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![ogwuche E.I
Figure 32.28 Traditional surgical approaches for the treatment of benign prostatic hypertrophy. [From Grayhack JT, Sadlowski RW. Results of surgical treatment of benign prostatic hyperplasia. In:
Grayhack JT, Wilson JD, Scherbendke MJ, eds. Benign prostatic hyperplasia, NIMADD workshops proceedings, Feb 20–21, 1975. US Department of Health, Education and Welfare pub no (NIH) 76-
1113, 1976, with permission.]
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BENIGN PROSTATIC HYPERPLASIA for MBBS 600L Students
- 1. BENIGN PROSTATIC HYPERPLASIA Presentation& Mgt Medical students lecture series By Dr Ogwuche E. I MBBS,FWACS Professor of Urology, BSU, Makurdi 3/21/2024 1 ogwuche E.I
- 2. introduction • BPH isthe most common benign tumor in men, and its incidence is age-related. • The prevalence of histologic BPH in autopsy studies rises from approximately 20% in men aged 41-50, to 50% in men aged 51-60, and to over 90% in men older than 80. • Although clinical evidence of disease occurs less commonly, symptoms of prostatic obstruction are also age- related. • At age 55, approximately 25% of men report obstructive voiding symptoms. At age 75, 50% of men complain of a decrease in the force and caliber of their urinary stream. 3/21/2024 2 ogwuche E.I
- 3. • Risk factorsfor the development of BPH are poorly understood. Some studies have suggested a genetic predisposition, and some have noted racial differences. Approximately 50% of men under the age of 60 who undergo surgery for BPH may have a heritable form of the disease. This form is most likely an autosomal dominant trait, and first-degree male relatives of such patients carry an increased relative risk of approximately 4-fold. 3/21/2024 ogwuche E.I 3
- 4. Anatomy • Location • Relations •Zones • lobes 3/21/2024 ogwuche E.I 4
- 5. Prostatic zonal anatomy 3/21/2024ogwuche E.I 5
- 6. ogwuche E.I BPH • ≥40yrs—increasedgrowth • Only 1 in 10 in 50yrs have symptoms • Size vs symptoms • Microscopic, macroscopic, clinical BPH • Obstruction may result from - static or dynamic components 3/21/2024 6
- 7. ogwuche E.I BPH: Pathology •testosterone →dihydrotestoterone → BPH • Periurethral glands • fibromyoadenoma 3/21/2024 7
- 8. ogwuche E.I BPH: Aetiology •Age- increased growth with age • Testes (testosterone) • Increased 5-alpha reductase activity • Positive family hx • Genetic • Oestrogen imbalance • Growth factors 3/21/2024 8
- 9. ogwuche E.I BPH: effects-1 •Urethra-narrow, lengthened, tortous,outflow rersistance • Bladder- hypertrophy, cellules sacculation, trabeculation, diverticulum, atony, residual urine, retention, ca 3/21/2024 9
- 10. ogwuche E.I BPH: effects-2 •Ureter-hydroureter, kinking • Kidney-hydronephrosis, renal failure • General- stasis, infection, calculi, ca • Size vs obstruction • Median lobe ball valve effect 3/21/2024 10
- 11. ogwuche E.I BPH: symptoms •Frequency, Nocturia • Difficulty with micturition-hesitancy,poor stream, terminal dribbling • Urgency • Retention- acute, chronic • Incontinence • Haematuria • Recurrent UTI • Fxs of renal failure- 3/21/2024 11
- 12. ogwuche E.I BPH- • LUTO=lower urinary tract obstruction • LUTO- irritative and obstructive symptoms • IPSS - 3 irritative symptoms - 4 obstructive symptoms QOL due to urinary symptoms 3/21/2024 12
- 13.
- 14. ogwuche E.I BPH: signs •General • anaemia, oedema,dehydration, ↑BP, • CVS, RS • Full bladder • Urethra-r/o stricture • Hernial orifices • DRE • bimanual • neurologic 3/21/2024 14
- 15. ogwuche E.I BPH: complications •Retention • UTI • Diverticula • Hydroureter, hydronephronesis • Calculus • Haematuria • Renal failure • Effects on QOL e.g. sleep, recreation, erectile function etc 3/21/2024 15
- 16. ogwuche E.I BPH: Investigations •diagnosis urethrocystoscopy urethral cath- r/o stricture • extent urine m/c/s, urea, electrolytes & creatinine, (gfr), pcv ultrasound- kub (+ pvr) intravenous urogram? ipss, peak urine flow rate( n=≥ 20ml/s),observe • baseline- gxm blood, urinalysis,hiv, hbsag,ecg, chest x-ray, psa 3/21/2024 16
- 17. ogwuche E.I BPH: Differentials •Urethral stricture • Ca prostate • Bladder neck obstruction • Ca bladder • Bladder calculus • neurogenic bladder • DM, Depression 3/21/2024 17
- 18. ogwuche E.I BPH; Mx-Watchful waiting • Pts with minimal symptoms(IPSS<8, QOL-not bothered) • Follow up- IPSS, DRE, PSA,PFR,PVR,USS • Contraindication- complication 3/21/2024 18
- 19. ogwuche E.I Medical treatment •Alpha blockers-phenoxybenzamin,prazosin, doxazosin, tamsulosin, alfuzocin, terazosin • 5-alpha reductase inhibitors – finasteride, dutesteride (avodart) Testosterone→Dihydrotestosterone by 5αR • Combinations- alpha blockers +finasteride • Plant extracts 3/21/2024 19
- 20. ogwuche E.I BPH-Mx Retention •Acute -Catheter-urethral -suprapubic puncture???? -duration of cath • Chronic –Assess renal function-u/e/cr, uss, ivu -good renal function-surgery next list -poor fxn-continous drainage -correct fluid/electrolytes,acidosis, anaemia -antibiotic cover - change catheter 2wkly -prostatectomy when normal 3/21/2024 20
- 21. ogwuche E.I PRE-OP PREP •Catheter drainage if in retention. No need if none • Prophylactic antibiotics • Correct fluid/elec, anaemia,uraemia,nutrition • Screen to exclude pulmonary, cardiac dss, DM. ie do CXR, Echo, RFTs, urinalysis, FBS • Other Ix-GXM, urine mcs,HIV,HbsAg etc 3/21/2024 21
- 22. ogwuche E.I Figure 32.28Traditional surgical approaches for the treatment of benign prostatic hypertrophy. [From Grayhack JT, Sadlowski RW. Results of surgical treatment of benign prostatic hyperplasia. In: Grayhack JT, Wilson JD, Scherbendke MJ, eds. Benign prostatic hyperplasia, NIMADD workshops proceedings, Feb 20–21, 1975. US Department of Health, Education and Welfare pub no (NIH) 76- 1113, 1976, with permission.] 3/21/2024 22
- 23. ogwuche E.I PROSTATECTOMY-Methods • Preliminarycystoscopy • Transvesical • Retropubic • Transperineal • Transurethral TURP(gold standard) • TURis 3/21/2024 23
- 24.
- 25. ogwuche E.I Prostatectomy-complications 1 •Haemorrhage • Clot retention • Urinary infection • Persistent vesicocutaneous fistula • Wound infection • Incontinence of urine • epididymoorchitis 3/21/2024 25
- 26. ogwuche E.I Prostatectomy-complications 2 •Impotence • Infertility from retrograde ejaculation • Urethral stricture • Bladder neck stenosis • Damage to ureters • Osteitis pubis • TURP SYNDROME- 3/21/2024 26
- 27. ogwuche E.I Minimally invasivemethods-1 • Ballon dilatation • High intensity focused ultrasound(HIFU) • Trasurethral needle ablation(TUNA) • Microwave treatment • Stents • Transurethral incision of prostate • Laser prostatectomy 3/21/2024 27
- 28. ogwuche E.I BPH: Conclusion •Common affliction amongst men • Presents with LUTS • DRE important in assessment • Can be managed by watching waiting, drugs,open prostatectomy or minimally invasive means • Haemorrghage and clot retention are major early post-op complx 3/21/2024 28