Benign Prostatic

Hyperplasia(BPH)

BY. Abdi Mohamed

 Normal Prostate Anatomy
• Prostate weights ~20g

• Measures ~ 4 by 3 by 2 cm

• Base = superior portion and continuous with bladder neck.

• Apex = inferior portion of prostate, continuous with striated sphincter.

Sagittal View of the Prostate
Plexus of Anterior Middle
lobe lobe Posterior lobe
Santorini

Seminal vesicle

Base of
prostate Rectum
Pubic bone
Puboprostatic
ligament
Apex of prostate Denonvillier's fascia
Penis and
Urethra
Deep transverse
perineal muscle
 Lobes of the Prostate
The prostate is divided into lobes.
1. Anterior lobe is the portion of the gland that lies in front
of the urethra. It contains no glandular tissue but is made
up completely of fibromuscular tissue.
2. Median or Middle lobe is situated between the two
ejaculatory ducts and the urethra.
3. Lateral lobes make up the main mass of the prostate.
They are divided into a right and left lobes and are
separated by the prostatic urethra.
4. Posterior lobe is the medial part of the lateral lobes and
can be palpated through the rectum during DRE.
Lobes of the Prostate

Image Source: SEER Training Website

 PROSTATE histology
Prostatic tissue is formed of two components :
1. Glandular epithelial cells (70%)
2. Fibro muscular tissue (30%)

• The prostate is surrounded by the Prostatic capsule.

• Invasion of the capsule changes the stage of disease.
Normal histology of prostate formed of
Glands and Fibromuscular stroma

Glands: lined by two layers of cells which are inner cuboidal cells
and outer basal cells
Stroma :Fibro muscular stroma
 Prostate zones
Transitional zone (TZ)
• Surrounds the prostatic urethra
• Commonest site for benign prostatic hyperplasia(BPH).

Central zone (CZ)

• Cone shaped region that surround the ejaculatory ducts
(extends from bladder base to the Verumontanum)

• Only 1-5% of prostate cancer from this region .

Peripheral zone (PZ)

• Posteriolateral prostate
• Majority of prostatic glandular tissue
• Origin of up to 70% of prostate adenocarcinoma
• A model of Prostate.
1. Prostatic urethra
2. Transitional zone → Site of BPH
3. Periurethral zone
4. Fibro-
Fibro-muscular zone
5. Central zone and ejaculatory ducts
6. Peripheral zone → Site of Ca
What causes BPH?
BPH is part of the natural
aging process, like getting
gray hair or wearing glasses

BPH cannot be prevented

BPH can be treated

 …..
Half of all men over the age of 60yrs will
develop an enlarged prostate.

By the time men reach their 70’s and 80’s,

80% will experience urinary symptoms
But only 25% of men aged 80 will be
receiving BPH treatment
 BPH - Proposed Etiologies
1-Alterations in the testosterone/estrogen balance:
Enlarged prostate may be caused by lower levels of testosterone
(male hormone) production in middle to old age.
As men age, the levels of testosterone in their blood decreases,
leaving a higher proportion of estrogen (female hormone), so a
higher amount of estrogen within the prostate gland can increase
activity that promotes cell growth.
2- Induction of prostatic growth factors.
3- Increased stem cells/decreased stromal cell death
4- Frequently occurs in the hospital setting b/c of limited mobility & are
receiving medications that decrease bladder contractility, including opiates
or anticholinergics.
5- Constipation, a common side effect of those medications, can itself
worsen urinary retention.
 Pathophysiology
• Common in older men; varies from mild to severe
• Change is actually hyperplasia of prostate
– Nodules form around urethra
• Incomplete emptying of bladder leads to infections
• Continued obstruction leads to distended bladder, dilated
ureters, renal damage
– If significant, surgery required
• Not change to cancer prostate.
• Although some patients receiving large doses of narcotics or those with
chronically decompensated bladders may not experience discomfort,
most patients with AUR have significant pain.
• Lasted several days (often accompanied by overflow incontinence),
patients may be in renal failure.
• DRE reveals smooth, firm, enlarged gland
 BPH BOO Incomplete
emptying of
bladder.
Frequency
Bladder Distention Infection(Cystitis)

Increase pressure Pyelonephritis

inside bladder
Diverticula
formation Dilated ureters

Hydronephrosis

RF
Diverticula in bladder
• If BPH causes BOO, the musculature
of the bladder hypertrophies to
overcome the obstruction and
appears trabeculated.
trabeculated
• Significant BPH is associated with
increased blood flow, Congestion of
prostatic venous plexuses and the
resultant veins at the base of the
bladder are apt to cause Hyperaemia
& Haematuria.
Haematuria
Trabeculation of the bladder from
prostatic obstruction.
 …
• When a prostate enlarges benignly, it does so because
adenomas form in its lateral lobes. These are joined
anteriorly by a narrow anterior commissure, which is the
most anterior part of the prostate.
• As the adenomas form:
1. They compress the normal tissues of the prostate around them to
form a false capsule.
capsule
2. They compress the prostatic urethra from side to side.
• Posteriorly the median lobe of the bladder enlarges
superiorly and extends upwards into the bladder.
With Freyer's method you open a patient's bladder through
the abdomen, insert your finger in the plane between the
adenomas and the false capsule,
capsule and shell them out.
out Doing
this without injuring his membranous urethra needs skill.
 BPH—Signs and Symptoms
• Initial signs
– Obstruction of urine flow
• Hesitancy : delay between trying to urinate and the flow
actually beginning.

• Dribbling
• Decreased force of urine stream
• Incomplete bladder emptying
– Frequency,
– Nocturia : need to urinate at night
– Recurrent Urinary Tract Infections
 Lower Urinary Tract Symptoms secondary to
prostatic urethra obstruction.
Obstructive symptoms Storage or Irritative Symps
• Hesitancy in initiating voiding • Frequency
• Straining to pass urine • Urgency
• Weak stream/Intermittence • Nocturia
• Prolonged micturition • Urge incontinence
• Urinary retention • Nocturnal incontinence
• Feeling of incomplete
bladder emptying
• Post-void Dribbling

LUTS is not specific to BPH – Not everyone with

LUTS has BPH and not everyone with BPH has LUTS
Urgency: an increasingly strong desire to void
Hesitancy: be slow to start micturation
Diagnosis of BPH
• Hx
– Age & sex
– Onset of the symptoms
– Determine which symptoms are predominant( irritative or obstructive)
– Hx of hematuria ,UTI, Diabetis ,CNS disease, urinary retention
– Hx of STD, sexuality
– Trauma, surgery of LUT or instrumentation
– Alcohol, Drug intake & Cigarette smoking
 Dx…
• The patient can present with:
1. Prostatic symptoms before urinary flow is completely obstructed.
He may have:
a. Frequency of micturition which interferes seriously with sleep
b. Difficult voiding
c. Poor stream.
2. Acute retention of urine,
urine perhaps precipitated by a recent drinking bout.
bout
3. Chronic retention. The bladder remains distended when micturition is over,
and may dribble urine continuously and painlessly(Retention
painlessly Retention with overflow).
overflow
4. ''Acute on chronic' retention.
retention He has had a poor flow for some time, and
his bladder is large and has recently become painful.
painful He may progress to
retention with overflow.
overflow
• Symptoms should be quantified by using the International Prostate
Symptom Score (I-PSS) questionnaire Or American Urologic
Association symptom score(AUA)
• The AUA symptom score was developed to measure outcomes
in studies of different treatments for BPH.
• It should be used to assess the severity of symptoms of BPH,
but not for differential diagnosis.
• It consists of seven questions: Frequency, Nocturia, Weak urinary stream,
Hesitancy, Intermittence, Incomplete emptying and Urgency, each of which is
scored on a scale of 0 (not present) to 5 (almost always present) to
yield a total score(TS) ranging from 0 to 35.
• Symptoms are classified as:
– TS = 0 to 7 → Mild symptoms
– TS = 8 to 19 →Moderate symptoms
– TS = 20 to 35 →Severe symptoms.
 International Prostate Symptom Score (IPSS)
About More than
Not at <1 time < half Almost Your
Questions to be answered all in 5 the time
half the half the
always score
time time

1 Over the past month, how often have you had a

sensation of not emptying your bladder completely 0 1 2 3 4 5
after you finished urinating?

2 Over the past month, how often have you had to urinate
0 1 2 3 4 5
again less than 2 hours after you finished urinating?

3 Over the past month, how often have you found you
stopped and started again several times when you 0 1 2 3 4 5
urinated?

4 Over the past month, how often have you found it

0 1 2 3 4 5
difficult to postpone urination?

5 Over the past month, how often have you had a weak
0 1 2 3 4 5
urinary stream?
stream

6 Over the past month, how often have you had to push
0 1 2 3 4 5
or strain to begin urination?

7 Over the past month, how many times did you most
0 3 4
5
1 2
typically get up to urinate from the time you went to (5 or
(none) (1 time) (2 time) (3 time) (4 time)
bed at night until the time you got up in the morning? more)

Sum of numbers (AUA symptom score):

 Dx cont.
P/E
V/S
General assessment (chest,cvs,anemia,external genitalia)
Abdominal examination
Feel for palpable kidneys
Feel the size of the bladder (Bladder distention)
Tenderness
Dullness
DRE:
Prostate size, consistance, noduls
Pelvic floor tone flactuance & pain
Prostate size does not correlate with symptoms severity & degree of
urodynamic obstruction & Rx outcome
Prostate is Large, Smooth, Firm, Convex, Elastic, Mucosa moves over the prostate
NS examination (r/o cauda equina lesions)
GUT examination - Feel the urethra for strictures
On DRE:
 Abnormalities of the Prostate on DRE

Normal Prostate Gland

• Soft, Rounded
• Heart-shaped structure about 2.5 cm in length.
• The median sulcus can be felt between the two lateral lobes.

• Only the posterior surface of the prostate is palpable.

• Anterior lesions, including those that may obstruct the urethra, are
not detectable by physical examination.
 ….
BPH
1. Symmetrically enlarged, Convex
2. Firm though, Smooth
3. Mucosa moves over the prostate
4. The median sulcus may be
obliterated.
• Finding a normal-sized gland by palpation,
however, does not rule out this diagnosis.
• Prostatic hyperplasia may obstruct urinary
flow, causing symptoms, yet not be palpable.
Cancer of the Prostate
1. Asymmetric(A distinct hard nodule
that alters the contour of the gland
may or may not be palpable).
2. Area of hardness, irregular
3. Nodularity spread outside the prostatic
bed
4. Mucosa does not moves over the
prostate
5. The median sulcus may be obscured.
• Hard areas in the prostate are not always
malignant.
• They may also result from prostatic stones,
chronic inflammation, and other conditions.
Prostatitis
• Acute prostatitis is an acute, febrile condition caused by
bacterial infection.
• The gland is very Tender, Swollen, Firm, and Warm.
• Chronic prostatitis does not produce consistent physical findings
and must be evaluated by other methods.
Consequences of BPH
■ No symptoms, no BOO
■ No symptoms, but urodynamic evidence of BOO
■ Lower urinary tract symptoms, no evidence of BOO
■ Lower urinary tract symptoms and BOO
■ Others (Acute/Chronic retention, Haematuria,
Urinary infection and Stone formation)
 HEMATURIA
• Presence of blood in the urine.
• May be caused by a lesion anywhere in the urinary tract
• Is commonly caused by urinary infection, especially in young women.
• Can be gross and microscopic.
– Microscopic hematuria can be detected with a dipstick if hemoglobin
concentration is > 0.003 mg/L (which is equal to 1 to 2 RBC/HPF of spun urine)
– False positive on dipstick occurs when myoglobin is present.
– Is always abnormal whether microscopic or macroscopic.
• 60% of hematuria is from lower and middle tract disease.
• Cause of gross hematuria with a dipstick negative for blood are:
– Anthocyanin dye in beets and berries
– Pyridium
– Porphyria
– Some food colorings
• Haematuria may be intermittent or persistent.
• Blood appearing at the beginning of the urinary stream
indicates a lower urinary tract cause.
• Uniform staining throughout the stream points to a
cause higher up.
• Terminal haematuria is typical of severe bladder
irritation caused stone or infection.
– Terminal haematuria is typical of schistosomiasis.
• If the patient experiences pain with haematuria, the
characteristics of the pain may help to identify the source
of the bleeding.
• If there is a malignant cause for the haematuria there is
usually no pain.
In BPH
Causes of hematuria
• 0 to 20 years:
– Acute urinary tract infection (UTI)
– Glomerulonephritis
– Congenital urinary tract abnormality
• 20 to 60 years:
– Acute UTI
– Bladder cancer
– Renal stones
• > 60 years:
– Benign prostatic hypertrophy (men)
Other Causes of HEMATURIA
• Renal disease—Glomerulonephritis, pyelonephritis, vascular abnormalities,
polycystic kidney, granulomatous disease, interstitial nephritis, neoplasm
• Postrenal causes: Cystolithiasis, Cystitis, Prostatitis, Urethritis, Epididymitis
• Coagulopathy
• Anticoagulation
• Sickle cell disease
• Collagen vascular disease
•
■ HEMATURIA Is investigated by:
– Examination of midstream specimen for infection
– Cytological examination of a urine specimen
– Intravenous urogram and/or urinary tract ultrasound scan
– Flexible or rigid cystoscopy
 Diagnosis.....
• Symptom assessment

• Digital Rectal Examination(DRE)

– inaccurate for size but can detect shape and consistency

• Ultrasonography: Determine Prostate Volume (PV)

• Urodynamic analysis
 Investigations
Investigations of men with LUTS
• Essential investigations
■ Urine analysis by dipstick for blood, glucose and protein
■ Urine culture for infection
■ Serum creatinine
■ Urinary flow rate and residual volume measurement
• Additional investigations
■ PSA if indicated
■ Pressure–flow studies
 Investigations
Urinalysis
• Should be checked because a poorly emptying bladder is prone to infection.
• Dipstick & /or via centrifuged sediment for blood, bacteria, protein, glucose …
• Cytology for severe irritable symptom
• Urine culture
Renal function test & Serum electrolytes
(Serum creatinine to R/o renal insufficiency, BUN)
Help to evaluate the patient with occult & progressive renal damage secondary to silent
prostatism
RI Occurs in 13% of case
BPH with RI increase the risk of post.op. complication with RI 25% & 17% without RI
• Elevated creatinine level suggests that AUR has resulted in renal dysfunction,
dysfunction and these
patients are at risk for postobstructive diuresis
• These patients must be closely watched for excessive urine output, often caused by an
osmotic diuresis due to retained nitrogenous waste products or a temporary renal
concentrating defect.
• Chronic retention with a blood urea of up to 12 mmol/l is common in the elderly, but provided
underlying causes, such as heart failure, are corrected, it is no great risk in itself,
But BUN >15
>15 mmol/L is great risk
 ….
– Fluid and electrolytes must be replaced if the urine output exceeds
200 mL/h
mL/h,
/h especially if hemodynamic instability or electrolyte
imbalances are seen.
– Fluid replacement typically is 0.5 mL of 0.45 normal saline for every
1 mL of urine output above 200 mL in 1 hour, although sodium and
potassium supplementation requirements depend on the
electrolyte status of the patient
– Once the bladder is adequately drained, the cause of AUR should
be addressed.

Haemoglobin; it should be above 10 g/dl. Don't

operate unless you can transfuse.
 …..
Measurement of prostate-specific antigen (PSA)
– To R/o prostatic Ca, which can coexist with BPH
• PSA is a predictor of disease progression and screening tool for Cancer Prostate.
– Normal is 0-4ng/ml
– High correlation between PSA and PV
• Values tend to increase with increasing Prostatic Volume and increasing age
• Men with larger prostates have higher PSA levels
– PSA may be used as a prognostic marker for BPH.
– PSA value >4ng/ml or DRE indurations or nodularity
needs transrectal US & multiple biopsy
– PSA & DRE increase the detection rate of prostate Ca
over DRE alone
Using PSA To Detect Cancer-Related PSA
Changes In Patients On 5-ARI’s

Establish new baseline PSA after 12

months of %-ARI treatment
– Subsequent increases in PSA may indicate
noncompliance, prostate cancer, or other
prostate-related conditions that may need
evaluation
Postvoidal residual urine
Obtained after voiding of urine with a catheter
transabdominal US
NV= less than 5 ml (78%), less than 12ml(100%)
Residual volume of urine (100–250 ml) are relatively strong indications for
operative treatment

Uroflometry(Flow rate measurement)

Electrical recording of the urine flow rate, Noninvasive
urodynimic test
Quantifies strength of urine stream
2 to 3 voids with voided volume 150 to 200ml
For a voided volume > 200 ml, Peak flow rate:
rate
• > 15 ml/s is normal.
• 10–
10–15 ml/s is equivocal.
• < 10 ml/s is low → Pathologic
Pressure-flow urodynamic studies
Done to distinguish b/n low pressure flow rate
secondary to BOO & decompensated bladder
Reliable if BOO not Dxed by flow rate, initial evaluation
& PVR
– Pressures > 80 cmH2O are high → Pathologic
– Pressures between 60 and 80 cmH2O are equivocal.
– Pressures < 60 cmH2O are normal
Imaging studies
IVP/US/KUB, look for:
Dilated kidneys or Ureters - Degree of hydrouretero-
hydrouretero-nephrosis
Bladder & Prostate size
Signs that he has enough renal function to excrete the contrast medium.
Stones or Diverticula.
Not indicated for initial evaluation of LUTS
Indications
Hematuria or UTI
Hx of urolithiasis
Hx of urinary tract surgery
Upper tract imaging is indicated
Concomitant hematuria
Hx of urolithiasis
Elevated creatinine
Increased post voidal residual & Hx of UUTI
 – CONTRAINDICATIONS TO IVU or IVP.
1. Dehydration & BUN over 10 mmol/l (65 mg/dl)
It will probably fail because the dye will not be excreted in adequate
concentration to be visible. It is certainly not worth doing if BUN is over
17 mmol/l (100mg/dl.
2. RF, Hepatic failure, which may be aggravated.
3. Cardiac failure; there is a risk of arrythmia.
4. Hyperuricaemia
5. Infancy.
6. The first trimester of pregnancy is a relative contraindication, but
the danger is minimal.
7. Any previous reaction to contrast medium or other allergic disease.
8. Multiple myeloma.
• CONTRAST MEDIUM. Use ''Urografin' 60% or ''Conray 420'. Rarely, the pt may have a
reaction, so make sure you have ready 0.5 ml of adrenalin 1/1000 and promethazine 25
mg for intramuscular injection. Cardiac arrest has followed injection, so be prepared to
resuscitate.
 Inv. Cont.
Cystourethroscopy (Urethroscopy)
Indications
Hematuria
Urethral stricture
Bladder Ca
Prior LUT surgery

Advantage – Can identify:

Voidal obstruction of urethra or bladder neck
Prostate enlargement
Bladder stone
Trabeculation
Diverticula's
BPH : show marked hyperplasia in the number of prostatic glands
 Differential Diagnosis of BPH
(i.e. from other causes of urinary obstruction)
• Bladder neck contracture/Stenosis • PUV
• Bladder neck hypertrophy/Fibrosis • Phymosis
• Bladder calculi/Stone
• Paraphymosis
• Bladder Ca.
• Diabetic neuropathy
• Neurogenic bladder (DYSKINESIA
(DYSKINESIA)
DYSKINESIA)
• Prostatitis • Multiple sclerosis
• Prostate Ca. • Parkinson's disease
• Urethral stricture
• Impacted urethral stone
• Urinary tract infection

PUV: Posterior Urethral Valve

 DDx…
• If there is the symptoms of BOO with acute or chronic
retention, but no large prostate, there are two possibilities:
1. DYSKINESIA or Bladder-
Bladder-neck dysfunction(formerly called bladder-
neck obstruction), is a functional rather than a mechanical obstruction.
You cannot diagnose it by the size of the prostate or by looking at the
bladder neck. It is not mechanically tight, but fails to open up during a
voiding contraction. You can easily insert a catheter, which drains
quantities of urine, and cystoscopy shows trabeculation of the bladder.
2. BLADDER-
BLADDER-NECK STENOSIS is a mechanical obstruction due to fibrosis or
previous prostatic surgery, or schistosomiasis. As with a urethral stricture,
passing a catheter is difficult or impossible. Treatment is by incising the
bladder neck, if possible endoscopically, deeply enough to divide all its
circular fibres.
 Treatment
Aim of Rx
Relieving LUTS
Decreasing BOO
Improving bladder emptying
Reversing renal insufficiency
Preventing feature episodes of hematuria
,UTI & urinary retention
When should BPH be treated?

BPH needs to be treated ONLy IF:

Symptoms are severe enough to bother
the patient and affect his quality of life
Complications related to BPH
Treatment….
• Urethral catheter as quickly as possible.
• BPH or urethral strictures often make the placement of
a catheter difficult.
• A coude (French for curved)
curved) catheter is helpful in
negotiating past the angulations' in the PU
• Curved portion is maintained at the 12 o'clock position
as it is passed through the urethra
• A common mistake is to use a smaller catheter to
bypass the enlarged prostate.
• A larger (18F to 20F/Ch) catheter is less flexible & is
more likely to push into the bladder
• Smaller catheters are useful for by passing a urethral stricture.
stricture
• Catheter meets resistance closer to the meatus, as
many strictures occur in the distal urethra, narrower
• Using a 12F or 14F catheter often will allow the passage of
the catheter into the bladder.
– Ch = Charriere for catheter sizes
Coude catheter
 Rx cont.
• Catheter placement is not successful, a suprapubic cystostomy
should be placed.

• Aspiration with a finder needle should be used first to localize the

bladder & avoid intra-abdominal contents, although bowel injury is
unlikely with a distended bladder filling the pelvis.

• Hematuria is the cause, continuous bladder irrigation is necessary to

prevent clot formation.

• Through a large three-way catheter that has an additional port for

fluid inflow

• Fluid is infused by gravity only b/c pressure could result in bladder

rupture if outflow is occluded.
 …

• If he is not be well enough for you to remove the prostate

immediately because of:
– Obstructive uropathy; BUN high(Over 15 mmol/l ) and urine infected.
– He may have been precipitated into retention by a serious illness,
such as pneumonia or other RTI, Heart failure
• Drain the bladder for a week or two(Urethral Catheter placement or
suprapubic cystostomy), and investigate him meanwhile.
If you are in an area where Schistosoma haematobium is
endemic, and commonly causes carcinoma of the bladder, try
to avoid doing a suprapubic cystostomy. In some areas this is
responsible for up to 10% of cases of urinary obstruction. If a
patient does have carcinoma of his bladder, and you do a
suprapubic cystostomy, it will never close.
close
Treatment options
Watchful waiting Rx

Medical therapy
– alpha-adrenergic blockers (for BPH symptoms)
– 5-ARIs
– Combinations of the above

Minimally invasive
– TUMT
– TUNA
– ILC
5-ARIs=5-alpha-reductase inhibitors
ILC=interstitial laser coagulation (also known as LITT)
Operative therapy TUIP=transurethral incision of prostate
TUMT=transurethral microwave thermotherapy
– TURP (gold standard) TUNA=transurethral needle ablation
TURP=transurethral resection of prostate
– TUIP
– Open surgery (prostatectomy)
 Watchful waiting Rx
For mild symptoms
AUA symptom score<8
Flow rate >10ml/s
Good bladder emptying(RU<100ml)
Needs base line evaluation (annually)
Advice for:
Limit fluid intakes at evening
↓ alcohol & coffee containing products
Maintain time voiding schedules
Pharmacologic Therapy For BPH

– α-adrenergic blockers
– 5α-reductase inhibitors
– Combination therapy
• Beneficial when prostate size is less than 40g.
 Medical therapy
Alpha adrenergic blocker drugs
Tamsulosin(alpha 1a selective) – Most selective
Terazosin(longe acting)
Duxazosin(longe acting)
The tension of prostate smooth muscle is mediated by alpha1
adrenorecepter
98%of alpha1AR located in prostate
By blocking this receptors
Decrease the resistance a longe bladder neck, prostate,&
urethra( Relaxing of smooth muscle of internal sphincter)
Relieve dynamic component of the obstruction
Advantage of alpha adrenergic blockers
Well tolerated
Reduce out flow resistance
Are safe in the elderly & ↓Boo
Treatment of choice with pt.HPT
Side effects
Asthenia
Headache
Distribution of Alpha Receptors
in the Prostate and Bladder
Detrusor

Trigone
Internal Sphincter

Prostate Gland

Pelvic Floor

External Sphincter
 Alpha Blockers
• Mechanism:
– Relax smooth muscle in
bladder neck and prostate
– Improve urinary flow (Qmax)
and bothersome symptoms

• Agents indicated for

symptomatic BPH include:
– Tamsulosin
– Alfuzosin
– Doxazosin
– Silodosin
– Terazosin
BPH = Benign Prostatic Hyperplasia
 AUA Guidelines

• Tamsulosin, Alfuzosin, Doxazosin and Terazosin

are appropriate treatment options for patients with
LUTS secondary to BPH.

• The adverse event profile appears slightly different

between the four alpha-blocking agents
Differential Effects of α-Blockers
on Blood Pressure
• Tamsulosin, Alfuzosin and Silodosin
– Not indicated for the treatment of hypertension
– Initial dose titration not required

• Doxazosin and Terazosin

– Indicated for the treatment of hypertension
– Initiated at a low dose to avoid a first-dose
phenomenon (ie, Syncope)
 Rx cont.
Androgen suppression (5α-reductase inhibitor)
drugs -Finasteride* - Flutamide
Is an enzyme responsible to the conversion of the testosterone
to DHT which promotes growth of prostate tissue
Finasteride is competitive inhibitor. Of this enzyme.
Lower intraprostatic levels of DHT →↓Prostate size
(By inhibiting of its growth ,apoptosis & involution )
Max reduction of prostate volume by 6/12→20%→ size
reduction
1/3 of the pt has improvement of symptom score.
Given 5mg daily for 6 months.
 Two 5α-Reductase (5AR) Isoenzymes
Convert Testosterone to DHT

Type II 5AR

Testosterone DHT

Type I 5AR Prostate

enlargement
 Near Complete DHT Suppression Requires
Inhibiting Both 5AR Isoenzymes

Dutasteride

Finasteride
Type II 5AR

Testosterone DHT

Type I 5AR Prostate

Dutasteride
volume
reduced
PSA Is Reduced in a Predictable Manner
Mean change in serum PSA (%)
with Dutasteride
20 15.8
10.7
10 5.5 6.8
2.8 2.2 Placebo
0
–9.2
-10
-20
-30 –35.7
-40 –43.5 Dutasteride
–48.6 –50.5 –52.4
-50
-60
1 3 6 9 1 1 1 2 2
Baseline Month
2 5 8 1 4
 Minimally invasive
Intraprostatic stents
– Tubular device left in the urethra (absorbable or nonabsorbable)
– An alternative for indwelling catheter for pts.unfit for surgery
– Success rate is from 50 to 90%
– The insertion is endoscopicaly(us guided)
– Temporally or permanent( after radical prostatectomy with
incontinence)
Transurethral microwave therapy(TUMT)
Deliver heat to the prostate via urethra catheter or transrectal route
Damaging to sympatatic nerve ending & induction of apoptosis →
↓ prostate size
Takes one hour as out pt with LA
Less complication(like impotence)
Does not cure BPH –reduce urinary frequency,urgency,sraing &
intermittent flow.
Transurethral Microwave Therapy(TUMT)

• Microwave energy
causes tissue necrosis
• Cooling channels in
catheter cool urethra
 Principles of Thermotherapy
• Blood supply of BPH adenoma more fragile
than prostate capsule
• Adenoma can be heated to cause necrosis
• Capsule protected by better blood flow
• Tissue necrosis, nerve damage/destruction
lead to improved voiding symptoms
 Min.inva.Rx cont.
Lasers delivered heat
Causes destruction of the prostate tissue (coagulation necrosis or
vaporization of prostate tissue)
Destroyed tissue then contract→ ↓prostate size
Increase flow rate=9to15ml/sec
Symptoms score improve by 50%
Decrease bleeding ,fluid absorption, length of hospital stay
↓the incidence of retrograde ejaculation& impotence compared with
TURP

Transurethral needle ablation of the prostate(TUNA)

Radiofrequencey energy through twin needle to burn the enlarged
prostate
Thermal injury to lateral lobe induce necrosis of hyper plastic prostate
&improve symptom score
 Schematic of TUNA
Procedure

Completed Procedure
Creation of a Lesion
with 8 Lesions
Ablation: the removal of diseased or unwanted tissue from the body by surgical or other means.
 Interstitial Laser Therapy
• Lesions created throughout
prostate

• Laser fiber alignment critical

• Median lobe can be treated

 Operative therapy

Indication of surgical intervention

Obstruction
• Acute urinary retention
• BPH related hydronephrosis or renal function deterioration
Gross hematuria
Vesical stone
Frequent urinary tract infection (UTI)
• CONTRAINDICATIONS for surgical intervention
1. A patient whose general condition is very poor.
poor
2. Very poor renal function,
function which does not improve after catheterization.
3. Severe sepsis.
4. Limited mobility and senility (rather than age alone).
A very senile old man is likely to be permanently incontinent
anyway, and will be better with permanent urethral drainage
through a small Foley catheter, or, if you cannot pass one, with a
permanent suprapubic cystostomy
5. A malignant prostate is a contraindication to Freyer's and
especially to Ghadvi's prostatectomy, but is very suitable
for transurethral resection
Operative therapy…
Types of open prostatectomy:
1. Transvesical (Freyer's method )(TVP)
2. Transurethrally (TURP)
3. Transperineum(Ghadvi's
Trans method )
4. Retropubically (Millin's retropubic operation )(RPP)

Success
AUR & CUR=100%
sever symptoms & urodynamically proven BOO =90%
Mild symptoms =65
Unobstructed detrusor instability =do not respond well
 …
• If a patient needs his prostatic obstruction
relieved, there are three ways you can do it.
You can use:
1. A modification of Freyer's method (TVP) - in which
prostatic adenomas are removed through the bladder.
2. Ghadvi's method - in which they are removed laterally
through the perineum.
3. The injection method - which scleroses them with a
mixture of glycerine and phenol.
Possible alternatives, Millin's retropubic operation
1. Freyer's method
– Its advantages:
1. If you cannot cystoscope a patient, you can look into the bladder to exclude
diverticula, carcinoma, stones, and bladder-neck fibrosis .
2. You can control bleeding more easily.
3. When well done, mortality is low.
– Its disadvantages:
It normally requires large quantities of irrigating fluid.
2. Transurethral resection
– Needs much skill and an expensive resectoscope.
3. Millin's retropubic operation
– It is more dependent on preliminary cystoscopy and is more difficult.
– It also needs good lighting, more help, and better postoperative care.
Pre-op preparation
Preparation of 2unit of blood
Counseling, And Inform the pt about benefit &
risk; and Obtain consent
– Retrograde ejaculation
– Bladder neck contracture (BNC)
– Urethral stricture
– Erectile dysfunction
– Urinary incontinence
– UTI
– Untoward effects(DVT, Pulmonary embolism)
 TURP
Developed in 1920 & 30s in USA
Used endoscopy (fibroptic lighting together with the Hopkins, rod lens
wide angle system for visualization)
High energy electrical current is used ,entire device attached to video
camera
Gold standard ( 90% of prostatectomy)
Solution used for TURP →5%DW ,1.5 %glycine ,cystol
Under regional or GA with lithotomy position
Through resectoscope the prostate is removed
MAX flow rate improve 9 to 18 ml/sec & symptom score by 70%
Indications
- AUR
- Recurrent hematuria
- Recurrent infection
- Renal insufficiency
- Upper urinary tract dilatation +
- Gland size <40gm* <80gm
 Cxn.
TUR-syndrome
Characterized by hyponatremia, HPT, nausea & vomiting,
bradicardia, visual disturbance, mental confusion.
Due to absorption of irrigating fluid through cut open veins
In 2% of all TURP
Risk factors:
* Much fluid for irrigation
*↑Resection time >90mnt &
* Gland>45gm,
RX: Diuretics & Correct electrolytes
 Open prostatectomy(Freyer's method )
Indications
All other indications for TURP +
Large prostate >80gm with concomitant:
Bladder stone
Urethral stricture
Inguinal hernia
Previous hypospadias repair
Ankylosis of the hip & other orthopedic condition
Sever symptoms unresponsive to medical Rx
Contraindications
The presence of prostate cancer
Small fibrous gland
Previous prostatectomy
Pelvic surgery that obliterate access to the prostate gland
 Procedure
1. SKIN INCISION - Make a Pfannensteil or less satisfactorily, a 7 cm midline incision
immediately above the pubis longitudinally between the recti.
2. Peel the peritoneum off the anterior surface of the bladder → Keeping the pulp of
your finger in contact with the pubic symphysis, push your finger into the retropubic
space.
3. Insert stay sutures into the anterior wall of the bladder and then incise it in the
sagittal plane.
CAUTION ! Don't enter his peritoneal cavity. If by mistake you do so, immediately suture it.
4. Put two fingers of your right hand into the bladder. Feel inside to exclude
neoplasms and the orifices of diverticula. You can easily miss these. Feel the
prostate and internal urinary meatus.
4.1. If the prostate is enlarged,
enlarged and you can easily get your fingers into the internal urinary
meatus, enucleate the prostate as described below.
4.2. If the prostate is not enlarged,
enlarged and there is a tight internal meatus which you cannot put
your finger into, there is a bladder-
bladder-neck fibrosis → Do wedge resection out of the
bladder neck.
TO ENUCLEATE THE PROSTATE
1. Remove the self-retaining retractor.
2. Put your index finger into the prostatic urethra.
3. Use your left index finger to split into the recess between the anterior commisure
(which should remain in situ) and the left lateral lobe of the prostate at about 10 o'clock.
o'clock
4. Open up the plane between the gland and the false capsule as far distally as you can.
5. Separate it through at least 900, and preferably 1500.
6. Use your right index finger to repeat the procedure on the right side starting at about
2 o'clock,
o'clock so as to free the prostate from within its bed (False capsule).
7. There is usually a residual attachment distally. Pull the prostate up into the bladder
to make this taut.
8. Divide it near the prostate, either blindly with curved dissecting scissors or with your
finger.
CAUTION !
1. Divide the attachment close to the prostate, or you may damage the internal sphincter which
surrounds the membranous urethra, deep and superficial to the perineal membrane.
2. Preserve the anterior commisure. Damage to either may lead to incontinence of urine or a stricture.
stricture
9. Remove the entire prostate, including its median lobe, by bringing it into the
bladder with your index finger.
10. If it is still lightly attached proximally to the mucosa of the bladder, separate it with
scissors.
11. Removing each lateral lobe separately may be easier. One will bring the median
lobe with it.
12. TO ENLARGE THE BLADDER NECK, first check the position of the ureteric orifices.
Cut a wedge out of the bladder neck in the 6 o'clock position level with the ureteric
orifices and between them. The mucosa of the bladder overhangs the prostatic
cavity, and if you don't do this pt may get retention of urine later ('‘Bladder
Bladder-
Bladder-neck
obstruction').
obstruction OR If there is Bladder-neck stenosis/Fibrosis:
– Identify the orifices of the ureters. Make deep cuts in the bladder neck in the
5 and 7 o'clock positions, sloping towards one another so as to excise a
wedge of the bladder neck, as in J, in the next figure. You must go deep
enough to divide the circular fibres of the neck of the bladder. When you
have cut them the neck of the bladder will spring open, and the obstruction
will be relieved.
J - Cutting a wedge out of the bladder neck.
13. Mopping out the prostatic cavity
14. TO CONTROL BLEEDING insert two figure of eight sutures in the 4 and 8 o'clock
positions, taking care to avoid the ureters. Then put a tight gauze pack in the
prostatic cavity. After 3 minutes, take it out and assess the amount of bleeding.
15. Blow up the balloon of a 50 or 75 ml Foley catheter, until it fits snugly in the
prostatic bed (usually 30 - 50 ml is required). This will help to stop bleeding.
16. Continue irrigation
17. Close the bladder wall with two layers of
continuous ''0' or 2/0 chromic catgut.
If the bladder is very thin and weak, close
it with figure of eight sutures like this.
18. Insert a 2 cm wide corrugated rubber drain in
the retropubic space → Don't forget to do this.
Even if you think you have closed the bladder securely,
it may still leak. If urine extravasates, it may cause a
serious cellulitis.
19. Close the abdominal wall in layers
 How to ''milk' a catheter to dislodge clots.
Pinch it at ''x' between the finger and thumb of your left hand.
Pinch it just distally with your right hand (''y'). Move the fingers of your
right hand down the catheter (''z') keeping its lumen closed.
Then suddenly stop pinching with your left hand.
Post-op Mx
Measure input & output
Bladder irrigation - It is usually necessary for 24 to 48 hours. You will need about
4 bags of fluid in the first 24 hours, and less the next day. You may need to continue
irrigation until the 4th day.
Effective pain management - Morphine.
1st POD - Fluid diet, Ambulation ,Deflate balloon(10ml↓) & irrigate
residual clot
2nd POD - Regular diet
3rd POD - Remove retro pubic catheter & Let down the balloon
4th POD - Discharge with catheter
Remove the urethral catheter on day 8 to 12.
Catheter keeps the bladder collapsed while it heals.
• Let down the balloon on the third day,
unless there is much bleeding; if so,
wait until bleeding stops. His prostatic
cavity will then become smaller
naturally, and there will be less danger
of secondary haemorrhage.
 Complications of prostatectomy
• Local
– Haemorrhage - is a major risk
– Sepsis- Bacteraemia
– Incontinence - It improves during the next 3 months
– Retrograde ejaculation and impotence - (> 50%)
– Urethral stricture
– Bladder neck contracture
– Reoperation
• It is now well known that, after 8 years, 15–18% of men with BPH will undergo
repeat TURP.
• The rate after open prostatectomy(TVP) is about 5%.
• The reasons include a technically imperfect primary procedure and a speculative
repeat operation in men with symptoms who are cystoscoped after operation.
– Suprapubic fistula - it will probably close spontaneously before discharge. If it is slow to heal,
the LUT is probably obstructed. So drain the bladder with a catheter for up to 10 more days.
• General complications
– Pulmonary & Cardiovascular
• Pulmonary atelectasis, pneumonia, myocardial infarction, CHF and DVT are all potentially life-
threatening conditions that can affect this elderly and often frail group of men.
– Epididymitis
– Septicaemia
– DVT (unusual in the developing world)
– Ileus
– Uraemia and Oliguria
– Postoperative shock
– Bladder tamponade.
– Water intoxication
• The absorption of water into the circulation at the time of irrigation can give rise to CHF,
Hyponatraemia and Haemolysis.
– Osteitis pubis - Rare
Complications of prostatectomy…
One of the difficulties of any prostatectomy is that the raw bed
of the prostate bleeds after you have removed its adenomas.
There are several ways to reduce this bleeding:
1. You can use diathermy (if you have it) during the operation.
2. You can put a suture or two into the prostatic bed.
3. You can compress the walls of the prostatic bed with the balloon of a
Foley catheter -75ml balloon - (The standard method). ).
4. As a last resort you can pack prostatic bed, and leave the pack in place.
If he bleeds, the clot may obstruct the urethra and distend the bladder
(Clot
Clot retention).
retention This opens up the vessels in the prostatic bed, makes the
bleeding worse, and is the great hazard of prostatectomy. Prevent it by
washing away the blood, as it collects (With a stream of irrigating fluid).
 Methods of irrigation
1. Three
Three--way irrigating Foley catheter (preferably plastic rather than rubber)
in the urethra, and wash away the blood in the bladder with a stream of
irrigating fluid.
2. Two-
Two- way Foley catheter through the urethra, and introduce fluid into the
bladder through a suprapubic catheter.
3. You can put a two-channel Foley catheter in the bladder, give quantities
of intravenous fluid and frusemide,
frusemide and let the urine wash the blood out
of the bladder this way.
4. You can use suprapubic suction and no irrigation.
5. You can leave a large suprapubic tube in the bladder and remove clots
with forceps.
6. You can leave a catheter in the urethra, pass a de Pezzer catheter
suprapubically, and pack the prostatic bed.
 …
• If you are going to irrigate the bladder, you
will need about 10 litres of fluid. This can be:
1. Intravenous saline.
2. Sterile saline made from tap water. The disadvantage of this
is that it may enter the circulation through the prostatic sinuses,
sinuses
and if it is not pyrogen free, it may give him rigors.
3. Sterile 3.8% sodium citrate (which is no better than saline).
 Complications of BPH

• Obstruction & Acute urinary retention

• Gross hematuria
• Vesical stone
– Decompensation of Bladder 2nd to Detrussor muscle over distention & hypertrophy.
– Diverticula in bladder
• Frequent urinary tract infection (UTI)
• Hydronephrosis or RF.
URETHRAL STRICTURE
Is a fixed ,abnormal narrowing of the urethral lumen
Produce Sx of UT obstruction & upper tract dilation & damage
Rare in ♀

AETIOLOGIES
CONGENITAL Postoperative
TRAUMATIC Prostatectomy (4%)
INFLAMATORY Repair of ruptured Urethra
Post gonococcal urethritis Amputation of penis
Post urethral chancre
Tuberculous Malignancy
Balanitis xerotica obliterans Prostatic ca
Penile ca
INSTRUMENTAL (IATROGENIC) Urethral ca
Indwelling catheter Radiotherapy
Urethral endoscopy
Generally
Infective strictures affect areas where
Para- urethral glands are numerous:
Proximal bulbar urethra
Distal penile urethra
Traumatic strictures
Direct crushing injury – Distal bulbar urethra
Indirect (pelvic #) - Membranous urethra
Instrumentation strictures affect the
narrowest parts of urethra:
Fossa navicularis
Peno-
Peno-scrotal junction
Membranous urethra
1. The prostatic urethra.
2. The bulb of the urethra.
3. The perineal urethra.
4. The fossa navicularis.
5. The external meatus.
 INVESTIGATIONS
1. Urine Culture
2. Urinary Flow rate
Low flow rate + Prolonged voiding → Outflow obstruction
Not specific for US

3. URETHROGRAPHY
Retrograde –site, length & caliber of Stricture
Voiding
Ante grade
can’t demonstrate Extent of spongiofibrosis
4. URETHROSCOPY
Stricture viewed as white circumfrential scar of fibrous tissue
Most useful during surgery
5. Others
IVU
U/S
 TREATMENT
Dilation
Filiform & follower
Gum elastic bougie
Metal sounds
Self dilatation with Nelaton catheter
Visual Internal Urethrotomy(VIU)
Optical - Otis urethrotome or laser
Blind
OPEN URETHROPLASTY
Excision & end to end anastomosis
Substitution
Onlay patch graft/fLAP
PEDICLED FLAP
FREE GRAFT
TUBE GRAFT
Perineal urethrostomy (Temporary/Permanent)
Suprapubic Urethral catheterization
Supratrigonal diversion [eg. ileal conduit]
 summery
• For men with suspected BPH, an alpha blocker such as tamsulosin
should be started.
• Finasteride or dutasteride, which shrink the prostate, work over several
months and will not provide significant benefit in the short term.
• Narcotics should be tapered as tolerated, & constipation should be
treated.
• Acute spinal cord compression, accompanied by saddle paresthesias,
is emergency that requires neurosurgical or orthopedic consultation.
• Most cases, except severe neurologic injuries, patients will be able to
resume voiding, & the catheter can be removed after 1 to 2 days.
• Postvoid residuals should be checked with :
- Ultrasound device or
- Catheterization to determine the residual amount of urine left after
the patient tries to empty their bladder.
• Inability to void or a postvoid residual over 150 to 200 mL is risked for
the development of another episode of AUR.
• Patients may be given the option of an indwelling catheter for another
few days with a subsequent voiding trial, or
• Learning the self intermittent catheterization technique,