dr. mugalo e.l

8/14/2019 Dr. Mugalo e.l

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BPH.DR. MUGALO E.L


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EPIDEMIOLOGY

Present in 50% of men above 60yrs,and88% aged 80 yrs.

25% of men >50 yrs have LUTS orobjective signs of BOO

About 40% of men in their 4th decade& >90% those >80yrs or more have

detectable BPH


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RISK FACTORS.

AGE-40% in men >50yrs,>90% inmen >80yrs.

Genetics

Race-Less in Asian men ,High inCaucasians

Diet-modest association ,western

type diet risk factor high in protein,fat & carbohydrates


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HISTORY

LUTS, Haematuria ,Dysuria.

Previous pelvic surgery, Neuropathy-Parkinsons d/se, CVA, etc

Cardiac problems ,DM, Diabetesincipidus


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SYMPTOMS-Not dse-

Weak stream, incomplete emptying,frequency, norcturia,urgency,intermitency ,straining.(IPSS)

Quality of life question


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BPH.


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PATIENT EVALUATION

History-luts,haematuri,dysuria

Exam-abd-bladder,CNS,DRE

INVESTIGATIONS-Urine(haematuria), Blood-renal fuction,PSA

US-size(TRUS),residual volume,R/O

bladder Tumour,Trus guided biopsy ifPSA is high


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IPSS-SCORE

This score allows you to calculate thesymptomatic frequenc5-6y and toclassify the patients according to thisfrequency.

-mild 0-7 Moderate 8-19 Severe 20-35

QoL assessement (8th

question) Good 0-1 Medium 2-4


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uroflowmetry

Noninvasive test to detect lowerurinary tract obstruction.

Qmax15mls/sec=no BOO

Low flow rate suggests BOO.


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Post void Residual Volume

PVR is a safety parameter

Men with a significant PVR should bemonitored more closely if they electnon-surgical therapy.

It can be measured accurately non-invasively with trans abdominal US

Elevated residual volume-stasis ofurine can increse the risk of UTI and


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Differentials

Bladder cancer

Neurological disease

Drug induced bladder Dysfunction DM/Diabetes insipidus

UTI,Detrusor Instability

Detrusor failure


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OBSTRUCTIVE PROSTATEB ni n Pr t ti H rtr h


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TREATMENT.

GENERAL RECOMMENDATIONS.

1.Avoid substance that can exacerbatesymptoms or cause urinary retensio.

-a) -agonists e.g. decongestantscontaining pseudoephidrine,anddietsuppliment ephedra.

-b)anticholinergics--c)caffeine and alcohol

-d)s ic and acidic foods


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TREATMENT. GENERALRE MMENDATI N

2.Norcturia can be reduced by.

-a)fluid intake in the evening

-b)avoid diuretics in the evening-c)patients with low extremity edemaneed to elevate their legs for onehour before bed time this mobilizesedema fluid and helps eliminate itbefore going to bed.


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TREATMENT.

WATHFULL WAITING.

-Repeating the evaluation at least once ayear.

-indicated for men with mild and notbothersome symtoms (ie AUA symptomscore


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TREATMENT.

-Blockers

Relax smooth muscles in the prostate fibromuscularstroma.

Achieve a dose dependent improvement in maximumurinary flow rate and symptom score

Can prevent BPH progression

Maximum response usually observed in 1-2 weeks.

-1A adrenergic receptors are the primary subtypeof -1 receptor in the prostate.

Side effects-dizziness,fatigue(asthenia),nasalcongestion,syncope,ortostatic hypotension,retrogradeejaculation.

Examlpes-terazosin(hytrin),doxazocin(cardura),tamsulosin(floma


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TREATMENT.

5-reductase inhibitors-finasteride(proscar) inhibits type II 5-reductase detasteride(Avodart) inhibits typeI and type II 5-reductase .

The enzyme that converts testosterone toDHT

Low DHT leads to:

-a)prostate volume by 20%-25 %.

-b)max urinary flow rate by approximately10%

-c)im roves s m tom scores b


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5-reductase inhibitors

-e) the risk BPH progression

-f)total PSA by 50% after 6 month oftreatment . In men on a 5-

reductaseinhibitor for 6 months thePSA during treatment , should bedoubled in before order to compare it toPSA before treatment.

-g)Increaseds testosterone by 10-20%(usually clinically insignificant)

-h)May help stop chronic haematuia from


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5-reductase inhibitors

Achieves maximum effect within 6-9months

Inicated for men with large prostates>40gm

Adult dose-finasteride 5mg po qday,dutasteride 0.5mg po q day

Adverse effects-impotence


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Combination therapy

Medical Therapy of ProstateSymptoms(MTOPS) trial randomized studyshowed that both -blockers and5-reductase inhibitors prevent progression of

BPH;however , the combination theapy isbetter than either agent alone.

Benefits of combination therapy are betterin men with PSA>4.0ng/ml and prostate

volume >40ngcc. Therapy did not reduce renal insufficiency,

UTI,or incontinence, but did reduce


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MINIMALLY INVASIVE

TUNA-Transurethral NeedleAblation.Radiofrequency (RF) wavesheat the prostate and create thermal

necrosis. TUMT-Transurethral Microwave Therapy.

Microwave heat the prostate and createthermal necrosis.

Emerging Minimally InvassiveTherapies. E.g. Interstitial LaserCoagulation, absolute ethanol


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SURGICAL THERAPY.

INDICATIONS.

1.absolute;

a)Refractory urinary retension

b)Recurrent UTIc)Bladder stones

d)Renal insufficiency from BPH

2.Moderate indications-AUA symptom score8 and any of the following.

a)Substatial bother symptoms

b)sing post voidal residual on serial exams

c)Low maximum flow rate (es


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SURGICAL THERAPY.

TUIP(Transurethral Incision of Prostate)-

-1 or 2 incisions at 5 and/or 7 oclockextending from the bladder neck to

immediately above cephalad to theverumontanum.the incision should bedeep to he fobrous prostate capsule.

Similar efficiency to TURP,but lower

rate of retrograde ejaculation. Suitable for smaller prostates (


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TURP.

Use of a resection loop to removechipsof prostate tissue.

Success rate is higher when;

a. pre-op maximum flow rate


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TURP.

Complications.

-posesulting in hyponatremit-opbleeding

-TUR syndrome(2% incidence)-excesiveabsorption of hypotonic irrigationfluid from prostatic vascular bedresulting in in hyponatremia,hypervolemia,HT,mentalconfussion,nausea,vomiting,vissualdisturbance.


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OPEN PROSTATECTOMY.

Reserved for large prostates (>80cc),or men who can not tolerate TURP.

Approaches-

transvesical/suprapubic,retropubic,and perineal.

Transvescical approach is ideal for

patients with bladder stones orrequire diverticulum repaire.


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OTHER SURGICAL

Holmium laser resection/enucleationof the prostate.

Trans urethral laser

coagulation(VLAP, vissual laserablation of the prostate)-laser energycoagulates the prostate withoutvapourizational laser vapourisation

Trans urethral laser vapourization

Transurethral electrovapourization-


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PERSISTENT SYMPTOMS AFTERR I AL TREATMENT.

In 15-20 % of men after surgical treatment. Do urodynamics which will reveal

-38% remain obstructed

-25% have poor detrusor contraction-50% have detrusor overactivity in absence ofa neurological disorder-which may persistup to 1 year.

-70% have detrusor overactivity when

neurological disorder is present. Detrusor overactivity and shincter damage

are the most common causes ofincontinence after invassive treatment.

dr. mugalo e.l

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