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OBSTRUCTIVE UROPATHY &OBSTRUCTIVE UROPATHY &Benign prostatic hyperplasia Benign prostatic hyperplasia (BPH)(BPH)
Urology DepartmentUrology Department
Under-graduate coursesUnder-graduate courses
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
DEFINITION• Obstructive uropathy is structural or functional
hindrance of normal urine flow, sometimes leading to renal dysfunction (obstructive nephropathy).
TYPES• acute or chronic.• partial or complete.• unilateral or bilateral.
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OBSTRUCTIVE UROPATHY
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• In children: the most common causes are urethral valves or stricture and stenosis at the ureterovesical or ureteropelvic junction.
• In young adults: the most common cause is a calculus.
• In older adults: the most common causes are BPH or prostate cancer, retroperitoneal or pelvic tumors, and calculi.
© ©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
ETIOLOGY
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Dilation of the collecting ducts and distal tubules and chronic tubular atrophy with little glomerular damage.
• Obstructive uropathy without dilatation can also occur when:
1. fibrosis or a retroperitoneal tumor encases the collecting systems.
2. Mild obstructive uropathy.
3. an intrarenal pelvis.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
PATHOPHYSIOLOGY
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Obstructive nephropathy is renal dysfunction (renal insufficiency, renal failure, or tubulointerstitial damage) resulting from urinary tract obstruction.
• Mechanism
1. increased intratubular pressure
2. local ischemia,
3. UTI.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
OBSTRUCTIVE NEPHROPATHY
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Pain is common, usually along T11 to T12.• Absolute anuria occurs with complete obstruction at the
level of the bladder or urethra or bilateral obstruction.• Infection complicating obstruction may cause: dysuria,
pyuria, urgency and frequency, pyelonephritis, and occasionally septicemia.
• palpable flank mass, particularly in massive hydronephrosis of infancy and childhood.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
SYMPTOMS & SIGNS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Urinalysis and serum electrolytes, BUN, and creatinine.
• Imaging: for suspected ureteral or more proximal obstruction:
Abdominal ultrasonography is the initial imaging test of choice in most patients without urethral abnormalities.
Voiding cystourethrography and cystourethroscopy for suspected urethral obstruction.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
DIAGNOSIS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
IVU (contrast urography= intravenous pyelography [IVP]= excretory urography)
Pelvi-abdominal CT is sensitive for diagnosing obstructive nephropathy and is used when obstruction cannot be shown by ultrasonography or by intravenous urography.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
DIAGNOSIS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
Antegrade or retrograde pyelography is preferred to studies that involve vascular administration of contrast agents in the azotemic patient.
Radionuclide scans.
MRU (Magnetic resonance of urine).
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
DIAGNOSIS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Treatment consists of eliminating the obstruction
• Temporarily by: JJ stent or nephrostomy tubes.
• Permanently by:
Surgery
Instrumentation (eg, endoscopy, lithotripsy)
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
TREATMENT
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
Benign prostatic hyperplasia Benign prostatic hyperplasia (BPH)(BPH)
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
ZONAL ANATOMY OF THE PROSTATE:
The prostate is a compound tubuloalveolar gland composed of stroma and parenchyma.
Composed of zones: The transition zone surrounds the
urethra proximal to ejaculatory ducts. The central zone. The peripheral zone. The anterior fibromuscular stroma.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
DEFINITION BPH is a slowly progressive nodular
hyperplasia of the periurethral
(transition) zone of the prostate.
EPIDEMIOLOGY •BPH is the most common neoplasm in man.•The aetiology of BPH is multifactorial: the presence of testes and aging is most important.•Pathology is found in 50% of men in their 5th decade and in 90% of men in their ninth decade.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
BPH
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Stages: BPH is a progressive disease.
1. Mild infravesical obstruction leads to minimal S/S.
2. Increase of infravesical obstruction with bladder compensation by detrusor hypertrophy leads to LUT obstructive symptoms.
3. Severe infravesical obstruction with bladder instability and decrease compliance leads to Irritative S/S.
• The obstructive component can be subdivided into:
A- Mechanical: due to transition zone enlargement.
B- Dynamic: due to adrenergic stimulation of stromal smooth muscle.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
PATHOPHYSIOLOGY
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• The symptoms are: obstructive (and/or) irritative S/S
1.Obstructive S/S: due to prostatic enlargement Hesitancy = delayed initiation of the act. Weak stream of urine = decrease in the force & caliber
of the urinary stream Abdominal straining Intermittency.
Sense of incomplete evacuation. Terminal micturation dribbling. Post voiding dribbling.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
SYMPTOMS AND SIGNS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
2. Irritative S/S: due to the secondary response of the bladder to the outlet resistance.
dysuria, increased frequency, nocturia, Urgency and urge incontinence.
3- Retention: a- Acute retention means sudden inability to micturate +/- agonizing supra pubic pain.
b- Chronic retention refers to increase in the post voiding volume which may present with retention with over flow, nocturnal enuresis or stress incontinence.
4- Haematuria. 5- Uraemic symptoms.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
SYMPTOMS AND SIGNS
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• General examination e.g, Earthy look of uremia.
• Abdominal examination:
Inspection: a- Suprapubic bulge.
b- Scars of previous operations.
Palpation: a- Loin tenderness.
b- Suprapubic tenderness.
Percussion: Suprapubic dullness.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
PHYSICAL EXAMINATION
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• DRE: evaluates size, consistency of the prostate, anal tone and rectal mucosa.
• Genital examination
• Neurological examination
• Observation of the patient
act of micturation.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
PHYSICAL EXAMINATION
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Urine analysis and C/S.
• Serum Creatinine.
• Pelvi-abdominal U/S with post voiding assessment.
• PSA (Prostatic specific antigen) It is an organ specific (arises only from prostatic acini) but not disease specific (increases with other prostatic diseases).
• Uroflowmetry.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
Recommended investigations
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Further imaging of UUT. (IVP) if associated hematuria, stone diseases, or previous urologic operation.
• Urethrocystogram. If previous urethral instrumentations or surgeries.
• Urodynamic and Pressure/flow study. Indicated only in complicated cases as cases with previous neurologic disease or operation.
• Urethro cystoscopy.
• TRUS & biopsy If elevated PSA
or Suspicious DRE.
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
Optional investigations
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• Watchful waiting: In patients with mild symptoms.
• Medical treatment:
1. Phytoherapy (Plant extract): mechanism of action is unknown.
2. Alpha reductase inhibitor: affects the epithelial component of the prostate, resulting in reduction in the size of the gland and improvement in symptoms.
3. Alpha-adrenoceptor blacker: affect subtype alpha-1 adrenoreceptors. (dynamic component of obstruction).
4. Combination.
• Surgical treatment: Minimally invasive or open.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
TREATMENT
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
A- Absolute indications:
• Upper urinary tract affection.
• Uremia.
• Recurrent attacks of acute retention.
• Severe obstructive symptoms (high IPSS score).
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By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
Indications of surgical intervention
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
B- Relative indications:
• Moderate symptoms (moderate IPSS score).
• Recurrent UTI.
• Hematuria.
• Stone bladder.
• Transurethral resection of the prostate.
• Transurethral incision of the prostate
• Laser therapy
• Ballon dilatation.
• Transurethral microwave treatment.
• Intraprostatic stents.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
Minimally-invasive surgery
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
• either:
Transvesical or
Retropubic.
©
By Mohammed Ibrahim, MBBcH
Revised by M.A.Wadood , MD, MRCS
Open Surgery (Prostatectomy)
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
Thank YouThank You
By Moh.Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS
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