BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3....
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Transcript of BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3....
BPH, Inflammatory diseases of prostate
As. Prof. Lukáš Bittner M.D., FEBU
Urologická klinika 3. LF UK a FNKV
BPH (Benign Prostatic Hyperplasia)
Most common „benign tumor“ in menPrevalence
20% age 41-50 50% age 51-60›90% older than 80
Prevalence of BPH
Etiology BPH
MultifactorialEndocrine controlled
Positive correlation between levels of fT and E and volume of BPH
Increase of E causing induction of androgen receptor, ꜛsensitivity
BPH
Pathology of BPH
BPH develops in transition zoneHyperplastic process, increase of cell No.Nodular grown pattern of stroma +
epitheliumStroma composed of collagen and smooth muscle • Smooth muscle target for alfa- blockers• Epithelium target for 5-alfa –reductase inhibitors• Collagen does not respond to medical Th
Anatomy of the prostate
Pathophysiology of BPH
Obstruction
Mechanical obstruction• Intrusion of prostate into the urethral lumen or bladder
neck= higher bladder outlet resistance
Dynamical obstruction • prostatic stroma is rich in adrenergic nerve supply, level
of autonomic stimulation sets the tone of prostatic urethra
Surgical anatomy
3 lobes2 lateral1 median (impalpable)
Prostate 25y.o.
Prostate 50y.o.
Clinical Findings
Hesitancy*Decreased force and
caliber of streamSensation of incomplete
bladder emptyingDouble voidingPost void dribbling
* Difficulty in beginning
UrgencyFrequencyNocturia
=LUTS Low Urinary Tract Syndrom
IPSS score
0-7 Mild8-19 Moderate20-35 Severe
Examination
DRES PSAUrinalysisPost void residuum- USGUFM
Uroflowmetry (UFM)
UFM terminology
UFM findings
Differential Diagnosis
Urethral strictureBladder neck contractureBladder stoneCaPInfectionTumor of bladder
Absolute surgical indication
Refractory urinal retention
Recurrent urinary tract infection from BPH
Gross hematuria from BPH
Bladder stones from BPHRenal insufficiency from
BPHLarge bladder diverticula
from BPH
Medical therapyof BPH
IPSS mild symptoms- watchful waiting
Alpha-blockers5-alfa reductase inhibitorsPhytotherapy
Alpha-blockers
Prostate and bladder base contains alpha-1 adrenoreceptorsShows contractile response
Fast onsetTime limited efficiencySide effects: hypotension, dizziness,
headache, retrograde ejaculationTamsulosin, Alfuzosin- alpha 1a selective,
once daily
5-alfa reductase inhibitors
Block conversion of T to dihydrotestosteronAffects epithelial component
Reduction of size (6monts 20%)PSA is reducedLate onset, long actingReduced risk of acute retention and need of
surgerySide effects: erectile dysfunction, decreased
libido, gynekomastiaFinasteride, Dutasteride, once daily
Phytotherapy
Saw palmeto berry (serenoa repens)Bark of Pygeum africanum
No benefit in randomised trials
Surgical therapy
Conventional therapyTransurethral resection of prostate (TURP)Open simple prostatectomy
Minimal invasive therapyLaser therapyTUNATUMTStents
Surgical treatment algorithm
Transurethral resection of Prostate (TURP)
TURP
TURP
Shorter hospital stayMinimal to moderate
bleeding
Strictures of urethra5% of EDTUR sy.
TUR Syndrome
The intrusion of salt-free irrigation fluid in open veins or perforation of the prostate capsule can cause a volume overload and dilutional hyponatremia (<125 mmol/l) of the patient.
SymptomsConfusionnausea and vomitingarterial hypertensionBradycardiapulmonary edema and impaired vision.
TUR Syndrome
Risk factorsProstate volume over 45 mlresection time over 90 minheight of the irrigation fluid by the patient over 70
cm. Lab controla
Sodium levelTreatment
Furosemide is given (20–40 mg i.v.)hypertonic NaCl solution slowly
Transvesical prostatectomy (TVPE)
TVPE
TVPE
Safe for urethraShorter operation time
Moderate to severe bleeding
Longer hospital stay
Acute bacterial prostatitis
Acute prostatitis
Associated with UTIascending urethral infectionReflux of infected urine from bladder
Most common urologic Dg. In men ≤50
Presentation
Abrupt onsetFeverChillsMalaiseBack/rectal/perineal painUrinary sy
• Frequency• Urgency• Dysuria
Findings
DRE- tender, warm, enlarge glandUrinalysis WBCSerum: leukocytosis, elevation PSA
Avoid prostatic massage, urethral catheterization
Causative organisms
E. coliProteusKlebsiellaPseudomonas
Treatment
Trimethoprim and fluoroquinolonesGood penetration4-6 weeks
If urine retention present- placement of suprapubic catheter
Chronic bacterial prostatitis
Present withDysuriaUrgencyFrequencyRecurrent UTI
DREOften normal
PSA may be elevated
4- Cup Test (Stamey)
Collect firs 10 mL voided urine (VB1)Discard next 100mLCollect next 10 mL (VB2)Massage prostate and collect prostate
expressate (ESP)Collect first 10 ml of voided urine after
massage (VB3)
interpretation
All specimen ≤103 CFU/mL not bacterial prostatitis
VB3 of EPS › 103 CFU/mL bacterial prostatitis
Only VB1 pos.- urethritisALL positive- treat UTI and repeat
Alternative – voided specimen before and after prostatic massage
Treatment of Chronic Prostatitis
Trimethoprim and fluoroquinolonesDuration of Th 3-4 months
Alfa blocker will reduce symtom recurrences