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Hyperplasia
Benign Prostatic
Hyperplasia
Generalised disease of
the prostate due to
hormonal derangement
which leads to
enlargement of the gland
(increase in the number
of epithelial cells and
stromal tissue)to cause
compression of the
urethra leading to
symptoms
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BPH
Proposed Etiologies
Cause not completely understood
Reawakening of the urogenital sinus to proliferate
Change in hormonal milieu with alterations in the
testosterone/estrogen balance
Induction of prostatic growth factors
Increased stem cells/decreased stromal cell death
Accumulation of dihydroxytestosterone, stimulation by
estrogen and prostatic growth hormone actions
BPH facts
Occurs in 50% of men over 50 and in
80% of men over 80 have BPH
BPH progresses differently in every
individual
Many men with BPH may have mild
symptoms and may never need
treatment
BPH does not predispose to the
development of prostate cancer
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Benign Prostatic
Hyperplasia
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BPH Pathophysiology
Normal BPH
BLADDER
Hypertrophied
detrusor muscle
PROSTATE
URETHRA Obstructed
urinary flow
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Clinical manifestations
Voiding symptoms
decrease in the urinary stream
Straining
Dribbling at the end of urination
Intermittency
Hesitancy
Pain or burning during urination
Feeling of incomplete bladder emptying
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Clinical manifestations
Irritative symptoms
urinary frequency
urgency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection
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Benign Prostatic
Hyperplasia
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AUA Symptom Score Sheet
More
Less Less
than
than 1 than About half Almost Your
Not at all half
time half the the time always score
the
in 5 time
time
Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your 0 1 2 3 4 5
bladder completely after you finish urinating?
Frequency
Over the past month, how often have you had to urinate again less than two hours after 0 1 2 3 4 5
you finished urinating?
Intermittency
Over the past month, how often have you found you stopped and started again several 0 1 2 3 4 5
times when you urinated?
Urgency
Over the last month, how difficult have you found it to postpone urination? 0 1 2 3 4 5
Weak stream
Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
Straining
Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5
5 times Your
None 1 time 2 times 3 times 4 times
or more score
Nocturia
Over the past month, many times did you most typically get up to urinate from the 0 1 2 3 4 5
time you went to bed until the time you got up in the morning?
Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.
DRE
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BPH
Danger Signs on DRE
Firm to hard nodules
Irregularities, unequal lobes
Induration
Stony hard prostate
Any palpable nodular abnormality
suggests cancer and warrants
investigation
Optional Evaluations and
Diagnostic Tests
Urine cytology in patients with:
Predominance of irritative voiding symptoms.
Smoking history
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BPH SYMPTOMS
Differential Diagnosis
Urethral stricture
Bladder neck contracture
Carcinoma of the prostate
Carcinoma of the bladder
Bladder calculi
Urinary tract infection and prostatitis
Neurogenic bladder
BPH TREATMENT
INDICATIONS
Absolute vs Relative
Severe Moderate
obstruction symptoms of
Urinary retention prostatism
Signs of upper Recurrent UTIs
tract dilatation Hematuria
and renal Quality of life
insufficiency issues
Treatment Options
Mild to severe symptoms with little
bother
Manage with watchful waiting.
Risk of therapy outweighs the benefit of medical or
surgical treatment
Nutritional supplements
Saw Palmetto
Alpha blockers
Doxazosin (Cardura), Terazosin (Hytrin),
Tamsulosin (Flomax), Alfuzosin (Uroxatral)
5-alpha reductase inhibitors
Finasteride (Proscar), Dutasteride
(Avodart)
Combination therapy
Alpha blocker and 5-alpha reductase
inhibitor
medication
Benefits Disadvantages
Convenient Expensive
No loss of work Drug Interactions
time
Must be taken every
day
Minimal risk
Manages the problem
instead of fixing it
Medical Management
Alpha adrenergic receptor blockers
promote smooth muscle relaxation in the prostate
fatigue,
Other problems can occur when pt is also taking
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Alpha-Adrenergic Blockers
Equal clinical effectiveness
Slight differences in adverse event profile
Orthostasis (lower in tamsulosin)
Ejaculatory dysfunction (higher in
tamsulosin)
Decreased energy levels
Nasal congestion
Increase in CHF risk with doxazosin
Must titrate doxazosin and terazosin to
effective levels
Medical Management
5 alpha reductase inhibitor ) finasteride: Proscar(
Reduce size of prostate gland by up to 30 %
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5-Alpha Reductase
Inhibitors
Agents are effective and appropriate treatment
for patients with lower urinary tract symptoms
and demonstrable enlargement of the prostate.
Decreased libido
cancer
Combination Therapy
Concomitant use of alpha blockers
and 5-alpha reductase inhibitors
Should be reserved for patients
who are at significant risk of
progression and adverse outcome
Poor surgical candidate
Patient wants to avoid surgery
Significant cost associated with dual
medications
Medical Management
Herbal therapy
saw palmetto fruit
use to improve
urinary symptoms
and urinary flow
Problem with
herbal therapy
long term
effectiveness
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surgical treatment
Surgical Management
Irritative voiding symptoms
Bladder neck contracture
UTI
Risk of incontinence 1%
Decline in erectile function
absorption)
Hemorrhage
Bladder spasms
Preoperative Goals
Restoration of urinary drainage
Treatment of any urinary tract
infection
Understanding of procedure,
implications for sexual functioning
and urinary control
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Preoperative care
Antibiotics
Allow pt to discuss concerns about
surgery on sexual functioning
Prostatic surgery may result in
retrograde ejaculation
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Postoperative Goals
No complications
Restoration of urinary control
Complete bladder emptying
Satisfying sexual expression
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Postoperative Care
Monitoring
Continuous irrigation & maintain
catheter patency
Blood clots and hematuria are expected
for the first 24-36 hours
After catheter is removed check for
urinary retention and urinary stream
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TURP
Sphincter tone may be poor after
catheter is removed. Kegal exercise
pelvic muscle floor technique is
encouraged. Starting and stopping
the urinary stream is helpful.
Stool softeners to avoid straining
Sitting and walking for long periods
should be avoided
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Discharge planning
Catheter care
Managing urinary incontinence
Oral fluid intake 2,000-3,000 cc per day
Observe for s/s of urinary tract infection
Prevent constipation
Avoid lifting
No driving or intercourse after surgery
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Surgical approaches for
prostatectomy
Retropubic
Midline abd.
incision
Perineal
Incision between
the scrotum and
anus
Suprapubic
Abdominal incision
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Prostatectomy
Complications:
Bleeding
Postoperative pain
Risk for infection
Erectile dysfunction
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BPH TREATMENT
New Modalities
Minimally invasive: (Prostatic
Stents,TUNA,TUMT, HIFU,Water-
induced Thermotherapy)
Laser prostatectomy
(VLAP,ILC,CLAP,TULIP,HoLRP)
Electrovaporization (TUVP,TVRP)
heat therapies
Destroy prostate tissue with heat
Tissueis left in the body and is
expelled over time (called
sloughing)
Impotence
Incontinence
Laser Photoselective
Vaporization of the Prostate
(Laser PVP)
TURP-equivalent 7 year improvement in
symptom score and urination parameters
Decreased risk of bleeding and TUR
syndrome, otherwise similar adverse
effect profile
May be done on anti-coagulated patients