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1. KABWE CENTRAL HOSPITAL SURGERY “BPH” Wisdom’s Lecture Notes BANDA WISDOM CHILUFYA

2. OUTLINE ANATOMY DEFINATION ETIOLOGY PATHOPHYSIOLOGY CLINICAL FEATURES INVESTIGATIONS COMPLICATIONS MANAGEMENT

3. PATTERN OF UROLOGY

4. ANATOMY It is an accessory gland of male reproductive system. It is composed of glandular tissue embedded in fibromuscular stroma. McNeal Divided Prostate into Three Zones • Peripheral zone – prone for carcinoma. • Periurethral transition zone where BPH arises. • Central zone .

5. ANATOMY

6. PROSTATE GLAND Bladder neck pyramidal in shape. Measures 4X3X2cm 10-20gm Zones Mc Neil 1972

7. McNeal Divided Prostate into Three Zones • Peripheral zone – prone for carcinoma. • Periurethral transition zone where BPH arises. • Central zone .

8. PROSTATE Prostatic vessels inferior vesical Valvless veins Batson (3 and 9 O clock) Prostate capsule Denonvilliers Fascia

9. PROSTATE SPECIFIC ANTIGEN (PSA) It is a protease, produced from the prostatic epithelium secreted in the semen to cleave and liquefy the seminal coagulum formed after ejaculation. PSA is organ specific. Normal value is 4 ng/ml of plasma. In practice PSA between 4-10ng/ml is suggestive of BPH and above 10 ng/ml is suggestive of CA prostate ( Proff Kasonde Bowa -consultant urologist)

10. Benign Prostatic Hyperplasia (BPH) It is benign enlargement of prostate which occurs after 50 years, usually between 60 and 70 years.

11. Etiology : Unknown but theories: (1) Hormonal dependent theory: (Role of Androgen) testosterone →5 α- reductase enzyme → 5 DHT → ↑ growth factors → enlargement. (2) Role of estrogen: (Hormonal imbalance) there's associated ↑ of serum estrogen. (↑ E / T Ratio) (3) Programmed cell death regulation: (Apoptosis) ↓ apoptosis (↑ cell growth ) (4) Neoplastic theory: BPH is considered as Benign tumor.

12. Lower urinary tract symptoms (LUTS) Symptoms of voiding • Hesitancy • Intermittent stream –stops and starts Poor flow (not improving by straining) • Dribbling even after micturition Incomplete emptying

13. Symptoms of storage Frequency Urgency Nocturia Urge incontinence

14. DRE (Digital Rectal Examination): Prostate size & contour can be assessed (5S) Symmetrically enlarged, Smooth surface, Soft to firm, preserved Sulci, Sliding rectal mucosa over it)

15. Complications. Recurrent hematuria Renal stones Recurrent urinary tract infection Renal failure Retention (acute and chronic) The above are also indications for prostatectomy

16. Investigations: Laboratory: Urine analysis. Liver & kidney function. Urine MCS. PSA (prostate specific Ag) 2. Urodynamic study ( Uroflowmetry ) Q max (peak) = normal > 15 ml / sec. < 10 ml / sec means obstruction to bladder outflow.

17. 3. Imaging: TRUS. (Trans-rectal ultrasound) MRI. IVU: to show back pressure on the kidney. 4. BIOPSY Core needle biopsy

18. Treatment: Prophylaxis: avoid ppt factor e.g. Excess work, worry, weather (cold), wine, women, withholding urine in bladder, spices, constipation. 2 . Medical therapy: α 1 - blockers: e.g. Tamsulosin , Alfuzosin . block α- receptors in the urethra → ↓decreases its tone. 5α- reductase inhibitors: e.g. Finasteride ( proscar )-resulting into shrinking of the prostate

19. 3. SURGICAL MANAGEMENT Intra prostatic stent Balloon dilatation TURP-Trans Urethral resection of the prostate Trans urethral vaporization Trans urethral incision Open prostatectomy Laser

20. Conditions associated with raised PSA Prostate cancer BPH Prostatitis UTI Ejaculation Medical procedures Digital rectal examination

21. Assignment Symptoms of BPH Conditions that raises the PSA Indications for prostatectomy in BPH Describe the medical management of BPH Describe the international prostate severity score

22. KABWE CENTRAL HOSPITAL “PROSTATE CANCER” Wisdom’s Lecture Notes BANDA WISDOM CHILUFYA

23. Introduction Most common malignancy in elderly men Second most common cause of cancer related death in elderly men

24. Risk factors for Prostate Cancer Increased risk Family history First degree relation Family history of BRCA gene mutation Race Scandinavian African American Age Diet Decreased risk Race Asian Diet high in: Plant Vitamin A Isoflavonoids Lycopenes Selenium Vitamin E

25. McNeal’s description (1972): 3 zones PERIPHERAL ZONE- Site of origin of 60- 70% of all carcinomas of the prostate. CENTRAL ZONE. TRANSITIONAL ZONE- BPH originates in this zone.

26. Gleason Grading System

27. Grading: According to Gleason score (0-10 ) 2 – 4 → well differentiated tumour 5 – 7 → moderately differentiated 8 – 10 → undifferentiated tumour

28. History Symptoms late Backache-central back pain Hematospermia LUTS (hesitancy, poor stream, post micturition dribbling, dysuria, frequency, urgency, nocturia ,) Loss of weight

29. Examination DRE Prostate firm to hard, may be nodular, mucosa adherent to prostate, usually enlarged gland Median sulcus obliterated +/- blood gloved finger

30. Investigation U/s Prostate biopsy PSA ( >10 ng/ml is highly suggestive of CA prostate) Pelvic x-ray Bone scan Ct scan

31. Treatment Treatment depends on stage of disease, patient's age and general fitness Treatment options: Radical radiotherapy Radical prostatectomy Hormonal

32. Local disease Observation Radical radiotherapy Radical prostatectomy Locally advanced disease Radical radiotherapy Hormonal therapy Metastatic disease Hormonal therapy

33.   Hormonal therapy 80% of prostate cancers are androgen dependent for their growth Hormonal therapy involves androgen depletion Produces good palliation until tumours 'escape' from hormonal control Androgen depletion can be achieved by: Bilateral orchidectomy LHRH agonists - goseraline Anti-androgens - cyproterone acetate, flutamide

34. ‘THE MOST IMPORTANT INNOVATION IN MEDICINE TO COME IN THE NEXT 10 YEARS; THE POWER OF HUMAN HAND” Abraham Verghese

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