BPH [Compatibility Mode]

7/21/2019 BPH [Compatibility Mode]

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Bladder outlet obstruction & Obstructive

uropathy

BPH

.



Introduction

• Noncancerous enlargement of the prostate gland• Is a proliferative process of cellular

elements(sromal& epithelial cell proliferation)

• Occurs primarily in transion zone of the prostate

• Increase with age

• Hormonally dependent(testosterone&DHT)

• Not all men with Bph have LUTS or not all men with

LUTS have Bph the same can be said for Boo



Anatomy

• Wal nut –sized gland

• Part of reproductive system

• Has 3 lobes & 4 zones

• The transion zone surrounds the urethra• Located in front of the rectum ,below the bladder

• Blood supply from inferior vesical.mid

hemorroidal,&internal pudenda

• Venous drain (to pelvic plexus & bastone veins)



Functions

• Produce alkaline fluid for liquefaction of thesemen ,comprises~ 70% of seminal volume,

provides nutrients for the sperm ,

•Conduit for semen to pass

• Prevent retrograde ejaculation by closing the

bladder neck during sexual climax



Definition & epidemiology

• Enlargement of the prostate glands due to an

increased number of epithelial & stromal cell

in periurethral area



Epidemiology

• In U.S.A 14 million have symptoms of BPH

• Worldwide about 30 million

• Common in male older than 50ys

• By age of 60 =60% & by age of 80=90%

• Sexual activity (increase fibro muscular stromal cell)

& increase the risk of BPH• Alcohol( decrease plasma testosterone & increase of

testosterone clearance& decrease the risk of BPH

• Smoking increase testosterone & estrogen level & ithas positive & inductive effect of on development of

BPH



Etiology

Unknown

Aging

Hormonal effects

Androgen is important for both normal & abnormal growthof the prostate

90% of prostatic androgen is in form of DHT( fromtesticular androgen & 10% from adrenal androgen)

Stromal – epithelial cells interaction produce growthfactors (epidermal GF, insulin like GF,fibroblast GF)

Increased estrogen increase the expression of AR in agingprostate & increase prostate size



Pathogenesis

(Gland Enlargement)

Occurs as results of increased Number ofepithelial & stromal cell ( increased cellproliferation)

Disruption of equilibrium between cell death

& cell proliferation(decreased in cell death)Androgen requiring during development,

puberty,& aging

Castrated men or no androgen results no BPH



Common symptoms

(symtomatology)

Prostatism =LUTS

Classified in to irritative

obstructive frequency

Weak urine stream urgency

Difficulty starting urination urge incontinency

Dribbling enuresis

Needing to urinate several times

Straining

Sensation poor bladder emptying



Symptomatology……

• Scoring system IPSS

AUA

• Used for assessment of symptom severity

• Assess the response to therapy

• Detect symptom progression ( in watchful waiting Rx)• Can not used to establish the DX of BPH(infections,tumor

,bladder disease will have a high ipss)

• According to IPSS – 0-9 mildly symptomatic

– 8-19 moderately symptomatic – 20-35 severely symptomatic



Effects of BPH

Initially bladder becomes hypertrophiedIncrease postvoidal residuals ,poor

contractility

LUTS & Boo

Urinary retention

Hematuria ,urinary infection

Stone formation ,trabeculation

Bladder irritability ,renal insufficiency



DDX of BOO

• BPH

• BNC

• Bladder stone

• Urethral stricture

• Prostatic cancer

• Neurogenic bladder



Diagnosis of BPH

• To pathologist is microscopic Dx(cellular proliferation

of stomal & epithelial elements)

• To radiologist makes the Dx in presence of bladder

neck elevation of cystogram phase of IVP or enlarged

prostate

• To urodynamist -elevated voiding pressure

-low urinary rate

• To practicing urologist is constellation of sign &

symptom



Diagnosis…..

• Hx – onset of the symptoms

– Age

– Hx of STD

• Determine which symptoms are predominant(

irritative or obstructive)

• Determine severity of the symptoms by IPSS)

• Hx of hematuria ,UTI,diabetis ,NS disease ,urinary

retention, surgery ofLUT



Diagnosis…..

•

P/E general assessment

(chest,cvs,anemia,external genitalia)

Abdominal examination

Bladder distention

Dullness

Tenderness



Diagnosis….

• DRE –prostate size,consistance,noduls

-pelvic floor tone flactuance &pain

- prostate size does not correlate with symptomsseverity & degree of urodynamic obstruction & Rx

outcome

• Prostate is large,smooth,convex,elastic,firm,mucosamoves over the prostate

• Ns examination (r/o cavaequina lesions)



Investigations

U/A –dipstick & /or via centrifuged sediment forblood,bact,prot,glucos …

-cytology for severe irritable symptom

-urine culture

PSA to R/o prostatic Ca which can coexist withBPH

• Large BPH may have slightly elevated PSA

• PSA value >4ng/ml or DRE induration or nodularityneeds transrectal us & multiple biopsy

• PSA & DRE increase the detection rate of prostate Caover DRE alone



Investigations….

Serum creatinine to R/o renal insufficiency

occurs in 13% of case

BPH with RI increase the risk of post.op. complication

with RI 25%

17% without RI Help to evaluate the pt.with occult & progressive renal

damage secondary to silent prostatism

Postvoidal residual urine

-obtained after voiding of urine with a catheter

transabdominal usNV= less than 5 ml (78%), less than 12ml(100%)



Investigations….

Pressure flow studies

-done to distinguish b/n low pressure flow rate secondaryto Boo & decompensated bladder

- Reliable if Boo not Dxed by flow rate, initial evaluation & PVR

uroflometry- electrical recording of the urine flow rate

-noninvasive urodynimic test

-quantifies strength of urine stream

-2 to 3 voids with voided volume 150 to 200ml in flow rate

clinic



Investigations ….

Imaging studies

IVP/US/KUB

-determine bladder & prostate size

-degree of hydronephrosis-not indicated for initial evaluation of LUTS

Indications

- UTI -hematuria -Hx of urolithiasis -Hx of urinary

tract surgery



Investigations…..

Upper tract imaging is indicatedConcomitant hematuria

Hx of urolithiasis

Elevated creatinine

Increased post voidal residual &Hx of UUTI

UrethroscopyIndications -hematuria -urethral stricture

-bladder Ca -prior LUT surgery

Advantage -prostate enlargement -bladder stone -trabeculation -diverticula's -voidal obstruction of

urethra or bladder neck



TREATMENT

Aim of Rx

Relieving LUTS

Decreasing Boo

Improving bladder emptying

Reversing renal insufficiency Preventing feature episodes of hematuria ,UTI

&urinary retention

the treatment includesMedical therapy

Minimally invasive

Operative therapy



Medical therapy

Alpha adrenergic blocker drugsTerazosin(longe acting)

Duxazosin(longe acting)

Tamsulosin(alpha 1a selective)

The tension of prostate smooth muscle is mediatedby alpha1 adrenorecepter

98%of alpha1AR located in prostate

By blocking this receptors

Decrease the resistance a longe bladder neck,

prostate,& urethra( relaxing of smooth muscle)Relieve dynamic component of the obstruction



Medical therapy

Advantage of alpha adrenergic blockersWell tolerated

Reduce out flow resistance

Are safe in the elderly & Boo

Treatment of choice with pt.HPT

Side effects

Asthenia

Headachedizziness



Medical therapy

Androgen suppression (5alpha-reductase inhibitor)drugs -finasteride* -flutamide

Is an enzyme responsible to the conversion of thetestosterone to DHT which promotes growth of prostatetissue

Finasteride is competitive inh. Of this enz Lower intraprostatic levels of DHTprostate size

(By inh of its growth ,apoptosis &involution )

Max reduction of prostate vol.by 6/1220% size reduction

1/3 of the pt has improvement of symptom score



Treatment…. Watchful waiting Rx

For mild symptoms

AUA symptom score<8 flow rate >10ml/s

good bladder emptying(RU<100ml)

-Needs base line evaluation (annually)

Advice for: Limit fluid intakes at evening

↓ alcohol & coffee containing products Maintain time voiding schedules



Minimally invasive Mx of BPH

Intraprostatic stents

• Tubular device left in the urethra (absorbableor nonabsorbable)

• An alternative for indwelling catheter forpts.unfit for surgery

• Success rate is from 50 to 90%

• The insertion is endoscopicaly(us guided)

• Temporally or permanent( after radical

prostatectomy with incontinence)



Minimally invasive Mx…

Transurethra microwave therapy

Deliver heat to the prostate via urethra catheter or

transrectal route

Damaging to sympatatic nerve ending & induction ofapoptosis → ↓ prostate size

Takes one hour as out pt with LA

Less complication(like impotence)

Does not cure BPH –reduce urinaryfrequency,urgency,sraing &intermittent flow



Minimally invasive…..

Lasers delivered heat

Causes destruction of the prostate tissue(coagulation necrosis or vaporization of prostatetissue)

Destroyed tissue then contract→ ↓prostate size

Increase flow rate=9to15ml/sec

Symptoms score improve by 50%

Decrease bleeding ,fluid absorption, length ofhospital stay

↓the incidence of retrograde ejaculaon&impotence compared with TURP



Minimally invasive….

Transurethral needle ablation of the prostate

Radiofrequencey energy through twin needle

to burn the enlarged prostate

Thermal injury to lateral lobe induce necrosisof hyper plastic prostate &improve symptom

score



Prostatectomies

Types TURP

RP

TVP

Success AUR & CUR=100%

sever symptoms & urodynamically proven BOO =90%

Mild symptoms =65

Unobstructed detrusor instability =do not respond well



Prostatectomies….

Pre-op preparation Two unit of blood

Counseling

Obtain consent

Inform the pt about benefit &risk – Retrograde ejaculation

– Erectile dysfunction

– Urinary incontinence – UTI ,BNC ,& urethral stricture



prostatectomies

TURP

Developed in 1920 & 30s in USA

Used endoscopy (fibroptic lighting together with theHopkins, rod lens wide angle system for visualization

High energy electrical current is used ,entire deviceattached to video camera

Gold standard ( 90% of prostatectomy)

Solution used for TURP →5%DW ,1.5 %glycine ,cystol



TURP……

Under regional or GA with lithotomy position

Through resectoscope the prostate is

removed

MAX flow rate improve 9 to 18 ml/sec & symptomscore by 70%

Indications -AUR -recurrent infection

-recurrent hematuria -renal insufficiency

-upper urinary tract dilatation

-gland size <40gm*



Open prostatectomy

Indications Large prostate >80gm with concomitant bladder

stone

Ankylosis of the hip &other orthopedic condition

Sever symptoms unresponsive to medical Rx

All other indications for TURP

Urethra stricture or previous hypospadias repair

Associated inguinal hernia



Open prostatectomy….

Generalpreparation of 1-2unit of blood

counseling (inform the risks)incontinence

Retrograde ejaculationImpotence

BNC,UTI,Urethral stricture

Needs of blood transfusion

untoward effects(DVT,pul.embolism)



Open Prostatectomy …. Anesthesia -spinal or epidural (standard)

- GA

the resection could be retro pubic or suprapubic approach

Retro pubic prostatectomy is the enucleation of hyperplasicprostatic adenoma through a direct incision of the anteriorprostatic capsule

Advantage compared with TVP

Anatomical exposure of the prostate

Direct visualization of the prostatic adenoma duringenucleation to ensure complete removal

Visualization of the prostatic fossa after removal to controlbleeding &minimal surgical trauma to uri,bladder



Open prostatectomy…..

TVP is enucleation of the hyperplasic adenomathrough an extra peritoneal incision of the loweranterior bladder wall

This operation ideally suited pt.with

Large median lobe protruding in to bladder Clinically significant bladder diverticulum

Large bladder calculi

In obese (difficult to access to the prostatic capsule&dorsal vein complex)

Disadvantage( visualization of the apical adenoma is↓ →post. Op. urinary connence)



Therapeutic optionsIn older men with obvious palpable enlargedprostate or PSA>1.4ng/ml the choice is

Life style change

Alpha blocker &5-alpha reductase inh.

TURP

In younger men with obstructive symptoms ,smallprostate & PSA<1.4ng/ml the choice is

Life style change

Alpha adrenergic blocker

TUIP



Open prostatectomy….

Contraindications

small fibrous gland

The presence of prostate cancer

Previous prostatectomy Pelvic surgery that obliterate access to the

prostate gland



Prostatectomy…..

Post-op Mx

Measure output input

Bladder irrigation

Effective pain mx

1st p.o.day fluid diet, ambulation ,deflate balloon(10ml↓)

& irrigate residual clot

2nd p.o.day regular diet

3rd p.o.day remove retro pubic

4th p.o.day discharge with catheter 5- 7 pod day remove catheter



Prostatectomy…..

Complications

Bleeding -urethral catheter traction with 50ml ofsaline to compress the bladder neck & prostatic fossa

-bladder irrigation to prevent clot formation

-the inflow through urethral catheter &out flowthrough the suprapubic tube

-if the bleeding persist cystoscopic inspection of theprostatic fossa &bladder neck

-if marked bleeding continue to persist →open re-

exploration



Complications……

Perforation of the bladder & prostatic capsule (INTURP)

Incontinency (if damaged external sphinctermechanism)

Retrograde ejaculetion(80-90%) & impotence (3-6%due to damage of the nerves associated witherection)

Bladder neck contracture

Urethral stricture

SepsisDeath(0.2 to 0.3%)



Complications….

TUR-syndrome

In 2% of all TURP

Due to absorption irrigating fluid through cut openveins

Characterized by (hyponatremia →↓Na+,HPT,nauesa& vomiting,bradicardia,visualdisturbance,mental confusion)

Risk factors (gland>45gm,↑resecon me >90mnt &

much fluid for irrigation RX diuretics &correct electrolytes



Urethral stricture

Arise from varies causes

Can occur secondary to inflammation or ischemicprocess leading scar ssue formaon→scar ssuecontract &↓the calibre of urethral lumen→resistance to ante grade flow of urine→common in

male (longer urethral)Anterior urethral stricture is secondary to scaring in

spongy erectile tissue of the corpus spongiosum(more common)

The post. Urethral stricture is due to a fibro tic

process



Etiology

Inflammatory →post. Gonorrheal

(common),Tbc,schstosomiasis

Traumatic →external injury to pelvis area

Instrumental →longe term use of urethralcatheter or cystoscopy

Post.op →open prostatectomy &amputaon

of penis

congenital



Clinical manifestation

Obstructive voiding symptoms

Decrease force of stream

Incomplete emptying of the bladder

Terminal dribbling

Urinary intermitency

Urinary retention



Diagnosis

HX (previous op, trauma,STD ,)

P/E (suprapubic & genital area)

Urethroscopy →to detect the degree of

narrowing of the urethraRetrograde urogram →site,degree,number

&length of stricture(failure to pass the

medium beyond the tightness



Treatment

Accurate diagnosis &assessment of location & lengthof the stricture is important for the Rx

Temporally or short term Rx(pt with acute pain orsever blocking of the urine flow)

• Suprapubic catheter

• Nephrostomy tube (inserted in pt. back to draindirectly from kidney

• Dilation –gradually open the urethra

-used different size buggies

-the goal is to strech the fibrotic tissue withoutproducing more scar



Treatment ….

Endoscopic internal urethrotomy

For short to medium stricture at the external end ofthe urethra

Under direct vision the stricture is cut open withknife, laser or electrocautory

Release of scared tissue

Leave small catheter for 3-5 days(opose woundcontraction & allow epithelazation)

Success rate→50% permanent cure of simple

stricture



Treatment …..

Complications

Bleeding

Infection

Recurrence of the stricture

Advantages

Is minimally invasive

More rapid recovery

Minimal scaring

Less risk of infection from surgery



Treatment …..

Open urethral reconstruction

Most common effective Rx

Used for longer stricture (length 1-2cm)

Extensive mobilization of the corpus sponiosum

Involves complete excision of the fibrotic (stenosed)segment with reanastomosis of the spatulated cutend(tension free & widely patent)

Some times need replacement of strictured urethra(free-fulthicknes or pediculated skin

graft)→myocuyaneous patch of perianal skin &dartus muscle ,bucal mucosa,penile skin



Treatment ….

Permanent catheter or implant stent

For the pt. who chooses no to undergo

surgery or who has sever stricture

Provide a patent lumenMost successful in short length stricture in the

bulbous urethra

If all else fails →urinary diversion (appendico-vesicostomy



Complications

Retention of urine

Urethral diverticulum →excision &repair

Periurethral abscess →drain, anbiocs &

suprapubic catheterUrethral fistula



Bladder calculus

Primary bladder calculus

are developed in sterile urine often originated in

the kidney

pass down to the urether then to bladder &enlarges

Secondary bladder calculi

occurs in presence of infections ,Boo , foreign

body



Bladder calculi

Composition

Are mixed with one component in excess

Are simple or multiple in number

Uric acid is most common in adults(50%)Ammonium acid urate ,calcium oxalate are

common in pediatric age

Most are mobile with bladder same are fixed

to bladder mucosa (when formed in suture, intumors or retained stents



Bladder calculi. ….

Risk factors

• Male (8x than female)

• ↑age

•Poor fluid intake

• Incomplete emptying of the bladder

• Recurrent urinary infection

• Foreign body (nonabsorbable suture ,metal

staples,stents & catheter fragments)



Clinical features

Male 8x than female

Asymptomatic

Frequency →the earliest symptom common during

day time

Sensation of incomplete bladder emptying

Pain ▬at the of micturation

▬referred to the tip of penis & labia majora

aggravated by movs. Screaming & puling the peniswith the hand at the end of urination



Clinical feature….

Hematuria▬bright red blood at the end of

micturation

Interruption of urinary stream

Pyuria(rare)

Symptoms of urinary infection

P/E

Suprapubic area

Rectal or vaginal exam. (large calculi is palpable infemale



Investigations

♣ U/A (for blood, pus, crystals typical of calculi)

♣ CBC

♣ plain abdominal x-ray –radiopaque calculus seen

♣US

♣ IVU---filling defect in case of radiolucent calculus

♣ Cystoscopy – to examine the inside of the bladder



Treatment

♠ Medical Rx

Alkalization of urine for dilution of the uric acid stone

Analgesic

Antibiotics

♠ Surgical Rx --Indications Failed medical Rx

Recurrent infection

Suprapubic pain & AUR

Gross hematuria



Treatment ….

▲Cystolitholapxy ▬through cystoscope

lithotrite the calculus is broken. fragments are

crushed in to small pieces then removed

▲Suprapubic lithotomy ▬the calculusevacuated through suprapubic incision

▲Suprapubic cystolitholapxy

▲ECSWL



Bladder neck contracture

Causes Boo

Muscular hypertrophy

Stenosis of the tissue at the neck following

TURP or dense fibrotic stenosis as result ofover use of diathermy (coagulating diathermy)



Treatment

Alpha adrenergic blocker drugs cause

relaxation bladder neck →→improve urinary

flow

Transurethral incision of the fibrotic tissue ofbladder neck is an operative option



References

Campbell's Urology 8th edition

Schwartz's Principles of surgery 8th edit

Sabiston Text book of surgery

Internet



Neurogenic bladder

The lower urinary tract mechanism regulated bybiomechanics of bladder & urethral muscle &controlled by NS

Causes of neurologic bladder dysfunction

Trauma to spinal cord →→disrupts normalsupraspinal circuit that control the urine storage &release

Stroke

Herniated intervertebral disc

Degenerative neurological disease (multiplesclerosis) ,diabetes ,syphilis ,acute infection



Symptoms

Similar as other causes of LUTS

Diagnosis

Hx →which feature suggesve of an

underlying neurological disease Symptoms & signs

P/E –rectal examinaon (↓perianal sensaon,poor anal sphincter tone & absence of bulb

cavernous reflex ) Lower abdominal exam..



investigations

U/A CBC RFT

U/S IVP

Urodynamic studies(urine flow rate,cystometry&postvoidal residual)

Complications Urinary leakage & urinary retention

Damage to tiny blood vessels of kidney

Infections of the bladder & urethra

Formation of kidney stone



Management

Goals

Prevention of upper tract damage

Urinary continence

Effective bladder emptying

Essential to ensure low pressure urine storage

,low pressure voiding &adequate bladder

drainage with elimination of UTI &stone

formation



Management ….

Conservative Rx

Catheterization (urethral or suprapubic)

Avoid longe term urethral catheterization to preventurethral injury

Suprapubic catheter can avoid urethral erosion,inflammation & dilation

Prophylactic antibiotic to reduce the incidence ofinfection

Artificial sphincter around the neck of the bladder toprevent urinary incontinence



Medical management

Aim

↑ing intravesical pressure or ↓ in oulow resistant→↑bladder emptying

Parasympatomimic drugs (bethanechol) stimulate

muscarinic cholinergic ▬↑intravesical pressure Facilitating urine storage by reducing bladder

contraclity or ↑ing oulow resistance

Anticholinergic drugs (propantheline) is effective insuppressing detrusor contractility



Surgical Mx

For impeding or existing danger to UUT orintractable urinary incontinence (reducedbladder compliance ,a high leak point pressure& detrusor dyssynergia )

Bladder augmentation →ileocystoplastycommonly used , the bladder is bivalved incoronal or sagital plane

Bladder substuon →in pt.with contracted

high pressure bladder



Surgical Mx…..

Urinary diversion can be either incontinent (urinepass through an open conduit in to external

collecting system) or continent (urine is drained from

bowel reservoir via a catheterizable stoma ) classical

incontinent urinary diversion is the ileal conduit Indian pouch == used cecum ,ascending colon & the

proximal third of transverse colon to construct the

pouch & terminal ileum brought out as a continent

stoma

Documents

BPH [Compatibility Mode]