Download Benign Prostatic Hypertrophy

2008
BENIGN PROSTATIC
HYPERTROPHY
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 > 50 = 41% have symptoms
of LUTS
 Only 18% have a diagnosis
 Only 10% aware of drugs or
surgery that will help it
Risk factors
 Age
 ? obesity
Differential diagnosis
• Poorly controlled diabetes
• Neurological disorders
• Urinary tract infections
• Abacterial prostatitis
• Overactive bladder
• Drugs – diuretics, anticholinergics,
antidepressants
• Lifestyle factors – caffeine, alcohol, xs fluids
Abnormal symptoms
 The presence of the following symptoms
indicates referral to urologist for futher
assessment
 Urinary incontinence
 Retention
 Dysuria
 Haematuria
 Acute change in symptoms
Examination
 Palpation of abdomen for
 enlarged bladder
 enlarged kidneys
 constipation
 Rectal examination for
 Size and consistency of prostate gland
Investigations
• Blood tests
– Fbc esr
– U&e’s
– 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 for doing them
 Patient reassurance
 Patient explanation
 Objective assessment of symptoms
 Diagnostic precision
 Ranking of treatment options
 Prediction of treatment outcome
Specialist investigations
 Uroflowmetry
 max flow rate and volume of residual urine after
voiding – low flow rate indicates need for TURP
 Bladder pressure studies
 pressure measurement during filling and
emptying (cystometry) gives information on
over/under activity of detrusor muscle and
obstruction of bladder outlet. Predicts response to
treatment. Use antimuscarinics for over activity
and turp for bladder outlet obstruction
Specialist investigations
 Urinary tract imaging
 Ultrasound to estimate residual urine
 Urethroscopy
 Visual inspection of bladder and uerethra is used
in dysuria or haematuria
Assesment
• A validated questionnaire using international
prostate symptom scale.
• Completion gives total score of 35
– 1–7
– 8 – 19
– 20 – 35
mild
moderate
severe
• Response to the quality of life questionnaire
strong predictor or whether intervention is
necessary
Scoring system
– Ask 7 questions. Answers on scale 0 – 5 depending
on severity of symptoms
– For first 6 questions scores are
•
•
•
•
•
•
Not at all
< 1 in 5
< half the time
About half the time
> half the time
Almost always
=0
=1
=2
=3
=4
=5
– Q7
• Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5
Questions
In last month how often have you
1.
2.
3.
4.
5.
6.
7.
Had sensation of not emptying bladder completely
Had urge to urinated < 2 hours after previously
finished
Found you stopped and started again several times
Found it difficult to postpone urination
Had a weak stream (compared to when aged 30)
Had to push or strain to begin urination
How many times did you get out of bed per night to
urinate
Quality of life
• If you were to spend the rest of your life with
your urinary condition the way it is now, how
would you feel about that?
– Delighted
0
– Pleased
–
–
–
–
1
Mostly satisfied
Mixed feelings3
Mostly dissatisfied
Terrible
5
2
4
Management
 Lifestyle modification
 Reduce fluid intake
 Stop diuretics if poss
 Avoid xs night time fluid intake/caffeine
/alcohol
 Empty bladder before long
trips/meetings
Management
 Treat co morbid contributing
conditions
 Diabetes
 uti
Management
 Drug therapy
 Alpha blockers
 Improve bladder and prostate smooth
muscle tone
 More effective than 5 alpha reductase
inhibitors
 All work equally well
 Tamsulosin and alfuzosin require no dose
titration
Management
 Drug therapy
 5 alpha reductase inhibitors
 Reduce prostate volume
 Reduces risk of prostate cancer, increases risk of
high grade disease
 Combined therapy
 Men with large prostate > 40g or PSA >4 or
moderate to severe symptoms combined therapy
will prevent 2 episodes of clinical progression per
100men over 4yrs. Much less effective for men with
smaller prostates
Management
 Drug therapy
 Storage problems
 Men with symptoms of urinary urgency, frequency,
small, urine volumes and nocturia in the absence of
serious obstructive symptoms are categorised as
over active bladder
 Bladder training
 Biofeedback
 Antimuscarinic drugs ( oxybutinin, tolteridine) alone
or in combination with treatment for obstructive
symptoms
Management
 Surgery
 TURP
 Greatest improvement in symptoms
 5% severe haemorrhage risk
 Requires GA
 Alternative energy sources for TURP
 Ultrasound
 Laser
 microwave
Management
 Surgery
 Adverse effects of surgery
 Loss of ejaculation
 Erectile dysfunction
 Retrograde ejaculation
 Incontinence
 Stricture formation
 Urinary retention