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Bladder outlet obstruction
1.
2.
3. LEARNING OBJECTIVES:
Case study
What is BOO?
Pathophysiology
Clinical features
IPSS
BPH
Investigations
Treatment
4. CASE STUDY:
A sixty year old male came to opd with
severe difficulty in voiding , weak urinary
stream & straining his ultrasound reveals 55
gm prostate & residual urine of 70ml . His PSA
is 2-4 gm per ml.
5. BOO
It’s urodynamic concept of low flow rates and
high intravesical pressures.
Causes:
*BPH.
*CAP.
*bladder neck stenosis.
*urethral stricture.
*neuropathic conditions.
6. Pathophysiology
Boo over time will result in..
increase in the intravesical voiding pressure
(>80 cm H2O), bladder muscle hypertrophy
(trabiculation, sacculation and diverticulum
formation).
High pressure may transmit to the upper tract
causing hydroureter, hydronephrosis and renal
insufficiency.
Boo results in incomplete bladder evacuation
(residual urine) which predisposes to UTI and
stone formation.
Decrease uro flow rate under 10 ml /sec
14. Precipitating causes for retention
Severe pain. MI, joint pain.
Psychological upset.
Cold exposure.
Constipation.
Drugs
Anticholenergic & diuretic
,decongestant,antihistamin
Ignoring first desire for urination.
15. Clinically
Usually normal.
Distended bladder.in acute or chronic
retention
PR ex: enlarged prostate, smooth,
regular, firm, maintained median
sulcus and mobile rectal mucosa
Normal anal sphincter tone.
Normal bulbocovernosus reflex
18. Cystoscopy: enlarged prostate, trabiculation &
stones.
Size of the prostate has no relation with the
severity of the symptom but the degree of
urethral compression.
25. INDICATION OF SURGERY IN
BPH
SEVERE SYMPTOMS
FAILURE OF MEDICAL TREATMENT
COMPLICATIONS LIKE:
ACUTE URINARY RETENTION
CHRONIC RETENTION
REPEATED HEMATURIA
REPEATED UTI
VESICAL STONE
RENAL IMPERMENT DUE TO CHRONIC
RETENTION
32. One of the most common malignant tumor
affecting males over the age of 65 in western
countries.
33. Pathology
95% of the tumor are adenocarcinoma and
derived from acinar epithelium
75% of CAP arise from peripheral zone.
grading:
Gleason’s grade based on the degree of
glandular differentiation and growth pattern.
34. Spread
Direct invasion: to nearby structures.
Denonvvilliar’s fascia act as barrier.
Lymphatic: internal, external & common iliac
Blood: to the lower lumber vertebrae & pelvic
bones due to reverse blood flow from
vesicoprostatic plexus to the emissary veins
of the bones during coughing & sneezing
(OSTEOBLASTIC)
36. Presentation
Accidental during histopathological ex after
prostatectomy.
During PR ex
High PSA
BOO.
Metastatic: back ache, sciatica, paraplegia
or pathological fractures..
37. *
BPH CAP
Younger age older
Symptoms slowly
progressive
Rapid progression
Usually no back or
bone pain
More back ache &
neurological
symptoms
Smooth rubbery
prostate with sulcus
Hard irregular prostate
with obliterated sulcus
38. Rectal examination:
Stony hard irregular prostatic nodule,
obliterated median sulcus, difficulty in
moving the rectal mucosa over it and fixity.
Normal PR ex does not exclude CAP.
40. Investigations
PSA: prostatic tumor marker for diagnosis and
follow up, it may also increase in prostatitis and
BPH.
10 ng/ml normal,
10-15 suspicious.
>15 is diagnostic.
Acid phosphatase: prostatic fraction.
Alkaline phosphatase: in bone metastasis.
47. Hormonal therapy
Its trearment of choice for metastatic tumor
Cap is hormonal dependant (androgen), and
about one third of tumors are hormone-
insensitive.
Androgen ablation may change the course of
the disease.
48. Methods of androgen ablation
surgical
Bilateral orchiectomy: complete or subcapsular.
medical
LHRH agonist: (Zoladex)/28 days SC.
Anti androgen: (Nilutemide) 250 mg/6h.
.
49. RESEARCH:
According to research done in 2015 by wah
medical collage, wah cantt
Of the 1500 patients in the study, 810(54%)
were females and 690(46%) were male.
Lower urinary tract pathologies were found in
480(32%) patients.
50. The most common pathology among males
was enlarged prostate in 127(8.4%) patients.
Among females, urethral stenosis was the
most common pathology in 57(3.8%)
patients. Transitional cell carcinoma was seen
in 57(3.8%) patients having haematuria with
inconclusive ultrasound and intravenous
urography. All patients tolerated the
procedure well.
51.
52. Aging Population= More BPH
Not all Male LUTS=BPH
Not all BPH=LUTS
Consider CombinationTherapy
Quality of life issues
prostatic cancer 52