DOC-20240811-WA0018.. and many more pptx

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1. BENIGN PROSTATIC HYPERPLASIA(BPH) DR. LUNGU P (MBCHB) LECTURER/COORDINATOR - KCHS 8 May 2022 1

2. Layout of presentation Anatomy Definition Epidemiology Pathophysiology Symptoms Physical examination Investigations Treatment 2

3. Anatomy of Prostate 8 May 2022 3

4. ZONAL ANATOMY OF THE PROSTATE: The prostate is a compound tubuloalveolar gland composed of stroma and parenchyma . Composed of 3 zones of McNeal: The transition zone surrounds the urethra proximal to ejaculatory ducts. The central zone. The peripheral zone. The anterior fibromuscular stroma . 4

5. 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. BPH 5

6. Risk factors P oorly understood. Genetic predisposition, and some have noted racial differences. Approximately 50% of men under the age of 60 who undergo surgery for BPH may have a heritable form of the disease. This form is most likely an autosomal dominant trait, and first-degree male relatives of such patients carry an increased relative risk of approximately fourfold. Dr.Lungu p. 8 May 2022 6

7. Etiology The etiology of BPH is not completely understood. Multifactorial and endocrine controlled clinical evidence have shown Circulating Testosterone is converted to DHT by 5-alpha-reductase – DHT stimulates prostatic tissue hypertrophy Castration results in the regression of established BPH and improvement in urinary symptoms. Dr.Lungu p . 8 May 2022 7

8. Pathology BPH is truly a hyperplastic process (increase in cell number). Microscopic evaluation reveals a nodular growth pattern that is composed of varying amounts of stroma and epithelium. Stroma is composed of varying amounts of collagen and smooth muscle. The differential representation of histologic components of BPH may explain the potential responsiveness to medical therapy. Response to a specific therapy is not reliably predictable. 8 May 2022 8

9. Gross appearance of hyperplastic prostatic tissue obstructing the prostatic urethra forming “lobes.” A , Isolated middle lobe enlargement. B , Isolated lateral lobe enlargement. C , Lateral and middle lobe enlargement. D , Posterior commissural hyperplasia (median bar).   8 May 2022 9

10. Stages: BPH is a progressive disease. Mild infravesical obstruction leads to minimal S/S. Increase of infravesical obstruction with bladder compensation by detrusor hypertrophy leads to LUT obstructive symptoms. Severe infravesical obstruction with bladder instability and decrease compliance leads to Irritative s/s . PATHOPHYSIOLOGY 10

11. S/S OF BPH - LUTS CLASSIFICATION OF LUTS VOIDING (OBSTRUCTIVE) Hesitancy Poor stream Intermittency Incomplete voiding Straining Terminal dribbling Post-micturition dribbling Haematuria Dysuria STORAGE (IRRITATIVE) Frequency Urgency Urge Incontinence F requency Nocturnal enuresis ( nocturia )

12. Retention: a- Acute retention - sudden inability to micturate +/- supra pubic pain. b- Chronic retention - increase in the post voiding volume which may present with retention with over flow, nocturnal enuresis or stress incontinence. Haematuria . Uraemic symptoms. Other SIGNS/SYMPTOMS 12

13. DIFFERENTIALS OF LUTS LUTS not disease-specific. Differentials include: Urethral stricture. UTI – urinalysis + MCS Prostate cancer – high PSA, hematuria Cystitis, cystolithiasis, bladder ca. Neurogenic bladder – consequence of neurological disease (DM, Stroke ) 8 May 2022 13

14. Evaluation of LUTS 14

15. 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. PHYSICAL EXAMINATION 15

16. DRE: i . Enlargement= diffuse ii. Consistence : firm,rubbery & homogenous iii. Median sulcus = palpable iv. Rectal mucosa = freely mobile over the gland v. Non tender Genital examination Neurological examination Observation of the patient act of micturation . PHYSICAL EXAMINATION 16

17. DRE findings BPH: diffuse, non tender, firm, medium sulcus palpable, rectal mucosa freely mobile over gland Prostatitis: diffuse , tender, soft, medium sulcus palpable , rectal mucosa freely mobile over gland Prostate Ca. : irregular, non tender, hard, medium sulcus obliterated, rectal mucosa immobile over gland 17

18. Urine analysis and C/S. Serum Creatinine . Pelvi -abdominal U/S with post voiding assessment. PSA (Prostatic specific antigen) organ specific (arises only from prostatic acini) but not disease specific (increases with other prostatic diseases). Uroflowmetry .   By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Recommended investigations 18

19. 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 . By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Optional investigations 19

20. Video-cystoscopy unit consists of: A , a camera head, which is placed directly over the eyepiece of the cystoscopic lens; B , video-cart containing a TV monitor, light source, video camera controller, and video-recording device (VCR). 20

21. Tripple Assessment Of Prostatism DRE U/S – Transurethral/ Transrectal Prostate Biopsy Differentials For Elevated PSA (Ranges) Normal </= 4ng/mL Prostatitis/ Prostaic Manipulations – 5 - 8ng/mL Bph – 10 - 20ng/mL Prostate Ca – > 20ng/mL 21

22. TREATMENT OF BPH AIMS OF TREATMENT: Relieve urinary symptoms. Improve quality of life. Reduce the complications of bladder outflow obstruction. Treatment options depend on… Age Symptom score (IPSS) Histology Infection

23. Watchful waiting: ( In patients with mild symptoms). Medical treatment: (moderate ipss score) 5 Alpha reductase inhibitors: affects the epithelial component - reduction in the size of the gland Finestaride 5mg OD PO x 3/12 – 6/12, then for life Alpha 1 blockers: affect subtype alpha-1 adrenoreceptors . (reduce muscle tone to relieve obstruction). e.g. Prazosin , Doxazosin,Tamsulosin (Flomax) 0.4mg OD PO x 2/52 – 4/52, then for life Combination . TREATMENT 23

24. Benefits Convenient No loss of work time Minimal risk Disadvantages Expensive Not all are covered by Medical schemes Drug Interactions Must be taken every day Manages the problem instead of fixing it 24 medication n n n n n n n n

25. SURGICAL TREATMENT: Minimally invasive or open – technique Procedures Prostatectomy (open / TURP – for younger patients) Castration (for elderly patients) Indications Severe IPSS score Complications Failed Medical treatment 25

26. A- Absolute indications: Recurrent Upper urinary tract affection. Uremia. Recurrent attacks of acute retention. Severe obstructive symptoms (high IPSS score).   Bladder stone Indications of surgical intervention B- Relative indications: Moderate symptoms (moderate IPSS score). Recurrent UTI. Hematuria. 26

27. Transurethral resection of the prostate. Transurethral incision of the prostate Laser therapy Ballon dilatation. Transurethral microwave treatment. Intraprostatic stents. Minimally-invasive surgery 27

28. TURP “ Gold Standard ” of care for BPH Uses an electrical “knife” to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow (transurethral resection of the prostate) n n n 28

29. the “ gold standard ” - TURP Benefits Widely available Effective Long lasting Disadvantages Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter 4-6 week recovery 29 n n n n n n n

30. Intra-Prostatic Stent 30 8 May 2022

31. Interstitial Laser Coagulation 31 8 May 2022

32. Hyperthermia of BPH 32 8 May 2022

33. Transurethral Dilatation of Prostate 33 8 May 2022

34. either: Transvesical or Retropubic . Open Surgery (Prostatectomy) 34

35. Complications of surgery Bleeding Surgical site infection Importence Infertility 35