Session 14- Benign prostate hyperplasia(BPH).pptx

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1. CMT 06207 Benign Prostatic Hyperplasia (BPH) and Urethral Stricture Session 14 By Dr. Stephen S. Kasaizi

2. Learning Objectives By the end of this session, students are expected to be able to: Define Benign prostate hypertrophy (BPH) and urethral stricture Describe clinical feature of BPH and urethral stricture Describe the causes of urethral stricture List the differential diagnosis of BPH and urethral stricture Describe the management of BPH and urethral stricture

3. Definition It is benign enlargement of prostate which occurs after 50 years, usually between 60 and 70 years. BPH affects both glandular epithelium and connective tissue stroma.

4. Normal prostate and Enlarged prostate

5. Subdivision of the prostate The prostate can be subdivided in to two ways In lobes In Zones

6. Division of Prostate in to lobes The "lobe" classification is more often used in anatomy. The prostate is incompletely divided into five lobes: Anterior lobe (or isthmus) Posterior lobe Right lateral lobe Left lateral lobe Median lobe( or middle lobe)

7. Division of Prostate in to Zones The prostate has been described as consisting of three or four zones. This "zone" classification is more often used in pathology. The prostate gland has four distinct glandular regions, two of which arise from different segments of the prostatic urethra: Peripheral zone Central zone Transition zone Anterior fibro-muscular zone (or stroma

8. Pathology BPH usually involves median and lateral lobes or one of them. It involves adenomatous zone of prostate, i.e. submucosal glands. Median lobe enlarges into the bladder. Lateral lobes narrow the urethra causing obstruction. Urethra above the verumontanum gets elongated and narrowed. Bladder initially takes the pressure burden causing trabeculations, sacculations and later diverticula formation.

9. Activity: Brainstorming What are the clinical presentations of a patient with BPH?

10. Clinical features Frequency occurs due to introversion of sensitive urethral mucosa into the bladder or due to cystitis and urethritis. Urgency, hesitancy, nocturia. Overflow and terminal dribbling. Difficulty in micturition with weak stream and dribble. Pain in suprapubic region and in loin due to cystitis and hydronephrosis respectively. Acute retention of urine.

11. Summary of clinical features Symptoms of voiding Hesitancy Poor flow not improving by straining Dribbling even after micturition Intermittent stream—stops and starts Poor bladder emptying Episodes of near retention Symptoms of storage Frequency Nocturia Urgency Urge incontinence Nocturnal incontinence

12. Activity: Brainstorming Mention three (3) differential diagnosis of BPH.

13. Differentia diagnosis Stricture urethra. Bladder tumour, carcinoma prostate. Neurological causes of retention of urine like diabetes, tabes , disseminated sclerosis, Parkinson’s disease. Idiopathic detrusor activity. Bladder neck stenosis; bladder neck hypertrophy.

14. Investigations Urine for microscopy and Culture and Sensitivity Blood urea and serum creatinine. Abdominal Ultrasound-look for presence of residual urine. 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.

15. Investigation cont… Cystoscopy. Prostate specific antigen (PSA). IVU—to see kidney function. Serum electrolytes. NB: Normal peak urine flow rate is 20 ml/sec. In obstruction, it is less than10 ml/sec.

16. Treatment BPH has two modalities of treatment; Medical treatment Surgical treatment Drugs used in medical treatment Alpha 1 adrenergic blocking agents 5-alpha reductase inhibitor Surgical treatment when medical treatment has failed or patient has contraindication for medical treatment

17. Indications for Surgery Prostatism (frequency, dysuria, urgency). Acute retention of urine. Chronic retention of urine with residual urine more than 200 ml. Complications like hydroureter, hydronephrosis, stone formation, recurrent infection, bladder changes, bladder stones Haematuria .

18. Urethral stricture

19. Definition Urethral stricture is narrowing of the urethral lumen causing functional obstruction This is due to formation of fibrous tissue following damage to the urethral mucosa Most common cause of urethral stricture is ureteropelvic junction (UPJ) obstruction which could be congenital or acquired narrowing at the level of UPJ

20. Activity: Brainstorming What are the causes of urethral stricture?

21. Causes and risk factors It can follow treatment for another urological condition, pelvic radiation therapy or urinary diversion surgery External traumatic injury like straddle injuries. Congenital anomalies may result in to stricture Most commonly caused by gonococal urethritis and chlymidia , transmitted through sexual intercourse. Could be associated with pelvic fracture Can follow urological procedures like catheterization

22. Clinical features Poor urinary stream Forking and spraying of the stream Incomplete emptying Frequency, dysuria Retention and often with overflow Pain, burning micturition, suprapubic tenderness Thickening and button-like feeling in bulbar urethra (Bulbous urethra is felt clinically by lifting the scrotum in midline in the perineum)

23. Investigations Urine microscopy and culture. Blood urea and serum creatinine. IVU to see hydronephrosis and function of kidney. Ultrasound abdomen. X-ray of pelvis to see old fracture with history of trauma.

24. Investigation cont… Ascending urethrogram is an essential investigation to see the site, type, extent and false passage. Urodynamic studies. Urethroscopy

25. Treatment Intermittent dilatation Surgery. Refer the patient to a higher center for further evaluation and treatment.

26. Key points BPH is benign enlargement of prostate which occurs after 50 years, usually between 60 and 70 years. The prostate is subdivided in to five lobes or four zones. There are two treatment modalities for BPH; Medical and surgical Urethral stricture is narrowing of the urethral lumen causing functional obstruction Urethral stricture is most commonly caused by gonococal urethritis transmitted through sexual intercourse.

27. Evaluation Mention lobes of prostate Mention for investigation for the patient with BPH Define urethral stricture Mention four (4) causes of urethral stricture

28. Reference Siram Bhat M (2015) SRB’s Manual of surgery( 5 th edition). Prakash Rao Thangam venghese Joshua. K.Rajgopal Shenoy, Anitha shenoy (2016) Manipal Manual of surgery (4 th edition). CBS New Delhi F.Charles Brunkardi (2019) Schwartz’s principles of surgery (11 th edition). McGraw-Hill Education Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2006). Bailey and Love’s Short Practice of Surgery (25 th edition.). London: Hodder Arnold