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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.
THANK YOU