2. INTRODUCTION
Urinary outflow obstruction and stasis with reflux of urine is of significant
importance in urological disorders because of their effects on renal functions
May lead to :
hydronephrosis
recurrent infection
Renal failure
Stone formation
Negatively affect quality of life significantly
BOO explained as decreased urine flow less than 10ml/sec. it is urodynamic concept
,over time will result in increased voiding intravesical pressure > 80 cm H2O.
Can occur in all age groups and both gender,but the etiology is different.
Common problem in elderly male population
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4. MICTURITION
• Filling phase
• The walls of ureters contain smooth muscle arranged in spiral ,longitudinal and
circular bundles ,but no distinct layers.
• Regular peristaltic contractions occurring one to five times per minute move the
urine to the bladder.
• The ureters pass obliquely through the bladder wall and also there are no
ureteral sphnicters as such,this configuration keeps the ureters closed except during
the perstaltic wave preventing reflux of urine from the bladder.
• Expected bladder capacity =30+(age in yrs x 30) ml.
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5. CONT…
• Emptying phase
• Contraction of the circular muscle ,detrusor muscle is mainly responsible in
this phase
• Internal urethral sphincter: smooth muscle bundles on either side of proximal
urethra .
• External urethral sphincter : skeletal muscle sphincter at membranous
urethra.
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8. ETIOLOGY OF BOO
• In adults the etiologies are acquired
• Mostly primary in the urinary tract but can be secondary to extrinsic lesions
invading or compressing the urinary passage
• BPH
• Urethral stricture
• Prostatic ca
• Bladder neck contracture
• Pelvic masses invading or compressing bladder outlet
• Neurogenic bladder
• UB neck ca
• Stone diseases
•
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9. ANATOMY OF PROSTATE
• Prostate :
• Accessory gland of male reproductive system (add secretion to seminal fluid)
• Measures 4x3x2cm as inverted cone shape
• Weight about 20 gram normally-
• Five lobes (ant., Post., median/middle, 2 lateral)
• Three zones (peripheral, transitional and central)
• Two capsules: true(condensation of peripheral part), false capsule
• Situated b/n UB and urogenital diaphragm
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10. BLOOD SUPPLY
Arteries ;inferior vesical,middle rectal,and internal pudendal artery
branchs:
Veins form a prostatic plexus which receives the dorsal vein of the penis
and drains into the internal iliac vein
Lymphatic drainage is primarily to the obturator and internal iliac nodes
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12. BENIGN PROSTATIC
HYPERPLASIA(BPH)
• BPH is one of the most common disease in aging men and common cause of
LUTS/BOO.
• 50% men over 50 years
• 90% men over 80 years
• Only 40% may complain symptoms
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14. CONT…
• Testosterone diffuses into prostate and stromal epithelial cells. Within
epithelial cells, it binds directly to the androgen receptor.
• In prostate stromal cells, the majority binds to 5AR (type II) on the nuclear
membrane, is converted to DHT, and then binds (with greater affinity and, therefore,
greater potency than testosterone) to the androgen receptor in the stromal cell.
• Some of the DHT formed in the stromal cells diffuses out of these cells and
into nearby epithelial cells (a paracrine action). Thereby inducing transcription of
androgendependent genes and subsequent protein synthesis.
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15. CONT…
• Slow and insidious changes occur in two main types
• Overgrowth of glandular elements
• Overgrowth of connective tissue elements
• Initial hyprtrophy =detrusor decompensation==poor bladder
tone=diverticula formation==increasing urine volume
(reflux)=hydronephrosis and upper tract dysfunction.
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16. PATHOPHYSIOLOGY CONT…….
• Dynamic component of BPO: 1-adrenoceptor-mediated prostatic
smooth muscle contraction. Smooth muscle accounts for
approximately 40% of the area density of the hyperplastic prostate and
human prostate contracts following administration of alpha adrenergic
agonists.
• Static component of BPO: mediated by the volume effect of BPE
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17. BENIGN PROSTATIC HYPERPLASIA
SYMPTOMS AND SIGNS
• Lower urinary tract symptoms can be described as:
● Voiding symptoms
● hesitancy
● poor flow
● intermittent stream – stops and starts;
● dribbling (including after micturition);
● sensation of poor bladder emptying;
● episodes of near retention.
• Storage symptoms
● frequency;
● nocturia;
● urgency;
● urge incontinence;
● nocturnal incontinence
• Haematuria and acute urinary retention may be the presenting complaint
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18. CONT…
• Approach to the patient
• Detailed history –urinary diary
• DRE –
• Labs-PSA,cr, cbc,U/A
• Flow rate measurement :
• Upper tract scan
• Cystourethroscopy
• Pressure flow studies –predict outcome after TURP (OPTIONAL)
• Post-void residual urine volume (PVR) -Along with serum creatinine, it indicates whether
watchful waiting is safe. PVR volume is <350mL,( no surgery)
•
•
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20. MANAGEMENT
• Goals of treatment
• To improve bothersome symptoms.
• To prevent symptom progression.
• To reduce long-term complications (urinary retention, renal insufficiency).
• The management is based on severity of the symptoms as well the availability of
treatment modalities.
• Initially offer lifestyle modification advice (e.g. advice on fluid intake, sugar control)
• mild or moderate bothersome LUTS—discuss active surveillance
- reassurance, lifestyle advice, no immediate treatment,
-regular follow-up
#active intervention (conservative management, drugs, surgery).
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21. CONSERVATIVE MANAGEMENT
• Storage symptoms: If overactive bladder (OAB) suspected, offer
supervised bladder training, advice on fluid intake, lifestyle advice and,
if needed, containment products, i.e. pads or sheaths; offer supervised
pelvic floor exercises for stress incontinence —continue for
at least 3 months before considering other options.
• Voiding symptoms: offer intermittent self-catheterization (ISC) before
indwelling or suprapubic catheterization if less invasive means fail to
correct LUTS consider medical and surgical interventions.
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22. DRUG TREATMENT
• Offer drug treatment where conservative options are unsuccessful or
inappropriate; take account of comorbidities and current treatments;
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23. CONT…..
• Alpha blocker classification
Alpha blockers are categorized by their selectivity for the AR and by their
elimination half-life.
• Non-selective: phenoxybenzamine—effective symptom control, but
high side effect profile.
• α1: prazosin, alfuzosin, indoramin.
• Long-acting α1: terazosin, doxazosin, alfuzosin SR.
• Subtype selective: tamsulosin—relatively selective for α1a-AR subtype
compared to the α1b subtype.
• Percentage of patients who respond to alpha blockers
Patients are able to perceive a 4-point improvement in IPSS. If ‘response’
is defined as >25% improvement in symptoms relative to placebo, most
studies describe response rates of 30–40%.
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24. 5α-REDUCTASE INHIBITORS
• 5α-reductase inhibitors inhibit the conversion of testosterone to DHT, the
more potent androgen in the prostate .
• causes shrinkage of the prostatic epithelium and, therefore, a reduction in prostate
volume.
• finasteride ,dutasteride
• Can be used in combination with alpha blocker.
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25. MINIMALLY INVASIVE MANAGEMENT OF
BPH:
• The two broad categories of alternative surgical techniques are minimally invasive
and invasive.
• All are essentially heat treatments, delivered at variable temperature and power and
producing variable degrees of coagulative necrosis (minimally invasive) of the
prostate or vaporization of prostatic tissue (invasive).
•
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26. CONT…
• Transurethral microwave
thermotherapy (TUMT)
• Transurethral radiofrequency needle
ablation (TUNA) of the prostate
• Transurethral electrovaporization of
the prostate (TUVP)
• as effective as TURP for symptom control
and relief of BOO,
• Holmium laser enucleation of the prostate
(HoLEP)
•
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27. TURP AND OPEN PROSTATECTOMY
• Indications for TURP
• Bothersome LUTS that fail to respond to changes in lifestyle or
medical therapy.
• Recurrent acute urinary retention.
• Renal impairment due to BOO (high-pressure chronic urinary retention).
• Recurrent haematuria due to BPE.
• Bladder stones due to prostatic obstruction.
• Open prostatectomy
Indications
• Large prostate (>100gm).
• TURP not technically possible (e.g. limited hip abduction).
• Failed TURP (e.g. because of bleeding).
• Urethra too long for the resectoscope to gain access to the prostate.
• Presence of bladder stones which are too large for endoscopic
cystolitholapaxy, combined with marked enlargement of the prostate.
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29. URETHRAL STRICTURES AND STENOSES
• A urethral stricture is a scar in the subepithelial tissues of the corpus
spongiosum which constricts the lumen of the urethra and make it narrower.
• The 2nd commonest cause of Lower urinary tract obstruction in sub Saharan Africa
• Age range 2o-40 years
• Female -Uncommon ~3%
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The transition zone surrounds the urethra proximal to the ejaculatory ducts. The central zone surrounds the ejaculatory ducts and projects under the bladder base. The peripheral zone constitutes the bulk of the apical, posterior, and lateral aspects of the prostate. The anterior fibromuscular stroma extends from the bladder neck to the striated urethral sphincter.
Peripheral zone (PZ), central zone (CZ) and transitional zone (TZ) at apex of pre-prostatic sphincter (PPS). Seminal vesicles (SV) and ducti deferentes (DD) fuse to form ejaculatory ducts opening alongside verumontanum (V).
The seminal vesicles lie just cephalad to the prostate under the base of the bladder. They are about 6 cm long and quite soft. Each vesicle joins its corresponding vas deferens to form the ejaculatory duct. The ureters lie medial to each, and the rectum is contiguous with their posterior surfaces.
Peripheral zone: Nearly 75% of the glandular prostate, the peripheral zone surrounds most of the central zone and much of the urethra; in other words, it surrounds the posterior and lateral areas of the prostate gland. Its glands drain into the prostatic urethra.
Central zone: The central zone, which is nearly 25% of the glandular prostatic parenchyma, envelops the ejaculatory ducts and extends toward the base of the urinary bladder.
Transitional zone: This zone is less than 5% of the glandular prostate. The transition zone is composed of two minute glandular regions which are lateral to the preprostatic sphincter and directly related to the proximal urethral segment. The periurethral region is related to this zone and to the junction of the proximal and distal urethral segments. Periurethral ducts, which are responsible for the genesis of benign prostatic hyperplasia, are present.
Stroma ;The anterior fibromuscular stroma is nonglandular. It constitutes ⅓ of the prostatic tissue within the prostatic capsule but is in continuity with the detrusor muscle of the neck of the urinary bladder. It is heavily fixed with the anterior surfaces of the three glandular zones, and represents the periurethral gland region.
Three capsule:
The true capsule is a very thin covering surrounding the gland in toto.
The false capsule (periprostatic fascia or prostatic sheath) is an extraperitoneal fascia (visceral layer of endopelvic fascia).
The peripheral part of the prostate becomes compressed by BPH against the surrounding endopelvic connective tissue(true and false capsules), forming a surgical capsule (pathologic capsule). When enucleation of the prostate is performed, the plane between the compressed peripheral tissue and the adenomatous tissue permits removal of the adenoma, leaving behind the peripheral condensed prostatic tissue and the anatomic capsule.
Between the true and false capsules is a venous plexus, the prostatic or pudendal venous plexus present.
A typical history and a flow rate <10 mL/s (for a voided volume of >200 mL;
Finasteride is a competitive inhibitor of the enzyme 5α-reductase (type II isoenzyme), which converts testosterone to DHT. Finasteride, therefore, lowers serum and intraprostatic DHT levels. Epristeride is a dual inhibitor of 5α-reductase. Whether it has any clinically significant advantages over finasteride remains to be established.
