A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY
BENIGN PROSTATIC ENLARGEMENT
(BPH)
DR. CHONGO SHAPI (BSc. HB, MBChB)

2. BENIGN PROSTATIC ENLARGEMENT (BPE)
Etiology
Thought to related to
1. Hormones–balance between testosterone, estrogen,
prolactin and growth factors.
2, Age-the mesenchymal theory that apoptosis of cells is
slowed in favor of cell proliferation with advancing age.
Clinical presentation
Quiz: Outline the clinical presentation of a patient with
benign prostatic enlargement?
History
Age usually greater than 40 years. With both irritative and
obstructive urinary symptoms.
Irritative Symptoms
Due to chemical from the urine deposit on the wall of
bladder and stimulate contractility.
➢ Nocturia
➢ Frequency
➢ Urgency/urge incontinence
➢ Dysuria
Obstructive symptoms
Can be mechanical due to the prostatic enlargement or
dynamic obstruction- the increased tone of the bladder neck
and internal sphincter
➢ Intermittency/hesitancy
➢ Poor urinary stream
➢ Incomplete emptying and dribbling-Acute or
chronic RF
➢ Straining
Any symptoms of complications:
-Acute urinary retention
➢ Suprapubic pain
➢ Complete inability to pass urine
-Chronic urinary retention
➢ Usually painless
➢ Can pass some urine –presence of other
complications
-Signs of UTI- Fever, Dysuria and frequency.
-Pyelonephritis-flank pains, fever and vomiting
-Renal failure-Leg edema, scrotal edema
Physical examination
General examination-complications
Anemia-chronic renal failure
Pitting edema.
Fever-UTI
Abdominal examination
-Suprapubic distension-acute retention-full bladder.
-Abdominal distension especially flanks-Hydronephrosis
-Suprapubic tenderness and full bladder.
DRE
-Normal anal sphincter tone.
-Prostate is firm, smooth and mucosa over is mobile
-Medial sulcus felt, the symmetry maintained.
Neurological examination
-Tests for the sacral plexus to rule out any cause of
neurogenic bladder.
➢ Perianal senation and anal wink
➢ S1, S2, S3 tests of sensation from the lateral foot
and back of thigh and ischial tuberosity.
➢ ? Diabetis neuropathy
Pathophysiology
Symptoms of benign prostatic hyperplasia related to either
the obstructive component of the prostate or to the
secondary response of the bladder to the outlet resistance.
Obstruction can be due to either mechanical or dynamic
As prostatic enlargement occurs, mechanical obstruction
may result from intrusion into the urethral lumen or bladder
neck, resulting in a higher bladder outlet resistance.
Prostatic size on digital rectal examination (DRE) correlates
poorly with symptoms.
The dynamic component of prostatic obstruction explains
the variable nature of the symptoms. The prostatic stroma is
composed of smooth muscle and collagen and is rich in
adrenergic nerve supply. Level of autonomic stimulation
thus sets a "tone" to the prostatic urethra. Alpha-blocker
therapy decreases this tone, resulting in a decrease in outlet
resistance.
The irritative voiding complaints result from the secondary
response of the bladder to the increased outlet resistance.
Bladder outlet obstruction results in detrusor muscle
hypertrophy and hyperplasia as well as collagen deposition.
This leads to a decrease in bladder compliance, but detrusor
instability also occurs. Also due to chemical from the urine
deposit on the wall of bladder and stimulate contractility
Investigations
Laboratory
1.FHG
➢ WBC and differential to rule out any UTI
➢ ESR and C-reactive proteins
2.Urinalysis
Dipstick-nitrites show UTI R/o hematuria
Mcroscopy-RBC casts,WBC
3.U/E and Creatinine
Rule out obstructive uropathy to upper tracts
4.PSA
Usually age dependent but 0-4 ng/dl regarded as normal
range.
0-49 years 2.5ng/dl
50-59 years 3.5ng/dl
60-69 years 4.5ng /dl
70-79 years 5.5ng/L
>90 years >6.5ng/dl
Other conditions with increased PSA include
1.Prostatitis
2.Prostatic infarction
3.DRE or prostatic massage for culture
4.Sexual intercourse(when doing PSA patient abstains for
3days)
5.Instrumenation- passing sound
6.Cancer of the prostate
Predictive value of PSA for cancer prostate
0-4 g/dl 5% chance(poorly differentiated cancer)
4-10 g/dl 25%
>10g/dl >65%
5. Diabetic Neuropathy - RBS
6.Urine flow rate/urodynamic studies
Using a urine flow meter. Q max is the maximum flow rate
in ml/sec.
Normal flow rate in male is 20-25 ml/sec
Females 25-30 ml/sec(short urethra)
Elderly male 60 years 10-15 ml/second
Qmax cut off for intervention is 10 ml/sec

3. Imaging
1.Abdominal ultrasound
Features to be evaluated:
-Post void residual urine-U/s first on full bladder then
patient voids to determine the residual urine. (Normal -
<30mL)
-Size of the prostate
-Upper urinary tract-Bladder, ureters, kidneys for any
hydronephrosis
2.Transrectal U/S (TRUS) ± TruCut Biops
3..IVU
Any features of RF
Otherwise optional because its expensive and radiation
exposure
IVU and U/S complimentary
3.Urodynamic studies-MCU
Graphic representation of micturition cycle depends on the
bladder and the urethra.
Rule out other causes e.g. Strictures, Calculi
5.Pressure-flow studies
Neurological disorders eg
-Back surgery
-Spinal injury
-Medical conditions -DM, Multiple myeloma,
Parknisonism.
Intravesical pressure-chronic obstruction bladder loses its
contractility. It gets low.
Maximum intravesical pressure is 60 mmHg. If pressure too
low then the patient may not benefit from prostatectomy
because of the lack of bladder wall contractility.
Detrussor pressure=Intra-abdominal pressure-intravesical
pressure
MANAGEMENT-
Depend on presentation (acute or Chronic retention),
IPSS and response to catheterization.
A.ACUTE URINE RETENTION
-Relieve the obstruction by catheterization-Suprapubic or
transurethral.
-Usually use foley’s catheter
-Silicone catheter avoids irritation thus better.
-Usually use gauge 16 or 18 for adults
-Catheterization procedure.
▪ Aseptic technique
▪ Clean and drape the genitalia
▪ Clean glans and urethral meatus with 3-4 swabs
dipped in antiseptic
▪ Lubricate foleys catheter with K-Y jelly and or
remican jelly. Some jelly may also be applied at
the tip of glans penis
▪ Hold the penile shaft on the palm of the left hand
and Apply traction forwards
▪ Insert the catheter into the urethral meatus, and
advance it down the penile urethra to the base of
the penis with successive, steady movements.
▪ Advance the catheter to the hilt (even if urine is
obtained earlier) to ensure that the balloon is not
inflated in the urethra.
▪ Inflate the balloon with the proper amount of
sterile water for its size (usually 5 mL), and
withdraw the catheter until the balloon is pulled
snugly against the trigone.
▪ Obtain a specimen for appropriate tests (at a
Connect the urinary drainage system bag to the catheter
▪ Tape the catheter to the upper thigh, leaving
sufficient slack so that movement of the leg will
not pull on the catheter.
▪ Patient kept on catheter for 2 weeks.
-Meanwhile do urinalysis
-Keep patient on prophylactic antibiotics-Nitrofurantoin,
Nalidixic acid, Quinolones
-Offer medical therapy in terms of the following
a)Alpha –blockers
Prostate <40cm3
- Drugs of choice - α1A-blockers e.g..
-Phenoxybenzamine-very toxic
-Prazosine
-Terazosin
-Doxazosine-long acting
-Tamulsine-highly selective for alpha 1 receptors
-Alfuzosine
These ↓ smooth muscle tone (prostate & bladder)
S/E - Drowsiness; depression; dizziness; BP↓; dry mouth;
ejaculatory failure; extrapyramidal signs; nasal congestion;
weight ↑
b)- 5α-reductase inhibitors
e.g. finasteride, duta-steride
Used Prostate >40cm3 - Reduce testosterone's conversion
to dihydro-testosterone, the androgen which is effective.
Adverse-loss of hair, retrograde ejaculation, impotence
Combination of the two drugs often used.
c)Phytotherapy
Sans -palmetto berries
Pygium africanum
E.purpurae
After two weeks, do a trial without catheter of urine flow
and the IPSS score
If the flow rate is more than 10 mls/sec then management
depends on the IPSS score and patients desire.
IPSS score of 0-7 (mild) or 8-19(moderate symptoms)
management can be by watchful waiting and lifestyle
modification eg reducing fluid intake intake before bed
-The patient may continue with medical therapy above for
3 months.
Indications for surgery if any of the following:
1.Recurent urinary retention
2.Flow rate less than 10 ml/second
3.Deteriorating IPSS score
4. Failed medical therapy-compliance? Drug expired?
Usually medical treatment for 3 months.
5.Upper urinary tract complications as hydronephrosis
6.Recurent/refractory UTI
7.Renal failure
8.Prostatic calculi
9. Haemorrhage - Occasionally venous bleeding from a
ruptured vein overlying the prostate
10.Patient cant afford the medical therapy anymore
11.Patients choice
12. Presence of co-morbidity and deterioration of quality of
life.
13.Occupational consideration

4. minimum, routine urinalysis should be performed
If the flow rate is less than 10 mls/sec and severe IPSS
score(20-35) then surgical review
Continue with catheter and medication as they await
surgery.
NB. In chronic retention of urine –slow decompression of
the bladder by catheterization to avoid bleeding
If in renal failure then post catheterization go into a diuretic
phase
B.PATIENT WITHOUT ACUTE URINE RETENTION
Do IPSS
Mild and moderate score do watchful waiting and lifestyle
modification.
-reduce fluid intake in evening.
-Stop Alcohol and cigarette smoking
Severe without complications do medical treatment
above20-35 (IPSS).
With complications surgery
Surgery
Minimally invasive
1.Intraprosatic stents
2.Baloon dilatation
3.Lazer
4.Thermal ablation
5.Cryotherapy
6.Bladder neck incision
7.High Intensity focused ultrasound (HIFU)
8.Transurethral Needle Ablation (TUNA)
Invasive Surgery
Transurethral Procedures;
i)Transurethral Resection of the Prostate (TU-RP) – (Main)
Indicated for small prostates - 50-60g;Post-op - Put a 3-way
catheter (Balloning, irrigation & drainage) for 5-7days
ii)Transurethral Incision of the Prostate(TU-IP) - It relieves
pressure on the urethra with minimal destruction & less risk
of sexual dysfunction - Best surgical option for those with
small glands <30gm
iii)Transurethral Laser-Induced Prostatectomy (TU-LIP)
Open procedures
Larger prostates (usually > 75 g) may require open surgery
using the suprapubic or retropubic approach, permitting
enucleation of the adenomatous tissue from within the
surgical capsule. Becacause larger prostates require longer
transurethral resection times, with an increased risk of
TURP syndrome and anesthesia complications.
Transurethral resection of the prostate (TURP)
50-70g of prostate timed operation 90 minutes
i)Transvesical prostatectomy/(Frayer's prostatectomy)
*Post-op - Twin-tube bladder irrigation with warm saline to
wash out clots till effluent is clear (1-2days); Remove
urethral catheter after 8-14days.
ii)Retropubic prostatectomy/(Milin's prostatectomy)
*Post-op - Put a 3-way catheter (Balloning, irrigation &
drainage) for 5-7days
Advantages of Open Procedures;
-Reduced re-operation rate (1.8%)
-Peak flow post-operation is good
Transurethral resection of the prostate (TURP)
Standard is surgery is Transurethral resection of the prostate
(TURP) is preferred because of low morbidity . The major
complications include bleeding requiring transfusion,
failure to void, and infection; rarer is "TURP syndrome,"
severe hyponatremia due to systemic absorption of the
hypotonic bladder irrigation fluid used intra -operatively.
Symptoms are referable to excess ammonia production (a
glycine metabolite), excess fluid absorption (hyponatremia,
hypervolemia), or both (water intoxication
Ammonia intoxication
Ammonia encephalopathy may be manifested as a delayed
awakening in the postoperative period that persists despite
correction of intravascular fluid volume and electrolyte
balance.
Severe forms-somnolence, marked alteration in
consciousness seizures,coma
Patients may develop convulsions and/or oliguria up to 24
hours after the operation
Hyponatremia-Hypervolemia
Initial hypertension followed by hypotension, bradycardia,
headache, visual disturbance, restlessness, chest pain,
agitation, confusion, and lethargy
Post-op Advice
1.Avoid driving for 2wks after the operation
2.Avoid sex for 2wks after surgery
3.Expect to pass blood in the urine for the first 2wks
4. At first you may need to urinate more frequently than
before. In 6wks, things should be much better - but the
operation cannot be guaranteed to work (8% fail, & lasting
incontinence is a problem in 6%)
5.12-20% may need repeat TURPs within 8yrs, compared
with 1.8% of men undergoing open prostatectomy
6. If feverish, or if urination hurts, do urinalysis, m/c/s.
Complications of TURP
1.Haematuria/Haemorrhage
2.Infection; prostitis
3.Incontinence - ≤10%
4. Retrograde ejaculation - 65% - Resection of the sphincter
in the upper part of the prostate & bladder neck that
subserves a sexual function.
5.Erectile Dysfunction - ≤14% - results from damage of the
region of the neurovascular bundle supplying the autonomic
innervation to the copora of the penis in close relationship
to the posterolateral aspect of the prostatic capsule
6.Haematospermia
7.Urethral trauma/Stricture
8.Clot retention near strictures
9.Post TURP syndrome (↓T° , ↓Na+) - Systemic absorption
of the hypotonic bladder irrigation fluid used
intraoperatively (usually 1.2% Glycine or Purisol is used -
isosmolar & high conductance) leads to;
➢ Hypervolaemia with ↑BP
➢ Dilutional ↓Na+
➢ Haemolysis
➢ Cerebral oedema
Management Diuresis - Furosemide + Mannitol
10.Rupture of the Denonvilliers' fascia causing a faecal
fistula
11.20% need redoing within 10yr