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BPH.

DR. MUGALO E.L


EPIDEMIOLOGY
• Present in 50% of men above 60
yrs,and88% aged 80 yrs.
• 25% of men >50 yrs have LUTS or
objective signs of BOO
• About 40% of men in their 4th decade
& >90% those >80yrs or more have
detectable BPH
RISK FACTORS.
• AGE-40% in men >50yrs,>90% in
men >80yrs.
• Genetics
• Race-Less in Asian men ,High in
Caucasians
• Diet-modest association ,western
type diet risk factor high in protein,
fat & carbohydrates
HISTORY
• LUTS, Haematuria ,Dysuria.
• Previous pelvic surgery, Neuropathy-
Parkinson’s d/se, CVA, etc
• Cardiac problems ,DM, Diabetes
incipidus
SYMPTOMS-Not d’se
specific-IPSS
• Weak stream, incomplete emptying,
frequency, norcturia,urgency,
intermitency ,straining.(IPSS)
• Quality of life question
BPH.
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 if
PSA is high
IPSS-SCORE
• This score allows you to calculate the
symptomatic frequenc5-6y and to
classify the patients according to this
frequency.
• -mild 0-7
• Moderate 8-19
• Severe 20-35
QoL assessement (8th question)
• Good 0-1
• Medium 2-4
• bad
uroflowmetry
• Noninvasive test to detect lower
urinary tract obstruction.
• Qmax<10ml/sec=BOO
• Qmax>15mls/sec=no BOO
• Low flow rate suggests BOO.
Post void Residual Volume
(PVR)
• PVR is a safety parameter
• Men with a significant PVR should be
monitored more closely if they elect
non-surgical therapy.
• It can be measured accurately non-
invasively with trans abdominal US
• Elevated residual volume-stasis of
urine can increse the risk of UTI and
bladder stones.
Pressure-Flow Studies
• Differentiates between patients with
a low Qmax due to BOO and those
whose low Qmax is due to
decompensated or neurogenic
bladder.
• Low flow rate and high detrusor
pressure on urodynamics-advanced
stages may also reveal detrusor
overactivity or acontractile bladder.
Differentials
• Bladder cancer
• Neurological disease
• Drug induced bladder Dysfunction
• DM/Diabetes insipidus
• UTI,Detrusor Instability
• Detrusor failure
OBSTRUCTIVE PROSTATE
Benign Prostatic Hypertrophy
OBSTRUCTIVE PROSTATE
Benign Prostatic Hypertrophy
OBSTRUCTIVE PROSTATE
Benign Prostatic Hypertrophy
OBSTRUCTIVE PROSTATE
Benign Prostatic Hypertrophy
TREATMENT.
• GENERAL RECOMMENDATIONS.
• 1.Avoid substance that can exacerbate
symptoms or cause urinary retensio.
-a) α-agonists e.g. decongestants
containing pseudoephidrine,anddiet
suppliment ephedra.
-b)anticholinergics-
-c)caffeine and alcohol
-d)spicy and acidic foods
TREATMENT. GENERAL
RECOMMENDATIONS
• 2.Norcturia can be reduced by.
-a)↓fluid intake in the evening
-b)avoid diuretics in the evening
-c)patients with low extremity edema
need to elevate their legs for one
hour before bed time –this mobilizes
edema fluid and helps eliminate it
before going to bed.
TREATMENT.
• WATHFULL WAITING.
-Repeating the evaluation at least once a
year.
-indicated for men with mild and not
bothersome symtoms (ie AUA symptom
score <8).
• PHYTOTHERAPY.
-not recommended by AUA
-largely unknown mechanisn of action
-saw palmentto most widely used,does
TREATMENT.
• α-Blockers
• Relax smooth muscles in the prostate fibromuscular
stroma.
• Achieve a dose dependent improvement in maximum
urinary flow rate and symptom score
• Can prevent BPH progression
• Maximum response usually observed in 1-2 weeks.
• α-1A adrenergic receptors are the primary subtype
of α-1 receptor in the prostate.
• Side effects-dizziness,fatigue(asthenia),nasal
congestion,syncope,ortostatic hypotension,retrograde
ejaculation.
• Examlpes-
terazosin(hytrin),doxazocin(cardura),tamsulosin(floma
x/contoflo),alfuzosin(xatral/uroxatral)
TREATMENT.
• 5α-reductase inhibitors-
finasteride(proscar) inhibits type II 5α-
reductase detasteride(Avodart) inhibits type
I and type II 5α-reductase .
• The enzyme that converts testosterone to
DHT
• Low DHT leads to:
-a)↓prostate volume by 20%-25 %.
-b)↑max urinary flow rate by approximately
10%
-c)improves symptom scores by
5α-reductase inhibitors
-e)↓ the risk BPH progression
-f)↓total PSA by 50% after 6 month of
treatment . In men on a 5α-
reductaseinhibitor for ≥6 months the
PSA during treatment , should be
doubled in before order to compare it to
PSA before treatment.
-g)Increaseds testosterone by 10-20%
(usually clinically insignificant)
-h)May help stop chronic haematuia from
the prostate .
5α-reductase inhibitors
• Achieves maximum effect within 6-9
months
• Inicated for men with large prostates
>40gm
• Adult dose-finasteride 5mg po q
day,dutasteride 0.5mg po q day
• Adverse effects-
impotence<5%,decrease in
libido<4%, decrease in volume of
Combination therapy
• Medical Therapy of Prostate
Symptoms(MTOPS) trial randomized study
showed that both α-blockers and5α-
reductase inhibitors prevent progression of
BPH;however , the combination theapy is
better than either agent alone.
• Benefits of combination therapy are better
in men with PSA>4.0ng/ml and prostate
volume >40ngcc.
• Therapy did not reduce renal insufficiency,
UTI,or incontinence, but did reduce
progression of voiding symptoms, acute
MINIMALLY INVASIVE
THERAPY.
• TUNA-Transurethral Needle
Ablation.Radiofrequency (RF) waves
heat the prostate and create thermal
necrosis.
• TUMT-Transurethral Microwave Therapy.
Microwave heat the prostate and create
thermal necrosis.
• Emerging Minimally Invassive
Therapies. E.g. Interstitial Laser
Coagulation, absolute ethanol
injection,water induced thermal
SURGICAL THERAPY.
• INDICATIONS.
1.absolute;
a)Refractory urinary retension
b)Recurrent UTI
c)Bladder stones
d)Renal insufficiency from BPH
2.Moderate indications-AUA symptom score
≥8 and any of the following.
a)Substatial bother symptoms
b)↑sing post voidal residual on serial exams
c)Low maximum flow rate (esp<15mls/sec)
SURGICAL THERAPY.
• TUIP(Transurethral Incision of Prostate)-
-1 or 2 incisions at 5 and/or 7 o’clock
extending from the bladder neck to
immediately above cephalad to the
verumontanum.the incision should be
deep to he fobrous prostate capsule.
• Similar efficiency to TURP,but lower
rate of retrograde ejaculation.
• Suitable for smaller prostates (<30gm)
and for men who wish to reduce he risk
of retrograde ejaculation.
TURP.
• Use of a resection loop to remove
“chips”of prostate tissue.
• Success rate is higher when;
a. pre-op maximum flow rate
<15ml/sec.
b. Patient is substantially bothered by
their symptoms.
• Higher risk of bleeding than TUIP.
TURP.
• Complications.
-posesulting in hyponatremit-op
bleeding
-TUR syndrome(2% incidence)-excesive
absorption of hypotonic irrigation
fluid from prostatic vascular bed
resulting in in hyponatremia
,hypervolemia,HT,mental
confussion,nausea,vomiting,vissual
disturbance.
OPEN PROSTATECTOMY.
• Reserved for large prostates (>80cc),
or men who can not tolerate TURP.
• Approaches-
transvesical/suprapubic,retropubic,an
d perineal.
• Transvescical approach is ideal for
patients with bladder stones or
require diverticulum repaire.
OTHER SURGICAL
THERAPIES.
• Holmium laser resection/enucleation
of the prostate.
• Trans urethral laser
coagulation(VLAP, vissual laser
ablation of the prostate)-laser energy
coagulates the prostate without
vapourizational laser vapourisation
• Trans urethral laser vapourization
• Transurethral electrovapourization-
electric (cutting) current vapourizes
PERSISTENT SYMPTOMS AFTER
SURGICAL 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 of
a neurological disorder-which may persist
up to 1 year.
-70% have detrusor overactivity when
neurological disorder is present.
• Detrusor overactivity and shincter damage
are the most common causes of
incontinence after invassive treatment.

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