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Epidemiology BPH
Common over 40 yrs of all races & cultures
Prevalence by age 60 = 50 % 70 = 70 % 80 = 90 %
From 40 80 : 10 % chance of undergoing prostatectomies
Number of prostatectomies per year per 1000 men > 55 yrs Belgium USA France Denmark Japan UK 14 13 13 12 9 7
Prostate
Antibacterial
Zinc
Pathophysiology
1.
The static component Hyperplastic nodule of transition zone The dynamic component Smooth muscle tone in the prostate, prostatic capsule & bladder neck
The detrusor component Loss of contractile, uninhibited
2.
3.
Histology
Increase in the stromal component, both smooth muscle and connective tissue.
Pathogenesis
1. Dihydrotestosterone hypothesis
(Testo. Bind with TBG & Albumen ; Unbound testo. 1 3 %) formed by 5-alpha reductase isoenzymes type 1 & 2 within the prostate binds to receptors in the nucleus, leads to cell replication epithelial & stromal hyperplasia
Risk factors
Age Race Environment and dietary higher in men consuming milk lower in men consuming soya (phytooestrogen) Associated conditions DM, Hypertention (20 30 %), Obesity
Classical symptoms
Obstructive
Weak stream Straining Hesitancy Intermittency Incomplete emptying Terminal dribbling Prolonged micturition Overflow incontinence
Irritative
Frequency Urgency Nocturia Urge incontinence Small voided volume
Other symptoms
Haematuria Dysuria Haematospermia Low back pain (hydronephrosis) Nausea (uremic) Urinary retention Edema
Diverticulum
Anamnesis
Medical history Disease (CVA, HNP, DM, Tumor, MS) Pelvic surgery Instrumentation Medicine (e.g. phenylpropanolamine) Provocative event (alcohol)
Anamnesis
IPSS (= AUA)
Self assesment *
Obstructive : incomplete emptying, weak stream, straining, intermittency
Irritative
Physical examination
Inspection
Abdominal palpation
Phimosis
Meatus stenosis
Dilatator / Bougies
Paraphimosis
DRE
Diagnosis / Investigations
Urinalysis (ery,leuc,bact) Serum Urea, Creatinine, PSA Uroflowmetry & post-void residual urine *
X-Abdomen & USG Kidney TRUS (Transrectal Ultrasound) of the Prostate
IVU (cystogram)
Interpretation
normal equivocal obstructed
Transrectale ultrasonography
Residu
Hydronephrosis
Giant Prostate
> 10 ng / ml
effect
none none 1.9 X 4.1 X 53 X 57 X
Treatments
Watchful waiting
for patients with minor symptoms and no objective signs of complications
Relative
- Severe haematuria - Socially disabling symptoms - Disturbance of sleep, rest
Absolute
- Obstructive uropathy - Overflow incontinence - Repeated retention - Vesicle stone - Severely decompensated bladder - Chronic / recurrent infection
Medical therapy Alpha-1 blockers (Prostate tone) - Doxazosin - Alfuzocin - Terazosin - Tamsulosine (selective) 5-alpha reductase inhibitors (Prostate volume) - Finasteride (type 2) - Dutasteride (type 1 & 2)
Alpha-1 blockers
- improve flow by 3-5 ml/sec - effective 60 % - drowsiness, headaches - postural hypotention - discontinuation before cataract surgery !!!
Finasteride
- reduced prostate volume - improve flow by 2.7 ml/sec - reduced libido - reversible impotence - decreases PSA by 50 %
Serenoa repens
Surgical therapy Open prostatectomy Transvesical (Hrynchack, Freyer 1901) Retropubic subcapsule (Millin 1947)
- prostate volume > 100 grm - hospital stay 10 12 days - mortality rate 1 %
3 way catheter
T.U.R. Prostate
Post-operative complications Retrograde ejaculation 60 % Haemorrhage 15 % Impotence 15 % Urethra stricture 5% Bladder-neck sclerosis 5% Epididymitis 4% TUR syndrome 2% Incontinence 1%
Stricture urethra
GreenLight Laser
120 -W
Less Bleeding Less Pain No Erectile Dysfunction No TUR Syndrome Stay one night Quick recovery
Vaporization
Bloodless procedure Less pain No risk of water intoxication Short catheterization (< 24 hours) < 1 % cases of erectile dysfunction Rapid urine flow improvement Quick return to normal activities Definitive and long lasting treatment No pathology specimen
New Finding
Anti-inflammatory Antioxidants
Differential diagnosis
Teratoma
Chordoma
Suprapubic cystostomy
As result of absorption of irrigant Sodium < 120 mmol / l Widening QRS complex ST depression
Mean volume of irrigant absorbed during TURP 900 ml 30 % absorbed by intravascular route
(venous pressure 6 cm H20)
Circulatory distress Hypervolaemia - elevate CVP Diffusion interstitial - plasma (transient) follow leakage of water from plasma - interstitial - Hypotention
Dilution of protein Lowers oncotic pressure - pulmonary oedema
Classic syndrome
Prevention / Management
good surgical technique avoid overfilling the bladder limit resection time (90 min.) routine administration of Furosemide
14 li