BPH - KSB

Report
BENIGN PROSTATIC
HYPERPLASIA
Dr.Arun Narayanaswamy
Urology Unit
Amiri Hospital
OUTLINE
BPH
Anatomy of Prostate
 Aetiology
 Pathophysiology
 Incidence
 Clinical presentation
 Investigations
 Management

Catheterisation
Indications
 Catheter types
 Technique
 Complications

Anatomy of Prostate gland
Walnut-sized. Part of male reproductive system
 Location
Anterior to rectum,
Just distal to bladder,
Encircling the neck of
bladder and urethra


Normal weight – 20gm
Anatomy of Prostate gland
Prostatic parenchyma divided into 4 Zones.
 Biologically and anatomical distinct.

Functions of Prostate gland
Secretes alkaline fluid–30% of seminal volume
Actions - Lubrication and nutrition for sperm,
Liquefaction of the seminal plug,
Neutralizes acidic vaginal environment
 Prevents retrograde ejaculation (ejaculation
resulting in semen being forced backwards into
the bladder) by closing the bladder neck during
sexual climax.

What is BPH ?

BPH is part of the natural aging process,
like getting gray hair or wearing glasses

Characterized by hyperplasia of
prostatic stromal and epithelial cells.

Occurs in the Transitional zone.

Results in formation of nodules in the
periurethral region of the prostate.
What is BPH ?
Urethra
Peripheral Zone
Transition zone
Aetiology of Hyperplasia

DHT-mediated hyperplasia aided by estrogens
In aging men, estradiol levels increase.
Mechanism of Obstruction

Mechanical Component - When sufficiently
large, the nodules compress the urethral canal
Mechanism of Obstruction
 Dynamic Component - Large numbers of
alpha-1-adrenergic receptors present in the
smooth muscle of the stroma and capsule
of the prostate, bladder neck.
Stimulation causes ↑ in smooth-muscle tone
Pathology of BPH
Gross - Circumscribed grey white nodules
 Histology
Epithelial - Glandular proliferation or dilation
Stromal - Fibrous or Muscular proliferation
 Mostly common - Fibroadenomyomatous pattern

BPH - Bladder Effects
Bladder wall -  contractile force leads to:
Hypertrophy or Trabeculation, and Irritability.
 Bladder may gradually weaken
Increased residual urine volume
Acute or chronic urinary retention.
 Biopsy
-  smooth-muscle fibers /  in collagen
- Decrease compliance, Impair contraction

Prevalence of BPH
•25% - 40-49 years
•50% - 70 & older
•90% at 85 years
Source: J Urol 1984;132:474
• Only 50% develop clinical symptoms.
• Severity of symptoms not related to size.
• Second most common surgery after
cataract extraction in men > 65 years.
Common Terms
• LUTS
Lower-urinary-tract symptoms
• BPE
Benign prostatic enlargement
(macroscopic)
• BPH
Benign prostatic hyperplasia
(microscopic/histologic)
• BOO
Bladder-outlet obstruction
Symptoms
Obstructive Symptoms
(Voiding)
Elective
- Weak stream
- Straining to void
- Hesitancy
- Intermittency
- Terminal dribbling
- Incomplete emptying
Irritative Symptoms
(Storage)
Emergency
- Acute urinary
retention
- Chronic Retention
with overflow
- Dysuria
- Frequency
- Nocturia
- Urgency
- Incontinence
- Nocturnal enuresis
Symptom Assessment




International Prostate Symptom Score (IPSS)
/ AUA Score
Based on a survey & questionnaire developed
by the American Urological Association (AUA).
7 questions about the severity of symptoms.
Total score: Mild
0- 7
Moderate 8 - 19
Severe
20 - 35
Sexual history

Studies have identified LUTS as an independent
risk factor for erectile / ejaculatory dysfunction.
Physical Examination
Suprapubic area - Bladder distension
 Neurological examination Decreased anal sphincter tone
Absent bulbocavernosus reflex
 Palpate the scrotum: epididymo orchitis
 Signs of CRF, Pallor

Rectal Examination
Left lateral position
 Index finger of the dominant hand.
 Palpate circumferentially
- windshield wiper movement

Rectal Examination
Prostate size and contour, Median sulci
 Consistency
 Nodules, Hardness, Asymmetry suggestive of malignancy.
 Pain - Prostatitis,
Fluctuance - Prostate abscess
 Rectal mucosa

Complications of BPH
Urinary retention
 Recurrent UTIs
 Gross hematuria
 Bladder calculi
 Bladder Diverticuli
 Renal failure or uremia

Differential Diagnosis
Urethral Strictures
 Bladder Stones
 Neurogenic Bladder
 Prostatitis
 Bladder Tumours
 Radiation Cystitis
 Interstitial Cystitis

Investigations






Basic Iab:
 CBC / S.Creat
 Urine routine / culture
PSA(prostate specific antigen)
Xray KUB :calculi
Ultrasound
Uroflowmetry
Flexible Cystoscopy
Prostate Specific Antigen






Secreted by Prostatic cells.
Normal <4ng/dl
Marker for Carcinoma Prostate – Elevated.
BPH does not lead to prostate cancer.
However men at risk for BPH are also at risk
for prostate cancer and so should be screened.
Not disease specific - Also  in BPH,
Prostatitis,DRE,Catheterization
High PSA →Trans rectal US and Biopsy
Ultrasonography




Prostate – Size (>20cm3:abnormal), Nature
Bladder – Wall thickness, Diverticuli, Calculi
Kidneys - Hydronephrosis
Post micturition residual volume(>50-100ml)
Uroflowmetry
 Simple noninvasive test to document voiding
 Peak Flow rate (>15ml/s is normal)
 Voiding time, Voiding pattern
 Volume of voided urine – atleast 150ml
Uroflowmetry
Cystometry - Pressure flow



Invasive – Urethral / Rectal catheterization.
Indication - To distinguish  bladder contractility
(detrusor underactivity) from outlet obstruction.
BOO -Low urine flow rates accompanied by
High intravesical voiding pressure (>60 cm water)
Cystoscopy
Flexible cystoscopy can be easily performed
in an office-based setting using topical gelintraurethral anesthesia without sedation.
Indicated when Suspicion of
 Urethral stricture - h/o STD,
prolonged catheterization,
or trauma
 Detrusor hypocontractility DM
Treatment Options
 Watchful waiting
 Medical management
 Surgical approaches
- Endoscopic surgery
- Minimal invasive procedures
- Open surgery
Watchful Waiting
 For mild symptoms.
 Follow up 1 to 2 times yearly
 Suggestions that help reduce symptoms
- Avoid caffeine and alcohol
- Alteration of timing, volume of fluid intake
Medical Management
Benefits
Convenient
No loss of work time
Minimal risk
Types –
Disadvantages
Drug Interactions
Must be taken every day
Does not fix problem
Side Effects
Cost
Alpha Adrenergic Blockers
5 alpha reductase inhibitors
Alpha 1 Adrenergic
Receptors
Alpha Blockers - Rationale
 BPH predominantly stromal (Smooth muscle )
proliferative process - Dynamic Obstruction
 Mediated by the alpha1A-adrenergic receptors.
 Density of receptors changes with
prostate size & age.
 Alpha-adrenergic receptor-blocking agents
Relax the smooth muscle
Decrease outflow resistance.
Alpha Blockers - Agents




Nonselective
- Phenoxybenzamine
Short-acting selective a1-blocker
- Prazosin,
Long-acting selective a1-blockers
- Terazosin, Doxazosin
Long-acting selective a1A-subtype
- Tamsulosin
- Alfuzosin
- Silodosin

Alpha Blockers - Advantages
Quick action
 Improves urinary flow 4- to 6-point improvement is expected
in IPSS/AUA scores
 No adverse effect upon sexual drive
 No effect on PSA

Alpha Blockers - Disadvantages
No effect on Prostate volume
 No reduction in risk of acute urinary
retention or BPH-related surgery.
 Lowers blood pressure
 Fatigue, nasal congestion, headache
 Retrograde Ejaculation
 Intraoperative floppy iris syndrome (IFIS) Miosis, iris billowing, and prolapse in
patients undergoing cataract surgery

5 Alpha Reductase - Rationale





Prostatic growth depends on androgenic
stimulation by DHT.
5a-reductase mediates conversion.
Agents that block 5a-reductase inhibit
growth and therefore help in BPH
Types - type I and type II
Type II predominates in the prostate and
other genital tissues.
5 Alpha Reductase - Agents
 Finasteride Selective inhibitor of type II 5a-reductase
 Dutasteride Newer agent. Has affinity for both Types
 Similar efficacy.
 Both agents actively reduce serum DHT
levels by more than 80%,
Change in Prostate Volume
% Change in prostate
volume from baseline
30
20
Dutasteride
Finasteride
a-blockers
10
0
-10
-20
-30
McConnell et al. (1998); McConnell et al. (2003); Roehrborn et al. (2002); Lowe et al. (2003)
5 Alpha Reductase - Advantages
Reduce prostate volume by 20%
 Improve symptoms in a third of men and
increase peak flow by around 2ml/s
 55% reduction in incidence of urinary retention,
and likelihood of surgery for BPH.
 Longer acting
 Less side effects than alpha blockers
 Can reverse male pattern balding

5 Alpha Reductase - Advantages

Reduce bleeding during surgery.
5 Alpha Reductase - Disadvantages
Slow to act - Takes up to six months to work
 Not effective for mildly enlarged prostates
 Can affect sexual function
 Can cause breast swelling
 Transmitted in semen and can cause birth
defects. Users should have protected sex.
 Caution in liver function abnormalities
 Lowers serum PSA level by 50% .

Combination Therapy
• Activates Two Distinct and Complementary
Mechanisms of Action.
Alpha blockers
Relaxes prostatic
and bladder-neck
smooth muscle
through sympathetic
activity blockade
Rapidly relieve
symptoms
5-Alpha reductase inhibitors
Reduces prostate
enlargement through
hormonal mechanisms
Arrest disease
progression
Dutasteride+Tamsulosin / Finasteride+Tamsulosin.
Decrease in Symptom Score
Increase in Peak Flow
Combination Therapy

Patients with prostates >30 gm.

Superior to monotherapy over long term.

Risk of acute urinary retention decreased by
79% - Combination therapy
31% - a-blocker alone
67% - 5a-reductase inhibitor alone.

Alpha blocker may be withdrawn after 6 months
Phosphodiesterase 5 Inhibitors
Treatment of associated ED
 Nitric oxide known to mediate smooth muscle
relaxation in the lower urinary tract.
 Improvements in Urinary symptoms reported
 Smallest necessary dose.
 Should not be taken within 4 hours of any
alpha-blocker

Anticholinergics
Treatment of Frequency / Urgency.
 Relaxes Detrusor muscle.
 Historically, discouraged because of concerns
of inducing urinary retention.
 Recommend only in patients who do not have
an elevated PVR.
 Not to be used when PVR is greater than
250-300 mL

Phytotherapy
Considered emerging therapy
 Saw palmetto (American dwarf palm) Leaf
 South African star grass (Hypoxis rooperi) roots
 African plum tree (Pygeum africanum) bark
 Stinging nettle (Urtica dioica) roots
 Rye (Secale cereale) pollen
 Pumpkin (Cucurbita pepo) seeds
Active components - Phytosterols, Fatty acids,
Lectins, Flavonoids, Plant oils, & Polysaccharides
Phytotherapy
Modes of action:
 Antiandrogenic, Antiestrogenic effect
 Inhibition of 5-alpha-reductase
 Blockage of alpha receptors
 Antiedematous, Anti-inflammatory effect
 Inhibition of prostatic cell proliferation
 Interference with prostaglandin metabolism
 Protection and strengthening of detrusor
Algorithm for Medical Therapy
Patient
IPSS ≤7
IPSS >7
No or
little
bother
Prostate small
No Treatment
Prostate large
Preventive therapy
5a-Reductase Inhibitor
Moderate to
severe
bother
Prostate small
aAdrenergic
Blocker
Prostate large
5a-Reductase
Inhibitor
Combination Rx
Follow Up
Diet
 Diet low in fat and red meat and high in
protein and vegetables may reduce the risk
of symptomatic BPH.
Long-term Monitoring
 At least biannually evaluation to discuss the
efficacy of medication and potential dose
adjustment.
 Atleast annual DRE and PSA screening.
Indication for Surgery




Dissatisfied with medical management
Unwilling to take daily medication
Financial constraints
Complicated BPH




Renal dysfunction(obstructive uropathy)
Recurrent attacks of acute retention of urine
Recurrent UTI, Haematuria
Bladder Calculi
Surgical Options



Endoscopic Surgery
TURP
Bladder neck incision
Laser Prostatectomy
Minimally invasive
TUNA,TUMT, Balloon dilatation, Stents
Open prostatectomy
Trans Urethral Resection
of Prostate (TURP)
 Gold Standard of care for BPH
 Endoscopic electrocautery “knife” used.
 Obstructive symptom improved - 80~90%
 Irritative symptom improved - 30%
 Low mortality rate - 0.2%
 Morbidity - 18%
TURP - Technique


Regional /General anesthesia
Working sheath placed in
the urethra through which a
hand-held device with an
attached wire loop is placed.
TURP - Technique

High-energy electrical cutting current is run
through the loop and used to shave away
prostatic tissue.

The entire device is usually attached to a video
camera to provide vision for the surgeon.
TURP - Technique
TURP
Post-op:
• Three way catheter
• Continuous bladder
irrigation with
N.Saline until urine
clear of clots
TURP
Disadvantages
Benefits
n
Widely available
n
Effective
n
Long lasting
n
Side effects and
complications
n
1-4 days hospital stay
n
1-3 days catheter
n
4-6 week recovery
TURP - Complications
Immediate
 Bleeding and clot retention
 Capsular perforation / fluid extravasation
 Sepsis
 TURP syndrome
TURP Syndrome




Absorbtion of Irrigation fluid (glycine)
into the open prostatic vein
Fluid overload - Pulmonary oedema,
Cerebral oedema
Haemodilution - Hyponatraemia,
Haemolysis
Treatment - Stop Surgery, IV frusemide,
Hypertonic saline
TURP - Complications
Delayed
 Urethral stricture
 Bladder neck contracture
 Retrograde ejaculation(90%)
 Impotence (5-10%)
 Incontinence (0.1%)
Trans Urethral Incision
of Prostate (TUIP)
Indications
Small prostates
Cannot tolerate TURP (medical conditions)
 Advantage over TURP
Less bleeding
Less fluid absorption
Lower incidence of retrograde ejaculation
Lower incidence of impotence.

Laser Prostatectomy
Mechanism
Heats tissue - Causing coagulative necrosis,
and subsequent tissue contraction
 Evaporate - Melts away, prostate tissue.
More effective.
 Knifelike fashion - To directly cut away
prostate tissue

Laser Prostatectomy
Types

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



Transurethral laser-induced prostatectomy (TULIP)
Visual laser ablation of the prostate (VLAP)
Interstitial laser coagulation of the prostate (ILC)
Holmium:YAG laser resection of prostate (HoLRP)
Holmium:YAG laser enucleation of prostate (HoLEP)
Photoselective Vaporisation of Prostate Green light prostatectomy (PVP)
Green Light Prostatectomy (PVP)
n
Uses a very high powered green laser and a thin,
flexible fiber
n
Fiber is inserted into
the urethra through a
cystoscope
Green Light Prostatectomy (PVP)
n Quickly and precisely vaporizes and removes the
enlarged prostate tissue
n The green laser energy is hemostatic, so there is
almost no bleeding
Green Light Prostatectomy (PVP)
Enlarged Prostate
n
n
Urethra is obstructed
Urine flow blocked
After GreenLight PVP
n
n
Urethra is open
Normal urine flow is
restored
Laser Prostatectomy
Advantages
Catheter time less - 24 hours.
 Reduced hospital stay 59 vs 86 hours
 Equal results.
 Less bleeding. 23.3 vs 2.1 ml per minute. Useful
inpatients who require anticoagulation.
 TUR syndrome is not seen
  incidence of impotence / retrograde ejaculation

Laser Prostatectomy –
Disadvantages
Longer operating time - 74 vs 57 min.
 No tissue for biopsy - Vaporization technique.
 Dysuria / Urgency - Healing from laser
treatment does not occur until after a period
of weeks when dead cells slough.

Minimally Invasive Therapy




Developed during the last decade to
challenge TURP
Aim – Minimise anesthesia, blood loss, fluid
absorbption, risk and hospital stay.
Mechanism Heat destruction causing necrosis.
Mechanical approaches.
Efficacy – Between medical therapy & TURP.
Minimally Invasive Therapy




Transurethral microwave thermotherapy (TUMT):
Heat delivered to prostate via urethral catheter.
Transurethral needle ablation of the prostate
(TUNA): High-frequency radio waves delivered
using a transurethral device with needles.
Cryotherapy
High-intensity focused ultrasound(HIFU)
Delivered rectally or extracorporeally
Minimally Invasive Therapy




Transurethral balloon dilatation of prostate
Intraprostatic stent
Flexible devices that can expand when put in
place to improve the flow of urine.
Complications - Encrustation, Pain, Incontinence,
Overgrowth of tissue through the stent (making
removal difficult).
Transurethral ethanol ablation of the prostate
Botulinum toxin-A injection of the prostate
Open Prostatectomy


Indication Large prostate(>100gm)
Co existing bladder pathology : calculi, diverticula.
Lithotomy position not possible : eg:Hip joint disease
Technique Lower abdominal incision.
Retropubic/Transvesical
The inner core of the prostate (adenoma), which
represents the transition zone, is shelled out,
leaving the peripheral zone behind.
Urinary Catheterisation
Facilitates direct drainage of urinary bladder.
Indications
Diagnostic
 Collection of uncontaminated urine
specimen
 Monitoring of urine output
 Imaging of the urinary tract
Indications
Therapeutic
 Acute urinary retention
 Chronic retention causing hydronephrosis
 Continuous bladder irrigation (hematuria)
 Intermittent catherisation Neurogenic bladder
 Hygienic care of bedridden patients

Short-term drainage (eg, post surgery)
Urinary Retention - Acute



Features
Painful
Normal renal function
Precipitating event
- UTI
- Fluid overload
- Constipation
- Medication
Causes







BPH
Urethral Stricture
Urethral Stone
Trauma
Neurogenic
Psychogenic
Post op
Urinary Retention - Chronic
Features
 Painless
 Impaired renal function
 Large residual volume
Causes


BPH
Impaired Detrusor
contractility
Contraindications for
Urethral Cath
Traumatic injury to the lower urinary tract male patients with pelvic or straddle-type
injury.
 Signs for injury - Blood at the meatus, Perineal
hematoma, High-riding or boggy prostate.
 Retrograde urethrogram should be performed
prior to catheterisation
 Catheterisation by urologist.

Urinary Catheterisation
Urethral Catheter
Urinary Catheterisation
Suprapubic Catheter
Equipment
Povidone-iodine
 Sterile cotton balls
 Water-soluble lubrication gel
 Sterile drapes, Sterile gloves
 Urethral catheter
 Prefilled 10-mL syringe
 Urobag for collection

Catheter Types

Foleys
- 2 way Catheter
- 3 way irrigation catheter
(gross hematuria)

Tip
- Straight tip
- Coudé tip:
(Prostatic Obstruction)
Catheter Sizes
Adults 14F 16F 18F
 Hematuria catheters 20F 22F 24F
 Children – Smaller
 Infants feeding tubes

Colour coded
Catheter Material
Latex (silicone-coated)
 Pure silicone
 Silver alloy
 Antibiotic-impregnated

Catheterisation Technique
Prophylactic antibiotics
 Males - Supine
Female - Frogleg position, with knees flexed.
 Sterile gloves
 Clean with antiseptic solution
 Sterile drapes.

Instillation of Jelly
Hold penis firmly and extended
 Place tip of syringe / applicator in the meatus
 Apply gentle but continuous pressure
and apply a generous amount of jelly.
 Occlude the urethral tip and for a couple of
minutes to allow the anesthetic to take effect.

Catheterisation Technique
Males - Hold the penis at approximately 90°
and stretch it upward to straighten out penile
urethra, slowly and gently introduce catheter.
 Females – Separate labia and visualize meatus.

Catheterisation Technique
Advance the catheter until the proximal Yshaped ports are at the meatus.
 Wait for urine to drain from larger port to ensure
that distal end of the catheter is in the Bladder.

Catheterisation Technique
After urine return, inflate the balloon with
distilled water through the cuff inflation port.
 Maximal recommended volume
for balloon inflation can be found
on inflation valve (10-30 mL).
 Lubricant jelly–filled distal
catheter openings may delay urine return. If
no spontaneous return of urine occurs, try
attaching a 60-mL syringe to aspirate urine.

Catheterisation Technique
Gently withdraw the catheter until
resistance is met.
 Secure catheter to thigh with a wide tape.
 Uncircumcised patient – Reduce foreskin.
Failure to do so can cause paraphimosis.

Catheter Removal

Use a syringe to empty the balloon, and then
apply gentle traction.
Complications
Infections - Urethritis, Cystitis,
Pyelonephritis, and Transient bacteremia
 Bleeding
 Creation of false passages
 Inflation of the balloon inside the
urethra resulting urethral tear.
 Urethral strictures
 Encrustation
 Fragmentation

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