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25% of men >50 yrs have LUTS or objective signs of BOO. 40% of men in their 4th decade and >90% those >80yrs or more have detectable BPH RISK FACTORS. Genetics Race-Less in Asian men,High in Caucasians Diet-modest association,western type diet risk factor high in protein, fat and carbohydrates.
25% of men >50 yrs have LUTS or objective signs of BOO. 40% of men in their 4th decade and >90% those >80yrs or more have detectable BPH RISK FACTORS. Genetics Race-Less in Asian men,High in Caucasians Diet-modest association,western type diet risk factor high in protein, fat and carbohydrates.
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25% of men >50 yrs have LUTS or objective signs of BOO. 40% of men in their 4th decade and >90% those >80yrs or more have detectable BPH RISK FACTORS. Genetics Race-Less in Asian men,High in Caucasians Diet-modest association,western type diet risk factor high in protein, fat and carbohydrates.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato PPTX, PDF, TXT o leggi online su Scribd
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.