dr arun narayanaswamy urology unit amiri hospital n.
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Dr.Arun Narayanaswamy Urology Unit Amiri Hospital. Benign prostatic Hyperplasia. BPH Anatomy of Prostate Aetiology Pathophysiology Incidence Clinical presentation Investigations Management. Outline. Catheterisation Indications Catheter types Technique Complications.

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Benign prostatic Hyperplasia


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outline

BPH

Anatomy of Prostate

Aetiology

Pathophysiology

Incidence

Clinical presentation

Investigations

Management

Outline

Catheterisation

  • Indications
  • Catheter types
  • Technique
  • Complications
slide3

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

slide4

Prostatic parenchyma divided into 4 Zones.

Biologically and anatomical distinct.

Anatomy of Prostate gland

slide5

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.

Functions of Prostate gland

slide6

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 ?

slide7

Urethra

Peripheral Zone

Transition zone

What is BPH ?

slide8

Aetiology of Hyperplasia

  • DHT-mediated hyperplasia aided by estrogens In aging men, estradiol levels increase.
slide9

Mechanism of Obstruction

  • Mechanical Component - When sufficiently large, the nodules compress the urethral canal
slide10

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
slide11

Gross - Circumscribed grey white nodules

Histology Epithelial - Glandular proliferation or dilation Stromal - Fibrous or Muscular proliferation

Mostly common - Fibroadenomyomatous pattern

Pathology of BPH

slide12

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

BPH - Bladder Effects

slide13

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.
slide14

Common Terms

  • LUTS Lower-urinary-tract symptoms
  • BPE Benign prostatic enlargement (macroscopic)
  • BPH Benign prostatic hyperplasia (microscopic/histologic)
  • BOO Bladder-outlet obstruction
slide15

Symptoms

Obstructive Symptoms

(Voiding)

Irritative Symptoms

(Storage)

- Dysuria

- Frequency - Nocturia

- Urgency

- Incontinence

- Nocturnal enuresis

Elective

- Weak stream

- Straining to void

- Hesitancy

- Intermittency

- Terminal dribbling

- Incomplete emptying

Emergency

- Acute urinary

retention

- Chronic Retention

with overflow

slide16

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
slide17

Studies have identified LUTS as an independent risk factor for erectile / ejaculatory dysfunction.

Sexual history

slide18

Suprapubic area - Bladder distension

Neurological examination - Decreased anal sphincter tone Absent bulbocavernosus reflex

Palpate the scrotum: epididymoorchitis

Signs of CRF, Pallor

Physical Examination

slide19

Left lateral position

Index finger of the dominant hand.

Palpate circumferentially - windshield wiper movement

Rectal Examination

slide20

Prostate size and contour, Median sulci

Consistency

Nodules, Hardness, Asymmetry - suggestive of malignancy.

Pain - Prostatitis, Fluctuance - Prostate abscess

Rectal mucosa

Rectal Examination

slide21

Urinary retention

  • Recurrent UTIs
  • Gross hematuria
  • Bladder calculi
  • Bladder Diverticuli
  • Renal failure or uremia

Complications of BPH

slide22

Urethral Strictures

  • Bladder Stones
  • Neurogenic Bladder
  • Prostatitis
  • Bladder Tumours
  • Radiation Cystitis
  • Interstitial Cystitis

Differential Diagnosis

slide23

Investigations

  • Basic Iab:
    • CBC / S.Creat
    • Urine routine / culture
  • PSA(prostate specific antigen)
    • Xray KUB :calculi
  • Ultrasound
  • Uroflowmetry
  • Flexible Cystoscopy
slide24

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
slide25

Ultrasonography

  • Prostate – Size (>20cm3:abnormal), Nature
  • Bladder – Wall thickness, Diverticuli, Calculi
  • Kidneys - Hydronephrosis
  • Post micturition residual volume(>50-100ml)
slide26

Uroflowmetry

  • Simple noninvasive test to document voiding
  • Peak Flow rate (>15ml/s is normal)
  • Voiding time, Voiding pattern
  • Volume of voided urine – atleast 150ml
slide28

Invasive – Urethral / Rectal catheterization.

Indication - To distinguish  bladder contractility (detrusorunderactivity) from outlet obstruction.

BOO -Low urine flow rates accompanied by High intravesical voiding pressure (>60 cm water)

Cystometry - Pressure flow

slide29

Cystoscopy

Flexible cystoscopy can be easily performed in an office-based setting using topical gel- intraurethralanesthesia without sedation.

  • Indicated when Suspicion of
  • Urethral stricture - h/o STD, prolonged catheterization, or trauma
  • Detrusorhypocontractility - DM
slide30

Treatment Options

  • Watchful waiting
  • Medical management
  • Surgical approaches
    • - Endoscopic surgery
    • - Minimal invasive procedures
    • - Open surgery
slide31

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
slide32

Medical Management

Disadvantages

Drug Interactions

Must be taken every day

Does not fix problem

Side Effects

Cost

Benefits

Convenient

No loss of work time

Minimal risk

Types – Alpha Adrenergic Blockers 5 alpha reductase inhibitors

slide34

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 - Rationale

slide35

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

slide36

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 - Advantages

slide37

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

Alpha Blockers - Disadvantages

slide38

5 Alpha Reductase - Rationale

  • Prostatic growth depends on androgenic stimulation by DHT.
  • 5-reductase mediates conversion.
  • Agents that block 5-reductase inhibit growth and therefore help in BPH
  • Types - type I and type II
  • Type II predominates in the prostate and other genital tissues.
slide39

Finasteride - Selective inhibitor of type II 5-reductase

  • Dutasteride - Newer agent. Has affinity for both Types
  • Similar efficacy.
  • Both agents actively reduce serum DHT levels by more than 80%,

5 Alpha Reductase - Agents

slide40

Change in Prostate Volume

% Change in prostate volume from baseline

Dutasteride

Finasteride

a-blockers

30

20

10

0

-10

-20

-30

2 yrDB

4 yrOL

PLESS4 yr

MTOPS4 yr

6 yrOL

MTOPS

Dox4 yr

McConnell et al. (1998); McConnell et al. (2003); Roehrbornet al. (2002); Lowe et al. (2003)

slide41

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

slide42

5 Alpha Reductase - Advantages

  • Reduce bleeding during surgery.
slide43

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% .

5 Alpha Reductase - Disadvantages

slide44

Combination Therapy

  • Activates Two Distinct and Complementary Mechanisms of Action.

Alpha blockers

5-Alpha reductase inhibitors

Relaxes prostatic and bladder-neck smooth muscle through sympathetic activity blockadeRapidly relieve symptoms

Reduces prostate enlargement through hormonal mechanisms Arrest disease progression

Dutasteride+Tamsulosin / Finasteride+Tamsulosin.

slide47

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

Combination Therapy

slide48

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

Phosphodiesterase 5 Inhibitors

slide49

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

Anticholinergics

slide50

Considered emerging therapy

  • Saw palmetto (American dwarf palm) Leaf
  • South African star grass (Hypoxisrooperi) roots
  • African plum tree (Pygeumafricanum) bark
  • Stinging nettle (Urticadioica) roots
  • Rye (Secalecereale) pollen
  • Pumpkin (Cucurbitapepo) seeds

Active components - Phytosterols, Fatty acids, Lectins, Flavonoids, Plant oils, & Polysaccharides

Phytotherapy

slide51

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

Phytotherapy

slide52

Patient

IPSS >7

IPSS ≤7

Moderate tosevere bother

No or littlebother

Prostate small

Prostate small

Prostate large

Prostate large

-Adrenergic

Blocker

No Treatment

Preventive therapy5-Reductase Inhibitor

5-Reductase InhibitorCombination Rx

Algorithm for Medical Therapy

slide53

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.

Follow Up

slide54

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
slide55

Surgical Options

  • Endoscopic Surgery TURP Bladder neck incision Laser Prostatectomy
  • Minimally invasiveTUNA,TUMT, Balloon dilatation, Stents
  • Open prostatectomy
slide56

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%
slide57

TURP - Technique

  • Regional /General anesthesia
  • Working sheath placed in the urethra through which a hand-held device with an attached wire loop is placed.
slide58

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

slide60

TURP

  • Post-op:
    • Three way catheter
    • Continuous bladder irrigation with N.Saline until urine clear of clots
slide61

TURP

Benefits

Widely available

Effective

Long lasting

Disadvantages

Side effects and complications

1-4 days hospital stay

1-3 days catheter

4-6 week recovery

n

n

n

n

n

n

n

slide62

TURP - Complications

  • Immediate
  • Bleeding and clot retention
  • Capsular perforation / fluid extravasation
  • Sepsis
  • TURP syndrome
slide63

TURP Syndrome

  • Absorbtion of Irrigation fluid (glycine) into the open prostatic vein
  • Fluid overload - Pulmonary oedema, Cerebraloedema
  • Haemodilution -Hyponatraemia, Haemolysis
  • Treatment - Stop Surgery, IV frusemide, Hypertonic saline
slide64

TURP - Complications

  • Delayed
  • Urethral stricture
  • Bladder neck contracture
  • Retrograde ejaculation(90%)
  • Impotence (5-10%)
  • Incontinence (0.1%)
slide65

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.

Trans Urethral Incision of Prostate (TUIP)

slide66

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 Mechanism

slide67

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)
  • PhotoselectiveVaporisation of Prostate - Green light prostatectomy (PVP)
slide68

Green Light Prostatectomy (PVP)

Uses a very high powered green laser and a thin, flexible fiber

n

Fiber is inserted into

the urethra through a cystoscope

n

slide69

Green Light Prostatectomy (PVP)

Quickly and precisely vaporizes and removes the enlarged prostate tissue

The green laser energy is hemostatic, so there is almost no bleeding

n

n

slide70

Green Light Prostatectomy (PVP)

After GreenLight PVP

Enlarged Prostate

Urethra is open

Normal urine flow is restored

  • Urethra is obstructed
  • Urine flow blocked

n

n

n

n

slide71

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 Advantages

slide72

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.

Laser Prostatectomy – Disadvantages

slide73

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.
slide74

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
slide75

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
slide76

Open Prostatectomy

  • Indication - Large prostate(>100gm) Co existing bladder pathology : calculi, diverticula.Lithotomyposition 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.
slide77

Facilitates direct drainage of urinary bladder.

Indications

Diagnostic

  • Collection of uncontaminated urine specimen
  • Monitoring of urine output
  • Imaging of the urinary tract

Urinary Catheterisation

slide78

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)

Indications

slide79

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
slide80

Urinary Retention - Chronic

  • Causes
  • BPH
  • Impaired Detrusor contractility
  • Features
  • Painless
  • Impaired renal function
  • Large residual volume
slide81

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.

Contraindications for Urethral Cath

slide82

Urinary Catheterisation

Urethral Catheter

slide83

Urinary Catheterisation

Suprapubic Catheter

slide84

Povidone-iodine

  • Sterile cotton balls
  • Water-soluble lubrication gel
  • Sterile drapes, Sterile gloves
  • Urethral catheter
  • Prefilled 10-mL syringe
  • Urobag for collection

Equipment

slide85

Foleys - 2 way Catheter - 3 way irrigation catheter (gross hematuria)

  • Tip - Straight tip - Coudé tip: (Prostatic Obstruction)

Catheter Types

slide86

Adults 14F 16F 18F

  • Hematuria catheters 20F 22F 24F
  • Children – Smaller
  • Infants feeding tubes

Colour coded

Catheter Sizes

slide87

Latex (silicone-coated)

  • Pure silicone
  • Silver alloy
  • Antibiotic-impregnated

Catheter Material

slide88

Prophylactic antibiotics

Males - Supine Female - Frogleg position, with knees flexed.

Sterile gloves

Clean with antiseptic solution

Sterile drapes.

Catheterisation Technique

slide89

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.

Instillation of Jelly

slide90

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

slide91

Advance the catheter until the proximal Y-shaped 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

slide92

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

slide93

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.

Catheterisation Technique

Catheter Removal

  • Use a syringe to empty the balloon, and then apply gentle traction.
slide94

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

Complications