27. 27. Differential Diagnosis Of Symptoms  Causes Of Irritative Symptoms  UTI  Bladder Stones  Interstitial Cystitis  Cancer of the Bladder  Cancer of the Prostate  Chronic Cystitis  Bilharziasis  Neurological Disorders  CVA  Brain Tumour  Internal Hydrocephalus  Parkinsonism  Multiple Sclerosis  Syringomyelia  DM Medrockets.com
  28. 28. 2. Obstructive Symptoms ◦ Urethral stricture. ◦ Carcinoma of prostate. ◦ Bladder cancer. ◦ Bladder calculi. ◦ Phimosis ◦ paraphimosis ◦ Neurogenic bladder. Others are : ◦ ageing, psychiatric disorders such as depression, diuretics, chronic renal failure, polydipsia and excessive consumption of beverages such as tea and coffee. Medrockets.com
  29. 29.  diverticulitis  infection  calculi- mostly struvite due to urease producing orgs (proteus, pseudomonas, pyocyanea, klebsiella) also Ca Oxalate calculi  hematurai  chronic retention  post obstructive diuresis  post obstructive hemorrhage  recurrent infection Renal failure Complications of bph Medrockets.com
  30. 30. INVESTIGATIONS 1. Urinalysis: check for blood, glucose, protein. Mid steam urine for bacteriology. 2. Urine culture for infection. 3. Full Blood Count. 4. BUE, serum creatinine, urea and electrolytes 5. Serum Prostatic Specific Antigen (PSA) 6. Abdominal ultrasonography, plain abdominal X- ray, IVU, 7. Urethrocystoscopy. 8. Urine Flowrate, Post-void Residual Urine, Pressure Flow Urodynamics. Medrockets.com
  31. 31. – Transrectal Ultrasound of The Prostate (TRUS) And TRUS-Guided Prostatic Biopsy – Colour Doppler Imaging Of The Prostate – Retrograde Urethro-Cystography – Chest X-ray Medrockets.com
  32. 32. MANAGEMENT OF BPH Watchful Waiting Medical Therapy Minimally Invasive Treatment Surgery- Surgery for BPH is most commonly performed endoscopically; however, if the prostate gland is greater than 60g, an open prostatectomy is performed. ◦ Transurethral incision of prostate ◦ Transurethral resection of prostate ◦ Transvesical prostatectomy ◦ Retropubic prostatectomy( millin’s) Medrockets.com
  33. 33. Watchful waiting This option is usually offered to patients with IPSS of 8 or less who are not much bothered by the symptoms due to BPH. This involves regular assessment of IPSS, PFR, PSA and PVR, abdominal ultrasonography and DRE Watchful waiting can be replaced by medical therapy or surgical treatment if the condition changes. Medrockets.com
  34. 34. Medical Therapy For BPH The ideal candidates are those with IPSS scores under 19 with bothersome symptoms but with no complications such as haematuria, stones, retention or uraemia. They are carefully followed up for continuation or change in therapy. 1. Alpha Adrenergic Blockers. long-acting alpha-l- adrenergic blockers Terrazosin and doxazosin and the selective alpha 1A tramulzosin. ◦ Side-effects are minor and reversible and include a flu-like syndrome and dizziness.. ◦ The drugs are expensive but they are effective for medical therapy of BPH.
  35. 35. Androgen Suppression: The rationale is to reduce the level of dihydrotestosterone and thereby shrink the prostate volume so as to relieve the obstruction. 5-Alpha reductase inhibitors ◦ finesteride (proscar) and episteride ◦ The side-effects include loss of libido and erectile dysfunction. Zanoterone ◦ This is a steroid competitive androgen receptor antagonist. ◦ Its side-effects include breast pain and gynaecomastia.  Flutamide – It is an androgen receptor antagonist.  Aromatase Inhibitor (Atamestame) Medrockets.com
  36. 36. The list include: i) Hypoxis roopers (South African grass). ii) Urtica spp (stinging nettle). iii) Sabal serrulatum (dwarf palm). iv) Serenoa repens B (American dwarf palm). v) Cucurbitapepo (pumpkin seed). vi) Pygeum africannum (African plum) phytotherapy Medrockets.com
  37. 37. Indications for minimally invasive surgery include ◦ patients with moderate symptoms scores (IPSS 8 -19). ◦ and patients with severe symptoms but handicapped or unfit for surgery. Available Minimally Invasive Techniques are ◦ High intensity focused ultrasound (HIFU). ◦ Transurethral vaporization of prostate. ◦ Transurethral laser therapy (TULIP). ◦ Hyperthermia and thermotherapy. ◦ Intra-urethral stents. ◦ Transurethral needle ablation of prostate (TUNA). ◦ Transurethral balloon dilatation. Medrockets.com
  38. 38. Indications For Prostatectomy  Acute refractory urinary retention.  Chronic urinary retention  Recurrent episodes or severe haematuria  Bladder stones secondary to BPH  Recurrent UTI  Large bladder diverticula  Hydroureter and hydronephrosis  Uraemia (azotaemia) due to BPH. Others include – Symptoms of bladder outlet obstruction due to BPH which are moderate to severe, bothersome and interfere with the patient’s quality of life (usually IPSS score from 19 to 35) but which are not relieved by medical therapy or minimally invasive surgery
  39. 39. Frail elderly patients. Patients with severe CO-morbidity such as myocardial infarct, heart disease, liver failure, pulmonary disease, carcinomatosis etc A severe bleeding tendency and patients on anticoagulant. Medrockets.com
  40. 40. TURP The standard endoscopic procedure for BPH is a transurethral resection (TUR) of the prostate. TUR is performed with a nonhemolytic fluid such as 1.5% glycine. it is the Gold standard for reducing symptom scores. Medrockets.com
  41. 41. Complications of TURP Primary haemorrhage (5-15%) Secondary haemorrhage Urinary incontinence Urethral stricture Sexual Dysfunction  TUR syndrome Medrockets.com
  42. 42. Haemorrhage Clot retention Urinary tract infection Epididymo-orchitis Persistent vesico-cutaneous fistula Wound infection Incontinence of urine Complications of Open Prostatectomy Medrockets.com
  43. 43. Impotence (erectile dysfunction) Retrograde ejaculaton Infertility Urethral strictures Bladder neck stenosis Damage to the ureters Osteitis pubis Deep vein thrombosis Medrockets.com
  44. 44. Management of Acute Retention  The procedure should first be explained to the patient.  The suprapubic, scrotal and perineal areas are shaved and washed if necessary  diazepam 10mg given for sedation  A sterile trolley is set up containing an antiseptic (cetrimide, povidone iodine or chlorhexidine), sterile towels, swabs, penile clamp, syringe, catheters and a specimen bottle for urine.  A nurse should be on hand  positioning the patient comfortably  About 5-10m1 of lidocaine 1 %jelly is instilled into the urethra & massaged into it, retained by applying pressure with the thumb and finger  The urethra is anaesthetized in 4-5 minutes  A suitable catheter is selected - Jacques, Foley's, Nelaton Tiemann's or Gibbon's Medrockets.com
  45. 45.  A wide-bore 3-way or 2-way Foley's catheter is used if bleeding or irrigation is anticipated and a Nelaton catheter if not for indwelling. Otherwise a narrow (12F) plastic Jacques catheter is selected. An indwelling catheter should not fit tightly so that the secretions of the paraurethral glands can drain alongside it. The penis is held straight and the catheter inserted into the external meatus and gently advanced into the urethra. Urine is collected in a sterile bottle for culture and sensitivity, sugar and protein tests. The urine is then drained and the catheter removed Medrockets.com
  46. 46. Thank you Medrockets.com