CASE PRESENTATIONBENIGN PROSTATIC HYPERPLASIA

Created by :Widya Amalia Swastika1102011290

Adviser :Dr. Herry Setya Yudha Utama, SpB, MHKes,FInaCS

KEPANITERAAN KLINIK BEDAHFAKULTAS KEDOKTERAN UNIVERSITAS YARSIRSUD ARJAWINANGUN2015

Case Presentation

A. IdentityName: Mr. NAge: 63 years oldGender: MenTribe: JavaneseOccupation: -Address: Pekantingan In hospital since: august 19th 2015B. ANAMNESIS Main GrievanceDysuria since 2 years ago Historical of Present Disease 63 years old men came to RSUD Arjawinangun with painful during urination, straining when urinating, urinary incontinence, hematuria, and night-time urination. Fever (-), nausea (-), vomitus (-). Historical of Past DiseaseHipertension (-)Diabetes Melitus (-) Historical of Family DiseaseHipertension (-)Diabetes Melitus (-)

1. MEDICAL EXAMINATION Present Status General Condition: Moderate Awareness: Composmantis Blood Pressure: 120/80 Pulse: 82 x/minute Breathing: 24 x/minute Temperature: 36,3 C General StatusHead Form : Normal, Simetrical Hair: Black Colour Eye : Anemic Conjungtival -/- Icteric Schlera -/- Light Refleks (+) Isocor pupil right = left Ear: Normal form, cerumen (-), tympani membrane intac Nose: Normal form, No septum deviation, epitaction -/- Mouth: NormalNeck Enlargement of lymph nodes (-) Trachea in the middleThorax Lungs - pulmonary Inspection : The chest shape is symmetrical both of left and right Palpation : Fremitus tactile and vocal symmetrical right and left, crepitus (-), tenderness (-), rebound tenderness (-) Percussion : Sound of resonant in both lung fields Auscultation : Sound of vesicular and bronchial the entire lung field, ronkhi -/-, wheezing -/- Heart Inspection : Ictus cordis is not visible Palpation: Ictus cordis palpable on the left midclavicula ICS line 5 Percussion: Upper limit ICS 3 linea parasternalis sinistra Right limit ICS 4 linea sternalis dextra Left limit ICS 5 linea midclavicula sinistra Auscultation: Heart sound 1 2 pure regular, murmur (-), gallops (-)

Abdomen Inspection : flat abdomen shape, supple, not visible skin disordersLesion (-), Mass (-) Palpation : tenderness (-), rebound tenderness (-) Percussion : There was a whole field tympanic abdomen Auscultation : Bowel (+) Normal

Ektremitas Superior: Akral warm, Edema -/-, CTR < 2 Inferior : Akral wamt, Edema -/-, CTR < 2, Lump at left ankle

Genitalia : No abnormalities

2. INVESTIGATIONSLaboratory ExaminationTestResultNormalUnits

WBC9.35.2 12.410e3/uL

RBC4.494.2 6.110e6/uL

HGB12.812 18d/dL

HCT35.537 52%

MCH28.527 31fL

MCHC36.133 37g/dL

RDW14.311.5 14.5%

PLT324150 45010e3/uL

NEUT87.740 74%

LYMPH1.719 48%

MONO1.03.4 9%

EOS0.80 -7%

BASO0.20 - 1.5%

LUC2.70 - 4%

E. DIAGNOSIS OF WORKBenign prostatic hyperplasia (BPH)G. MANAGEMENT PLANNon-medical: Prostatektomimedical: Infusion RL 15 GTT / min Keterolac 2 x 1 Cefazoline 2 x 1

LITERATURE REVIEWAnatomi ProstatThe prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a mans fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

DefinitionBenign prostatic hyperplasia also called BPH is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction. Benign prostatic hyperplasia is a common disease with proliferation of prostatic stromal cells and the periurethral zone (transitional zone) of the prostate, which leads to lower urinary tract symptoms (LUTS).The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a mans life. Benign prostatic hyperplasia often occurs with the second growth phase. As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retentionthe inability to empty the bladder completelycause many of the problems associated with benign prostatic hyperplasia.

EpidemiologiSome studies have suggested that African American men are at higher risk and Asian men at lower risk for BPH than Caucasians, a 2000 study found no greater risk for African Americans and only a slightly lower risk for Asians. Among Caucasians in the study, men of southern European heritage were at greater risk while men of Scandinavian ancestry had a lower chance of developing BPH.Histologic evidence of prostate enlargement begins about the third decade of life and increases proportionally with aging. Specifically, about 43% of men in their 40s will have evidence of BPH, as will 50% of men in their 50s, 75% to 88% in their 80s, and nearly 100% of men reaching the ninth decade of life.Some evidence has reported a higher incidence of benign prostatic hyperplasia -- particularly fast-growing BPH -- in men with obesity, heart and circulatory diseases, and type 2 diabetes. Diabetes and hypertension, in any case, worsens urinary tract symptoms in men with BPH. In one study, flow rates were adversely affected by diabetes, although residual urine volumes were not significantly greater.

EtiologyThe actual cause of prostate enlargement is unknown. Factors linked to aging and changes in the cells of the testicles may have a role in the growth of the gland. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.Also, if the testicles are removed after a man develops BPH the prostate begins to shrink in size.Some facts about prostate enlargement: The likelihood of developing an enlarged prostate increases with age. BPH is so common that it has been said all men will have an enlarged prostate if they live long enough. A small amount of prostate enlargement is present in many men over age 40. More than 90% of men over age 80 have the condition. No risk factors have been identified other than having normally functioning testicles.

Patophisiology1. Theory of dihydrotestosterone

Figure 7. The control mechanism of prostate growth by DHTAndrogen metabolite dihydrotestosterone is very important in cell growth of the prostate gland. Formed of testosterone in prostate cells by the enzyme 5 alpha-reductase. DHT has formed binds to the androgen receptor and protein synthesis occurs subsequent growth factor that stimulates the growth of prostate cells.The levels of DHT in BPH are not much different levels with normal prostate, in bph, the activity of the enzyme 5 alpha-reductase and androgen receptor increase. This causes the cells of the prostate in BPH are more sensitive to DHT so that replication occurs more frequently than the normal prostate.

2. The imbalance between estrogen and testosteroneIn the increasingly older age, testosterone levels decreased while estrogen is relatively fixed, so that the ratio increases. Prostate estrogen play a role in the proliferation of cells of the prostate gland by increasing the sensitivity of prostatic cells to androgen stimulation, increasing the number of androgen receptors and decreasing the number of prostate cell death (apoptosis). So even though the stimulus formation of new cells due to stimulation of testosterone decreases, but the prostate cells that have been there have a long life so that the mass of the prostate becomes larger.3. The stromal-epithelial interactions

Stromal cells after stimulation of DHT and estradiol, stromal cells synthesize a growth factor that in turn affects the stromal cells themselves are intrakin and autocrine, as well as affect the epithelial cells in a paracrine. The stimulation causes the proliferation of epithelial cells and stromal cells.

4. The reduction in prostate cell deathDecreasing the number of prostate cells undergoing apoptosis caused the number of prostate cells as a whole to be increased, causing increased prostate mass. Allegedly androgen hormones play a role in inhibiting cell death process because after the castration performed an increase in activity of the prostate gland cell death. The growth factor TGF-beta plays a role in apoptosis.

5. Theory of stem cellsIn the prostate gland known as a stem cell, the cells that have the ability to proliferate very extensively. This cell life is very dependent on the presence of androgen hormones, so if this hormone levels decline as happened in castration, cause apoptosis. The proliferation of cells in BPH postulated as stem cell activity resulting in excessive production of stromal cells and epithelial cells.

Clinical ManifestationLower urinary tract symptoms (LUTS) are categorized either as voiding (formerly called obstructive) or storage (formerly called irritative) symptoms. BPH is often, but not always, the cause of LUTS, especially the voiding symptoms. Other medical conditions, such as bladder problems, can also cause these symptoms. Some men with BPH may have few or no symptoms. The size of the prostate does not determine symptom severity. An enlarged prostate may be accompanied by few symptoms, while severe LUTS may be present with normal or even small prostates.Voiding (Obstructive) SymptomsVoiding symptoms can be caused by an obstruction in the urinary tract, which may be due to BPH. (Obstruction is the most serious complication of BPH and requires medical attention.) Voiding symptoms include: A hesitation before urine flow starts despite the urgency to urinate Straining when urinating Weak or intermittent urinary stream A sense that the bladder has not emptied completely Dribbling at the end of urination or leakage afterwardStorage (Irritative) SymptomsStorage symptoms, also referred to as filling symptoms, include: An increased frequency of urination (every few hours) An urgent need to urinate and difficulty postponing urination Discomfort when urinating Frequent night-time urination, or nocturia, is one of the most publicized symptoms of BPH, but its also one of the trickiest, since many if not most cases of nocturia are not caused by BPH but by other conditions.DiagnosisA health care provider diagnoses benign prostatic hyperplasia based on a personal and family medical history a physical exam medical testsA personal and family medical historyTaking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man what symptoms are present when the symptoms began and how often they occur whether he has a history of recurrent UTIs what medications he takes, both prescription and over the counter how much liquid he typically drinks each day whether he consumes caffeine and alcohol about his general medical history, including any significant illnesses or surgeriesThe International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms and one question concerning quality of life. Each question concerning urinary symptoms allows the patient to choose one out of six answers indicating increasing severity of the particular symptom. The answers are assigned points from 0 to 5. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic)The first seven questions of the I-PSS are identical to the questions appearing on the American Urological Association (AUA) Symptom Index which currently categorizes symptoms as follows:

Physical ExamA physical exam may help diagnose benign prostatic hyperplasia. During a physical exam, a health care provider most often examines a patients body, which can include checking for discharge from the urethra enlarged or tender lymph nodes in the groin a swollen or tender scrotum taps on specific areas of the patients bodya. performs a digital rectal examA digital rectal exam, or rectal exam, is a physical exam of the prostate. The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.Many health care providers perform a rectal exam as part of a routine physical exam for men age 40 or older, whether or not they have urinary problems. If the prostate is healthy, it feels smooth, while an enlarged prostate may be felt as a bulge. If the prostate is enlarged, it will still feel smooth in the case of benign prostatic hyperplasia (BPH) is showed palpable enlarged prostate, prostate chewy consistency as touching the tip of the nose, flat surface, right and left lobes symmetric, not found nodules, and protruding into the rectumbut, if cancer is present, the prostate consistency hard or palpable nodules and between the lobes of the prostate is not symmetrical. While on prostate stones will be palpable crepitus.. The prostate may be painful when squeezed if it is inflamed or infected. The whole test may take around five minutes.

b. Lab examination Prostate-specific antigen, or PSA, is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in a mans blood. Healthy men have low amounts of PSA in the blood. The amount of PSA in the blood normally increases as a man's prostate enlarges with age. PSA may increase because of inflammation of the prostate gland (prostatitis) or prostate cancer. An injury, a digital rectal exam, or sexual activity (ejaculation) may also briefly raise PSA levels.

c. UroflowmetryTo determine whether the bladder is obstructed, the speed of urine flow is measured electronically using a test called uroflowmetry. The test cannot determine the cause of obstruction, which can be due not only to BPH, but possibly also to abnormalities in the urethra, weak bladder muscles, or other causes.

d. Postvoid Residual UrineOne of the important tests for urinary incontinence is the postvoid residual urine volume (PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a definite sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a catheter, a soft tube that is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal ultrasonography.

TreatmentTreatment options for benign prostatic hyperplasia may include lifestyle changes medications minimally invasive procedures surgeryA health care provider treats benign prostatic hyperplasia based on the severity of symptoms, how much the symptoms affect a mans daily life, and a mans preferences. Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.

Lifestyle ChangesA health care provider may recommend lifestyle changes for men whose symptoms are mild or slightly bothersome. Lifestyle changes can include reducing intake of liquids, particularly before going out in public or before periods of sleep avoiding or reducing intake of caffeinated beverages and alcohol avoiding or monitoring the use of medications such as decongestants, antihistamines, antidepressants, and diuretics training the bladder to hold more urine for longer periods exercising pelvic floor muscles preventing or treating constipationMedicationsA health care provider or urologist may prescribe medications that stop the growth of or shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia: alpha blockers 5-alpha reductase inhibitorsAlpha blockers. These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage: terazosin (Hytrin) doxazosin (Cardura) tamsulosin (Flomax) alfuzosin (Uroxatral) silodosin (Rapaflo) 5-alpha reductase inhibitors.These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth: finasteride (Proscar) dutasteride (Avodart)These medications can prevent progression of prostate growth or actually shrink the prostate in some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful for only moderately enlarged prostates.SurgeryFor long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when medications and minimally invasive procedures are ineffective symptoms are particularly bothersome or severe complications arise Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.Surgery to remove enlarged prostate tissue includes transurethral resection of the prostate (TURP) laser surgery open prostatectomy transurethral incision of the prostate (TUIP)A urologist performs these surgeries, except for open prostatectomy, using the transurethral method. Men who have these surgical procedures require local, regional, or general anesthesia and may need to stay in the hospital.The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some urologists prescribe antibiotics only when an infection occurs. Immediately after benign prostatic hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the opening of the penis to drain urine from the bladder into a drainage pouch.

TURP. With TURP, a urologist inserts a resectoscope through the urethra to reach the prostate and cuts pieces of enlarged prostate tissue with a wire loop. Special fluid carries the tissue pieces into the bladder, and the urologist flushes them out at the end of the procedure. TURP is the most common surgery for benign prostatic hyperplasia and considered the gold standard for treating blockage of the urethra due to benign prostatic hyperplasia.

Laser surgery.With this surgery, a urologist uses a high-energy laser to destroy prostate tissue. The urologist uses a cystoscope to pass a laser fiber through the urethra into the prostate. The laser destroys the enlarged tissue. The risk of bleeding is lower than in TURP and TUIP because the laser seals blood vessels as it cuts through the prostate tissue. However, laser surgery may not effectively treat greatly enlarged prostates.

Open prostatectomy.In an open prostatectomy, a urologist makes an incision, or cut, through the skin to reach the prostate. The urologist can remove all or part of the prostate through the incision. This surgery is used most often when the prostate is greatly enlarged, complications occur, or the bladder is damaged and needs repair. Open prostatectomy requires general anesthesia, a longer hospital stay than other surgical procedures for benign prostatic hyperplasia, and a longer rehabilitation period. The three open prostatectomy procedures are retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy. The recovery period for open prostatectomy is different for each man who undergoes the procedure. However, it typically takes anywhere from 3 to 6 weeks.

TUIPA TUIP is a surgical procedure to widen the urethra. During a TUIP, the urologist inserts a cystoscope and an instrument that uses an electric current or a laser beam through the urethra to reach the prostate. The urologist widens the urethra by making a few small cuts in the prostate and in the bladder neck. Some urologists believe that TUIP gives the same relief as TURP except with less risk of side effects.After surgery, the prostate, urethra, and surrounding tissues may be irritated and swollen, causing urinary retention. To prevent urinary retention, a urologist inserts a Foley catheter so urine can drain freely out of the bladder. A Foley catheter has a balloon on the end that the urologist inserts into the bladder. Once the balloon is inside the bladder, the urologist fills it with sterile water to keep the catheter in place. Men who undergo minimally invasive procedures may not need a Foley catheter.The Foley catheter most often remains in place for several days. Sometimes, the Foley catheter causes recurring, painful, difficult-to-control bladder spasms the day after surgery. However, these spasms will eventually stop. A urologist may prescribe medications to relax bladder muscles and prevent bladder spasms. These medications include oxybutynin chloride (Ditropan) solifenacin (VESIcare) darifenacin (Enablex) tolterodine (Detrol) hyoscyamine (Levsin) propantheline bromide (Pro-Banthine)

ComplicationThe complications of benign prostatic hyperplasia may include acute urinary retention. chronic, or long lasting, urinary retention. blood in the urine. urinary tract infections (UTIs) bladder damage. kidney damage. bladder stones.

Prognosis The outlook for benign prostatic hyperplasia is good; although it can cause significant discomfort, the condition is benign. As the prostate gland grows in size, symptoms may become worse, warranting medication or surgery. With appropriate medical and/or surgical management, the symptoms of an enlarged prostate gland can be treated effectively.

Daftar pustakahttp://www.niddk.nih.gov/health-information/health-topics/urologic-disease/benign-prostatic-hyperplasia-bph/Documents/ProstateEnlargement_508.pdfhttp://www.aafp.org/afp/2008/0515/p1403.pdfhttp://onlinelibrary.wiley.com/doi/10.1002/j.1939-4640.1991.tb00272.x/pdfhttps://www.nlm.nih.gov/medlineplus/ency/article/000381.htmhttp://pennstatehershey.adam.com/content.aspx?productId=10&pid=10&gid=000071

1