dd

1. 1
Good morning
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2. By- Mekuriaw (MD, GSR III)
Lower urinary tract obstruction

3. Out line
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 Summery of the anatomy of the LUT
 Introduction
 Approach
 BPH
 Urethral stricture

4. Anatomy of the lower urinary
tract
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5. Zones of the prostate
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6. urethra
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7. Introduction
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 Previously LUTS (especially those of
obstructive) used to be entertained with
more emphesis to BPH. But currently it is
understood that there are many other
factors that contribute to causation of
LUTS.
 Therefore, the current consensus is to
consider the LUT as a functional unit and
assess the multi-factorial etiology as a hall.

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Approach

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 BOO - Combination of low flow rates in the
presence of high voiding pressures.
- results from functional or anatomic causes.
- produces compression/resistance on bladder at
any location from the bladder neck to the urethral
meatus.
- produces LUTS.
 The prevalence of LUTS in men increases with
age.
 LUTS often significantly affects quality of life.

10. History
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 Storage/irritative symptoms (overactive
bladder syndrome)
 Symptoms like frequency, urgency, nocturia
and urgency incontinence
 Voiding/ obstructive urinary symptoms
 Hesitancy, incomplete sense of voiding,
dribbling, prolonged micturation, poor
stream, straining

11. WHO has adopted the IPSS to be the statndard
clinical tool to assess LUTS and its severety
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 LUTS
 IPSS= uses 7 symptoms and 1 quality of life,
scored out of 35 and used to guide our
subsiquent management of BPH.
 0-7= mild and don’t need treatment
 8-19= moderate severity
 20-35= severe symptoms
IPSS is an excellent tool but lacks
completeness as it does not include urinary
incontinence which is commonly present in
patients suffering from LUTS.

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 Voiding diary (including nocturia)
 comorbidities
 gross hematuria
 previous surgical intervention
involving the prostate, bladder, or
urethra.
 medication history
loop diuretics, β-blockers,
anticholinergic drugs

13. Physical examination
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 Palpable bladder
 Penile examination for meatal stenosis,
phymosis, palpable uretral stricture
 BMI/central obesity, pattern of secondary
sexual characteristics
 Neurologic evaluation including anal
tone/reflex and peripheral neurologic
evaluation
 DRE

14. Laboratory tests
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Urinalysis- to assess the causes of LUTS
 Pyuria and positive nitrite test
 considerUTI
 Gross hematuria
 Considere bladder CA
 Glucosuria, ketonuria, proteinuria
 Consider DM
 Urine cytology must be sent for patients
complaining severe storage symptoms and
are smokers.

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 Serum PSA level- important b/c
 It assesses the presence and risk of Pca
 Estimates prostate volume
 Correlates with LUTS severity
 predicts treatment outcome
 Risk of AUR and likelyhood of surgical intervention
 5alpha reductase reduces its serum level
 RFT- serum creatinine

16. URODYNAMICS
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 Post voiding residual volume
 <30ml= insignificant
 >50ml= significant
 >300ml= detrosur underactivity and signifies
 poor improvement of LUTS after surgery.
 More severe LUTS
 Can be assessed by bladder U/S or post-
voiding catheterization

17. Uroflowmetry
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 Measured parameters are peak flow rate,
urine volume, voiding pattern
 Does not differentiate wether low flow rate
is caused by either BOO or detrusor
disfunction
 A cut off point of flow rate <15ml/sec is
considered to be outflow obstruction.

18. imagings
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 Suprapubic ultrasonography and TRUS
 Measures PV
 Parameters to detect BOO
 Intravesical prostatic protrusion
 Bladder wall hypertrophy

19. Cystourethrogram
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 Bladder diverticula, urethral stricture,
vesicoureteral reflex.

20. Cystourethroscopy
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 Assesses morphology of prostate and bladder
neck, trabeculation, diverticula…
 Check the presence of middle lobe to
consider microablation or niddle aspiration
 Indicated if there is hematuria, previous
bladder CA, hx of recurrent UTI

21. BPH
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 It is a histologic definition rather than a
clinical definition
 BPH is the increased number of stromal and
epithelial cells around the urethra, (the reason
why it is called hyperplasia and not
hypertrophy)

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23. The size of the BPH does not correlate with
severity of LUTS, rather there are other
determining factors, like
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 Dynamic urethral resistance
 Anatomic pleomorphism
 Prostatic capsule

24. Consequences of BPH
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 No symptoms, no BOO
 No symptoms, but
urodynamic evidence of BOO
 LUTS , no evidence of BOO
 LUTS and BOO
 Others (acute/chronic
retention, haematuria,
urinary infection and stone
formation)

25. Obstruction induced changes in the bladder
function are mainly of three types.
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 Detrusor instability and decreased compliance
 Associated clinical symptoms are urgency and
frequency
 Decreased detrusor contractility
 Symptoms are poor urinary stream, hesitancy,
intermittency and increased residual volume
 Detrusor failure/ acontractile bladder
 Occurs rarely

26.  Urethra---Periurethral gland infection/abscess;
Prostatitits
 Upper Urinary Tract--- Hydro-ureter/nephrosis;
R.Failure
 Bladder ------adaptive one
Consequences of lower urinary tract
obstruction
Stage of compensation
Hypertrophic bladder
muscle
Able to completely empty
itself
Predominantly storage
symptoms
Stage of
decompensation
Detrusor muscle
weakens
Progressive increase in
PVRV
Worsening of storage
and voiding symptoms
Chronic urine retention
AUR
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 Although BPH causes
incomplete voiding in
the elderly, detrusor
dysfunction is also an
important cause of
incomplete voiding in
this age group due to
different changes.
 Altered sensation
 reduced detrusor
contractility
 Impaired central
processing

28. Complications of BPH
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 Bladdere stones
 Bladder decompensation
 Urinary incontinence
 UTI
 Renal failure
 Hematuria

29. Acute urinary retention
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 painful, palpable or percussible bladder, when
the patient is unable to pass any urine.
 Patients who have experianced AUR will have
an 80% of recurrence in the next 6months.
 Conditions that have high predictive value for
AUR development are
 Severe LUTS like incomplete voiding, having to
void again within 2 hours, poor stream,
 increased serum PSA level, flow rate <12ml/sec
and prostate volume >30ml

30. Management
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 Catheterization
 Suprapubic cystostomy
 prostatectomy

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 AUR can be either spontaneus or
precipitated
 Risk factors for precipitated AUR are
 Bladder overfilling,
 alcohol consumption,
 sexual activity,
 bed rest, bladder infection,
 excessive fluid intake,
 medications with adrenergic or
anticholinergic effects.

32. Management of BPH
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 Aim of Rx
 Relieving LUTS
 Decreasing Boo
 Improving bladder emptying
 Reversing renal insufficiency
 Preventing future episodes of hematuria,UTI &urinary
retention
 the treatment includes:-
Watchful waiting
Medical therapy
Minimally invasive
Operative therapy

33. Watchful waiting
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 Patient-driven treatment of choice
 For mild symptoms
 IPSS score<8 & good emptying(RU<100ml)
 Decreasing total fluid intake especially before bedtime (no
fluid for 2 hours before retiring).
 Moderating the intake of alcohol & caffeine.
 Maintaining time-voiding schedules.
 Periodic monitoring—yearly follow up.

34. MEDICAL THERAPY
For moderate to severe symptoms.
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Target prostate
 Decrease tone of
the prostate
 Alpha 1 blockers
 Decrease prostate
size
 5 alpha reductase
inhibitors
Target bladder
 Bladder
underactive
 Cholinergics.
 Bladder overactive
 Anticholinergics.

35. 5-alpha-reductase inhibitors
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 To shrink prostate by
preventing hormonal
changes that cause prostate
growth
 Finasteride (proscar)5 mg
daily
 Dutasteride (Avodart)
0.5mg daily
 Might take up to six months
to be effective 20% size
reduction
 1/3 of the pt has
improvement of symptom
score and PFR (≈1.5 mL/s)

36. Surgical management
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Indications
 Acute urinary retention
 Recurrent gross hematuria of prostatic origin
 Bilateral hydronephrosis with renal functional
impairment
 Bladder calculi , bladder diverticula
 Recurrent or persistent urinary tract infections
 Failed medical therapy

37. Surgical mgt contd…
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Invasive
-
Suprapubic/TV
P
- Retropubic
Minimally invasive
- TURP
- TU microwave therapy
- TU needle ablation
- Photo vaporization
- Laser prostatectomy
- Intraprostatic urethral
stents
- Interstitial laser
coagulation
- TU incision of prostate.

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 THE URETHRA
 Male
 Conveys urine and sperm cells.
 About 18-20 cm long & 8-9 mm in
diameter
 Extends from the neck of bladder to the
external meatus on glans.
 Internal(Involuntary) & external
(voluntary) sphincters.
Female
•3-4cm…only carries urine.

39. Urethral stricture
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 Men > women,
 Lag time between event and
presentation
Etiologies:
 Inflammatory →post.
Gonorrheal (common),Tbc,
schistosomiasis
 Traumatic →external injury to
pelvic area
 Instrumentation →long term
use of urethral catheter or
cystoscopy
 Post.op →open prostatectomy,
TURP &amputation of penis
 congenital
 Instrumentation
strictures: narrowest parts
 Fossa navicularis
 Peno scrotal junction
 Membranous urethra
 Infective strictures: where
paraurethral glands
numerous
 Proximal bulbar urethra
 Distal penile urethra
 Traumatic strictures
 Distal bulbar urethra –
direct crushing injury
 Membranous urethra –
indirect (pelvic #)

40. DIAGNOSIS
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HX (previous operation, trauma,
STD)
P/E (suprapubic & genital area).
Ixs-
 Urinary Flow rate; low flow rate
+ prolonged voiding → outflow
obstruction(Not specific for
stricture).
 Urethroscopy → to detect the
degree of narrowing of the
urethra.
 Retrograde urethrogam → site,
degree, number & length of
stricture (failure to pass the

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42. management
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 As a base line we need knowledge about
the location, length, depth and density of
the stricture.
 The goals of our mgt is either curative or
palliative.

43. Options
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 Dilation
 Can be curative, if there is no spongiofibrosis
 Internal urethrotomy
 Transurethral incision
 Laser urethrotomy
 Urethral stents
 Urethroplasty
 End to end urethral anastomosis

44. Summary
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 Assess all possible causes of LUTS apart
from BPH.
 Smaller sized BPH with LUTS of mild to
moderate severity can be managed with
medical therapy.
 AUR, after relief with catheterization,
TWOC must be tried by giving them alpha
blockers.
 Newer minimally invasive surgical options
are being the main stay of BPH treatment.

45. references
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 American urologic association guideline:
Management of BPH
 Campbell-Walsh-Weil Urology, 12th edition
 Uptodate
 European urologic association, non-
neurogenic LUTS management guideline

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