Benign Prostatic Hyperplasia & Incontinence New


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  • Incontinence is a kind of male urinary incontinence where the victim could not hold the urine long sufficient until he is in the ideal location to relieve themselves. It is a circumstance where you really wish to urinate but you could rarely make it to the toilet. Urine comes out on its own long before you could make it to the restroom in good time. This kind of male urinary incontinence treatment primarily has an effect on people already dealing with various other conditions and conditions.
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Benign Prostatic Hyperplasia & Incontinence New

  2. 2. INTRODUCTION <ul><li>BPH associated with 3 types of incontinence </li></ul><ul><li>- Urge incontinence </li></ul><ul><li>- Overflow incontinence </li></ul><ul><li>- Post prostectomy incontinence </li></ul>
  3. 3. WHY PREOPERATIVE ASSESSMENT? <ul><li>Multiple caues lead to incontinence thus concominant pathologies need evaluation </li></ul><ul><li>Associated neurological and sphincter mechanisms need to be considered while formulating the treatment plan </li></ul><ul><li>TURP leads to destruction of the internal sphincter mechanism, thus a functioning external sphincter is a must for post operative continence </li></ul>
  4. 4. CONTINENCE <ul><li>Requires a stable, compliant detrusor & a competent bladder outlet </li></ul><ul><li>Normal bladder holds amount of urine at low pressure </li></ul><ul><li>Normal sphincter resists abdominal pressure & relaxes during voluntary voiding </li></ul>
  5. 5. URINARY SPHINCTER <ul><li>2 functionally separate units </li></ul><ul><li>PROXIMAL URETHRAL SPHINCTER- </li></ul><ul><li>- Consists of bladder neck, prostate, prostatic urethra </li></ul><ul><li>- Innervated by autonomic pelvic nerve fibres </li></ul>
  6. 6. URINARY SPHINCTER <ul><li>2. DISTAL URETHRAL SPHINCTER- </li></ul><ul><li>- Extends from veru montanum to proximal bulbar urethra </li></ul><ul><li>- Composed of </li></ul><ul><li>a. Urethral mucosal infolding </li></ul><ul><li>b. Rhabdosphincter </li></ul><ul><li>c. Extrinsic paraurethral skeletal muscle </li></ul><ul><li>d. Supporting fascial investments </li></ul>
  7. 8. INCONTINENCE IN BPH <ul><li>CAN BE DUE TO </li></ul><ul><li>Bladder dysfunction </li></ul><ul><li>Sphincter dysfunction </li></ul><ul><li>Combination of both </li></ul>
  8. 9. URGE INCONTINENCE <ul><li>Leakage in absence of stress maneuvers & urinary retention </li></ul><ul><li>Usually preceded by abrupt onset of need to void </li></ul><ul><li>Caused due to </li></ul><ul><li>- Detrusor instability </li></ul><ul><li>- Impaired compliance of bladder </li></ul><ul><li>- Neurogenic </li></ul><ul><li>- Idiopathic </li></ul>
  9. 10. OVERFLOW INCONTINENCE <ul><li>Frequent leak of small amounts associated with urinary retention </li></ul><ul><li>Caused due to chronic obstruction by enlarged prostate </li></ul>
  10. 11. POSTPROSTECTOMY INCONTINENCE <ul><li>PROSTECTOMY MAY RESULT IN </li></ul><ul><li>Bladder dysfunction </li></ul><ul><li>Sphincter dysfunction </li></ul><ul><li>Overflow incontinence </li></ul>
  11. 12. POSTPROSTECTOMY INCONTINENCE contd.. <ul><li>BLADDER DYSFUNCTION of 2 types </li></ul><ul><li>Involuntary contraction </li></ul><ul><li>Impaired compliance </li></ul><ul><li>Both cause </li></ul><ul><li>- Increase in detrusor pressure </li></ul><ul><li>- Overcomes bladder outlet & sphincter resistence </li></ul>
  12. 13. POSTPROSTECTOMY INCONTINENCE contd.. <ul><li>SPHINCTER DYSFUNCTION </li></ul><ul><li>Proximal sphincter removed in turp & open prostectomy </li></ul><ul><li>Continence depends on intact distal sphincter </li></ul><ul><li>Direct injury to sphincter, supporting structures, nerves </li></ul>
  13. 14. POSTPROSTECTOMY INCONTINENCE contd.. <ul><li>OVERFLOW INCONTINENCE </li></ul><ul><li>Results from </li></ul><ul><li>Obstruction from residual adenoma </li></ul><ul><li>Bladder neck contracture </li></ul><ul><li>Anastomotic or urethral stricture </li></ul>
  14. 15. EVALUATION <ul><li>GOALS </li></ul><ul><li>- Determine type of incontinence </li></ul><ul><li>- Detect related urinary tract & nervous system pathology </li></ul><ul><li>- Comprehensive patient evaluation </li></ul>
  15. 16. EVALUATION contd.. <ul><li>EVALUATION CONSISTS OF </li></ul><ul><li>Detailed history </li></ul><ul><li>Clinical examination </li></ul><ul><li>Lab tests </li></ul><ul><li>USG for PVRU </li></ul><ul><li>Uroflowmetry </li></ul><ul><li>Urodynamic studies </li></ul>
  16. 17. HISTORY TAKING <ul><li>Type and severity </li></ul><ul><li>Precipitating events </li></ul><ul><li>Diaries & pad tests to quantify severity </li></ul><ul><li>Neurologic symptoms </li></ul><ul><li>Prior procedures </li></ul>
  17. 18. CLINICAL EXAMINATION <ul><li>STANDARD UROLOGIC EXAMINATION </li></ul><ul><li>- Bladder palpation </li></ul><ul><li>- Digital rectal examination </li></ul><ul><li>STRESS MECHANISMS PERFORMED to rule out stress incontinence </li></ul><ul><li>FOCUSSED NEUROLOGIC EXAMINATION </li></ul><ul><li>- Deep tendon reflexes & bulbocavernous reflex </li></ul><ul><li>- Perineal sensation </li></ul><ul><li>- Sphincter tone </li></ul>
  18. 19. LABORATORY TESTS <ul><li>Blood urea nitrogen </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Blood sugar </li></ul><ul><li>Urine routine microscopy & culture sensitivity </li></ul><ul><li>Prostate specific antigen </li></ul>
  19. 20. ULTRASONOGRAPHY <ul><li>To evaluate kidneys, upper urinary tract </li></ul><ul><li>To evaluate prostate </li></ul><ul><li>To evaluate post void residual urine </li></ul>
  20. 21. POST VOID RESIDUAL URINE <ul><li>Volume remaining immediately after completion of micturition </li></ul><ul><li>< 50 ml is normal </li></ul><ul><li>To assess emptying & rule out retention </li></ul><ul><li>Predicts higher failure rate with wait& watch regime </li></ul><ul><li>Doesn’t correlate well with other signs & symptoms of prostatism </li></ul>
  21. 22. UROFLOWMETRY <ul><li>Electronic recording of urinary flow rate throughout course of micturition </li></ul><ul><li>Composite measure of detrusor contraction and urethral resistance </li></ul><ul><li>Abnormal flow indicates obstruction or impaired contraction </li></ul>
  22. 23. UROFLOWMETRY <ul><li>Innaccurate if voided volume < 150 ml </li></ul><ul><li>Peak flow rate (PFR) more specific </li></ul><ul><li>PFR >15 ml/min have poor treatment outcome postprostectomy </li></ul><ul><li>PFR <15 ml/min doesn’t differentiate between bladder obstruction & decompensation </li></ul>
  23. 24. Urine flow rate curves: Note how the pattern of the curve is a useful adjunct to making a diagnosis. (a) Normal flow rate, (b) high-pressure low flow rate caused by bladder neck obstuction, (c) urethral stricture, (d,e) low-pressure low flow rates differing patterns, (f) straining to void. W, voided volume) URINARY FLOW RATE CURVES Normal and abnormal flow traces
  24. 25. URODYNAMIC STUDIES <ul><li>GOALS </li></ul><ul><li>Determine presence of bladder / sphincter dysfunction </li></ul><ul><li>Determine presence / absence of obstruction / neurogenic bladder </li></ul><ul><li>Adequacy of detrusor contractilty during voiding </li></ul>
  25. 26. URODYNAMIC STUDIES <ul><li>TYPES </li></ul><ul><li>Eye ball urodynamics </li></ul><ul><li>Single channel </li></ul><ul><li>urodynamics(cystometry) </li></ul><ul><li>Multichannel video urodynamics </li></ul><ul><li>Sphincter electromyography </li></ul><ul><li>Urethral pressure profilometry </li></ul><ul><li>Ambulatory urodynamics </li></ul><ul><li>Cystourethroscopy </li></ul>
  26. 27. MULTICHANNEL VIDEO URODYNAMICS <ul><li>Most precise diagnostic tool for disturbances of micturition </li></ul><ul><li>Synchronous measurement & display of urodynamic parameters with radiographic visualisation of lower urinary tract </li></ul>
  27. 28. URODYNAMIC STUDIES Poor compliance during later part of filling Phasic detrusor unstability during filling Urodynamic studies: Schematic representation of (left top) moderately poor compliance during the latter stages of filling and (left bottom) phasic detrusor instability during filling. In both cases high-pressure low-flow voiding also occurs, which indicates bladder outflow obstruction
  28. 29. Low – pressure low-flow voiding caused by a poorly contracting detrusor. P abd abdominal pressure, P det detrusor pressure, P ves intravesical pressure, RU, residual urine; W, voided volume
  29. 30. CYSTOURETHROSCOPY <ul><li>Information about </li></ul><ul><li>Urethral mucosa </li></ul><ul><li>Prostatic urethra </li></ul><ul><li>Bladder wall changes </li></ul><ul><li>Vesicourethral anastamosis </li></ul><ul><li>Useful when artificial urethral sphincter, urethral bulking agents, dilatation of sphincter is planned </li></ul>
  30. 31. TREATMENT <ul><li>Ranges from conservative to aggressive </li></ul><ul><li>Must be tailored to individual </li></ul><ul><li>Depends on cause, severity, effect on quality of life, expectations from treatment </li></ul>
  31. 32. TREATMENT <ul><li>URGE INCONTINENCE (DETRUSOR OVERACTIVITY) </li></ul><ul><li>- Eliminate underlying cause </li></ul><ul><li>- Symptomatic relief in 2/3 pts by TURP </li></ul><ul><li>- Adjusting timing or amount of fluid excretion </li></ul><ul><li>- Behavioral therapy& bladder training regimes if above method not successful </li></ul><ul><li>- For cognitively impaired prompted voiding used </li></ul><ul><li>- Medications like anticholinergics </li></ul>
  32. 34. TREATMENT <ul><li>OVERFLOW INCONTINENCE (UNDERACTIVE DETRUSOR) </li></ul><ul><li>- Decompression </li></ul><ul><li>if duration unknown </li></ul><ul><li>followed by voiding trial </li></ul><ul><li>- Augmented voiding techniques (AVT) </li></ul><ul><li>if decompression fails </li></ul><ul><li>if PVRU remains large </li></ul><ul><li>if retention chronic </li></ul><ul><li>- Intermittent or indwelling catheter </li></ul><ul><li>if AVT fails or voiding not possible </li></ul>
  33. 35. TREATMENT <ul><li>POSTPROSTECTOMY </li></ul><ul><li>BLADDER DYSFUNCTION </li></ul><ul><li>Fluid restriction & behavioral modification </li></ul><ul><li>Medications like anticholinergics </li></ul><ul><li>Pelvic floor exercises </li></ul><ul><li>Augmentation cystoplasty </li></ul>
  34. 36. TREATMENT <ul><li>SPHINCTER DYSFUNCTION </li></ul><ul><li>Pelvic floor exercises & biofeedback </li></ul><ul><li>Urethral bulking agents </li></ul><ul><li>Artificial urethral sphincter </li></ul><ul><li>Sling procedures </li></ul><ul><li>Urinary diversion or bladder neck closure with creation of continent stoma </li></ul>
  35. 37. CONCLUSION <ul><li>Incontinence is one of the most distressing complaints associated with BPH </li></ul><ul><li>Various causes may lead to or contribute to development of incontinence </li></ul><ul><li>Neurological and sphincter mechanisms need thorough evaluation before embarking on a treatment plan </li></ul><ul><li>Successful treatment depends on accurate diagnosis of the cause and immaculate assessment of the severity. </li></ul>
  36. 38. THANK YOU