ANATOMY

BENIGN PROSTATIC HYPERPLASIA

INCIDENCE

Most prevalent Benign Tumor > 50 yr old 50% at 50 yr have histological evidence >90 % after 80 yrs

ETIOLOGY

ENDOCRINE Low Testosterone High Estrogens Sensitization of Androgen Receptors

PATHOPHYSIOLOGY

HYPERPLASIA Epithelium Stroma (Smooth muscle)

Urethra Mechanical (Prostate Enlargement) Dynamic (Smooth Muscle in Stroma) Irritable (Bladder Response to outlet reistance )

Consequences of BPH ■ No symptoms, no BOO ■ No symptoms, but urodynamic evidence of BOO ■ LUTS, no evidence of BOO ■ LUTS and BOO ■ Others (acute/chronic retention, haematuria, urinary infection and stone formation)

SYMPTOMS (LUTS)OBSTRUCTIVE SYMPTOMS IRRITATIVE SYMPTOMS

Hesitancy decreased force and caliber of

stream Sensation of incomplete bladder

emptying double voiding (urinating a

second time within 2 hours of the previous void)

straining to urinate Dribbling (post-void ) Episodes of near retention Intermittant stream

urgency, frequency Nocturia Urge incontinence enuresis

MILD 0-7 MODERATE 8-19 SEVERE 20-35

SYMPTOMS (BOO)

Ac. Retention Ch. Retention Hematuria Impaired bladder emptying

SIGNS

Digital Rectal Examination (DRE) DRE typically takes less than a minute to perform. In

this procedure, the physician inserts a lubricated, gloved finger into the patient's rectum to feel the surface of the prostate gland through the rectal wall to assess the size, shape, and consistency of the gland. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose.

INVESTIGATION

CUE PSA USG IVU CYSTOSCOPY

URODYNAMIC STUDIES < 10 ml s–1 > 80 cmH2O

DIFFERENTIAL DIAGNOSIS

UTI Ca Prostate Urethral stricture Bladder neck contracture Vesical stone

TREATMENT

WATCHFUL WAITING MEDICAL SURGICAL

Medical Alpha Blockers 5α-Reductase Inhibitors(finasteride) Combination Therapy Phytotherapy

Alpha Blockers

Non Selective-Prazocin Selective(alpha 1a)-Tamsolin

5α-reductase Inhibitors

Finasteride Epithelial component Minimum-6 months(20% reduction in size) Large prostate(40cm3)

Combination Therapy

Risk of progression Large gland High PSA

Phytotherapy

saw palmetto berry (Serenoa repens) the bark of Pygeum africanum, the roots of Echinacea purpurea and Hypoxis rooperi, pollen extract, leaves of the trembling poplar

Surgical Management

INDICATIONS refractory urinary retention (failing at least one attempt

at catheter removal), recurrent urinary tract infection recurrent gross hematuria bladder stones Ch. Retention & renal insufficiency large bladder diverticula Severe Symptoms

Surgical

CONVENTIONAL TURP TUIP Open Prostatectomy

TURP Complication

Retrograde ejaculation Impotence Incontinence TUR syndrome Bleeding Stricture\stenosis

Transurethral Incision Of Prostate

Indication Moderate-Severe Symptoms Small Prostate with post Commisure

Hyperplasia(elevated bladder neck) Procedure

5 & 7 O clock

Open Prostatectomy

Indication Glands >100 g concomitant bladder diverticulum Bladder stone dorsal lithotomy positioning is not possible.

Approaches Suprapubic Retropubic (Millon) Perineal(young)

SurgicalMINIMALLY INVASIVE Laser

TULIP Visual contact ablative laser therapy Interstitial laser therapy

Transurethral electrovaporization of the prostate Hyperthermia Transurethral needle ablation of the prostate High-intensity focused ultrasound Intraurethral stents