BPH and obstructive uropathy

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.

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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)

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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)

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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

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.

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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.

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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

• 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.

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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

• 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.

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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.

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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.

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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.

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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.

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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.

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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