Bladder outflow obstruction

1. Brig
HAROON SABIR KHAN
FCPS(Surg), FCPS(Uro)
FEBU(Eur), MHPE(RIU)
Professor of Urology
BLADDER OUTFLOW
OBSTRUCTION

2. CAUSES OF BLADDER OUTFLOW
OBSTRUCTION
• CONGENITAL - URETHRAL VALVES & STRICTURES
• STRUCTURAL:
• Benign prostatic hyperplasia
• Carcinoma of the prostate
• Bladder neck stenosis
• Urethral stricture
• FUNCTIONAL:
• Bladder neck dyssynergia
• Neurological disease - spinal cord lesions, MS, diabetes
• Drugs - anticholinergics, antidepressants

3. • INCIDENCE:
• Affects 50% men older than 60 years
• Affects 90% of men older than 90 years
• ANATOMY OF THE PROSTATE:
• Location
• Normal weight and size
• ETIOLOGY OF BPH:
• Age relationship
• Role of androgen vs estrogen / receptors
• Family history
• ? Role of diet

4. • PATHOPHYSIOLOGY OF BOO:
• Size of prostate vis-a-vis BOO
• Compensatory phase (detrusor hyperplasia)
• Detrusor de-compensation ( PVRU)
• SYMPTOMS OF BPH (LUTS - Voiding):
• Obstructive
• Hesitancy
• Poor flow
• Intermittency of stream
• Terminal dribbling
• Sense of incomplete evacuation of bladder
• Retention of urine
• Acute / chronic

7. • IRRITATIVE SYMPTOMS (LUTS - Storage)
• Urgency
• Frequency
• Day time / Night time (nocturia)
• Urge incontinence

8. • COMPLICATIONS OF BPH:
• Bladder changes
• Trabeculation
• Saccules / diverticulae
• Upper tract changes
• Haematuria
• Acute / chronic retention of urine
• Vesical stones
• `UTIs
• Post obstructive renal failure (uraemia)

10. COMPLICATIONS OF BPH (cont)
• Manifestations of prolonged straining (intra abdominal
pressure)
• Hernias
• Haemorrhoids

11. EVALUATION OF THE BPE
• Prostate symptom scoring
• IPPS scoring (scoring chart)
• Per abdominal examination and DRE
• Ultrasound scan of KUB, prostate and PVRU

12. IPPS
Urinary Symptoms (Symptom
Score Criteria)
Not at
all
Less than 1
time in 5
Less than half
the time
About half
the time
More than half
the time
Almost
Always
1. Incomplete emptying
Over the past month, how
often have you had a
sensation of not emptying your
bladder completely after you
finished urinating?
0 1 2 3 4 5
2. Frequency
Over the past month, how
often have you had to urinate
again less than two hours after
you finished urinating?
0 1 2 3 4 5
3. Intermittency
Over the past month, how
often have you found you
stopped and started again
several times when you
urinate?
0 1 2 3 4 5
4. Urgency
Over the past month, how
often have you found it
difficult to postpone urination?
0 1 2 3 4 5

13. IPPS
Urinary Symptoms (Symptom
Score Criteria)
Not at
all
Less than 1
time in 5
Less than half
the time
About half
the time
More than
half the time
Almost
Always
5. Weak Stream
Over the past month, how
often have you had a weak
urinary stream?
0 1 2 3 4 5
6. Straining
Over the past month, how
often have you had to push
or strain to begin urination?
0 1 2 3 4 5
None 1 time 2 times 3 times 4 times 5 or more
times
7. Nocturia
Over the past month, how
many times did you most
typically get up to urinate from
the time you went to bed at
night until the time you got in
the morning?
0 1 2 3 4 5

14. IPPS
QUALITY OF LIFE DUE TO URINARY PROBLEMS
Delighted Pleased Mostly
Satisfied
Mixed-about
equally satisfied
and un-satisfied
Mostly dis-
satisfied
Unhappy Terrible
If you were to spend the
rest of your life with
your urinary condition
just the way it is now,
how would you feel
about that?
0 1 2 3 4 5 6

15. UROFLOWMETRY

16. OTHER INVESTIGATIONS
• Blood CP
• Renal function profile
• Urine DR
• PSA

17. TREATMENT OF BPH:
• Watchful waiting (Lifestyle changes)
• Pharmacological treatment
• Alpha adrenergic blockers
• Prazosin
• Terazosin
• Doxazosin
• Alfuzosin
• Tamsulosin

18. • 5 α-reductase inhibitors
• Finesteride (Proscar)
• Dutasteride (Avodart)
• Phytotherapy (plant extracts)
• Saw palmetto (acti-pro)
• β-sitosterols (pronals)

19. • SURGICAL MANAGEMENT:
• Open prostatectomy > 80gm
• RPP (Retropubic)
• TVP (Trans-vesical)
• TURP < 80gm

20. TURP

22. TUIP (BNI)

23. • OTHER MINIMALLY INVASIVE
METHODS
• Endoscopic laser ablation of prostate (ELAP)
• Holmium laser enucleation of prostate (HoLEP)
• Interstitial laser coagulation
• Transurethral electroevaporation of the prostate
(TUVP)
• Transurethral microwave thermotherapy of the
prostate (TUMT)
• Transurethral radio frequency needle ablation of the
prostate (TUNA)

24. • OTHER MINIMALLY INVASIVE
METHODS
• Water-induced thermotherapy (WIT)
• High-intensity focused ultrasound (HIFU)
• Prostatic stent (stenting)
• Urolume
• mamotherm

25. ?

26. THANK YOU