Transcript BPH - KSB
BENIGN PROSTATIC HYPERPLASIA Dr.Arun Narayanaswamy Urology Unit Amiri Hospital OUTLINE BPH Anatomy of Prostate Aetiology Pathophysiology Incidence Clinical presentation Investigations Management Catheterisation Indications Catheter types Technique Complications Anatomy of Prostate gland Walnut-sized. Part of male reproductive system Location Anterior to rectum, Just distal to bladder, Encircling the neck of bladder and urethra Normal weight – 20gm Anatomy of Prostate gland Prostatic parenchyma divided into 4 Zones. Biologically and anatomical distinct. Functions of Prostate gland Secretes alkaline fluid–30% of seminal volume Actions - Lubrication and nutrition for sperm, Liquefaction of the seminal plug, Neutralizes acidic vaginal environment Prevents retrograde ejaculation (ejaculation resulting in semen being forced backwards into the bladder) by closing the bladder neck during sexual climax. What is BPH ? BPH is part of the natural aging process, like getting gray hair or wearing glasses Characterized by hyperplasia of prostatic stromal and epithelial cells. Occurs in the Transitional zone. Results in formation of nodules in the periurethral region of the prostate. What is BPH ? Urethra Peripheral Zone Transition zone Aetiology of Hyperplasia DHT-mediated hyperplasia aided by estrogens In aging men, estradiol levels increase. Mechanism of Obstruction Mechanical Component - When sufficiently large, the nodules compress the urethral canal Mechanism of Obstruction Dynamic Component - Large numbers of alpha-1-adrenergic receptors present in the smooth muscle of the stroma and capsule of the prostate, bladder neck. Stimulation causes ↑ in smooth-muscle tone Pathology of BPH Gross - Circumscribed grey white nodules Histology Epithelial - Glandular proliferation or dilation Stromal - Fibrous or Muscular proliferation Mostly common - Fibroadenomyomatous pattern BPH - Bladder Effects Bladder wall - contractile force leads to: Hypertrophy or Trabeculation, and Irritability. Bladder may gradually weaken Increased residual urine volume Acute or chronic urinary retention. Biopsy - smooth-muscle fibers / in collagen - Decrease compliance, Impair contraction Prevalence of BPH •25% - 40-49 years •50% - 70 & older •90% at 85 years Source: J Urol 1984;132:474 • Only 50% develop clinical symptoms. • Severity of symptoms not related to size. • Second most common surgery after cataract extraction in men > 65 years. Common Terms • LUTS Lower-urinary-tract symptoms • BPE Benign prostatic enlargement (macroscopic) • BPH Benign prostatic hyperplasia (microscopic/histologic) • BOO Bladder-outlet obstruction Symptoms Obstructive Symptoms (Voiding) Elective - Weak stream - Straining to void - Hesitancy - Intermittency - Terminal dribbling - Incomplete emptying Irritative Symptoms (Storage) Emergency - Acute urinary retention - Chronic Retention with overflow - Dysuria - Frequency - Nocturia - Urgency - Incontinence - Nocturnal enuresis Symptom Assessment International Prostate Symptom Score (IPSS) / AUA Score Based on a survey & questionnaire developed by the American Urological Association (AUA). 7 questions about the severity of symptoms. Total score: Mild 0- 7 Moderate 8 - 19 Severe 20 - 35 Sexual history Studies have identified LUTS as an independent risk factor for erectile / ejaculatory dysfunction. Physical Examination Suprapubic area - Bladder distension Neurological examination Decreased anal sphincter tone Absent bulbocavernosus reflex Palpate the scrotum: epididymo orchitis Signs of CRF, Pallor Rectal Examination Left lateral position Index finger of the dominant hand. Palpate circumferentially - windshield wiper movement Rectal Examination Prostate size and contour, Median sulci Consistency Nodules, Hardness, Asymmetry suggestive of malignancy. Pain - Prostatitis, Fluctuance - Prostate abscess Rectal mucosa Complications of BPH Urinary retention Recurrent UTIs Gross hematuria Bladder calculi Bladder Diverticuli Renal failure or uremia Differential Diagnosis Urethral Strictures Bladder Stones Neurogenic Bladder Prostatitis Bladder Tumours Radiation Cystitis Interstitial Cystitis Investigations Basic Iab: CBC / S.Creat Urine routine / culture PSA(prostate specific antigen) Xray KUB :calculi Ultrasound Uroflowmetry Flexible Cystoscopy Prostate Specific Antigen Secreted by Prostatic cells. Normal <4ng/dl Marker for Carcinoma Prostate – Elevated. BPH does not lead to prostate cancer. However men at risk for BPH are also at risk for prostate cancer and so should be screened. Not disease specific - Also in BPH, Prostatitis,DRE,Catheterization High PSA →Trans rectal US and Biopsy Ultrasonography Prostate – Size (>20cm3:abnormal), Nature Bladder – Wall thickness, Diverticuli, Calculi Kidneys - Hydronephrosis Post micturition residual volume(>50-100ml) Uroflowmetry Simple noninvasive test to document voiding Peak Flow rate (>15ml/s is normal) Voiding time, Voiding pattern Volume of voided urine – atleast 150ml Uroflowmetry Cystometry - Pressure flow Invasive – Urethral / Rectal catheterization. Indication - To distinguish bladder contractility (detrusor underactivity) from outlet obstruction. BOO -Low urine flow rates accompanied by High intravesical voiding pressure (>60 cm water) Cystoscopy Flexible cystoscopy can be easily performed in an office-based setting using topical gelintraurethral anesthesia without sedation. Indicated when Suspicion of Urethral stricture - h/o STD, prolonged catheterization, or trauma Detrusor hypocontractility DM Treatment Options Watchful waiting Medical management Surgical approaches - Endoscopic surgery - Minimal invasive procedures - Open surgery Watchful Waiting For mild symptoms. Follow up 1 to 2 times yearly Suggestions that help reduce symptoms - Avoid caffeine and alcohol - Alteration of timing, volume of fluid intake Medical Management Benefits Convenient No loss of work time Minimal risk Types – Disadvantages Drug Interactions Must be taken every day Does not fix problem Side Effects Cost Alpha Adrenergic Blockers 5 alpha reductase inhibitors Alpha 1 Adrenergic Receptors Alpha Blockers - Rationale BPH predominantly stromal (Smooth muscle ) proliferative process - Dynamic Obstruction Mediated by the alpha1A-adrenergic receptors. Density of receptors changes with prostate size & age. Alpha-adrenergic receptor-blocking agents Relax the smooth muscle Decrease outflow resistance. Alpha Blockers - Agents Nonselective - Phenoxybenzamine Short-acting selective a1-blocker - Prazosin, Long-acting selective a1-blockers - Terazosin, Doxazosin Long-acting selective a1A-subtype - Tamsulosin - Alfuzosin - Silodosin Alpha Blockers - Advantages Quick action Improves urinary flow 4- to 6-point improvement is expected in IPSS/AUA scores No adverse effect upon sexual drive No effect on PSA Alpha Blockers - Disadvantages No effect on Prostate volume No reduction in risk of acute urinary retention or BPH-related surgery. Lowers blood pressure Fatigue, nasal congestion, headache Retrograde Ejaculation Intraoperative floppy iris syndrome (IFIS) Miosis, iris billowing, and prolapse in patients undergoing cataract surgery 5 Alpha Reductase - Rationale Prostatic growth depends on androgenic stimulation by DHT. 5a-reductase mediates conversion. Agents that block 5a-reductase inhibit growth and therefore help in BPH Types - type I and type II Type II predominates in the prostate and other genital tissues. 5 Alpha Reductase - Agents Finasteride Selective inhibitor of type II 5a-reductase Dutasteride Newer agent. Has affinity for both Types Similar efficacy. Both agents actively reduce serum DHT levels by more than 80%, Change in Prostate Volume % Change in prostate volume from baseline 30 20 Dutasteride Finasteride a-blockers 10 0 -10 -20 -30 McConnell et al. (1998); McConnell et al. (2003); Roehrborn et al. (2002); Lowe et al. (2003) 5 Alpha Reductase - Advantages Reduce prostate volume by 20% Improve symptoms in a third of men and increase peak flow by around 2ml/s 55% reduction in incidence of urinary retention, and likelihood of surgery for BPH. Longer acting Less side effects than alpha blockers Can reverse male pattern balding 5 Alpha Reductase - Advantages Reduce bleeding during surgery. 5 Alpha Reductase - Disadvantages Slow to act - Takes up to six months to work Not effective for mildly enlarged prostates Can affect sexual function Can cause breast swelling Transmitted in semen and can cause birth defects. Users should have protected sex. Caution in liver function abnormalities Lowers serum PSA level by 50% . Combination Therapy • Activates Two Distinct and Complementary Mechanisms of Action. Alpha blockers Relaxes prostatic and bladder-neck smooth muscle through sympathetic activity blockade Rapidly relieve symptoms 5-Alpha reductase inhibitors Reduces prostate enlargement through hormonal mechanisms Arrest disease progression Dutasteride+Tamsulosin / Finasteride+Tamsulosin. Decrease in Symptom Score Increase in Peak Flow Combination Therapy Patients with prostates >30 gm. Superior to monotherapy over long term. Risk of acute urinary retention decreased by 79% - Combination therapy 31% - a-blocker alone 67% - 5a-reductase inhibitor alone. Alpha blocker may be withdrawn after 6 months Phosphodiesterase 5 Inhibitors Treatment of associated ED Nitric oxide known to mediate smooth muscle relaxation in the lower urinary tract. Improvements in Urinary symptoms reported Smallest necessary dose. Should not be taken within 4 hours of any alpha-blocker Anticholinergics Treatment of Frequency / Urgency. Relaxes Detrusor muscle. Historically, discouraged because of concerns of inducing urinary retention. Recommend only in patients who do not have an elevated PVR. Not to be used when PVR is greater than 250-300 mL Phytotherapy Considered emerging therapy Saw palmetto (American dwarf palm) Leaf South African star grass (Hypoxis rooperi) roots African plum tree (Pygeum africanum) bark Stinging nettle (Urtica dioica) roots Rye (Secale cereale) pollen Pumpkin (Cucurbita pepo) seeds Active components - Phytosterols, Fatty acids, Lectins, Flavonoids, Plant oils, & Polysaccharides Phytotherapy Modes of action: Antiandrogenic, Antiestrogenic effect Inhibition of 5-alpha-reductase Blockage of alpha receptors Antiedematous, Anti-inflammatory effect Inhibition of prostatic cell proliferation Interference with prostaglandin metabolism Protection and strengthening of detrusor Algorithm for Medical Therapy Patient IPSS ≤7 IPSS >7 No or little bother Prostate small No Treatment Prostate large Preventive therapy 5a-Reductase Inhibitor Moderate to severe bother Prostate small aAdrenergic Blocker Prostate large 5a-Reductase Inhibitor Combination Rx Follow Up Diet Diet low in fat and red meat and high in protein and vegetables may reduce the risk of symptomatic BPH. Long-term Monitoring At least biannually evaluation to discuss the efficacy of medication and potential dose adjustment. Atleast annual DRE and PSA screening. Indication for Surgery Dissatisfied with medical management Unwilling to take daily medication Financial constraints Complicated BPH Renal dysfunction(obstructive uropathy) Recurrent attacks of acute retention of urine Recurrent UTI, Haematuria Bladder Calculi Surgical Options Endoscopic Surgery TURP Bladder neck incision Laser Prostatectomy Minimally invasive TUNA,TUMT, Balloon dilatation, Stents Open prostatectomy Trans Urethral Resection of Prostate (TURP) Gold Standard of care for BPH Endoscopic electrocautery “knife” used. Obstructive symptom improved - 80~90% Irritative symptom improved - 30% Low mortality rate - 0.2% Morbidity - 18% TURP - Technique Regional /General anesthesia Working sheath placed in the urethra through which a hand-held device with an attached wire loop is placed. TURP - Technique High-energy electrical cutting current is run through the loop and used to shave away prostatic tissue. The entire device is usually attached to a video camera to provide vision for the surgeon. TURP - Technique TURP Post-op: • Three way catheter • Continuous bladder irrigation with N.Saline until urine clear of clots TURP Disadvantages Benefits n Widely available n Effective n Long lasting n Side effects and complications n 1-4 days hospital stay n 1-3 days catheter n 4-6 week recovery TURP - Complications Immediate Bleeding and clot retention Capsular perforation / fluid extravasation Sepsis TURP syndrome TURP Syndrome Absorbtion of Irrigation fluid (glycine) into the open prostatic vein Fluid overload - Pulmonary oedema, Cerebral oedema Haemodilution - Hyponatraemia, Haemolysis Treatment - Stop Surgery, IV frusemide, Hypertonic saline TURP - Complications Delayed Urethral stricture Bladder neck contracture Retrograde ejaculation(90%) Impotence (5-10%) Incontinence (0.1%) Trans Urethral Incision of Prostate (TUIP) Indications Small prostates Cannot tolerate TURP (medical conditions) Advantage over TURP Less bleeding Less fluid absorption Lower incidence of retrograde ejaculation Lower incidence of impotence. Laser Prostatectomy Mechanism Heats tissue - Causing coagulative necrosis, and subsequent tissue contraction Evaporate - Melts away, prostate tissue. More effective. Knifelike fashion - To directly cut away prostate tissue Laser Prostatectomy Types Transurethral laser-induced prostatectomy (TULIP) Visual laser ablation of the prostate (VLAP) Interstitial laser coagulation of the prostate (ILC) Holmium:YAG laser resection of prostate (HoLRP) Holmium:YAG laser enucleation of prostate (HoLEP) Photoselective Vaporisation of Prostate Green light prostatectomy (PVP) Green Light Prostatectomy (PVP) n Uses a very high powered green laser and a thin, flexible fiber n Fiber is inserted into the urethra through a cystoscope Green Light Prostatectomy (PVP) n Quickly and precisely vaporizes and removes the enlarged prostate tissue n The green laser energy is hemostatic, so there is almost no bleeding Green Light Prostatectomy (PVP) Enlarged Prostate n n Urethra is obstructed Urine flow blocked After GreenLight PVP n n Urethra is open Normal urine flow is restored Laser Prostatectomy Advantages Catheter time less - 24 hours. Reduced hospital stay 59 vs 86 hours Equal results. Less bleeding. 23.3 vs 2.1 ml per minute. Useful inpatients who require anticoagulation. TUR syndrome is not seen incidence of impotence / retrograde ejaculation Laser Prostatectomy – Disadvantages Longer operating time - 74 vs 57 min. No tissue for biopsy - Vaporization technique. Dysuria / Urgency - Healing from laser treatment does not occur until after a period of weeks when dead cells slough. Minimally Invasive Therapy Developed during the last decade to challenge TURP Aim – Minimise anesthesia, blood loss, fluid absorbption, risk and hospital stay. Mechanism Heat destruction causing necrosis. Mechanical approaches. Efficacy – Between medical therapy & TURP. Minimally Invasive Therapy Transurethral microwave thermotherapy (TUMT): Heat delivered to prostate via urethral catheter. Transurethral needle ablation of the prostate (TUNA): High-frequency radio waves delivered using a transurethral device with needles. Cryotherapy High-intensity focused ultrasound(HIFU) Delivered rectally or extracorporeally Minimally Invasive Therapy Transurethral balloon dilatation of prostate Intraprostatic stent Flexible devices that can expand when put in place to improve the flow of urine. Complications - Encrustation, Pain, Incontinence, Overgrowth of tissue through the stent (making removal difficult). Transurethral ethanol ablation of the prostate Botulinum toxin-A injection of the prostate Open Prostatectomy Indication Large prostate(>100gm) Co existing bladder pathology : calculi, diverticula. Lithotomy position not possible : eg:Hip joint disease Technique Lower abdominal incision. Retropubic/Transvesical The inner core of the prostate (adenoma), which represents the transition zone, is shelled out, leaving the peripheral zone behind. Urinary Catheterisation Facilitates direct drainage of urinary bladder. Indications Diagnostic Collection of uncontaminated urine specimen Monitoring of urine output Imaging of the urinary tract Indications Therapeutic Acute urinary retention Chronic retention causing hydronephrosis Continuous bladder irrigation (hematuria) Intermittent catherisation Neurogenic bladder Hygienic care of bedridden patients Short-term drainage (eg, post surgery) Urinary Retention - Acute Features Painful Normal renal function Precipitating event - UTI - Fluid overload - Constipation - Medication Causes BPH Urethral Stricture Urethral Stone Trauma Neurogenic Psychogenic Post op Urinary Retention - Chronic Features Painless Impaired renal function Large residual volume Causes BPH Impaired Detrusor contractility Contraindications for Urethral Cath Traumatic injury to the lower urinary tract male patients with pelvic or straddle-type injury. Signs for injury - Blood at the meatus, Perineal hematoma, High-riding or boggy prostate. Retrograde urethrogram should be performed prior to catheterisation Catheterisation by urologist. Urinary Catheterisation Urethral Catheter Urinary Catheterisation Suprapubic Catheter Equipment Povidone-iodine Sterile cotton balls Water-soluble lubrication gel Sterile drapes, Sterile gloves Urethral catheter Prefilled 10-mL syringe Urobag for collection Catheter Types Foleys - 2 way Catheter - 3 way irrigation catheter (gross hematuria) Tip - Straight tip - Coudé tip: (Prostatic Obstruction) Catheter Sizes Adults 14F 16F 18F Hematuria catheters 20F 22F 24F Children – Smaller Infants feeding tubes Colour coded Catheter Material Latex (silicone-coated) Pure silicone Silver alloy Antibiotic-impregnated Catheterisation Technique Prophylactic antibiotics Males - Supine Female - Frogleg position, with knees flexed. Sterile gloves Clean with antiseptic solution Sterile drapes. Instillation of Jelly Hold penis firmly and extended Place tip of syringe / applicator in the meatus Apply gentle but continuous pressure and apply a generous amount of jelly. Occlude the urethral tip and for a couple of minutes to allow the anesthetic to take effect. Catheterisation Technique Males - Hold the penis at approximately 90° and stretch it upward to straighten out penile urethra, slowly and gently introduce catheter. Females – Separate labia and visualize meatus. Catheterisation Technique Advance the catheter until the proximal Yshaped ports are at the meatus. Wait for urine to drain from larger port to ensure that distal end of the catheter is in the Bladder. Catheterisation Technique After urine return, inflate the balloon with distilled water through the cuff inflation port. Maximal recommended volume for balloon inflation can be found on inflation valve (10-30 mL). Lubricant jelly–filled distal catheter openings may delay urine return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. Catheterisation Technique Gently withdraw the catheter until resistance is met. Secure catheter to thigh with a wide tape. Uncircumcised patient – Reduce foreskin. Failure to do so can cause paraphimosis. Catheter Removal Use a syringe to empty the balloon, and then apply gentle traction. Complications Infections - Urethritis, Cystitis, Pyelonephritis, and Transient bacteremia Bleeding Creation of false passages Inflation of the balloon inside the urethra resulting urethral tear. Urethral strictures Encrustation Fragmentation THANK YOU