TOPIC

by
DR ISMAIL KHAN
ASSISTANT PROF DEPT OF GENERAL SURGERY
SARASWATHI INSTITTUE OF MEDICAL SCIENCES
Case Scenario

• 68 year old male presented to the casualty

with frequency of urination, red urine,
burning micturition, drops of urine in the
underwear just before sitting to the bath in
spite of waiting and straining to urinate,
urine flow is weaker and not continuous and
also, the urine again drops in his cloths
after he finishs voiding and stands up. for
the last three months and getting worst.
The smell of urine annoys him.
Case Scenario

• He is hypertensive on lisinopril 10mg.

• Physical examination revealed nothing but a
suprapubic mass and enlarged prostate with
a patent median sulcus and smooth rectal
mucosae on DRE.
• Hb is 11 grams, urinalysis uncountable pus
cells and RBCs, urea 80 crea 1.9. PSA 12ng/l.
• U/S abd: prostate 140g, PVRU 600/150ml.
• Cystoscopy: enlarged median lobe, biopsied.
 Also known as

•Benign Prostatic
Hypertrophy
(BPH)
Benign
Prostatic
Hypertrophy/ Hyperplasia
 Introduction:

• Benign prostatic hyperplasia (BPH) is

a benign enlargement of the
prostate gland.
• In many patients older than 50
years, the prostate gland enlarges,
extending upward into the bladder
and obstructing the outflow of urine
by encroaching on the vesicle orifice.
• This condition is known as benign
prostatic hyperplasia (BPH), the
enlargement, or hypertrophy, of the
prostate.
• It is the most common urologic
problem in male adults.
• About 50% of all men in their
lifetime will develop BPH.
• Of these men, almost half of
them will have bothersome
lower urinary tract symptoms.
 Definition:
• It is defined as, “ noncancerous
increase in size of prostate gland
which involves hyperplasia of
prostatic stromal and epithelial cell
resulting in formation of large, fairly
discrete nodules in transitional zone
of prostate, which push on and narrow
the urethra resulting in an increase
resistance to flow of urine from the
bladder.”
 Resulting in
Which formation
Non
involves of large,
cancerous
hyperplasia fairly
increase
of prostatic discrete
in size of
stromal and nodules in
prostate
epithelial transitional
gland
cell zone of
prostate
 Resulting in
an increase
Which push on
resistance to
and narrow
flow of urine
the urethra
from the
bladder
 Incidence:

• 50% of men having evidence of

BPH by age of 50years.
• 75% by age of 80 years.
 Causes and risk
factors:
• Dihydrotestosterone (DHT).
• Risk factors for prostate gland
enlargement include:
• Aging. Prostate gland enlargement
rarely causes signs and symptoms in
men younger than age 40. About
one-third of men experience
moderate to severe symptoms by
age 60 and about half do so by age
80.
• Diabetes and heart disease.
Studies show that diabetes, as
well as heart disease and use of
beta blockers, might increase
the risk of BPH.
• Lifestyle. Obesity increases the
risk of BPH, while exercise can
lower your risk.
 Clinical
Manifestations:

• Hesitancy in starting urination

• Increased frequency of urination
• Nocturia
• Urgency
• Abdominal straining
• Decrease in volume and force of
urinary stream
• Interruption of urinary stream
• Dribbling.
• Sensation of incomplete
emptying of the bladder
• Acute urinary retention (more
than 60 ml)
• Recurrent UTIS.
• Fatigue
• Anorexia
• Nausea and vomiting
• Pelvic discomfort and pain
• Ultimately azotemia
• Renal failure result with chronic
urinary retention and large
residual volumes
• Blood in the urine
 Assessment and
Diagnostic Methods:
• History collection
• Physical examination- including
digital rectal examination(DRE)
• Urinalysis to screen for
hematuria and UTI.
• Prostate-specific antigen (PSA)
level is obtained if the patient
has at least a 10-year life
expectancy and for whom
knowledge of the presence of
prostate cancer would change
management.
• Urinary flow-rate recording and the
measurement of postvoid residual
(PVR) urine.
• Urodynamic studies
• Urethrocystoscopy
• Ultrasound
• Complete blood studies, including
clotting studies.
 Medical Management:

• The treatment plan depends on the

cause, severity of obstruction, and
condition of the patient. Treatment
measures include the following:
1. Immediate catheterization if patient
cannot void (an urologist may be
consulted if an ordinary catheter
cannot be inserted).
2. A suprapubic cystostomy is
sometimes necessary.
3. “Watchful waiting” to monitor
disease progression.
 Pharmacologic
Management
• Alpha blockers.
These medications relax bladder neck
muscles and muscle fibers in the
prostate, making urination easier.
Alpha blockers — which include
alfuzosin (Uroxatral), doxazosin
(Cardura), tamsulosin (Flomax), and
silodosin (Rapaflo) — usually work
quickly in men with relatively small
• 5-alpha reductase inhibitors.

These medications shrink prostate

by preventing hormonal changes
that cause prostate growth.
These medications — which include
finasteride (Proscar) and dutasteride
(Avodart) — might take up to six
months to be effective.
• Combination drug therapy.

Doctor might recommend taking

an alpha blocker and a 5-alpha
reductase inhibitor at the same
time if either medication alone
isn't effective.
• Tadalafil (Cialis).
Studies suggest this medication,
which is often used to treat erectile
dysfunction, can also treat
prostate enlargement. However,
this medication is not routinely used
for BPH and is generally prescribed
only to men who also experience
erectile dysfunction.
 Surgical
Management:
 • Minimally

1. Invasive
Therapy

2.
• Invasive
Therapy
(A). Minimally Invasive
Therapy.

Minimally invasive therapies are

becoming more common as an
alternative to watchful waiting and
invasive treatment. They generally do
not require hospitalization or
catheterization.
• Transurethral • Transurethral • Laser
Microwave Needle Prostatectomy.
Thermotherapy Ablation.

1 2 3
• Photovaporiza- • Interstitial • Intraprostatic
tion laser Urethral
coagulation Stents.
(ILC).

4 5 6
 1. Transurethral
Microwave
Thermotherapy.
• Transurethral microwave
thermotherapy (TUMT) is an
outpatient procedure that involves
the delivery of microwaves directly to
the prostate through a transurethral
probe to raise the temperature of the
prostate tissue to about 113° F (45°
C). The heat causes death of tissue,
thus relieving the obstruction.
• Antibiotics, pain medication,
and bladder antispasmodic
medications are used tolerate
and prevent post procedure
problems.
• The procedure is not appropriate for
men with rectal problems.
• Anticoagulant therapy should be
stopped 10 days before treatment.
Mild side effects include occasional
problems of bladder spasm,
hematuria, dysuria, and retention.
 2. Transurethral Needle
Ablation.
• Transurethral needle ablation (TUNA) is
another procedure that increases the
temperature of prostate tissue, thus
causing localized necrosis. TUNA differs
from TUMT in that low-wave
radiofrequency is used to heat the
prostate. Only prostate tissue in direct
contact with the needle is affected,
thus allowing greater precision in
removal of the target tissue.
• Complications include urinary
retention, UTI, and irritative voiding
symptoms (e.g., frequency, urgency,
dysuria). Some patients require a
urinary catheter for a short time.
Patients often have hematuria for up
to a week.
 3. Laser Prostatectomy.

• The use of laser therapy through visual or

ultrasound guidance is an effective
alternative to transurethral resection of the
prostate (TURP) in treating BPH.
• The laser beam is delivered transurethrally
through a fiber instrument and is used for
cutting, coagulation, and vaporization of
prostatic tissue. There are a variety of laser
procedures using different sources,
wavelengths, and delivery systems.
 4. Photovaporization

• (PVP) uses a high-powergreen

laser light to vaporize prostate
tissue. Improvements in urine flow
and symptoms are almost immediate
after the procedure. Bleeding is
minimal, and a catheter is usually
inserted for 24 to 48 hours afterward.
PVP works well for larger prostate
glands.
 5. Interstitial laser
coagulation (ILC).
• The prostate is viewed through a
cystoscope.
• A laser is used to quickly treat
precise areas of the enlarged
• prostate by placement of
interstitial light guides directly
into the prostate tissue.
 6. Intraprostatic
Urethral Stents.
• Symptoms from obstruction in
patients who are poor surgical
candidates can be relieved with
intraprostatic urethral stents.
The stents are placed directly
into the prostatic tissue.
Complications include chronic
pain, infection, and encrustation.
 (B). Invasive
Therapy (Surgery)

• Invasive treatment of symptomatic

BPH involves surgery. The choice of
the treatment approach depends on
the size and location of the
prostatic enlargement and patient
factors such as age and surgical
risk.
 1. Transurethral
Resection of the
Prostate.
• Transurethral resection of the
prostate (TURP) is a surgical
procedure involving the removal
of prostate tissue using a
resectoscope inserted through
the urethra.
• TURP has long been considered the
gold standard for surgical treatments
of obstructing BPH. Although this
procedure remains the most common
operation performed, the number of
TURP procedures done in recent years
has declined due to the development
of less invasive technologies.
• TURP is performed under a
spinal or general anesthetic and
requires a 1- to 2-day hospital
stay. No external surgical
incision is made. A resectoscope
is inserted through the urethra
to excise and cauterize
obstructing prostatic tissue.
•A large three-way indwelling
catheter with a 30-mL balloon is
inserted into the bladder after the
procedure to provide hemostasis
and to facilitate urinary drainage.
The bladder is irrigated, either
continuously or intermittently,
usually for the first 24 hours to
prevent obstruction from mucus and
blood clots.
• The outcome for 80% to 90% of
patients is excellent, with marked
improvements in symptoms and
urinary flow rates.
• Postoperative complications include
bleeding, clot retention, and dilutional
hyponatremia associated with
irrigation.
 2. Transurethral Incision
of the Prostate.
• Transurethral incision of the prostate
(TUIP) is a surgical procedure done
under local anesthesia for men with
moderate to severe symptoms. Several
small incisions are made into the
prostate gland to expand the urethra,
which relieves pressure on the urethra
and improves urine flow.
• TUIP is an option for patients
with a small or moderately
enlarged prostate gland. TUIP
has similar patient outcomes to
TURP in relieving symptoms.
 Assessment

• Obtain history of voiding

symptoms, including onset,
frequency of day and nighttime
urination, presence of urgency,
dysuria, sensation of incomplete
bladder emptying, and
decreased force of stream.
Determine impact on quality of
life.
• Perform rectal (palpate size, shape,
and consistency) and abdominal
examination to detect distended
bladder, degree of prostatic
enlargement.
• Perform simple urodynamic measures
uroflowmetry and measurement of
postvoid residual, if indicated.
Patient Education
and Health
Maintenance
• Explain to patient not
undergoing treatment the
symptoms of complications of
BPH urinary retention, cystitis,
and increase in irritative voiding
symptoms. Encourage reporting
these problems.
• Advise patients with BPH to
avoid certain drugs that may
impair voiding, particularly OTC
cold medicines containing
sympathomimetics such as
phenylpropanolamine.
• Advise patient that irritative
voiding symptoms do not
immediately resolve after relief
of obstruction; symptoms
diminish over time.
• Tell patient postoperatively to
avoid sexual intercourse,
straining at stool, heavy lifting,
and long periods of sitting for 6
to 8 weeks after surgery, until
prostatic fossa is healed.
• Advise follow-up visits after
treatment because urethral
stricture may occur and
regrowth of prostate is possible
after TURP.
• Be aware of herbal or natural
products marketed for prostate
health.
 Complications

• Acute urinary retention

• Involuntary bladder contractions
• Bladder diverticula
• Cystolithiasis
• Vesicoureteral reflux
• Hydroureter
• Hydronephrosis
• Gross hematuria
• UTI
 THANK YOU
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