Prostatic enlargement and letus pptx - د.أحمد new

PROSTATIC ENLARGMENT&LUTS

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BPH is a histological diagnosis & doesn’t necessarily implies benign prostatic enlargement (BPE)or symptoms.
Bladder outlet obstruction(B.O.O.)
• Lower urinary tract symptoms( LUTS):
• It is not a diagnostic term &indicate all lower urinary tract symptoms that results from either bladder dysfunction or response of the bladder to a pathology in the prostate or urethra that causes bladder outlet obstruction. This symptom complex was previously referred to as prostatism

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BENIGN PROSTATIC HYPERPLASIA BPH

BPH is the most common benign tumor in men, and its incidence ( histological and clinical ) is age related.
Etiology
The etiology of BPH is not completely understood, but it seems to be multifactorial and endocrine controlled.

Both stromal &epithelial components can produce hyperplastic nodules causing BPH.

There is a positive correlation between levels of free testosterone , estrogen levels &volume of BPH.
No studies to date have been able to domonstrate the increased estrogen receptors level in human BPH.

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Pathology

BPH develops in the transitional zone as a hyperplastic process with nodules formation in the stroma (collagen & smooth muscles)&epithelium, this affects the potential responsiveness to medical treatment.
As BPH nodules in the transition zone enlarge, they compress the outer zones of the prostate, resulting in the formation of a so-called surgical capsule.

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This boundary separates the transition zone from the peripheral zone and serves as a cleavage plane for open enucleation of the prostate during open simple prostatectomies performed for BPH.

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Pathophysiology

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Symptoms of BPH are related to:1. Obstructive effect of the prostate ( mechanical & dynamic).2. The response of the bladder to outlet resistance.( causes detrusor instability ,low bladder compliance ,trabeculation & diverticulae formation in the wall of the bladder & ultimately causes bladder decompensation).
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Pathophysiology

Clinical Findings

A - OBSTRUCTIVE urinary symptoms :
• Urinary hesitancy.
• Decreased force of urination.
• Straining.
• Intermittency.
• Postvoid dribbling.
• Incomplete emptying.

B – Irritative urinary symptoms

• Frequency.
• Nocturia .
• Urgency.
• Urge Incontinence.
• C – Associated symptoms.
• Dysuria , hematuria , loin or suprapubic pain ,history of STD or urethral trauma , neurological symptoms , erectile functions ,retention of urine .
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SIGNS

• General Examination .
• Abdominal Examination.
• Genital examination.
• DRE.
• Focused Neurological Examination.
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INVESTIGATIONS

Routine

• G.U.E
• KFT.
• PSA.
• IPSS.
Optional
• U/S.
• IVU.
• UDS.
• CYSTOSCOPY.

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Differential Diagnosis

Urethral Stricture.
Bladder Neck Contracture.
Bladder Stone.
Ca. Prostate.
Neuropathic bladder.
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Treatment

A. WATCHFUL WAITING.
B. MEDICAL THERAPY.
C. MINIMALLY INVASIVE THERAPY.
D. CONVENTIONAL SURGICAL THERAPY

B. MEDICAL THERAPY.1-Alpha-blockers

Finasteride 5 mg dailyDutasteride 0.5 mg daily

2- 5-alpha-reductase inhibitors

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Reduce the incidence of AUR.

Reduce the need for surgical therapy.
Reduce blood loss after Prostatic surgery.

3. Combination therapy

4. Phytotherapy :
Several plant extracts have been popularized, including the saw palmetto berry, (Serenoa repens) the bark of Pygeum africanum.

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C. MINIMALLY INVASIVE THERAPY.

Indications of surgery

1- failure of medical therapy.

2- devolopment of complications:
recurrent UTI from BPH - recurrent gross hematuria from BPH – bladder stones from BPH – renal impairment & hydroureteronephrosis from BPH – refractory urine retention ( failure of cathetre removal for at least one attempt.

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Retropubic prostatectomy

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Transvesical prostatectomy

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Transurethral resection of the prostate - TURP

Transurethral resection of the prostate TURP

95% of simple prostatectomies can be done endoscopically.
Most of these procedures involve the use of a spinal anaesthesia and require a 1- to 2-day hospital stay.
Risks of TURP include retrograde ejaculation (75%), impotence (5–10%), and incontinence (<1%).

Complications include:

bleeding,UTI, urethral stricture or bladder neck contracture, perforation of the prostate capsule with extravasation,
and if severe, TUR syndrome resulting from a hypervolemic, hyponatremic state due to absorption of the hypotonic irrigating solution.
Clinical manifestations of the TUR syndrome include nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances.( Mortality Rate 40-50 %)

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