Dr Soumar DuttaGuwahati Refinery Hospital

The prostate is an accessory gland of the male reproductive system. The secretions of this gland add bulk to the seminal fluid.

Shape: Inverted coneApex, base & 4 surfacesSize: 4cm X 3cm X 2cmWeight: 8 GmConsistency: FirmLobes: 5 Histological 3 zones

outer /peripheralmiddle/transitionalinner/central

(I) Hormonal Theory (II) Neoplastic Theory

Pathogenesis:

Hyperplasia of both glandular epithelium and connective tissue stroma forming one or more nodules. May involve any part of the gland with the exception of ant. and post. lobes.May compress the rest of the gland forming a false/surgical capsule.

Changes in the urethra:

enlargement of the prostatic urethraexaggeration of the normal posterior curvature of the prostatic

urethraurethra compressed laterally reducing it to an A-P slit

Changes in the urinary Bladder:

Compensatory hypertrophy of the vesical detrussor Trabeculation of bladder wall.Hypertrophy of the trigone.Formation of diverticulaFormation of pool of residual urine- cystitis,calculus[triple PO4]

Changes in ureters and kidney:

Hydroureter and HydronephrosisVesicoureteric reflux- Ac. & Chr. Pyelonephritis

CLINICAL FEATURES

BEP seldom causes symptoms before 50 yrs of age No direct relation between the degree of enlargement and

severity of symptoms. Earlier prostatism term now replaced by “LUTS”.

OBSTRUCTIVE IRRITATIVE .Hesitancy .Frequency

.Poor flow .Nocturia

.Intermittent stream .Urgency

.Dribbling .Urge Incontinence

.Sense of incomplete evacuation .Nocturnal enuresis

.Episodes of near retention

Assessment Of A Patient With Prostatism/LUTS

General examination: to exclude renal insufficiency-raised BP, anemia

Local examination: palpable mass: distended bladder; hydronephrotic kidney.

External urethral meatus. DRE (Digital Rectal Examination)

surface

consistency

overlying mucosa.

midline sulcus Examination of nervous system.

Serum PSA: non specific Flow rate measurement: lowered in BEP

Volm 150-200 ml

Qmax >15 ml/s NORMAL

10-15 EQUIVOCAL

< 10 LOW

Voiding pressure: increased in BEP.

> 80 cm H2O HIGH

60-80 EQUIVOCAL

<60 NORMAL

USG (KUB) more sensitive TRUS

size, ecotecture, Post-void residue, Hydronephrosis,Hydroureter

Grading: Gr. I > 25 cm3

Gr. II >50 cm3

Gr. III > 75 cm3

Cystoscopy:

Indications:HaematuriaUrethral stricture or H/O urethritis.Prior TURP / Open Prostatectomy

IVP: Determines f(x) of kidneysHydronephrosis / HydroureterDiverticula of Bladder

Management of a patient with BPH/BOOPt may present with features of :

•Acute retention•Chronic retention with features of incontinence,hydronephrosis,hydroureter.•Haemorhage•Renal impairement•Complications of BOO: stone,infection,diverticula formation.•Severe symptoms of LUTS

Conservative medical treatment:strategies:

Smooth muscle relaxationAndrogen SupressionEstrogen Supression

Alpha- blockers: Relaxes smooth muscles -> decrease

urethral resistance.Non selective: phenoxybenzamine

Selective alpha 1 : Prazosine, Terazocin, Doxazocin.

Selective alpha 1a: Tamsulosin and Alfuzosin

Androgen suppression: Involution of Epithelial Component, decreasing Volm.

Anti-androgens: Flutamide5 Alpha Reductase Inhibitors: Finestride; Dutasteride

Estrogen suppression: Atamastane

Surgery:

Procedure: ProstatectomyApproach: Transurethral- TURP

Retropubic Transvesical Perineal

Complications:HaemorrhagePerforation of UB and prostatic capsule.IncontinenceUrethral stricturesRetrograde ejaculation and impotencyBladder neck ContracturesUrethral stricturesReoperationTUR Syndrome: water intoxication --> dilution

hyponatraemia.

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