Download BLADDER OUTLET OBSTRUCTION

BLADDER OUTLET
OBSTRUCTION
(B.O.O.)
BOO
It’s urodynamic concept of low flow rates and high
intravesical pressures.
Causes:
*BPH.
*CAP.
*bladder neck stenosis.
*urethral stricture.
*neuropathic conditions.
Pathophysiology
 Boo over time will result in..
increase in the intravesical voiding pressure (>80
cm H2O), bladder muscle hypertrophy
(trabiculation, sacculation and diverticulum
formation).
 High pressure may transmit to the upper tract
causing hydroureter, hydronephrosis and renal
insufficiency.
 Boo results in incomplete bladder evacuation
(residual urine) which predisposes to UTI and
stone formation.
 Decrease uro flow rate under 10 ml /sec
Symptomatology (LUTS
Obstructive:
Hesitancy
Straining
Weak stream
Intermittency.
Post voiding dribbling.
Retention of urine.
Irritative:
Frequency.,nocturia
Urgency & urge incontinence.
IPSS
[international prostatic symptom score]
Benign prostatic hyperplasia
BPH
Third most common urological pathology.
Starts at late 30s & appear clinically at 60s.
Theories:
Hormonal: DHT, growth factor.
Neoplastic: fibromyoadenoma.
Typically affects submucosal glands at
transitional zone.
Symptomatology
Boo (irritative and obstructive).
Symptoms are slowly progressive over
years, worsening at winter time.
Renal failure.
Hematuria.
Pain is not afeature of BPH the presence of
which may indicate acute retention,vesical
stone,infection,CAprostate
Precipitating causes for retention
Severe pain. MI, joint pain.
Psychological upset.
Cold exposure.
Constipation.
Drugs
Anticholenergic & diuretic
,decongestant,antihistamin
Ignoring first desire for urination.
Clinically
Usually normal.
Distended bladder.in acute or chronic
retention
PR ex: enlarged prostate, smooth,
regular, firm, maintained median
sulcus and mobile rectal mucosa
Normal anal sphencter tone.
Normal bulbocovernosus reflex
Investigations:
GUE: normal or UTI
RFT: normal unless there is renal failure
U/S:TRUS: BPH, vesical stone, residual
urine and hydronephrosis.
IVU:
Benign prostatic hyperplasia
Vesical stone
PSA: (prostate specific Ag)<10 ng/ml.
Cystoscopy: enlarged prostate,
trabiculation & stones.
Size of the prostate has no relation with the
severity of the symptom but the degree of
urethral compression.
Treatment
Conservative:
Avoid ppt factors.
Treat pains.
Treat UTI.
Αlfa blocker: prazocin 1 mg, terrazocin 2mg,
doxazocin 2mg.tamsulusin,alfuzosin At night
S/E hypotension, 1st dose syncope.
*
5 α reductase inhibitors: fenasteride,
prosteride 5 mg/day > 6 months.
S/E impotence.
Usually used in large gland
Semi surgical:
TUMT (trans urethral microwave thermotherapy)
HIFU ( high intensity focused u/s)
TUIP (Trans urethral incision of prostate)
TUNA (Trans urethral needle ablation)
Prostatic stents
TU baloon dilatation
TUMT
STENT
TUNA
Surgical treatment
Endoscopic:
TURP
Laser
Open surgery:
Trans vesical prostatectomy.
Rertopubic prostatectomy
INDICATION OF SURGERY IN BPH
 SEVERE SYMTOMS
 FAILURE OF MEDICAL TREATMENT
 COMPLICATIONS LIKE
 ACUTE URINARY RETENTION

CHRONIC RETENTION

REPEATED HEMATURIA

REPEATED UTI

VESICAL STONE

RENAL IMPERMENT DUE TO CHRONIC
RETENTION
TURP
Transvesical
retropubic
BEFORE TURP
AFTER TURP
Complications
Early:
Bleeding and clot retention.
TUR syndrom (water intoxication) due to.
dilutional hyponatremia.
Infection.
Wond infection[in open prostatectomy]
*
Late:
Urethral stricture
Bladder neck contracture
Retrograde ejaculation.
Incontinence.
Impotence.
Recurrence of BPH. After 5-10 years.
Carcinoma of the prostate
CAP
One of the most common malignant
tumor affecting males over the age of
65 in western countries.
Pathology
95% of the tumor are adenocarcinoma and
derived from acinar epithelium
75% of CAP arise from peripheral zone.
grading:
Gleason’s grade based on the degree of
glandular differentiation and growth
pattern.
Spread
Direct invasion: to nearby structures.
Denonvvilliar’s fascia act as barrier.
Lymphatic: internal, external & common
iliac
Blood: to the lower lumber vertebrae &
pelvic bones due to reverse blood flow
from vesicoprostatic plexus to the
emissary veins of the bones during
coughing & sneezing (OSTEOBLASTIC)
Osteoblastic lesion of secondary CAP
Presentation
Accidental during histopathological ex
after prostatectomy.
During PR ex
High PSA
BOO.
Metastatic: back ache, sciatica, paraplegia
or pathological fractures..
*
BPH
CAP
Younger age
older
Symptoms slowly
progressive
Rapid progression
Usually no back or
bone pain
Smooth rubbery
prostate with sulcus
More back ache &
neurological
symptoms
Hard irregular prostate
with obliterated sulcus
*
Rectal examination:
Stony hard irregular prostatic nodule,
obliterated median sulcus, difficulty in
moving the rectal mucosa over it and fixity.
Normal PR ex does not exclude CAP.
prostatic cancer
38
Investigations
PSA: prostatic tumor marker for diagnosis and
follow up, it may also increase in prostatitis and
BPH.
10 ng/ml normal, 10-15 suspicious.
>15 is diagnostic.
Acid phosphatase: prostatic fraction.
Alkaline phosphatase: in bone metastasis.
Radiological investigations
Plain X ray: osteoblastic lesion.
Bone scan: hot areas (active).
CT scan.
TRUS & biopsy (sixtant biopsy).
prostatic cancer
41
Differential Diagnosis
Not all patients with an elevated PSA
concentration have CaP.(BPH, urethral
instrumentation, infection, prostatic infarction,
or vigorous prostate massage)
Not all patients with an Induration of the
prostate have CaP.(chronic granulomatous
prostatitis, previous TURP or needle biopsy, or
prostatic calculi).
Not all patients with sclerotic bony lesion and
elevated alk. phosphatase have CaP.(Paget
disease)
prostatic cancer
42
Treatment
Watchful waiting:
Radical prostatectomy:
Enblock surgical removal of the entire
prostate, seminal vesicles and pelvic
lymph nodes. The bladder anastomosed to
the urethra.
Indicated for early disease and healthy fit pt.
2. Radical prostatectomy
prostatic cancer
44
ROBOTIC RADICQL PROSTQTECTOMY
prostatic cancer
45
Radiotherapy
external beam & brachytherapy
Indication:
1- Locally advanced disease.
2- Unfit patient for surgery.
3-Symptomatic metastases to relieve pain.
3. Radiation therapy
external beam
therapy
brachytherapy
prostatic cancer
47
Hormonal therapy
Its trearment of choice for metastatic tumor
Cap is hormonal dependant (androgen), and
about one third of tumors are hormoneinsensitive.
Androgen ablation may change the course
of the disease.
Methods of androgen ablation
surgical
Bilateral orchiectomy: complete or
subcapsular.
medical
LHRH agonist: (Zoladex)/28 days SC.
Anti androgen: (Nilutemide) 250 mg/6h.
.
prostatic cancer
50
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