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BPH.DR. MUGALO E.L
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EPIDEMIOLOGY
Present in 50% of men above 60yrs,and88% aged 80 yrs.
25% of men >50 yrs have LUTS orobjective signs of BOO
About 40% of men in their 4th decade& >90% those >80yrs or more have
detectable BPH
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RISK FACTORS.
AGE-40% in men >50yrs,>90% inmen >80yrs.
Genetics
Race-Less in Asian men ,High inCaucasians
Diet-modest association ,western
type diet risk factor high in protein,fat & carbohydrates
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HISTORY
LUTS, Haematuria ,Dysuria.
Previous pelvic surgery, Neuropathy-Parkinsons d/se, CVA, etc
Cardiac problems ,DM, Diabetesincipidus
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SYMPTOMS-Not dse-
Weak stream, incomplete emptying,frequency, norcturia,urgency,intermitency ,straining.(IPSS)
Quality of life question
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BPH.
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PATIENT EVALUATION
History-luts,haematuri,dysuria
Exam-abd-bladder,CNS,DRE
INVESTIGATIONS-Urine(haematuria), Blood-renal fuction,PSA
US-size(TRUS),residual volume,R/O
bladder Tumour,Trus guided biopsy ifPSA is high
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IPSS-SCORE
This score allows you to calculate thesymptomatic frequenc5-6y and toclassify the patients according to thisfrequency.
-mild 0-7 Moderate 8-19 Severe 20-35
QoL assessement (8th
question) Good 0-1 Medium 2-4
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uroflowmetry
Noninvasive test to detect lowerurinary tract obstruction.
Qmax15mls/sec=no BOO
Low flow rate suggests BOO.
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Post void Residual Volume
PVR is a safety parameter
Men with a significant PVR should bemonitored more closely if they electnon-surgical therapy.
It can be measured accurately non-invasively with trans abdominal US
Elevated residual volume-stasis ofurine can increse the risk of UTI and
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Differentials
Bladder cancer
Neurological disease
Drug induced bladder Dysfunction DM/Diabetes insipidus
UTI,Detrusor Instability
Detrusor failure
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OBSTRUCTIVE PROSTATEB ni n Pr t ti H rtr h
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OBSTRUCTIVE PROSTATEB ni n Pr t ti H rtr h
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OBSTRUCTIVE PROSTATEB ni n Pr t ti H rtr h
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TREATMENT.
GENERAL RECOMMENDATIONS.
1.Avoid substance that can exacerbatesymptoms or cause urinary retensio.
-a) -agonists e.g. decongestantscontaining pseudoephidrine,anddietsuppliment ephedra.
-b)anticholinergics--c)caffeine and alcohol
-d)s ic and acidic foods
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TREATMENT. GENERALRE MMENDATI N
2.Norcturia can be reduced by.
-a)fluid intake in the evening
-b)avoid diuretics in the evening-c)patients with low extremity edemaneed to elevate their legs for onehour before bed time this mobilizesedema fluid and helps eliminate itbefore going to bed.
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TREATMENT.
WATHFULL WAITING.
-Repeating the evaluation at least once ayear.
-indicated for men with mild and notbothersome symtoms (ie AUA symptomscore
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TREATMENT.
-Blockers
Relax smooth muscles in the prostate fibromuscularstroma.
Achieve a dose dependent improvement in maximumurinary flow rate and symptom score
Can prevent BPH progression
Maximum response usually observed in 1-2 weeks.
-1A adrenergic receptors are the primary subtypeof -1 receptor in the prostate.
Side effects-dizziness,fatigue(asthenia),nasalcongestion,syncope,ortostatic hypotension,retrogradeejaculation.
Examlpes-terazosin(hytrin),doxazocin(cardura),tamsulosin(floma
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TREATMENT.
5-reductase inhibitors-finasteride(proscar) inhibits type II 5-reductase detasteride(Avodart) inhibits typeI and type II 5-reductase .
The enzyme that converts testosterone toDHT
Low DHT leads to:
-a)prostate volume by 20%-25 %.
-b)max urinary flow rate by approximately10%
-c)im roves s m tom scores b
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5-reductase inhibitors
-e) the risk BPH progression
-f)total PSA by 50% after 6 month oftreatment . In men on a 5-
reductaseinhibitor for 6 months thePSA during treatment , should bedoubled in before order to compare it toPSA before treatment.
-g)Increaseds testosterone by 10-20%(usually clinically insignificant)
-h)May help stop chronic haematuia from
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5-reductase inhibitors
Achieves maximum effect within 6-9months
Inicated for men with large prostates>40gm
Adult dose-finasteride 5mg po qday,dutasteride 0.5mg po q day
Adverse effects-impotence
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Combination therapy
Medical Therapy of ProstateSymptoms(MTOPS) trial randomized studyshowed that both -blockers and5-reductase inhibitors prevent progression of
BPH;however , the combination theapy isbetter than either agent alone.
Benefits of combination therapy are betterin men with PSA>4.0ng/ml and prostate
volume >40ngcc. Therapy did not reduce renal insufficiency,
UTI,or incontinence, but did reduce
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MINIMALLY INVASIVE
TUNA-Transurethral NeedleAblation.Radiofrequency (RF) wavesheat the prostate and create thermal
necrosis. TUMT-Transurethral Microwave Therapy.
Microwave heat the prostate and createthermal necrosis.
Emerging Minimally InvassiveTherapies. E.g. Interstitial LaserCoagulation, absolute ethanol
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SURGICAL THERAPY.
INDICATIONS.
1.absolute;
a)Refractory urinary retension
b)Recurrent UTIc)Bladder stones
d)Renal insufficiency from BPH
2.Moderate indications-AUA symptom score8 and any of the following.
a)Substatial bother symptoms
b)sing post voidal residual on serial exams
c)Low maximum flow rate (es
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SURGICAL THERAPY.
TUIP(Transurethral Incision of Prostate)-
-1 or 2 incisions at 5 and/or 7 oclockextending from the bladder neck to
immediately above cephalad to theverumontanum.the incision should bedeep to he fobrous prostate capsule.
Similar efficiency to TURP,but lower
rate of retrograde ejaculation. Suitable for smaller prostates (
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TURP.
Use of a resection loop to removechipsof prostate tissue.
Success rate is higher when;
a. pre-op maximum flow rate
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TURP.
Complications.
-posesulting in hyponatremit-opbleeding
-TUR syndrome(2% incidence)-excesiveabsorption of hypotonic irrigationfluid from prostatic vascular bedresulting in in hyponatremia,hypervolemia,HT,mentalconfussion,nausea,vomiting,vissualdisturbance.
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OPEN PROSTATECTOMY.
Reserved for large prostates (>80cc),or men who can not tolerate TURP.
Approaches-
transvesical/suprapubic,retropubic,and perineal.
Transvescical approach is ideal for
patients with bladder stones orrequire diverticulum repaire.
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OTHER SURGICAL
Holmium laser resection/enucleationof the prostate.
Trans urethral laser
coagulation(VLAP, vissual laserablation of the prostate)-laser energycoagulates the prostate withoutvapourizational laser vapourisation
Trans urethral laser vapourization
Transurethral electrovapourization-
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PERSISTENT SYMPTOMS AFTERR I AL TREATMENT.
In 15-20 % of men after surgical treatment. Do urodynamics which will reveal
-38% remain obstructed
-25% have poor detrusor contraction-50% have detrusor overactivity in absence ofa neurological disorder-which may persistup to 1 year.
-70% have detrusor overactivity when
neurological disorder is present. Detrusor overactivity and shincter damage
are the most common causes ofincontinence after invassive treatment.