Benign enlargement of prostate

Find the powerpoint (PPt.) on Benign hyperplasia of Prostate with proper explanation and references were taken from the well known Books (Bailey and Love textbook of Surgery and others).

1. Benign enlargement of prostate ( Fibromyoadenoma) Sunil Kumar Daha

2. Surgical Anatomy: general intro., positon, relation

3. Structural Anatomy Size and Weight: Resembles inverted cone. Measures 3cm × 4cm × 2 cm : Walnut size Normal Weight: About 8 gram

4. Gross Features: Apex : directed downward, is in contact with fascia on superior aspect of urethral sphincter & deep perineal muscles. Base : Closely related to neck of the bladder Surfaces : Four surfaces: Anterior Posterior 2 Inferolateral Anatomy

5. Anterior surface: Composed of fibrous tissue Is narrow, convex from side to side . Lies 2 cm behind symphysis pubis Upper part connected to pubic bones by puboprostatic ligaments Lower end pierced by urethra. Anatomy Posterior surface: Is triangular in shape. Flattened from side to side. Convex from above downwards Seperated from Rectum by Fascia of Denonvilliers. Pierced on each side by Ejaculatory Duct.

6. Inferolateral surfaces: Related to side walls of pelvis. Levator ani muscle (Anterior fiber) enclose gland in pubourethral sling. Separated from muscle by plexus of veins embedded in its sheath Anatomy

7. Lobes: Composed of 3 lobes (cliniclly) 2 lateral 1 Middle/ Median lobe Anatomy

8. 3 Zones

9. Sphincter related to Prostate : Proximal urethral sphincter : Is in Preprostatic part of urethra Serves as sexual function and closes during ejaculation. If resected cause Retrograde Ejaculation. Distal urethral sphincter: Junction of prostatic and membranous urethra Horseshoe shaped with bulk lying anteriorly Anatomy

10. 2 Capsules

11. Blood supply: Artery:

12. Blood supply: Veins :

13. Nerve supply of Prostate: Prostatic plexus of nerve derived from: Lower part of Inferior Hypogastric plexus Supplied by both sympathetic and parasympathetic nerves Secretion are produced and released after stimulation of these nerves Lymphatic Drainage: Internal Illiac Nodes

14. BPH Aetiopathogenesis: 1.Hormonal theory: With age TS level drops slowly. But fall of estrogen level is not equal. So prostate enlarges through intermediate peptide growth factor. 2.Neoplastic theory: proliferation of all elemennts of prostrate: fibrous ,muscular and glandular resulting fibromyoadenoma

15. Secondary effects of BPH 1. Urethral change: compression, narrowing and distortion effect is more with median lobe When only one lateral lobe enlarges ;distortion of prostatic urethra occurs Secondary ascending infection can cause acute or chronic pyelonephritis. Often severe obstruction can lead to obstructive uropathy with renal failure.

16. 2.Change in bladder: bladder musculature hypertrophy Fasciculation Sacculation Diverticuli Stasis ,infection and stone 3. Change in ureter and kidney Hydronephrosis,hydroureter

17. Clinical features Frequency Urgency Hesitancy Acute retention of urine Chronic retention of urine Hematuria Terminal Dribbling Difficulty micturation with weak stream Infections: Cystitis, Urethritis Stone formation and residual urine.

18. Lower Urinary Tract Symptoms (LUTS) Voiding Poor flow (unimproved by straining) Intermittent stream – stops and starts Sensation of poor bladder emptying Hesitancy (worsened if the bladder is very full) Dribbling (including after micturition ) Episodes of near retention

19. Lower Urinary Tract Symptoms (LUTS) Storage Frequency Urgency Urgency incontinence Nocturia Nocturnal incontinence (enuresis).

20. Diagnosis 1. History : 1 age :>50 2.altered bladder function 3. distended abdomen 4, featutres of UTI 5. Features of ARF 2. Examination: GPE: signs of chronic renal impairment with anemia and dehydration P/A: Inspection: loss of transverse suprapubic skin crease palpable distended bladder distended abdomen DRE: Enlarged lateral lobes , firm and non-tender enlarged prostate Rectal mucosa is free Glans penis should be examined to exclude stenosis , phimosis , and epididymis are palpated for signs of inflammation

21. 3. Investigation Urine for R/E, M/E and C/S. Blood urea and serum creatinine, Serum electrolytes. U/S abdomen: assess size and wt. of prostate, residual urine , hydronephrosis . Urodynamics. Urine flow rate > 15 ml/sec is normal. 10-15 ml is equivocal; < 10 ml is low Voiding pressure < 60 cm of water is normal; 60-80 is equivocal; > 80 is high. Cystoscopy. Transrectal US (TRUS) :useful to find out nodules/possibility of carcinoma prostate Prostate specific antigen (PSA). IVU—to see kidney function.

22. International Prostate Symptom Score (I-PSS) 7 questions concerning urinary symptoms + 1 question concerning quality of life. The answers are assigned points from 0 to 5. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic) Mild (symptom score ≤7) Moderate (symptom score range 8-19) Severe (symptom score range 20-35)

23. Management Management of Acute Retention Urethral Catherization Suprapubic Cystostomy Urethral Instrumentation Retention not by drugs/constipation  Prostatectomy Unfit patients  Prostatic stent or catheter

24. 2. Chronic Retention Chronic retention + Low volumes of residual urine + No infection + Good renal function  Do prostatectomy, No catheterization If uremic  catheterization Haematuria  Due to collapse of the distended bladder and upper tract Post obstructive diuresis  maintain IV fluid & monitor Anaemic  Blood transfusion

25. Elective Treatment: Conservative Mild symptoms + Reasonable flow rates (> 10 /ml) + Good bladder emptying (residual urine < 100 ml)  Wait for 6 months A repeat assessment of symptoms, flow rates and ultrasound scan Advice  L imit fluid intake in the evening + Careful use of propantheline (helps with irritative symptoms)

26. Treatment 1.Medical Treatment 2.Surgical Treatment

27. Drugs α- Adrenergic blocking agents  I nhibits contraction of smooth muscle in prostate + Relaxation of sphincters eg. Prazosin, Terazosin, Tamsulosin 0.4mg OD (alpha 1a) for 12 weeks , alfuzocin 10mg OD , silodocin(most alpha 1 selective) – throughout life!!!

28. 5α-reductase inhibitors  I nhibits conversion of testosterone to DHT eg.  Finasteride , Dutasteride , Turosteride 40gm above combination treatment If less mono therapy of alpha adrenergic

29. Management Indications for prostatectomy includes: Refractory Acute retention – one failed trial of Catheter Chronic retention and renal impairment Complications of bladder outflow obstruction Hemorrhage Elective prostatectomy for severe symptoms Maximum flow rate <10 ml/s Increased residual volume: 100-250 ml

30. Methods of performing prostatectomy Transurethrally (TURP) Retropubically (RPP) Through the bladder (Transvesical; TVP) From the perineum 1 4 2 3

31. Operative management Most common reason for TURP: Severe symptoms Low flow rate < 12 ml/s Counseling men undergoing prostatectomy Retrograde ejaculation: 65% Erectile impotence: 5% Success rate: Very high Risk of reoperation: 15% after 8-10 years Morbidity rate: < 0.5% Severe sepsis: 6% + Severe hematuria: 3% Antibiotic treatment: 15-20%

32. Complications : Local Haemorrhage : If clot retention  Admit the patient  Wash the bladder, change catheter Sepsis : Bacteraemia in >50% of men with prolonged catheterisation  Prophylactic antibiotics Incontinence : Damage in external sphincter  A rtificial urinary sphincter Retrograde ejaculation and impotence : >50% due to disruption to bladder neck mechanism Urethral stricture : Due to prolonged catheterization Early stricture – bouginage Fibrotic stricture – optical urethrotome Bladder neck contracture

33. Complications : General Cardiovascular : Pneumonia, Myocardial infarction, Congestive cardiac failure and Deep venous thrombosis Water intoxication (TUR syndrome) : Absorption of water during transurethral resection congestive cardiac failure, hyponatraemia and haemolysis. Osteitis pubis : Rare

34. References Bailey and Love Short Practice of Surgery Robins Basic Pathology, 8 th Edition SRB’s manual of surgery, 4 th edition

35. Thank you