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BPH +
Vesicolithiasis
Patients identity
Name
: Mr Samin
No RM : 131489
Age : 68
Ocuppied :
Address :
Check in : 2 December 2013
ANAMNESIS
Autoanamnesis
Treatment
efforts :
He went to doctor with the same
complaint and has been using
catheter since Nov 18th 2013.
IPSS
= 29
Physical Examination
Conciousness:
Vital
CM
Sign
BP : 120/80 mmHg
HR : 84 x/minute
RR : 20 x/minute
Temp: 36,4 OC
Head :
eye : CA -/-, SI -/-, pupils isokor, 3
mm, LP +/+
Neck : lymph nodes doesnt enlarged
Thorax : Cor dan Pulmo within
normal limits
Abdomen : see localized status
Genitalia : catheter foley (+) with
urine 400cc
Extremity : within normal limits
Investigations
Laboratory
Tests
USG
Thorax
Photo
Laboratory Tests
Eritrosit : 4,91 million/mm3
Leukosit : 12.700 /mm3
Trombosit : 148.000 /mm3
Ht : 44 %
Hb : 14,7 mg/dL
MCV : 30 femtoliter
MCH : 90 picogram
CT : : 4 minutes
BT : 2 minutes
Blood Type : A
SGOT
: 15
SGPT : 12
Ureum : 17,2 mg/dL
Creatinine : 0,7 mg/dL
Glukosa : 86 mg/dL
HbsAg
: negative
Elektrolite :
Kalium : 3,48 mmol/L
Natrium : 153,8 mmol/L
Cl
: 110,2 mmol/L
USG Tests
Vesica urinaria :
The wall wickeness intraluminal, sediment, bladder stones
(+) 7,3 cm.
Prostate
The volume is bigger 51 mL
Parenchym texture echo homogen rough
SOL (-)
Impression :
Severe chronic cystitis
Vesicolithiasis
Prostate Hipertrophy
Right and left renal within normal limits
Thorax Photo
Active
pulmonary TB (-) /
Bronchopneumonia
Cardiomegaly (-)
Working Diagnose
BPH
+ Vesicolithiasis
Follow Up
3
Vesicolithotomy
/ sectio alta
Vital Sign :
BP : 110/70 mmHg
Temp : 36,9 C
HR : 60x/minute, regular,
RR
: 18x/minute
Laboratory Tests:
Eritrosit : 5,03 million/mm3
Leukosit : 17400 /mm3
Trombosit
: 156000 /mm3
Ht
: 45 %
Hb
: 14,9 mg/dL
MCH
: 30 picogram
MCV
: 90 femtoliter
MCHC
: 33 %
Vital Sign :
BP : 130/70 mmHg
Temp : 37,2C
HR : 96x/minute, regular
RR
: 20/minute
Continue the therapy
Vital Sign:
BP : 130/90 mmHg
Temp : 38C
HR : 92 x/minute, regular
RR
: 20 x/minute
Do spooling with 40 droplets per minute
Urinary Retention
Acute
urinary retention
urinary retention
Cause of urinary
retention
Bladder
outlet obstruction
hypoactive bladder
Pathophysiology
Acute
urinary retention
Pathophysiology
Chronic
urinary retention
Management of urinary
retention
Release
obstruction
urethral catheter
retaining
suprapubic systostomy
Treatment
causes
of the
neck dysfunction
Prostatic enlargement
Urethral stricture
External sphincter dyssynergia
Urethral meatal stenosis
BOO is a condition of progressive
degree
caliber of urine
Dysuria
Intermittency
Residual urine sensation
Pathogenesis of
Bladder outlet obstruction
Progressive
increased urethral
resistance
High voiding pressure and low flow
Bladder compensation in energy
Increased residual urine volume
Elevated intravesical pressure at endfilling
Bladder stone, diverticulum, UTI
Hydroureter, hydronephrosis, azotemia
Differential diagnosis of
male BOO and LUTS
Benign
prostatic enlargement
Bladder neck dysfunction
Spastic urethral sphincter
Poor relaxation of urethral
sphincter
Urethral stricture
Low detrusor contractility
Pseudodyssynergia due to
neuropathy
enlargement benign or
malignant, a sign
Prostatic hyperplasia
histological term
Prostatic obstruction a clinical
diagnosis
Bladder outlet obstruction an
urodynamic term
Lower urinary tract symptoms
symptom
Prostatic glandular
anatomy
Benign Prostatic
Hyperplasia
BPH
Histology of
Benign prostatic hyperplasia
Causes of symptoms
Hyperplasia
of epithelial and
stromal components of prostate
Progressive obstruction of urinary
outflow
Increased activity of detrusor
muscle
Causes
Frequency, nocturia
Poor flow , intermittent stream
Hesitation, terminal dribbling
Prevalence
Men
Clinical BPH
LUTS
( storage or empty
symptoms) due to histological
benign prostatic hyperplasia and
urodynamical bladder outlet
obstruction which has been
proven by urodynamic pressure
flow study as prostatic
obstruction
Treatment for LUTS and
restoration of normal storage and
empty function by reducing
prostatic enlargement either
Pathophysiology of
BPH and LUTS
Nodular
proliferation of prostate
gland
Increased stroma to epithelial
ratio to 2:1 to 5:1 in benign
prosatic hyperplasia
Increased smooth muscle
component
Detrusor compensatory change
and bladder dysfunction, detrusor
overactivity
Examination
Palpation
of abdomen for
enlarged bladder
enlarged kidneys
constipation
Rectal
examination for
Investigations
Blood tests
Fbc esr
U&es
Fasting blood sugar
? PSA level rises with increasing
volume of prostate gland
Urinalysis
Infection
haematuria
Investigations
Additional
tests as
appropriate by GP
Ultrasound for residual urine
volume
Urinary diaries
Specialist investigations
Reasons
Patient reassurance
Patient explanation
Objective assessment of symptoms
Diagnostic precision
Ranking of treatment options
Prediction of treatment outcome
Specialist investigations
Uroflowmetry
pressure studies
Specialist investigations
Urinary
tract imaging
Assesment
Not at all = 0
< 1 in 5 = 1
< half the time = 2
About half the time = 3
> half the time = 4
Almost always = 5
Q7
Never = 0, once = 1, 2x = 2, 3x = 3, 4x =
4, 5x = 5
& retropubic
prostatectomy
Transurethral prostatectomy
(TUR-Prostate)
Laser interstitial prostatectomy
Transurethral incision of prostate
Intraprostatic stent
Balloon dilatation of prostatic
urethra
Prostatic hyperthermia
urinary retention
Persistent or recurrent urinary tract infections
Significant hemorrhage or recurrent
hematuria
Bladder calculi secondary to bladder outlet
obstruction
Significant symptoms from bladder outlet
obstruction that are not responsive to
medical or minimally invasive therapy
Renal insufficiency secondary to chronic
bladder outlet obstruction
Complications of TURProstate
Peri-operative
bleeding
Urinary tract infection and urosepsis
Electrolyte imbalance, hemolysis,
acute tubular necrosis
Acute pulmonary edema
Bladder neck or urethral contracture
Retrograde ejaculation and erectile
dysfunction
Urge or stress urinary incontinence
Minimally invasive
procedure
Transurethral
vaporization- resection of
prostate (TUVRP)
Ho-YAG laser coagulation of prostate
Visual laser ablation of prostate (VLAP)
Transurethral needle ablation (TUNA)
High intensity focused ultrasound (HIFU)
Microwave hyperthermia
Minimally invasive = minimally
effective?
A higher re-treatment rate than TURP
although less complication occurs
Intra-Prostatic Stent
Interstitial Laser
Coagulation
Hyperthermia of BPH
Transurethral Dilatation of
Prostate
Prostatic specific
alpha- adrenoreceptor
Alpha
catalyzes
conversion of testosterone to
dihydrotestosterone
Inhibition of 5-alpha-reductase
can arrest prostatic growth and
relieve obstruction
Finasteride can improve
symptom score,Qmax, QOL score
Effective especially in prostatic
weight of >40 gm and effective
is effective therapy,
finasteride was not, combination
was no more effective than
terazosin alone
Combined dibenyline and
finasteride has an additive effect
than dibenyline or finasteride
alone in improvement of Qmax
and prostatic size
Vesicolithiasis / bladder
stone
Bladder
Etiology
Prostatic
enlargement
Epidemiology
Since
Stone composition
Calcium
stones
Calcium oxalate
Pure calcium phosphate
Magnesium ammonium
phosphate
Uric acid
Cystine
Pathophysiology
Most
Clinical Presentation
Suprapubic
pain
Dysuria
Intermittency
Frequency
Hesitancy
Nocturia
Urinary
retention
Gross hematuria
Examination
BNO-
ivp
USG
Cystoscopy
CT-
scan
Complication
Infection
Retensio
urine