8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
1/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
2/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
3/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
4/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
5/49
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.
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
6/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
7/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
8/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
9/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
10/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
11/49
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)
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
12/49
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*
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
13/49
Prostate growth
Increased urethral resistance
Decompensation
Flow
Bladder emptying ,hesitancy, intermittency
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
14/49
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.
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
15/49
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.
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
16/49
Symptoms LUTS
Weaker, smaller
stream
Hesitancy
Nocturia
Frequency
Urgency
interrupted flow
Feeling of incompleteemptying or retention
Terminal dribbling
Symptoms mayworsen with alcoholand caffeine, coldremedies
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
17/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
18/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
19/49
How to Assess the Patient?
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
20/49
Diagnosis
Anamnesis
Cardinal symptoms:
Weak S ream
Frequency
Nocturia
Storage symptoms, Voiding Symptoms
Scoring System : M.I, IPSS
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
21/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
22/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
23/49
IPSS (International Prostate
Symptom Score ).
0 7 : Mild
8 - 19 : Moderate20 35 : Severe
7 : Watchful & Waiting 7 : Medical treatment
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
24/49
Diagnosis
Physical
examination :
Prostate :
1. Size
DRE 2. Nodule3. Consistency
4. Tenderness
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
25/49
DRE
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
26/49
Diagnosis
Uroflowmetry Qmax
Residual urine TAUS
Catheter
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
27/49
Uroflowmetry
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
28/49
Lab test
Blood Count Serum Electrolyte
Serum Creatinine
Serum PSA
Urine :
Proteinuria
Sediment
Culture
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
29/49
IMAGING
TRUS Transabdominal Ultrasound
IVP
Cystography
CT-ScanMRI
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
30/49
Trans Rectal Ultra Sonography : Volumometry
Identification of hypoechoic lesions
Calcification Periprostatic vein
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
31/49
Urethral stricture
Bladder neck contracture
Differential diagnosis
Small bladder stone
Locally advanced prostate ca
Poor bladder contractility
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
32/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
33/49
Complications
Increased risk of UTI due to urinary retention
Calculi due to alkalinization of residual urine
vessels
Pyelonephritis
Renal failure
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
34/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
35/49
Treatment
Watchful waiting
Intervention therapies Minimally invasive therapies
Surgical therapies
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
36/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
37/49
Medical therapy
I.P.S.S. > 7
Flow > 5 ml/s
Residual urine < 100 ml No hard nodule
PSA < 4 ng/dl
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
38/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
39/49
Adrenergic stimuli Alpha adrenergic
stimuli increasestonus of smoothmuscle cell in the
,
neck and prostate Location of alpha
receptor:
BladderTrigonum
Prostate gland
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
40/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
41/49
Sintesis Protein
Hipotalamus
LHRHLHRH
ACTHACTH
Rationale of 5Alpha reductase inhibitor
Reseptor Inti
+
Transkripsi DNA
T DHT
5-reductase
DHT
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
42/49
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
43/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
44/49
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
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
45/49
Invasive Treatment for BPH TURP (gold standard)
Laser resection (Hol YAG Laser)
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
46/49
TURP
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
47/49
JARINGAN PROSTAT
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
48/49
TUIP
8/10/2019 Gus156 Slide Benign Prostate Hyperplasia
49/49
Top Related