Benign prostatic hyperplasia

SAM, MSIGWA-MD
UNIVERSITY OF DODOMA -
TANZANIA
04/09/2014 MSIGWA,SAM-MD 1

 The prostate is Greek for "protector“ or
“to stand before” .
 It is an exocrine gland of the male
reproductive system in most mammals
 In 2002, female paraurethral glands, or
Skene's glands, were officially renamed
the female prostate by the Federative
International Committee on Anatomical
Terminology

The prostate is a firm, partly gland and partly
muscular body, and is placed immediately
below the internal urethral orifice and around
the beginning of the urethra.
It is situated in the pelvic cavity, below the lower
part of the symphysis pubis, above the superior
fascia of the urogenital diaphragm, and in front
of the rectum.
Size of a chestnut and conical in shape

 Consist of a base, an apex, an anterior, a
posterior and two lateral surfaces.
 The base (basis prostatæ) is directed upward,
and is attached to the inferior surface of the
bladder, The greater part of this surface is
directly continuous with the bladder wall; the
urethra penetrates it.
 The apex (apex prostatæ) is directed
downward, and is in contact with the superior
fascia of the urogenital diaphragm

 Vessels and Nerves
 The arteries supplying the prostate are
derived from the internal pudendal, inferior
vesical, and middle hemorrhoidal.
 Its veins form a plexus around the sides and
base of the gland; they receive in front the
dorsal vein of the penis, and end in the
hypogastric veins.
 The nerves are derived from the pelvic
plexus

 The prostate is divided into lobes.
The anterior lobe
 is the portion of the gland that lies in front of
the urethra.
 It contains no glandular tissue but is made up
completely of fibromuscular tissue.

The median or middle lobe
is situated between the two ejaculatory ducts and
the urethra.
The lateral lobes
make up the main mass of the prostate.
 They are divided into a right and left lobe and
are separated by the prostatic urethra.

The posterior lobe
 is the medial part of the lateral lobes and can
be palpated through the rectum during digital
rectal exam (DRE).
 The prostate is surrounded by the prostatic
capsule. Invasion of the capsule changes the
stage of disease

 Divided into 3 zones :
Peripheral zone (PZ). .
 The peripheral zone is in the outer most part of the
prostate, and the lower peripheral zone is fairly
close to the rectal wall. The peripheral zone is the
most common site for prostatic adenocarcinoma
-70% of CAP originate here.
-largest anatomical subdivision.
-contains 70-75% of normal prostatic glandular
tissue
-no contribution to BPH.

Central zone (CZ);
 The central zone is in the center of the prostate and
cancer does not originate there often.
 25% of normal glandular tissue
-10% of CAP originate here.
Transition zone (TZ); .
 The transitional zone is above the central zone and is a
common site for benign prostatic hypertrophy, a non-malignant
condition of the prostate, but cancer may
originate there as well but not as often as in the
peripheral zone.
 5% of normal glandular tissue.
-lies adjacent to prostatic urethra.
-site of BPH.
-expands to compress the outer PZ to form the false
capsule.

 Preprostatic zone;
 1% of normal gland.
-smallest and most complex.
-sphincteric function prevents reflux
ejaculation.

 It secretes a slightly alkalic fluid, milky in appearance,
that usually constitutes 50–75% of the volume of the
semen along with spermatozoa and seminal vesicle
fluid.
 Prostate secretion in human consist of proteolytic
enzymes, prostatic acid phosphatase, beta-microseminoprotein,
prostate-specific antigen and zinc
(more than 500 times concentration than in blood!)
 Spermatozoa which was expelled in prostatic fluid
have better motility, longer survival and better
protection of the genetic material.
 The prostate also contains some smooth muscles that
help expel semen during ejaculation

 Testosterone will be transformed into a more active
form of the hormone, called dihydrotestosterone
(DHT) by 5-alpha-reductase in the prostate.
 When men gets older, part of the transition zone in the
prostate which grows throughout lifes will still be
reacted to the hormone which will cause
prostatomegaly.
 Adenomatous prostatic growth is believed to begin at
approximately age 30 years.
 An estimated 50% of men have histologic evidence of
BPH by age 50 years and 75% by age 80 years; in 40–
50% of these men, BPH becomes clinically significant. 04/09/2014 MSIGWA,SAM-MD 23

 The growth of the prostate is governed by many local
and systemic hormones whose exact functions are not
yet known.
 The main hormone acting on the prostate is
testosterone, which is secreted by the Leydig cells of
the testes under the control of luteinising hormone
(LH), itself secreted from the anterior pituitary under
the control of hypothalamic luteinising hormone
releasing hormone (LHRH).
 LHRH has a short half-life and is released in a pulsatile
manner. This pulsatile release is important, as
receptors for LHRH will become desensitised if
permanently occupied.

 The administration of LHRH analogues in a
continuous, non-pulsatile manner exploits the concept
of receptor desensitisation and forms the basis for
androgen deprivation therapy in prostate cancer.
 Testosterone is converted to 1,5- dihydrotestosterone
(DHT) by the enzyme 5α-reductase, which is found in
high concentration in the prostate and the perigenital
skin (type II).
 Other androgens are secreted by the adrenal cortex, but
their effects are minimal in the normal male.
 Oestrogenic steroids are also secreted by the adrenal
cortex and, in the ageing male, may play a part in
disrupting the delicate balance between DHT and local
peptide growth factors, and hence increase the risk of
BPH 04/09/2014 MSIGWA,SAM-MD 25

 Increased levels of serum oestrogens, by acting on the
hypothalamus, decrease the secretion of LHRH (and hence LH)
and thereby decrease serum testosterone levels.
 Thus, pharmacological levels of oestrogens cause atrophy of the
testes and prostate by means of reductions in testosterone.
 Other locally acting peptides are secreted by the prostatic
epithelium and mesenchymal stromal cells in response to steroid
hormones.
 These include epidermal growth factor, insulin-like growth
factors, basic fibroblast growth factor and transforming growth
factors alpha and beta.
 These undoubtedly play a part in normal and abnormal prostatic
growth, but as yet their functions are unclear

 A role for estrogens in the prostate pathology of
the ageing male appears likely with accumulating
evidence that estrogens, alone or in combination
with androgens, are involved in inducing aberrant
growth and/or malignant change.
 Animal models have supported this hypothesis in
the canine model, where estrogens “sensitize”
 the ageing dog prostate to the effects of
androgen[40].
 The evidence is less clear inhumans..

 Estrogens in the male are predominantly the
products of peripheral aromatization of
testicular and adrenal androgens
 While the testicular and adrenal production of
androgens declines with ageing, levels of total
plasma oestradiol do not decline.
 This has been ascribed to the increase in fat
mass with ageing (the primary site of
peripheral aromatization) and to an increased
aromatase activity with ageing.

 However, free or bioavailable estrogens may
decline due to an increase in sex hormone
binding globulin, which could translate to
lower intraprostatic levels of the hormone.
 The potentially adverse effects of oestrogens on
the prostate may be due to a shift in the intra-prostatic
estrogen:androgen ratio with ageing

 Prostate-specific antigen (PSA) is a glycoprotein that is
a serine protease.
 Its function may be to facilitate liquefaction of semen,
but it is a marker for prostatic disease.
 It is measured by an immunoassay, and the normal
range can differ a little from laboratory to laboratory.
 There is no real normal upper limit. The levels increase
with age, with prostate cancer and with BPH.
 There are age-related values but, in general, in men
aged 50–69 years, a level of about 3–4 ng ml –1 would
prompt a discussion about the need for prostate
biopsy.

 Its level in men with metastatic prostate cancer is
usually increased to > 30 ng ml –1 and falls to low
levels after successful androgen ablation.
 Men with locally confined prostate cancer usually
have serum PSA levels <10–15 ng ml –1
 Although PSA is a reliable marker for the
progression of advanced disease, it is neither
specific nor sensitive in the differential diagnosis
of early prostate cancer and BPH, as both diseases
are compatible with PSA in the range of 3–15 ng
ml–1

 PSA measurement has superseded
measurement of serum acid phosphatase.
 In summary, about 25% of men with a PSA of
4–10 ng ml –1 have prostate cancer (i.e. it is not
very specific), and about 15–20% of men with a
PSA of 1–4 ng ml –1 have prostate cancer.
 In general, one would advise men aged 50–69
years to undergo prostate biopsy if the PSA
was more than ~ 3 ng ml–1
. The threshold would be lower in younger men
with a strong family history

 Benign prostatic hyperplasia (BPH) is the
enlargement of the gland .
 As the prostate starts to enlarge it exerts
pressure on the walls of the urethra.

 This affect most men over the age of 50 but only
10% present with symptoms.
 The severity of symptoms depends on the
degree of encroachment on the prostatic
urethra.
 Anatomically, BPH is most strongly associated
with the posterior urethral glands (PUG) and
transitional zone (TZ) of the prostate.
 However, the majority of growth eventually
occurs in the TZ.
 Since prostatic cancer also occurs in the PZ,
BPH nodules in the PZ are often biopsied to rule
out cancer

 D. Incidence of BPH increases with age
1. Men aged 60 years: 50%
2. Men aged 80 years: 88%
 E. Incidence of symptomatic onset is related to
ethnicity
 1. African American men:onset at age 60 years
 2. Caucasian men: onset at age 65 years

 Increasing age
 Family history of BPH
 Diet
 Obesity
 Lack of physical activity
 Erectile dysfunction

 The only clearly defined risk factors for BPH
are age and the presence of circulating
androgens.
 BPH does not develop in men castrated before
the age of forty .
 But other factors may influence the prevalence
of clinical disease. These include:

 Clinical BPH appears to run in families.
 If one or more first degree relatives are affected, an
individual is at greater risk of being afflicted by the disorder
[54]. In a study
 by Sanda et al [55] the hazard-function ratio for surgically
treated BPH amongst first
 degree relatives of the BPH patients as compared to controls
was 4.2 (95% CI, 1.7 to
 10.2). The incidence of BPH is highest and starts earliest in
blacks than Caucasians and is lowest in Asians [47].
 Interestingly, despite having larger prostate glands, the age-adjusted
risk of BPH was the same for blacks as for whites
 Furthermore, in an Asian population, men presenting with
BPH are likely to have higher symptom scores than blacks
or Caucasians

 Diet has been reported as a risk factor for the
development of BPH.
 Large amounts of vegetables and soy products
in the diet may explain the lower rate of BPH in
the orient when compared to westernized
countries.
 In particular, certain vegetables and soy are
said to be high in phyto-oestrogens, such as
genestin, that have antandrogenic effects by an
as yet determined mechanism on the prostate
in vitro [

 It has not been possible to delineate any other
risk factors for BPH such as coronary
 artery disease, liver cirrhosis or diabetes
mellitus.
 There is also no causal relationship between
prostatic malignancy and benign hyperplasia

BPH is part of the natural
aging process, like getting
gray hair or wearing glasses
BPH cannot be prevented
BPH can be treated
n
n
n

 Several theories have been proposed to explain the etiology
of the pathological phase of BPH.
 The major theories include the hypotheses that pathological
BPH is due
Hormones
1) Dihydrotestosterone (DHT) hypothesis-a
shift in prostatic androgen metabolism that occurs with
aging, which leads to an abnormal accumulation of
dihydrotestosterone, thus producing the enlarged prostate.
This is supported by the
 fauilure of BPH development in men castrated before
puberty.

 Serum testosterone levels slowly but
significantly decrease with
 advancing age; however, levels of oestrogenic
steroids are not decreased equally.
 According to this theory, the prostate enlarges
because of increased oestrogenic effects.
 It is likely that the secretion of intermediate
peptide growth factors plays a part in the
development of BPH .

 2) Embryonic reawakening theory- assumes a reawakening of the
embryonic induction potential of prostatic stroma. In summary, a
change in the prostatic stromalepithelial interaction that occurs
with aging occurs, which leads to an inductive effect
 on prostatic growth.
 3) Stem cell theory featuring an increase in the total prostatic stem
cell number
 and/or clonal expansion of the stem cells into amplifying and
transit cells that
 occurs with aging.
 4) Inflammatory theory- Prostatic inflammation may contribute to
prostate growth
 due to the induction of cell growth due to the presence of
inflammatory markers and
 agents stimulating growth

 BPH affects both glandular epithelium and
connective tissue stroma to variable degrees.
 These changes are similar to those occurring in
breast dysplasia (see Chapter 50), in which
adenosis, epitheliosis and stromal proliferation
are seen in differing proportions.

 BPH typically affects the submucous group of
glands in the transitional zone, forming a
nodular enlargement.
 Eventually, this overgrowth compresses the PZ
glands into a false capsule and causes the
appearance of the typical ‘lateral’ lobes.

What is Benign Prostatic Hyperplasia?
Peripheral zone
Transition zone
Urethra

Peripheral zone
Transition zone
Urethra

 When BPH affects the subcervical CZ glands, a
‘middle’ lobe develops that projects up into the
bladder within the internal sphincter (Fig.
73.3).
 Sometimes, both lateral lobes also project into
the bladder, so that, when viewed from within,
the sides and back of the internal urinary
meatus are surrounded by an intravesical
prostatic collar

 It is important to realise that the relationship
between anatomical prostatic enlargement,
lower urinary tract symptoms (LUTS) and
urodynamic evidence of bladder outflow
obstruction (BOO) is complex
 Pathophysiologically, BOO may be caused in
part by increased smooth muscle tone, which is
under the control of α-adrenergic agonists

Urethra
The prostatic urethra is lengthened, sometimes to
 twice its normal length, but it is not narrowed
anatomically.
 The normal posterior curve may be so
exaggerated that it requires a curved catheter
to negotiate it.
 When only one lateral lobe is enlarged,
distortion of the prostatic urethra occurs.

Bladder.
If BPH causes BOO, the musculature of the
bladder
 hypertrophies to overcome the obstruction and
appears trabeculated (Fig. 73.5).
 Significant BPH is associated with increased
blood flow, and the resultant veins at the base
of the bladder are apt to cause haematuria.

 In both sexes, non-specific symptoms of
bladder dysfunction become more common
with age, probably owing to impairment of
smooth muscle function and neurovesical
coordination.
 Not all symptoms of disturbed voiding in
ageing men should therefore be attributed to
BPH causing BOO.

 Urologists prefer the term
 LUTS and discourage the use of the descriptive
term ‘prostatism’.
 The following conditions can coexist with BOO,
leading to difficulty in diagnosis and in
predicting the outcome of treatment:

1• idiopathic detrusor overactivity
2• neuropathic bladder dysfunction as a result of
diabetes, strokes, Alzheimer’s disease or
Parkinson’s disea
3.Degeneration of bladder smooth muscle giving
rise to impaired voiding and detrusor instability;
4• BOO due to BPH

• VOIDING
 – hesitancy (worsened if the bladder is very
full);
 – poor flow (unimproved by straining);
 – intermittent stream – stops and starts;
 – dribbling (including after micturition);
 – sensation of poor bladder emptying;
 – episodes of near retention.

• STORAGE
 – frequency;
 – nocturia;
 – urgency;
 – urge incontinence;
 – nocturnal incontinence (enuresis)

 This is a urodynamic concept based on the
combination of low flow rates in the presence of
high voiding pressures. It can be diagnosed
definitively only by pressure–flow studies.
 This is because symptoms are relatively non-specific
and can result from detrusor instability,
neurological dysfunction and weak bladder
contraction.
 Even low measured peak flow rates (< 10–12 ml s–
1) are not absolutely diagnostic because, in
addition to BOO, weak detrusor contractions or
low voided volumes (owing to instability) can be
the cause.

 Nonetheless, flow rates provide a useful guide
for everyday clinical management.
 Urodynamically proven BOO may result from:
 • BPH;
 • bladder neck stenosis;
 • bladder neck hypertrophy;
 • prostate cancer;
 • urethral strictures;
 • functional obstruction due to neuropathic
conditions.

 • Urinary flow rates decrease
 (for a voided volume > 200 ml, apeak flow rate
of > 15 ml s –1 is normal , one of 10–15 ml s –1
is equivocal and one < 10 ml s –1 is low
 • Voiding pressures increase
 (pressures > 80 cmH 2 O are high (Fig. 73.8),
pressures between 60 and 80 cmH 2 O are
equivocal and pressures < 60 cmH 2 O are
normal).

 1 The bladder may decompensate so that
detrusor contraction becomes progressively
less efficient and a residual urine develops.
 2 The bladder may become more irritable
during filling with a decrease in functional
capacity partly caused by detrusor overactivity
(see Chapter 76), which may also be caused by
neurological dysfunction or ageing, or may be
idiopathic.

 1 Acute retention of urine is sometimes the first
symptom of BOO.
 Postponement of micturition is a common
precipitating cause; overindulgence in beer and
confinement to bed on account of intercurrent
illness or operation are other causes.

 2 Chronic retention.
 In patients in whom the residual volume is >
250 ml or so the tension in the bladder wall
 increases owing to the combination of a large
volume of residual urine and increased resting
and filling bladder pressures (acondition
known as high-pressure chronic retention).
 The increased intramural tension results in
functional obstruction of the upper urinary
tract with the development of bilateral
hydronephrosis

 As a result, upper tract infection and renal
impairment may develop.
 Such men may present with overflow
incontinence, enuresis and renal insufficiency.
 These symptoms should alert the doctor to the
presence of this condition
 3 Impaired bladder emptying.
 If the bladder decompensates with the
development of a large volume of residual urine,
urinary infection and calculi are prone to develop.

 4 Haematuria. This may be a complication of
BPH. Other -causes must be excluded by
carrying out an intravenous urography (IVU),
cystoscopy, urine culture and urine cytological
examination.
 5 Other than pain from retention, pain is not a
symptom of BOO, and its presence should
prompt the exclusion of acute retention,
urinary infection, stones, carcinoma of the
prostate and carcinoma in situ of the bladder

History
 Symptom score sheets such as the International
Prostate Symptom Score (IPSS) assign a score
which gives information regarding the severity
of symptoms at the outset and changes over
time and following intervention.

Grading Scale (regarding questions below)
 Score 0: Not at all
 Score 1: Less than 1 in 5 times (<20%)
 Score 2: Less than half the time (<50%)
 Score 3: About half the time (50%)
 Score 4: More than half the time (>50%)
 Score 5: Almost always (>80%)

 Questions pertaining to the last month of
symptoms
 1. Incomplete voiding or emptying sensation
 2 .Frequency (urination within 2 hours of prior
void)
 3. Intermittency (stream stops and starts while
voiding)
 4. Urgency (difficulty postponing urination)
 5. Weak urinary stream
 6.Straining to begin urination
 7. Nocturia (How many times per night of waking
to void?)

 Interpretation (Add total score for 7 questions
above)
 Total score <7: Mild BPH Symptoms
 Total score 8 to 19: Moderate BPH Symptoms
 Total score >20: Severe BPH Symptoms

 General physical examination
 may demonstrate signs of chronic renal
impairment with anaemia and dehydration.

 Abdominal examination
 Abdominal extension is usually normal.
 In patients with chronic retention, a distended
bladder will be found on palpation, on
percussion and sometimes on inspection with
loss of the transverse suprapubic skin crease.
 The external urinary meatus should be
examined to exclude stenosis, and the
epididymides are palpated for signs of
inflammation.

 Normal size is 3.5 cms wide,
protruding about 1 cm into the lumen
of the rectum.
 Consistency: it is normally rubbery and
firm with a smooth surface and a
palpable sulcus between right and left
lobes.
 There should not be any tenderness.
 There should be no nodularity.

 The posterior surface of the prostate (what we
palpate) is in close contact with the anterior
rectal wall.
 A sulcus runs through the middle of the
prostate and divides it into right and left lobes.

 Size
 Contour
 Consistency
 Mobility
 Protrusion into the rectum
 Grade 1, Grade 2, Grade 3, Grade 4
 Sulcus present
 Pain with palpation

 Pencil eraser
 Tip of your nose
 Thenar pad

 Benign prostatic hypertrophy
 Prostate carcinoma
 Acute prostatitis
 Chronic prostatitis
 Others: Prostatic calculi or abscesses

 The normal tissue is replaced by collagen.
 Results in expansion of the capsule, leading to
pressure on the urethra; bladder and urinary
symptoms (as discussed earlier).
 All or part of prostate may enlarge.

 The degree of enlargement of the prostate may
not be related to symptoms
 i.e., a prostate that is markedly enlarged may not
obstruct urinary flow

 “Acute urinary retention” may occur, and in
general symptoms may be aggravated by:
 Exposure to cold
 Immobilization
 Attempts to retain urine
 Anesthetics, anticholinergics
 Ingestion of alcohol

 Size—enlarged
 Consistency: boggy, squishy, smooth
 Mobility—remains fairly mobile
 Protrusion—Grade depends on stage
 Sulcus—may be obscured (vs. obliterated)
 Should be nontender

 In benign enlargement,
 the posterior surface of the prostate is smooth,
convex and typically elastic, but the fibrous
element may give the prostate a firm consistency.
 The rectal mucosa can be made to move over the
prostate.
 Residual urine may be felt as a fluctuating
swelling above the prostate. It should be noted
that, if
 there is a considerable amount of residual urine
present, it pushes the prostate downwards,
making it appear larger than it is.

 The nervous system
 The nervous system is examined to eliminate a
neurological lesion. Diabetes mellitus, tabes
dorsalis, disseminated sclerosis, cervical
spondylosis, Parkinson’s disease and other
neurological states may mimic prostatic
obstruction.
 If these are suspected then a pressure–flow
urodynamic study should be carried out to
diagnose BOO.
 Examination of perianal sensation and anal tone is
useful in detection of an S2 to S4 cauda equina
lesion

 Urinalysis/MCS.
 Examination of urine
 The urine is examined for glucose and blood; a
midstream specimen should be sent for
bacteriological examination, and cytological
examination may be carried out if carcinoma in
situis thought possible.

 Blood tests(FBC+ESR, E&U/Cr)
 Serum creatinine, electrolytes and haemoglobin
should be measured.
 PSA: age specific.
 However if abnormal, then
-PSA velocity- a rise >0.75ng/ml/yr suggests CAP.
-PSA density- (PSA/prostatic vol.) results
>0.15ng/ml suggests CAP.
PSAD is aimed at differentiating rise in PSA due to
BPH from CAP.

 Upper tract imaging
 Most urologists no longer carry out imaging of
the upper tract in men with straightforward
symptoms.
 Obviously, if infection or haematuria is
present, then the upper tract should be imaged
by means of intravenous urogram or
ultrasound scan.
 Ultrasound of the testicles, prostate, and
kidneys is often performed, to rule out
malignancy and hydronephrosis

Cystourethroscopy
 Inspection of the urethra, the prostate and the urothelium of
the
 bladder should always be done immediately prior to
prostatectomy, whether it is being done transurethrally or
by the open route to exclude a urethral stricture, a bladder
carcinoma and the occasional non-opaque vesical calculus.
 The decision of whether to perform prostatectomy must be
made before cystoscopy.
 This should be based on the patient’s symptoms, signs and
investigations.
 Direct inspection of the prostate is a poor indicator of BOO
and the need for surgery

 Prostatic biopsy.
INDICATIONS:
 Abnormal DRE
 Elevated PSA >10ng/ml
 Free PSA percent < 20.
 Urine flow rate, post void residual urine,
Pressure flow Urodynamics.
Indicated in patients with moderate to severe
symptoms IPSS 8-20 where decisions have to
be taken on modalities of treatment.

 URINE FLOW RATE.
-Peak Flow Rate (PFR) >15ml/s = normal.
10-15ml/s = equivocal
<10ml/s suggests BOO.
 POST VOID RESIDUAL VOLUME.
-measured by transabd USS.
value >200ml indicate need for surgery.

 Urethrocystoscopy. Indicated prior to surgery
to select the correct operative modalities.
 Imaging of upper tract:
- IVU
-Abdominal USS
 TRUS and TRUS-guided biopsy.
 Colour doppler imaging of the prostate.

• Dipstick urinalysis should be performed in all
BPH-LUTS patients to rule out other diagnoses
that may cause LUTS.
• Abnormal/borderline urinalysis results should
be repeated and/or followed with a urine
culture

Urinalysis result Possible diagnosis
Hematuria Kidney stones
Bladder cancer
Pyuria or nitrates UTI
Urethral stricture
Proteinuria Underlying renal disease
Glucosuria diabetes

 BPH does not cause prostate cancer, however
men at risk of BPH are also at risk of
developing prostate cancer.
 It is a sensitive screening test for prostate
volume.
 Men at age 50 who are expected to live at least
10 more year.
 45 years in men who are at high risk ( African
American’s or close relative with prostate
cancer )
04/09/2014 MSIGWA,SAM-MD 100

 Help determine prostate and bladder size and
degree of hydronephrosis in patients with
urinary retention.
 Transrectal ultrasonography is recommended
in selected patients to determine the
dimensions and volume of the prostrate.
04/09/2014 MSIGWA,SAM-MD 101

 It is indicated in patients whom a malignancy
or foreign body is suspected.
04/09/2014 MSIGWA,SAM-MD 102

1-7 = mild 8-19 = moderate 20-35 = severe
04/09/2014 MSIGWA,SAM-MD 103

MODALTIES INCLUDE:
 Waitful watching
 Medical therapy
 Minimally invasive Rx
 Surgery.
04/09/2014 MSIGWA,SAM-MD 106

 WATCHFUL WAITING:
 Offer to pts with IPSS < or =8 who are not
bothered by their symptoms.
 Involves regular assessment of IPSS, PSA, PFR,
PVR.
 Contraindications: AUR, chronic retention,
recurrent UTI, dilatation of upper tracts.
04/09/2014 MSIGWA,SAM-MD 107

 Suitable for patients where:
- low risk of progression
- sx not particularly bothersome
 Regular monitoring using IPSS score will
objectively identify deterioration
 Education
 Lifestyle advice
 Reassurance
04/09/2014 MSIGWA,SAM-MD 108

Lifestyle
Patients should decrease fluid intake before
bedtime, moderate the consumption of alcohol
and caffeine-containing products, and follow
timed voiding schedules.
04/09/2014 MSIGWA,SAM-MD 109

 Alpha-blockers are a first-line option for men with
symptomatic bother who desire treatment
 5ARI’s are an effective option for symptomatic patients
with demonstrable prostatic enlargement
 Combination alpha-blocker and 5-ARI therapy
improves symptom score and peak urinary flow vs.
monotherapy; appropriate for patients with LUTS
associated with prostatic enlargement
 A PDE5 inhibitor can be used once-daily in men with
moderate to severe symptoms and bother, to effectively
reduce symptoms of BPH-LUTS while maintaining
sexual function
 Phytotherapy is not recommended by the CUA
04/09/2014 MSIGWA,SAM-MD 110

 Prostate smooth muscle tone is mediated via
a1-adrenergic receptor
 Blockage of the receptor leads to improvement
of flow rate and LUTS1
 Central a-receptors and the effect of agents on
these receptors likely play an additional role
 Density of adrenergic receptors changes with
prostate size and age
 Three a1-adrenergic receptor subtypes have
been identified (A, B, D)
Schwinn DA. BJU Int. 2000;86(suppl 2):11-22.
04/09/2014 MSIGWA,SAM-MD 111

 Nonselective
 Phenoxybenzamine
 Short-acting selective a1-blocker
 Prazosin, Alfuzosin
 Long-acting selective a1-blockers
 Terazosin
 Doxazosin
 Long-acting selective a1A-subtype
 Tamsulosin
 Alfuzosin-SR
04/09/2014 MSIGWA,SAM-MD 114

 All currently available a1-blockers induce fast
improvement in LUTS and flow rate parameters
with similar efficacy
 They are all well tolerated; however, the adverse
event spectrum differs between the agents
 Terazosin and doxazosin induce more dizziness, fatigue,
and asthenia
 Tamsulosin induces more ejaculatory disturbances
 None of the a1-blockers alter urodynamic
parameters, prostate volume or serum PSA
 None have been shown to alter the natural history
of the disease or prevent AUR / Surgery
04/09/2014 MSIGWA,SAM-MD 115

• Selective antagonist of α1-adrenoceptors located in:
• Prostate
• Prostatic capsule
• Bladder base
• Bladder neck
• Prostatic urethra
• Help relax smooth muscle in the bladder neck and prostate;
allow urine to flow more freely
• Selective and non-selective alpha-blockers exist
• Non-selective alpha-blockers are not commonly used for
BPH-LUTS
04/09/2014 MSIGWA,SAM-MD 116

• First line options include
Selective :- Alfuzosin
Tamsulosin
Silodosin
Non selective: Doxazosin
Terazosin
• Equal clinical effectiveness for LUTS secondary
to BPH
• Do not alter the natural progression of the
disease
• Choice of agent should depend on
comorbidities, side effect profile and tolerance
04/09/2014 MSIGWA,SAM-MD 117

 Retrograde ejaculation
 Asthenia •
 Dizziness
 Orthostatic hypotension
 Nasal congestion
04/09/2014 MSIGWA,SAM-MD 118

 Prostatic differentiation & growth depend on androgenic
stimulation
 Testosterone is converted to dihydrotestosterone (DHT)
within the prostatic stromal & basal cells facilitated by
5a-reductase enzyme
 5a-reductase inhibitor: deprive the prostate of its
testosterone support
 5a-reductase enzyme:
Type I: skin & liver
Type II: stromal & basal cells of prostate, seminal vesicle,
epididymis
Kirby RS et al. Br J Urol. 1992;70:65-72
Tam0m4/e0la9 /T2L0J1 e4t al. J Urol. 1993;149:342-344 MSIGWA,SAM-MD 119

Serum testosterone (T)
Serum Dihydrotestosterone (DHT)
DHT
DHT-androgen
receptor complex
Growth
factors
Unbalanced
T
5AR (1 and 2)
Prostate
cell
Increased
Cell growth
Cell death
04/09/2014 MSIGWA,SAM-MD 120

OH
O O
OH
H
5 a-reductase type 1 and 2
NADPH NADP
Testosterone Dihydrotestosterone
Avodart (dutasteride) - Dual (type 1&2) 5ARI
Proscar(finasteride) - Only type 2 5ARI
04/09/2014 MSIGWA,SAM-MD 121

• Indicated as first-line therapy for men with enlarged
prostates:
• Finasterideinhibits 5α-reductase Type 2 (prostate)
• Dutasterideinhibits 5α-reductase Type 1 AND 2 (liver, skin
and prostate)
• Blocks the conversion of testosterone to DHT
(responsible for prostate growth)
• Treatment with 5-ARIs reduce:
• Prostate size
• PSA
• Long-term risk of acute urinary retention
• Need for surgery
04/09/2014 MSIGWA,SAM-MD 122

 Reduced libido
 Decreased ejaculate volume
 Breast tenderness
04/09/2014 MSIGWA,SAM-MD 123

 Alpha blockers relax the smooth muscle of bladder neck
and prostatic capsule/adenoma, thereby improving
symptoms and flow rates, relieving obstruction
 5 ARIs reduce the action of androgens in the prostate,
inducing apoptosis, atrophy, and, by shrinking the prostate
improve symptoms, relieve obstruction and prevent AUR
& prostate surgery
5ARIs
Arrest disease progression
a1-adrenergic
blockers
Rapidly relieve symptoms
?
04/09/2014 MSIGWA,SAM-MD 125

Medical Therapy of Prostatic
Symptoms (MTOPS)
04/09/2014 MSIGWA,SAM-MD 126

 Combined alpha-blocker and 5-ARI therapy is
effective for LUTS associated with prostatic
enlargement
 Improves symptom score and peak urinary
flow greater than either monotherapy option
 Delays symptomatic disease progression
 Decreased risk of urinary retention and/or
prostate surgery
04/09/2014 MSIGWA,SAM-MD 127

 Promote smooth muscle relaxation.
 Improve LUTS.
 Improves quality of life.
 Effective in men with or without erectile
dysfunction.
 Tadalafil is the only approved PDE5 inhibitor
for BPH-LUTS.
04/09/2014 MSIGWA,SAM-MD 128

 Single arm therapy with alpha blocker
 Improve symptoms and prevent symptom progression
 Does not alter natural history or cross over to invasive therapy
 Single arm therapy with 5 ARI
 Treats symptoms only when LUTS associated with BPH (ie
enlargement or high PSA)
 Alters natural history in pts at risk (large gland, high PSA)
 Combination (doxazosin+finasteride) therapy is the
most effective form of treatment for LUTS and BPH
 Improve symptoms and flow rate
 Prevent AUR and/or surgery
 Alter the natural history of the disease
04/09/2014 MSIGWA,SAM-MD 129

 Headache
 Facial flushing
 Dyspepsia
04/09/2014 MSIGWA,SAM-MD 130

Drug class Time for symptom improvement
Alpha blockers 2-4 weeks
5 alpha reductase inhibitors Atleast 6 months
PDE5 inhibitors 4 weeks
04/09/2014 MSIGWA,SAM-MD 131

Case description Recommendation
Moderate – severe bother (PSA
1.3ng/ml)
Alpha blocker
Diabetes Alpha blocker
hypertension Alpha blocker
Erectile dysfunction Alpha blocker or PDE5
Enlarged prostate + PSA >
1.5ng/ml
5-ARI
Enlarged prostate + PSA >
1.5ng/ml + ED
5-ARI and/or PDE5
Bothersome sexual side effects
with α-blocker or 5-ARI PDE5
04/09/2014 MSIGWA,SAM-MD 132

A. Indications
 1. Failed medical therapy
 2. Refractory urinary retention
 3. Recurrent urinary tract infections
 4. Persistant haematuria
 5. Bladder stones
 6. Renal Insufficiency
04/09/2014 MSIGWA,SAM-MD 133

 Acute urinary retention
 Gross hematuria
 Frequent UTI
 Vesical stone
 BPH related hydronephrosis or renal function
deterioration
 Obstruction
IPSS≧8, prostate size, image study, UFR
cystoscopic findings, residual urine
04/09/2014 MSIGWA,SAM-MD 134

1. Transurethral Resection of the Prostate (TURP)
2. Open Prostatectomy (rarely used nowadays for
BPH alone)
 a. Very large prostate size
 b. Large median prostate lobe protruding into
bladder
 c. Urethral diverticulum
04/09/2014 MSIGWA,SAM-MD 135

Very large ( 80-100g ) Large ( 30-80g ) Small ( <30g )
Open prostatectomy TURP TURP
Laser prostatectomy
-holium
-greenlight
Laser prostatectomy
-holium
-greenlight
Minimally Invasive
- TUMT
- TUNA
04/09/2014 MSIGWA,SAM-MD 136

 Excessive bleeding requiring blood transfusion
 TUR syndrome
 Permanent sexual side effects:
 Retrograde ejaculation
 Erectile dysfunction (less common)
 Urinary tract infections
 Urinary incontinence
 Need for retreatment:
 Prostate regrowth
 Bladder/urethral strictures
04/09/2014 MSIGWA,SAM-MD 137

TURP
(transurethral resection of the prostate)
“Gold Standard” of care for BPH
Uses an electrical “knife” to surgically cut
and remove excess prostate tissue
Effective in relieving symptoms and
restoring urine flow
n
n
n
04/09/2014 MSIGWA,SAM-MD 138

 “Gold standard” of surgical treatment for BPH
 80~90% obstructive symptom improved
 30% irritative symptom improved
 Low mortality rate 0.2%
04/09/2014 MSIGWA,SAM-MD 139

 Done using a Resectoscope
 Used to Remove the Obstructing tissue in all
but the most enormous tissue,thereby carving a
passage way from the bladder
 Hospital stay is short
04/09/2014 MSIGWA,SAM-MD 140

 Gold Standard” of care for BPH
 Uses an electrical “knife” to surgically cut and
remove excess prostate tissue
 Effective in relieving symptoms and restoring
urine flow
04/09/2014 MSIGWA,SAM-MD 141

 Operation is performed through a modified
cystoscope
 Prostatic tissue is resected using an
electrically energized wire loop
 Prostatic capsule is usually preserved.
 Continuous irrigation is necessary to
distend the bladder and to wash away blood
and dissected prostatic tissue.
04/09/2014 MSIGWA,SAM-MD 142

•
04/09/2014 MSIGWA,SAM-MD 143

Ideally the irrigation
solution should be:
• Isotonic
• electrically inert
• Nontoxic
• Transparent
• inexpensive
• Nonhemolytic
• Nonmetabolized

 Prostate <60g.
 LUTS not responding to change in
lifestyle/medical therapy
 Recurrent acute urinary retention.
 Renal impairment due to BOO
 Recurrent hematuria due to BPH
 Small bladder stones due to BPH.
04/09/2014 MSIGWA,SAM-MD 145

Benefits
Widely available
Effective
Long lasting
Disadvantages
Greater risk of side effects
and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery
n
n
n
n
n
n
n
04/09/2014 MSIGWA,SAM-MD 146

 Immediate complication
bleeding
capsular perforation with fluid extravasation
TUR syndrome
 Late complication
urethral stricture
bladder neck contracture (BNC)
retrograde ejaculation
impotence (5-10%)
incontinence (0.1%)
04/09/2014 MSIGWA,SAM-MD 147

 Hemorrhage; primary and secondary.
 Urinary incontinence; maybe due to pre
existing detrusor instability +/- sphincter
weakness. Stress incontinence maybe due to
sphincter damage
04/09/2014 MSIGWA,SAM-MD 148

 Retrograde Ejaculation; usually during
ejaculation there is reflex closure of the internal
sphincter when semen enters the prostatic
urethra.
 Urethral stricture; common sites--- ext urethral
meatus, bladder neck and penoscrotal jxn.
0ccurs 4-10 months post surgery.
04/09/2014 MSIGWA,SAM-MD 149

• TURP syndrome:
• constellation of signs and symptoms caused by
the absorption of large volumes of isotonic
irrigating fluids through prostatic veins or
breaches in the prostatic capsule.
• The syndrome is characterized by
• hypervolemia,
• hyponatremia
• hypo-osmolarity

Manifest as
confusion
Seizures
visual disturbance
bradycardia.
Central to this syndrome is dilutional
Hyponatremia.
Can be prevented thus;limit Resection time,
04/09/2014 MSIGWA,SAM-MD 151

 Avoid aggressive resection near the the capsule
 Use a continous irrigating cystoscope-this
provides low pressure irrigation
04/09/2014 MSIGWA,SAM-MD 152

TURP syndrome is more likely
to occur:
1. The hydrostatic pressure of the
irrigation solution is high.
2. An excessively distended
bladder
3. Prostatic gland is large.
4. The Prostatic Capsule is
violated during surgery.
5. Duration of surgery (>60mins)
04/09/2014 MSIGWA,SAM-MD 153

 Two types
 Retropubic
 Transvesical
 Indications
 Prostate gland 70-100g
 Bladder diverticulum
 Large Hard ca stone
 Marked ankylosis of the Hip preventing
lithotomy position
04/09/2014 MSIGWA,SAM-MD 154

 It is the most effective method of treating BOO
due to BPH
 PFR inceasesto>20mls/s,symptoms improve
markedly.
 Likelyhood of px requiring further surgery is
0.4%,compaared to TURP 3.4%
 Complication rate 31.7% compared to TURP
16.1%
04/09/2014 MSIGWA,SAM-MD 155

 Haemorrhage-Follows inadequate haemostas
 Clot Retention,folows severe bleed and
inadequate nursing care
 UTI
 Epididymo-orchitis-Arise from retrograde
spread of infxn from prostatic fossa along the
vas to the Epididymis
 Erectile Dysfxn-carvenosal nerve controlling
erection may be destroyed during
prostatectomy
 Damage to the ureters
04/09/2014 MSIGWA,SAM-MD 156

 Retrograde ejaculation-bladder neck is
removed in prostatectomy
 Infertility
 Incontinence of urine-Due to mech effect of the
urethral catheter on the int sphincter of the
bladder neck
 DVT
04/09/2014 MSIGWA,SAM-MD 157

Contraindications
 small fibrous gland
 The presence of prostate cancer
 Previous prostatectomy
 Pelvic surgery that obliterate access to the prostate
gland
04/09/2014 MSIGWA,SAM-MD 158

 Post-op Mx
 Measure output input
 Bladder irrigation
 Effective pain mx
 1st p.o.day fluid diet, ambulation ,deflate
balloon(10ml↓) & irrigate residual clot
 2nd p.o.day regular diet
 3rd p.o.day remove retro pubic
 4th p.o.day discharge with catheter
 5- 7 pod day remove catheter
04/09/2014 MSIGWA,SAM-MD 159

 Complications
 Bleeding -urethral catheter traction with 50ml
of saline to compress the bladder neck &
prostatic fossa
-bladder irrigation to prevent clot formation
-the inflow through urethral catheter &out flow
through the suprapubic tube
-if the bleeding persist cystoscopic inspection of
the prostatic fossa &bladder neck
-if marked bleeding continue to persist →open re-exploration
04/09/2014 MSIGWA,SAM-MD 160

 Perforation of the bladder & prostatic capsule
(IN TURP)
 Incontinency (if damaged external sphincter
mechanism)
 Retrograde ejaculetion(80-90%) & impotence
(3-6% due to damage of the nerves associated
with erection)
 Bladder neck contracture
 Urethral stricture
 Sepsis
 Death(0.2 to 0.3%)
04/09/2014 MSIGWA,SAM-MD 161

 TUR-syndrome
 In 2% of all TURP
 Due to absorption irrigating fluid through cut
open veins
 Characterized by (hyponatremia →↓Na+
,HPT,nauesa& vomiting,bradicardia,visual
disturbance,mental confusion)
 Risk factors (gland>45gm,↑resection time
>90mnt & much fluid for irrigation
 RX diuretics &correct electrolytes
04/09/2014 MSIGWA,SAM-MD 162

 Two types
 Retropubic
 Transvesical
 Indications
 Prostate gland 70-100g
 Bladder diverticulum
 Large Hard ca stone
 Marked ankylosis of the Hip preventing
lithotomy position
04/09/2014 MSIGWA,SAM-MD 163

 Proper Positioning of the Patient
 Once anesthesia has been induced the patient is
positioned on the operating table in a supine
position
 Trendelenburg position without extension
04/09/2014 MSIGWA,SAM-MD 164

 A 2-0 chromic suture on a 58-inch
circle-tapered needle is passed in the
avascular plane between the urethra
and the dorsal vein complex at the
apex of the prostate.
 A tie is grasped and tied around the
dorsal vein complex. B, With 2-0
chromic suture material on a CTX
needle, a figure-of-eight suture is
placed through the
prostatovesicular junction just above
the level of the seminal vesicles to
control the main arterial blood
supply to the prostate gland.
 When placing this suture, care must
be taken to avoid entrapment of the
neurovascular bundles located
posteriorly and slightly laterally
04/09/2014 MSIGWA,SAM-MD 166

 Retropubic prostatectomy. A, With the
superficial branch of the dorsal vein complex
secured proximally and distally, a No. 15 blade
on a long handle is used to make the transverse
capsulotomy. B, Metzenbaum scissors are used
to develop the plane anteriorly between the
prostatic adenoma and the prostatic capsule.
04/09/2014 MSIGWA,SAM-MD 167

 Retropubic prostatectomy. A, With blunt
dissection with the index finger, the prostatic
adenoma is dissected free laterally and
posteriorly. B, Metzenbaum scissors are used to
divide the anterior commissure to visualize the
posterior urethra and verumontanum. C, The
index finger is then used to fracture the
urethral mucosa at the level of the
verumontanum. With this last maneuver,
extreme care is taken not to injure the external
sphincteric mechanism
04/09/2014 MSIGWA,SAM-MD 169

 Retropubic prostatectomy. A, View of the
prostatic fossa and posterior urethra after
enucleation of all the prostatic adenoma. Note
that the verumontanum and a strip of posterior
urethra remain intact. B, After placement of a
urethral catheter and, if needed, a Malecot
suprapubic tube, the transverse capsulotomy is
closed with two running 2-0 chromic sutures.
The two sutures are tied first to themselves and
then to each other across the midline to create a
watertight closure of the prostatic capsule.
04/09/2014 MSIGWA,SAM-MD 172

 Proper Positioning of the Patient
 After anesthesia has been induced, the patient
is positioned on the operating table in a supine
position.
 The table is placed in a mild Trendelenburg
position without extension
 22-Fr catheter is inserted into the bladder. After
residual urine is drained, 250 mL of saline is
instilled into the bladder and the catheter is
clamped.
04/09/2014 MSIGWA,SAM-MD 174

This image cannot currently be displayed.
04/09/2014 MSIGWA,SAM-MD 175

 Starting at the bladder neck posteriorly,
Metzenbaum scissors are used to develop the
plane between the prostatic adenoma and the
prostatic capsule (lateral view). B, Anterior
view of the same maneuver
04/09/2014 MSIGWA,SAM-MD 177

 Using the index finger, the prostatic adenoma
is enucleated from the prostatic fossa (lateral
view). B, Anterior view of the same maneuver.
With extreme large prostate glands, the left,
right, and median lobes should be removed
separately
04/09/2014 MSIGWA,SAM-MD 179

 After enucleation of the entire prostatic
adenoma, a 0-chromic suture is used to place
two figure-of-eight sutures to advance bladder
mucosa into the prostatic fossa at the 5- and 7-
o’clock positions at the prostatovesicular
junction to ensure control of the main arterial
blood supply to the prostate.
04/09/2014 MSIGWA,SAM-MD 181

 suprapubic tube, the cystotomy is closed in two
layers using a running 2-0 Vicryl suture,
enforced by tying of multiple interrupted 3-0
Vicryl stay sutures. A closed Davol suction
drain is placed on one side of the bladder and
exits via a separate stab incision
04/09/2014 MSIGWA,SAM-MD 183

 It is the most effective method of treating BOO
due to BPH
 PFR inceasesto>20mls/s,symptoms improve
markedly.
 Likelyhood of px requiring further surgery is
0.4%,compaared to TURP 3.4%
 Complication rate 31.7% compared to TURP
16.1%
04/09/2014 MSIGWA,SAM-MD 185

 Haemorrhage-Follows inadequate haemostas
 Clot Retention,folows severe bleed and
inadequate nursing care
 UTI
 Epididymo-orchitis-Arise from retrograde
spread of infxn from prostatic fossa along the
vas to the Epididymis
 Erectile Dysfxn-carvenosal nerve controlling
erection may be destroyed during
prostatectomy
 Damage to the ureters
04/09/2014 MSIGWA,SAM-MD 186

MINIMALLY INVASIVE TREATMENT.
 indicated in pts with IPSS 8-19
 Pts unfit for major surgery-pulmonary dxs,
liver dxs, MI etc.
 CONTRAINDICATIONS:
 Recurrent episodes of haematuria
 Bladder stone due to BPH
 Upper tract dilatation
 Recurrent UTI
 Renal insufficiency.
04/09/2014 MSIGWA,SAM-MD 187

 OPTIONS:
 High intensity focused ultrasound (HIFU)
 Transurethral vapourisation of prostate
 Transurethral laser therapy (TULIP)
 Intra-urethral stents
 Transurethral needle ablation of prostate
(TUNA)
 Transurethral balloon dilatation.
04/09/2014 MSIGWA,SAM-MD 188

 1. Transurethral Incision of the Prostate
 2. Transurethral Laser Induced Prostatectomy
(TULIP)
 a. Ultrasound-guided Nd-Yag laser
 b. Shorter procedure and fewer complications
than TURP
 c. No tissue samples for histopathology testing
04/09/2014 MSIGWA,SAM-MD 189

 3. Transurethral Microwave Thermotherapy (TUMT)
 a. Microwave probe heats to over 45 C
 b. Safe, effective method for urinary retention relief
 4. Transurethral Vaporization of the Prostate (TUVP)
 5. Transurethral Electrovaporization Prostate (TVP)
 6. Transurethral Needle Ablation of Prostate (TUNA)
 7. Hot Water Ballon Thermoablation
 a. Experimental procedure with good outcomes
 b. Minimal discomfort
04/09/2014 MSIGWA,SAM-MD 190

 8. Urethral Stent
 a. Risk of infection and re-blockage
 b. Indications
 i. BPH patients with high surgical risk
 ii. Short life expectancy
 9. Transurethral Balloon Dilation
 a. Rarely used due to high rate of symptom
recurrence.
04/09/2014 MSIGWA,SAM-MD 191

Temporary Stents
 Temporary stents are tubular devices that are
made of either a nonabsorbable or a
biodegradable material
 designed for short-term use, to relieve bladder
outlet obstruction (BOO)
04/09/2014 MSIGWA,SAM-MD 192

 Spiral Stents- e.g Urospiral,stent should remain
in the prostatic urethra for longer than 12
months
 Polyurethane Stents
 Biodegradable Stents
04/09/2014 MSIGWA,SAM-MD 193

 were introduced as a definitive treatment for
prostatic obstruction, particularly for patients
unfit for prostatic surgery
 Patients were able to void satisfactorily in most
cases, but complications were relatively high
 UroLume endourethral prosthesis
04/09/2014 MSIGWA,SAM-MD 194

 Heat treatment inducing necrosis of prostatic
tissue
 The aim is to increase prostatic temperature to
in excess of 60° C
 Uses low-level radiofrequency (RF) energy that
produces localized necrotic lesions in the
hyperplastic tissue.
04/09/2014 MSIGWA,SAM-MD 195

 These cover heat changes and differential
blood flow in the prostate
 Damages the sympathetic nerve endings
 Induction of apoptosis
04/09/2014 MSIGWA,SAM-MD 197

 “laser” stands for light amplification by the
stimulated emission of radiation
 There are four types of laser that can be used to
treat the prostate
1. Neodymium : Yttrium-Aluminum-Garnet
Laser
2. Potassium-Titanyl-Phosphate Laser
3. Holmium : Yttrium-Aluminum-Garnet Laser
4. Diode Laser
04/09/2014 MSIGWA,SAM-MD 199

The energy from lasers can be delivered as
follows:
 End firing
 Bare tip
 Sculptured tip
 Sapphire tip
 Side firing
 Metal or glass reflector
 Prismatic internal reflector
04/09/2014 MSIGWA,SAM-MD 200

 Retrograde ejaculation-bladder neck is
removed in prostatectomy
 Infertility
 Incontinence of urine-Due to mech effect of the
urethral catheter on the int sphincter of the
bladder neck
 DVT
04/09/2014 MSIGWA,SAM-MD 201

 Prostatitis
 Bladder obstruction
 Bladder cancer
 Neurogenic bladder
04/09/2014 MSIGWA,SAM-MD 202

 This is the commonest cancer in men. 52% of tumours at presentation are
localized to the prostate gland. It is rare below the age of 50.
 Most prostate cancers are slow growing; however, there are cases of
aggressive prostate cancers. The cancer cells may metastasize (spread)
from the prostate to other parts of the body, particularly the bones and
lymph nodes.
 Spread occurs to adjacent organs, e.g. bladder, urethra and seminal
vesicles.
 Spread to the rectum is rare. Lymphatic spread is to the iliac and para-aortic
nodes. Blood spread occurs early, especially to the pelvis, spine and
skull (osteosclerotic lesion).
 Prostate cancer may cause pain, difficulty in urinating, problems during
sexual intercourse, or erectile dysfunction.
04/09/2014 MSIGWA,SAM-MD 203

Genetic
 Men who have a first-degree relative (father or brother) with
prostate cancer have twice the risk of developing prostate cancer,
and those with two first-degree relatives affected have a fivefold
greater risk compared with men with no family history.
 Mutations in BRCA1 and BRCA2, important risk factors for
ovarian cancer and breast cancer in women, have also been
implicated in prostate cancer. Other linked genes include the
Hereditary Prostate cancer gene 1 (HPC1), the androgen receptor,
and the vitamin D receptor.
04/09/2014 MSIGWA,SAM-MD 204

Dietary
 Evidence supports little role for dietary fruits and vegetables in
prostate cancer occurrence.
 Red meat and processed meat also appear to have little effect in
human studies. Higher meat consumption has been associated
with a higher risk in some studies.
 Lower blood levels of vitamin D may increase the risk of
developing prostate cancer.
 Taking multivitamins more than seven times a week may increase
the risk of developing the disease.
 A 2009 study on folic acid supplements showed an association
with an increased risk of developing prostate cancer.
 Obesity and elevated blood levels of testosterone may increase the
risk for prostate cancer.
04/09/2014 MSIGWA,SAM-MD 205

Others
 Use of the cholesterol-lowering drugs ( statins )may also decrease
prostate cancer risk.
 Infection or inflammation of the prostate (prostatitis) may increase the
chance for prostate.sexually transmitted infections chlamydia, gonorrhea,
or syphilis seems to increase risk.
 There is an association between vasectomy and prostate cancer however
more research is needed to determine if this is a causative relationship.
04/09/2014 MSIGWA,SAM-MD 206

 Asymptomatic
 Hard craggy mass and nodule in prostate on rectal examination -
the median sulcus between the lobes may be obliterated
 Incontinence
 Dysuria
 Haematuria
 Hesitancy
 Dribbling
 Retention
 Bone pain - pathological fractures
 Sciatica
 Anaemia
 Weight loss
 Palpable bladder
 Tenderness over bone
 Hepatomegaly
04/09/2014 MSIGWA,SAM-MD 207

 Hb-FBC
 ESR
 U&Es
 Creatinine
 PSA - PSA Density (PSAD) - the blood PSA level divided by the size of the prostate, as
determined by TRUS - can help distinguish between BPH and prostate cancer. Basically,
with BPH, the PSA level should not be more than 15 percent of the size of the prostate.
PSA levels exceeding 15 percent of the size of the prostate are more likely to indicate the
presence of prostate cancer -- and the need for a biopsy.
 Transrectal Ultrasound (TRUS) scan and guided biopsy
 CXR : metastases in lungs or ribs
 Bone radiograph : sclerotic deposits in pelvis, spine or skull
 Bone scan is sensitive indicator of early metastases
 Ultrasound Spectral (USS) : residual urine, upper urinary tract
obstruction, and useful in prostate Ca grading.
Grade I - 3.0 to 3.8 cms 30 Gms.
Grade II - 3.8 to 4.5 cms 30- 50 Gms.
Grade III- 4.5 to 5.5 cms 50- 80 Gms.
Grade IV - 5.5. cms 85 Gms
04/09/2014 MSIGWA,SAM-MD 208

 Is used to help evaluate the prognosis of men with prostate cancer.
 It grades tumors on a scale of 1-5. You may have different grades
of ca in one biopsy sampel.
 The 2 main grades are added together.
- The higher the score,the higher the probability of the ca to spread
past the prostate.
 Scores 2-5 : Low grade prostate
 Scores 6-7 : Intermedieate (most prostate fall into this group)
 Scores 8-10:High grade ca
04/09/2014 MSIGWA,SAM-MD 209

Mainly TURP to relieve obstructive symptoms
Other treatment for Prostatic Cancer depends on staging.
 For cancer localized to prostate - observation with routine monitoring of PSA,
external beam radiotherapy or radical prostatectomy.
 For metastatic disease, hormonal manipulation is used, such as Luteinizing
releasing hormone releasing hormone (LHRH) agonist E.g. cyproterone acetate
or bicalutamide and silboestrol,which is rarely used nowadays (causes
gynaecomastioa and fluid retention)
 Local radiotherapy is used for bony metastatic pain
PROGNOSIS :
Variable - Depends on stage at presentation. Patients with clinically localized
tumor treated radically may expect a normal life expectancy. Those with
metastatic disease at presentation have a median 3-year survival.
04/09/2014 MSIGWA,SAM-MD 210

 This occurs most commonly in young adults.
 Acute bacterial prostatitis ususally presents as an acute
febrile illness.
 Chronic prostatitis presents with recurrent UTIs.
 If there is a past history of TB anywhere in the body,
suspect TB prostatitis.
04/09/2014 MSIGWA,SAM-MD 213

Acute Bacterial Prostatitis :
 Fever
 Low back pain
 Perineal pain
 Bladder irritation
 Outflow obstruction
 Enlarged tender prostate
Chronic Prostatitis :
 Sx of UTI - but mild or sometimes absent
 Dull perineal ache
 Normal or indurated irregular prostate
04/09/2014 MSIGWA,SAM-MD 214

Acute Prostatitis :
 FBC - TWC (raised)
 Mid -stream urine (MSU) - shows growth.
 Blood C&S
Common bacterias are:
Echerichiacoli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Se
rratia, andStaphylococcus aureus
 Prostatic massage may yield secretions containing white cells and
occasionally orgasms
 Culture for TB in chronic prostatitis
04/09/2014 MSIGWA,SAM-MD 215

Acute Prostatitis :
 Bed rest
 Hydration
 Antibiotics (I.V) eg. Ciprofloxacin, Co-trimoxazole and tetracyclines such
as doxycycline
 Analgesics
 Patients with urinary retention are best managed with a suprapubic
catheter or intermittent catheterization.
 Long term antibiotics eg. Ciprofoloxacin for 4-8weeks
 Escherichia coli extract and cranberry have a
potentially preventive effect
 Prostatic massage (may be effective)
TB Prostatitis :
 Anti - TB
04/09/2014 MSIGWA,SAM-MD 216

 What is prostate?
 What prostate does?
 What are the causes for enlargement of
prostate?
 How do we differentiate between each
cause?
 What are the treatment of BPH, Prostate
Ca and Prostatitis?
04/09/2014 MSIGWA,SAM-MD 217

 Bailey and love’s surgery
 Churchill’s Surgery
 Dr.Mwashambwa , M.Y lecture notice
 Oxford Clinical Surgery
 World Wide Web
 Salman Bangash 2014 ppt
 Dr. Shampile sydney ppt
04/09/2014 MSIGWA,SAM-MD 218

Benign prostatic hyperplasia

Recommended

Recommended

More Related Content

Viewers also liked

Viewers also liked (16)

Similar to Benign prostatic hyperplasia

Similar to Benign prostatic hyperplasia (20)

Recently uploaded

Recently uploaded (20)

Benign prostatic hyperplasia