2. ī¨ Generalised disease of the
prostate due to hormonal
derangement which leads
to enlargement of the
gland (increase in the
number of epithelial cells
and stromal tissue)to
cause compression of the
urethra leading to
symptoms
08/16/17 2
3. ī¨ Occurs in 50% of men over 50 and in 80% of
men over 80 have BPH
ī¨ BPH progresses differently in every individual
ī¨ Many men with BPH may have mild
symptoms and may never need treatment
ī¨ BPH does not predispose to the development
of prostate cancer
08/16/17 3
5. ī¨ Cause not completely understood
ī¨ Change in hormonal milieu with alterations in the
testosterone/estrogen balance
ī¨ Induction of prostatic growth factors
ī¨ Increased stem cells/decreased stromal cell death
ī¨ Accumulation of dihydroxytestosterone, stimulation by
estrogen and prostatic growth hormone actions
6. ī¨ Slow and insidious changes over time
ī¨ Complex interactions between prostatic urethral
resistance, intravesical pressure, detrussor
functionality, neurologic integrity, and general
physical health.
ī¨ Initial hypertrophyī detrussor decompensationī
poor toneī diverticula formationī increasing urine
volumeī hydronephrosisī upper tract dysfunction
8. ī¨ Voiding symptoms
īĄ decrease in the urinary stream
īĄ Straining
īĄ Dribbling at the end of urination
īĄ Intermittency
īĄ Hesitancy
īĄ Pain or burning during urination
īĄ Feeling of incomplete bladder emptying
08/16/17 8
9. ī¨ Irritative symptoms
urinary frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection
08/16/17 9
10. ī¨ History (STD, trauma, surgery)
ī¨ Other disorders (eg. neurologic, diabetes)
ī¨ Medications (anti-cholinergics)
ī¨ Functional Status
11. ī¨ Urinary retention
ī¨ UTI
ī¨ Sepsis secondary to UTI
ī¨ Residual urine
ī¨ Calculi
ī¨ Renal failure
ī¨ Hematuria
ī¨ Hernias, hemorroids, bowel habit change
08/16/17 11
13. 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
Your
score
Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your
bladder completely after you finish urinating?
0 1 2 3 4 5
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
Intermittency
Over the past month, how often have you found you stopped and started again several
times when you urinated?
0 1 2 3 4 5
Urgency
Over the last month, how difficult have you found it to postpone urination? 0 1 2 3 4 5
Weak stream
Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
Straining
Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5
Â
Â
None 1 time 2 times 3 times 4 times
5 times
or more
Your
score
Nocturia
Over the past month, many times did you most typically get up to urinate from the
time you went to bed until the time you got up in the morning?
0 1 2 3 4 5
Quality of life due to urinary symptoms
Delighted Pleased Mostly satisfied
Mixed â about equally
satisfied and dissatisfied
Mostly
dissatisfied
Unhappy Terrible
If you were to spend the rest of your life with your
urinary condition the way it is now, how would you
feel about that?
0 1 2 3 4 5 6
Â
Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.
15. ī¨ Firm to hard nodules
ī¨ Irregularities, unequal lobes
ī¨ Induration
ī¨ Stony hard prostate
ī¨ Any palpable nodular abnormality suggests
cancer and warrants investigation
16. ī¨ Urine cytology in patients with:
īĄ Predominance of irritative voiding symptoms.
īĄ Smoking history
ī¨ Flow rate and post-void residual
īĄ Not necessary before medical therapy but should be
considered in those undergoing invasive therapy or
those with neurologic conditions
ī¨ Upper tract evaluation if hematuria, increased
creatinine
ī¨ Cystoscopy
17.
18. ī¨ Elevated levels of PSA
īĄ 0 â 4 ng/ml
īē Prostatic pathology
ī¨ Correlates with tumor mass
ī¨ Some men with prostate cancer have normal
PSA levels
08/16/17 18
19. ī¨ Urethral stricture
ī¨ Bladder neck contracture
ī¨ Carcinoma of the prostate
ī¨ Carcinoma of the bladder
ī¨ Bladder calculi
ī¨ Urinary tract infection and prostatitis
ī¨ Neurogenic bladder
20. ī¨ Severe obstruction
ī¨ Urinary retention
ī¨ Signs of upper
tract dilatation and
renal insufficiency
ī¨ Moderate
symptoms of
prostatism
ī¨ Recurrent UTIâs
ī¨ Hematuria
ī¨ Quality of life
21. ī¨ Mild to severe symptoms with little
âbotherâ
īĄ Manage with watchful waiting.
īē Risk of therapy outweighs the benefit of medical or
surgical treatment
ī¨ Moderate to severe symptoms with bother
īĄ Management options include watchful waiting,
medical management and surgical treatment.
22. ī¨ Watchful waiting and behavioral
modification
ī¨ Medical Management
īĄ Alpha blockers
īĄ 5-alpha reductase inhibitors
īĄ Combination therapy
ī¨ Surgical Management
īĄ Office based therapy
īĄ OR based therapy
ī¨ Urethral stents
23. ī¨ âis the preferred management technique in
patients with mild symptoms and minimal
botherâ
ī¨ AUA score < 7,
ī¨ 1/3 improve on own.
24. ī¨ Decrease caffeine, alcohol )diuretic effect(
ī¨ Avoid taking large amounts of fluid over a short
period of time
ī¨ Void whenever the urge is present, every 2-3 hours
ī¨ Maintain normal fluid intake, do not restrict fluid
ī¨ Avoid bladder irritants to include dairy products,
artificial sweeteners, carbonated beverages
ī¨ Limit nighttime fluid consumption
ī¨ BPH symptoms can be variable, intermittent
26. Benefits
Convenient
No loss of work
time
Minimal risk
Disadvantages
Expensive
Drug Interactions
Must be taken every
day
Manages the problem
instead of fixing it
medication
īŽ
īŽ
īŽ īŽ
īŽ
īŽ
īŽ
27. Alpha adrenergic receptor blockers
ī¨ promote smooth muscle relaxation in the prostate
ī¨ Relaxation of the muscles facilitates urinary flow
ī¨ Doxazosin , Terazosin , Tamsulosin , Alfuzosin
ī¨ Side effects: postural hypotension, dizziness,
fatigue,
ī¨ Other problems can occur when pt is also taking
cardiac or other hypertensive drugs
08/16/17 27
28. īĄ Equal clinical effectiveness
īĄ Slight differences in adverse event profile
īē Orthostasis (lower in tamsulosin)
īē Ejaculatory dysfunction (higher in tamsulosin)
īē Decreased energy levels
īē Nasal congestion
īē Increase in CHF risk with doxazosin
īĄ Must titrate doxazosin and terazosin to effective
levels
29. 5 alpha reductase inhibitor ) finasteride)
ī¨ Reduce size of prostate gland by up to 30 %by up to 30 %
ī¨ Blocks the enzyme of 5 alpha reductase which is
necessary for the conversion of testosterone to
dihydroxytestostersone
ī¨ Regression of hyperplastic growth
ī¨ Donât work immediatelyDonât work immediately
ī¨ Small effect on symptom score and flow ratesSmall effect on symptom score and flow rates
08/16/17 29
30. ī¨ Agents are effective and appropriate treatment for
patients with lower urinary tract symptoms and
demonstrable enlargement of the prostate.
īĄ Average prostate size is 30 ccâs. Original studies showed
benefit only in men with prostate sizes greater than 50
ccâs.
31. ī¨ Finasteride (Proscar) and Dutasteride (Avodart)
īĄ Less effective for relief of BPH symptoms than alpha
blockers
īĄ Adverse events include
īē Decreased libido
īē Worsened sexual function (erectile dysfunction)
īē decrease volume of ejaculation
īē Breast enlargement and tenderness
īĄ Reduces risk of urinary retention by 3%/year.
īĄ PSA must be doubled if screening for prostate cancer
32. ī¨ Concomitant use of alpha blockers and 5-
alpha reductase inhibitors
īĄ Should be reserved for patients who are at
significant risk of progression and adverse
outcome
īē Poor surgical candidate
īē Patient wants to avoid surgery
īē Significant cost associated with dual medications
33.
34. ī¨ Office based therapies:
īĄ Transurethral microwave therapy (TUMT)
īĄ Transurethral needle ablation (TUNA)
īē Therapies are effective
or partially effective for
relieving the symptoms of BPH
īē Significant side effects/complications
associated with these treatments
have prompted a FDA warning
35. ī¨ OR based therapies
īĄ Open simple prostatectomy
īĄ TURP
īĄ Transurethral incision of the prostate
īĄ Laser photoselective vaporization of the prostate
(green light laser PVP)
īĄ Laser Prostatectomy
36. ī¨ Patients may select surgical treatment as initial
therapy if moderate or severe bother is present.
ī¨ Patients who have developed complications of
BPH (i.e urinary retention, renal insufficiency,
recurrent UTI) are best treated surgically.
ī¨ New surgical treatment have not demonstrated
better outcomes than TURP to date.
37. ī¨ Indicated for AUA score >16
ī¨ Transurethral Prostatectomy(TURP): 18%
morbidity with .2% mortality. 80-90%
improvement at 1 year but 60-75% at 5 years
and 5% require repeat TURP.
ī¨ Transurethral Incision of Prostate (TUIP): less
morbidity with similar efficacy indicated for
smaller prostates.
ī¨ Open Prostatectomy: indicated for glands > 60
grams or when additional procedure needed for
suprapubic/retropubic approaches
40. īĄGreater than 5% risk of:
īē Irritative voiding symptoms
īē Bladder neck contracture
īē UTI
īĄRisk of incontinence 1%
īĄDecline in erectile function
īĄ65% of retrograde ejaculation
īĄTUR syndrome (acute hyponatremia from free water
absorption)
īĄHemorrhage
īĄBladder spasms
TURP
41. ī¨ Restoration of urinary drainage
ī¨ Treatment of any urinary tract infection
ī¨ Understanding of procedure, implications for
sexual functioning and urinary control
08/16/17 41
42. ī¨ Antibiotics
ī¨ Allow pt to discuss concerns about surgery on
sexual functioning
ī¨ Prostatic surgery may result in retrograde
ejaculation
08/16/17 42
43. ī¨ No complications
ī¨ Restoration of urinary control
ī¨ Complete bladder emptying
ī¨ Satisfying sexual expression
08/16/17 43
44. ī¨ Monitoring
ī¨ Continuous irrigation & maintain catheter patency
ī¨ Blood clots and hematuria are expected for the
first 24-36 hours
ī¨ After catheter is removed â check for urinary
retention and urinary stream
08/16/17 44
45. ī¨ Sphincter tone may be poor after catheter is
removed. Kegal exercise pelvic muscle floor
technique is encouraged. Starting and
stopping the urinary stream is helpful.
ī¨ Stool softeners to avoid straining
ī¨ Sitting and walking for long periods should be
avoided
08/16/17 45
46. ī¨ Catheter care
ī¨ Managing urinary incontinence
ī¨ Oral fluid intake â 2,000-3,000 cc per day
ī¨ Observe for s/s of urinary tract infection
ī¨ Prevent constipation
ī¨ Avoid lifting
ī¨ No driving or intercourse after surgery
08/16/17 46
47. 08/16/17 47
ī¨ Retropubic
īĄ Midline abd.
incision
ī¨ Perineal
īĄ Incision between
the scrotum and
anus
ī¨ Suprapubic
īĄ Abdominal incision
50. Destroy prostate tissue with heat
Tissue is left in the body and is
expelled over time (called sloughing)
Transurethral Microwave Therapy (TUMT)
Transurethral Needle Ablation (TUNAÂŽ
)
Interstitial Laser Coagulation (ILC)
Water Induced Thermotherapy (WIT)
heat therapies
īŽ
īŽ
īŽ
īŽ
īŽ
īŽ
51. Benefits
Office treatments
Local anesthesia
Minimally
invasive
Reduced risk of
complications as
compared to
invasive surgical
âTURPâ
Disadvantages
Some symptoms will
persist for up to 3
months
Cannot predict who
will respond
May require
prolonged
catheterization
īŽ
īŽ
īŽ
īŽ
īŽ
īŽ
īŽ
53. ī¨ TURP-equivalent 7 year improvement in symptom
score and urination parameters
ī¨ Decreased risk of bleeding and TUR syndrome,
otherwise similar adverse effect profile
ī¨ May be done on anti-coagulated patients
Medications address the desire we all have to find a âcureâ to fix the problem. We all like a âquick and easyâ solution.
They can, however, become less effective over time.
Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.
Until recently, the only option we could offer patients for treatment of their symptoms was either an open abdominal surgical procedure, or a trans-urethral resection of the prostate.
Medications address the desire we all have to find a âcureâ to fix the problem. We all like a âquick and easyâ solution.
They can, however, become less effective over time.
Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.
Medications address the desire we all have to find a âcureâ to fix the problem. We all like a âquick and easyâ solution.
They can, however, become less effective over time.
Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.