Gus156 Slide Benign Prostate Hyperplasia

8/10/2019 Gus156 Slide Benign Prostate Hyperplasia

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Ref :

Clinical Manual of Urology, (Philip M.Hanno et al eds), McGraw-Hill Int ed, 3rd

ed, 2001 Smiths General Urology (Tanagho &

McAninch eds), Lange Medical Books, 15th

ed, 2000


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Definition

Regional nodular growth of varyingcombinations of glandular and stromal

pro era on a occurs n a mos a menwho have testes and who live long enough


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TERMINOLOGY

BPH(Benign Prostatic Hyperplasia):

histopathologic diagnosis

BPE(Benign Prostatic Enlargement) :

anatomic diagnosis

BOO(Bladder Outlet Obstruction):

anatomic diagnosis

BPO(Benign Prostatic Obstruction):

BOO caused by BPE

LUTS(Lower Urinary TractSymptoms): clinical manifestation of

lower urinary tract obstruction


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Introduction

Common non-neoplastic lesion.

Involves peri urethral zone.

BPH is common as men age. 25% by 50y, but 90% By 80y..!

About 10% are symptomatic.


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Prevalence

The Most Frequent Benign Tumor in Men 70 % of men above 60 years.*

** .

30 40 % of men above 70 years

Indonesia : The Second after Stone Disease in

Urology Clinic ***

* Berry SJ et all J Urol 1984 ;132:474-79

** Carter HB , Coffey DS. Prostate 1990;16 : 39-48

*** Rahardjo D,Birowo P,Pakasi LSMed . J of Ind 1999 ; 8(4) : 260 - 63


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Impact of ageing population

With life expectancy approaching 80 years inmany countries 88% chance developinghistological BPH

in life ex ectanc si nificantl the

number of men affected by BPH The number of men presenting with BPH

symptoms will 45% in the next 10 years

and further in the following decade


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Prevalence of histological BPH with age

77%87% 92%

60

80

100

Prevalence (%)Prevalence (%)

11%

29%

0

20

40

3140 4150 5160 6170 7180 80+

Berry SJ et al. J Urol 1984; 132: 4749Berry SJ et al. J Urol 1984; 132: 4749


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Anatomy

N weight about 20 g Classification of Lowsley : 5 lobes : anterior,

posterior, median, right lateral, left lateral

ccor ng o c ea :- peripheral zone

- central zone

- transitional zone- an anterior segment

- a preprostatic sphincter zone


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Causes

- Many theories

- The actual cause still not clear

- Factors are known to be important:

1. Male sex

2. Aging

3. Testosterone4. Growth Factors (EGF, FGF, IGF II)


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Pathophysiology

Nodular hyperplasia of glands and stroma.

Normal 20 to 30 50 to 100 gm.

Press upon the prostatic urethra. Obstruction - difficulty on urination

Dysuria, retention, dribbling, nocturia

Infections, hydronephrosis, renal failure.

Not a premalignant condition*


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Prostate growth

Increased urethral resistance

Decompensation

Flow

Bladder emptying ,hesitancy, intermittency


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Mechanism

Hormonal imbalance with ageing.

Estrogen sensitive peri-urethral glands.

Accumulation of DHT in the prostate and itsgrowth-promoting androgenic effect

Some Drugs (Finasteride) inhibit DHTdiminishes prostatic enlargement.


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Morphology

Microscopically, nodular prostatic hyperplasiaconsists of nodules of glands and intervening

.

The glands variably sized, with larger glandshave more prominent papillary infoldings.

Nodular hyperplasia is NOT a precursor tocarcinoma.


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Symptoms LUTS

Weaker, smaller

stream

Hesitancy

Nocturia

Frequency

Urgency

interrupted flow

Feeling of incompleteemptying or retention

Terminal dribbling

Symptoms mayworsen with alcoholand caffeine, coldremedies


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How to Assess the Patient?


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Diagnosis

Anamnesis

Cardinal symptoms:

Weak S ream

Frequency

Nocturia

Storage symptoms, Voiding Symptoms

Scoring System : M.I, IPSS


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1. KENCING TIDAK LAMPIAS

Dalam sebulan ini berapa sering anda merasakan sensasi tidak lampias

saat kencing (terasa belum habis) ?

2. Sering Kencing Dalam sebulan ini berapa sering anda merasa Ingin Kencing Lagi dalam

2 jam setelah anda Kencing

3.KENCING TERPUTUS PUTUS

5

Gejala Tidak Pernah < 20 % < 50 %

2 3

=50% > 50 % Hampir Selalu

0 1 2 3 4

4 50 1

BPH SYMPTOM SCORE / IPSS

,

lagi ( Terputus putus)4.TIDAK DAPAT MENUNDA KENCING

Dalam Sebulan ini Berapa sering anda merasa kesulitan untuk menunda

Kencing

5.PANCARAN KENCING YANG LEMAH

Dalam sebulan ini berapa sering anda mengalami Pancaran Kencing Lemah6. MENGEDAN SAAT KENCING

Dalam sebulan ini berapa sering anda mengedan sebelum memulai kencing

7.KENCING DI MALAM HARI

Dalam Bulan ini berapa sering anda harus bangun tidur di malam hari untuk

Kencing

5

4 5

0 1

0 1 2 3

1 2 3

2 3 4

4 5

Tdk Pernah, =0 1Kali, =1 2kali, =2 3kali, =3 4kali, =4 5kali, =5

0


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IPSS (International Prostate

Symptom Score ).

0 7 : Mild

8 - 19 : Moderate20 35 : Severe

7 : Watchful & Waiting 7 : Medical treatment


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Diagnosis

Physical

examination :

Prostate :

1. Size

DRE 2. Nodule3. Consistency

4. Tenderness


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DRE


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Diagnosis

Uroflowmetry Qmax

Residual urine TAUS

Catheter


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Uroflowmetry


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Lab test

Blood Count Serum Electrolyte

Serum Creatinine

Serum PSA

Urine :

Proteinuria

Sediment

Culture


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IMAGING

TRUS Transabdominal Ultrasound

IVP

Cystography

CT-ScanMRI


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Trans Rectal Ultra Sonography : Volumometry

Identification of hypoechoic lesions

Calcification Periprostatic vein


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Urethral stricture

Bladder neck contracture

Differential diagnosis

Small bladder stone

Locally advanced prostate ca

Poor bladder contractility


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Effects of benign prostatic obstruction

Irreversible bladder changes

Thickening of the bladder wall Recurrent haematuria

Bladder diverticulum formation

Repeat urinary tract infections

Bladder stone formation

Upper tract dilatation

Renal impairment


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Complications

Increased risk of UTI due to urinary retention

Calculi due to alkalinization of residual urine

vessels

Pyelonephritis

Renal failure


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Indication for treatment

Absolute or near absolute :

- refractory or repeated urinary retention- azotemia due to BPH

- recurrent gross hematuria

- recurrent or residual infection due to BPH- bladder calculi

- large residual urine

- overflow incontinence- large bladder diverticula due to BPH


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Treatment

Watchful waiting

Intervention therapies Minimally invasive therapies

Surgical therapies


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Watchful waiting

Altering modifiable factor such as:

Concomitant drug

Regulation of fluid intake especially in the evening

Dietary advice (avoid excessive intake of alcohol, andhighly seasoned or irritative foods)

Evaluation/ monitoring : after 6 months/ 1 year

IPSS, uroflowmetry, post-void

residual urine volume


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Medical therapy

I.P.S.S. > 7

Flow > 5 ml/s

Residual urine < 100 ml No hard nodule

PSA < 4 ng/dl


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Medical therapy Reducing smooth muscle tone (dynamic

component) : -1 adrenergic blocker Short acting : prazosin, afluzosin Long acting : doxasosin, terazosin, tamsulosin

Reducing prostatic mass (static component):5 redutase inhibitor (finasteride, epristeride)

estrogen aromatase inhibitorLHRH agonist / antagonist GF inhibitorantiandrogens

Unknownphytotherapy


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Adrenergic stimuli Alpha adrenergic

stimuli increasestonus of smoothmuscle cell in the

,

neck and prostate Location of alpha

receptor:

BladderTrigonum

Prostate gland


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Mode of action alpha blocking agent

Alpha adrenergic blocking agent blocks

smooth muscle cell:

intra urethral pressure

Improvement of urine flow

R ti l f 5Al h d t i hibit


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Sintesis Protein

Hipotalamus

LHRHLHRH

ACTHACTH

Rationale of 5Alpha reductase inhibitor

Reseptor Inti

+

Transkripsi DNA

T DHT

5-reductase

DHT


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Invasive Treatment for BPHAbsolute indication:

Chronic Retention With Hematuria

Concomitant Bladder stone

Intractable UTI Deteriorating kidney function

Relative indication:

Huge PVR due to obstruction or low Qmax Refuse medical treatment

Failure in medical treatment


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Intervention therapy

Minimally invasive therapy Thermotherapy

TUNA (Trans Urethral Needle Ablation)

TUMT (Trans Urethral Microwave Theraphy) Laser

Stent

Surgical therapy

TUIP (Trans Urethral Incision of the Prostate) TURP (Trans Urethral Resection of Prostate) Open prostatectomy TUVP (Transurethral Vaporization of the Prostat) Laser


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Invasive Treatment for BPH TURP (gold standard)

Laser resection (Hol YAG Laser)


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TURP


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JARINGAN PROSTAT


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TUIP


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Gus156 Slide Benign Prostate Hyperplasia

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