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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Location Anterior to rectum, Just distal to bladder, Encircling the neck of bladder and urethra
Normal weight – 20gm
Anatomy of Prostate gland
Biologically and anatomical distinct.
Anatomy 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.
Functions of Prostate gland
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 ?
What is BPH ?
Histology Epithelial - Glandular proliferation or dilation Stromal - Fibrous or Muscular proliferation
Mostly common - Fibroadenomyomatous pattern
Pathology of BPH
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
Source: J Urol 1984;132:474
- Frequency - Nocturia
- Nocturnal enuresis
- Weak stream
- Straining to void
- Terminal dribbling
- Incomplete emptying
- Acute urinary
- Chronic Retention
Studies have identified LUTS as an independent risk factor for erectile / ejaculatory dysfunction.
Neurological examination - Decreased anal sphincter tone Absent bulbocavernosus reflex
Palpate the scrotum: epididymoorchitis
Signs of CRF, Pallor
Index finger of the dominant hand.
Palpate circumferentially - windshield wiper movement
Nodules, Hardness, Asymmetry - suggestive of malignancy.
Pain - Prostatitis, Fluctuance - Prostate abscess
Complications of BPH
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
Flexible cystoscopy can be easily performed in an office-based setting using topical gel- intraurethralanesthesia without sedation.
Must be taken every day
Does not fix problem
No loss of work time
Types – Alpha Adrenergic Blockers 5 alpha reductase inhibitors
BPH predominantly stromal (Smooth muscle ) proliferative process - Dynamic Obstruction
Relax the smooth muscle
Decrease outflow resistance.
Alpha Blockers - Rationale
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
No reduction in risk of acute urinary retention or BPH-related surgery.
Lowers blood pressure
Fatigue, nasal congestion, headache
Intraoperative floppy iris syndrome (IFIS) - Miosis, iris billowing, and prolapse in patients undergoing cataract surgery
Alpha Blockers - Disadvantages
Finasteride - Selective inhibitor of type II 5-reductase
5 Alpha Reductase - Agents
% Change in prostate volume from baseline
McConnell et al. (1998); McConnell et al. (2003); Roehrbornet al. (2002); Lowe et al. (2003)
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.
Less side effects than alpha blockers
Can reverse male pattern balding
5 Alpha Reductase - Advantages
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
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.
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
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
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
Active components - Phytosterols, Fatty acids, Lectins, Flavonoids, Plant oils, & Polysaccharides
Moderate tosevere bother
No or littlebother
Preventive therapy5-Reductase Inhibitor
5-Reductase InhibitorCombination Rx
Algorithm for Medical Therapy
Diet low in fat and red meat and high in protein and vegetables may reduce the risk of symptomatic BPH.
At least biannually evaluation to discuss the efficacy of medication and potential dose adjustment.
Atleast annual DRE and PSA screening.
Trans Urethral Resection of Prostate (TURP)
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
Side effects and complications
1-4 days hospital stay
1-3 days catheter
4-6 week recovery
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)
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
Uses a very high powered green laser and a thin, flexible fiber
Fiber is inserted into
the urethra through a cystoscope
Quickly and precisely vaporizes and removes the enlarged prostate tissue
The green laser energy is hemostatic, so there is almost no bleeding
After GreenLight PVP
Urethra is open
Normal urine flow is restored
Reduced hospital stay 59 vs 86 hours
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
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
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
Foleys - 2 way Catheter - 3 way irrigation catheter (gross hematuria)
Males - Supine Female - Frogleg position, with knees flexed.
Clean with antiseptic solution
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
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.
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.
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.
Secure catheter to thigh with a wide tape.
Uncircumcised patient – Reduce foreskin. Failure to do so can cause paraphimosis.
Infections - Urethritis, Cystitis, Pyelonephritis, and Transient bacteremia