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Download Benign Prostatic Hyperplasia (BPH): Approach and Management
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Luen Shaun Chew Content Anatomical Relations Structure Neurovascular and lymphatics BPH – Definition Clinical Presentation Complications Investigations Management Anatomy Inferior to bladder Surrounds the prostatic urethra Conical Weight ~20g Length 3cm Anatomical Relations Superior – bladder neck Inferior – urogenital diaphragm Anterior – pubic symphysis separated by extraperitoneal fat; puboprostatic ligaments Posterior – rectum; fascia of Denonvilliers Lateral – Pubococcygeal of levator ani Structure 70% glandular 30% fibromuscular stroma Transition: surrounds urethra proximal to ejaculatory ducts Central: surrounds ejaculatory ducts projects to seminal vesicles under bladder base Peripheral: bulk of apical, posterior and lateral aspects Anterior fibromuscular stroma QUIZ! Which zone does BPH usually arise from? a) Transition b) Central c) Peripheral d) All/Any zones Which zone does Prostate ca usually arise from? a) b) c) d) Transition Central Peripheral All/Any zones Neurovascular and Lymphatics Arterial: Inferior vesical and middle rectal Venous: Prostatic venous plexus – internal iliac veins + vertebral venous plexus Innervation: Sympathetic (T10 – L2); 1 – andrenergic receptors Parasympathetic (S2 – S4) Lymphatics: Internal iliac nodes BPH – What is it? Increase in both stromal and glandular cells Very common, common cause of urinary retention in elderly 50% of men >50 years Usually affects transition zone, enlargement compresses urethra and peripheral zone becomes thinner (pseudocapsule) Aetiology: ?Local androgen imbalance between testosterone and oestrogen BPH - Presentation Asymptomatic Lower urinary tract symptoms (LUTS): Voiding – hesitancy, poor stream, straining, terminal dribbling Storage – frequency, urgency, nocturia, incontinence Acute/Chronic urinary retention BPH – Examination Abdominal examination – Distended, palpable bladder, suprapubic tenderness External genitalia – r/o urethral meatal stenosis DIGITAL RECTAL EXAMINATION (DRE): BPH vs Prostate ca Faecal impaction ?Tenderness BPH -Complications Retention Infection Bladder diverticula and stones Hydronephrosis – renal impairment BPH – Investigations Urinalysis Bloods – FBC, u+e PSA – if suspect cancer, need patient counselling Uroflowmetry – need at least 100mls of urine, max flow <10ml/sec – suggestive of obstruction Bladder scan – residual > 300mls indicates chronic urinary retention USS Renal – r/o hydronephrosis Urodynamics Transrectal Ultrasound (TRUS) +/- biopsy BPH - Management Conservative: 1. Reassurance, once prostate ca excluded Lifestyle changes ie decreasing fluid nocte, reduce caffeine intake ISC, Long-term catheter Medical: 2. α-blocker – Tamsulosin, Doxazosin, Alfuzosin 5α reductase inhibitors – Finasteride, Dutasteride Surgery: 3. TURP TUNA Laser/Microwave ablation Open Retropubic prostatectomy TURP Indication: Moderate-severe LUTS Complications of BPH Failure to medical tx Renal impairment due to LUTS Complications: Bleeding Infection Incontinence Strictures Impotence (20%) Retrograde ejaculation (>80%) TURP syndrome TURP syndrome Absorption of large volumes of irrigation fluid through prostatic venous plexus During or post-TURP Hyponatraemia, high nitrogen load Hypervolaemia Cerebral oedema Hypothermia Management: Fluid restriction Diuretics Summary BPH, common cause of urinary retention in elderly male DRE is essential in diagnosis BPH – transition zone, malignancy – peripheral zone Severity of LUTS and co-morbidities determines management of BPH Side effects of medical tx and possible complications of surgery Thank you Any questions?
