Benign Prostatic Hyperplasia (BPH)

Definition
Benign prostatic hyperplasia (BPH) is a condition in which the prostate gland becomes enlarged. However, the actual size of the gland does not necessarily predict symptom severity. Some men with minimally enlarged prostate glands may experience symptoms while other men with much larger glands may have few symptoms. BPH is very common among older men, affecting about 60% of men over age 60 and 80% of men over age 80. Source: Benign prostatic hyperplasia | University of Maryland Medical Center

Definisi
Benign prostatic hyperplasia (BPH) adalah suatu kondisi di mana kelenjar prostat menjadi membesar. Namun, ukuran sebenarnya dari kelenjar tidak selalu memprediksi keparahan gejala. Beberapa pria dengan pembesaran kelenjar prostat minimal mungkin mengalami gejala sementara pria lain dengan kelenjar yang jauh lebih besar mungkin memiliki beberapa gejala. BPH adalah sangat umum di kalangan pria yang lebih tua, mempengaruhi sekitar 60% dari pria di atas usia 60 dan 80% dari pria di atas usia 80. Sumber: hiperplasia prostat jinak | University of Maryland Medical Center

Etiology
Benign prostatic hyperplasia (BPH) causes possibly related to aging and aging is accompanied by changes hormon.dengan decreased serum testosterone levels, and increased serum estrogen levels

Etiologi
Penyebab BPH kemungkinan berkaitan dengan penuaan dan disertai dengan perubahan hormon.dengan penuaan kadar testosteron serum menurun,dan kadar esterogen serum meningkat.

Pathophysiology
BPH (Pembesaran prostat)

Retention VU neck and prostate

Phase compensation M.detrusor

Dekompensasi/ contraction

M.Detrusor tired

Retention urine

Hidronefrosis

Hidrouretero

Anamnesis
Symptoms in lower urinary tract: Acute Urinary Retention Nocturia Disuria Terminal Dribbling Hesitansi slow stream Urgency Frekuensi Residual urin

Symptoms in the upper urinary tract: Low back pain Lumps in the waist Fever Outside the urinary tract symptoms: Inguinal hernia Hemorroid

Physical Examination
Urinary Bladder is fully charged Palpable mass in the supra kistus symphysis due to urinary retention Always trickle of urine obtained unwittingly sign incontinence paradoksa Rectal toucher: Anal sphincter tone / bulbo-cavernous reflex rectal mucosa Prostate circumstances: nodules obtained no nodules prostate chewy consistency symmetric between the right lobe and a left lobe prostate boundary

Investigation Examination
Laboratory: Urine Sediment Kulture Urine Renal physiology Blood sugar

Radiology: Photos Plain Abdomen IVU Abdominal ultrasound

Degree Examination Prostate Obstruction Residual Urine Urine beam (flowrate) / uroflometri

Differential Diagnosis
Ca Prostate Striktur Uretra Ureterolithiasis

Penatalaksaan
purpose this terapy for bph is make a better quality of patient lives the terapy according patient moan, )....., as well as objective health of patient that result orlf the disease

Watchful waiting
Do not get therapy, but progression of the disease, the situation is still supervised physician bph patient skor ipss <7, minor moan which not disturb daily activity

Medikamentosa
skor IPSS > 7 when bph start cause disturbance feel and makes danger for lives, this medikamentosa recommended Inhibitor 5 redukstase

Fitoterapi
use specifict plnt extract for repair manifes cause prostrat obstruction fitoterapy may active as : anti-estrogen, antiandrogen, lower rates sex hormone binding globulin (SHBG), inhibisi basic fibroblast growth factor (bFGF) dan epidermal growth factor (EGF), mess metabolisme prostaglandin, efek antiinflammasi, lower outflow resistance, & minimize volume prostat

Terapi intervensi
open surgery, TURP, TUIP, TUVP, laser prostatektomi

Minimally invasive : thermoterapi, TUNA, installation stent, transurethal ballon dilatation.

complication
Urinary tractus infection Retensi urin Obstruksi dengan dilatasi uretra, hydrnefrosis Gagal ginjal

prevention
Reduce animal fat rich food Increase foods rich in lycopene Workout routine

Prognosis
Prognosis for BPH fickle and unpredictable in each individual, although symptoms tend to increase. However, BPH is not tackled immediately have a poor prognosis because it can develop into prostate cancer

Striktur Uretra

Definisi
Penyempitan atau penyumbatan dari lumen uretra sebagai akibat dari pembentukan jaringan fibrotik (jaringan parut) pada uretra dan / atau pada daerah peri uretra A stricture is a narrowing of the urethra, and can occur at any section of the urethra. There is some scar tissue around the affected part of the urethra and / in peri uretra

Etiologi
Infection Injury : iatrogenik : - catheterization - caliberation Eksterna :
- Straddle injury - Fracture pelvis

Trauma Infection

Lesion on urethral epihelial Incontinuity uretra

inflammation Fibrosis / kolagen reaction

Fibrous tissue

Stricture Uretra

Obstruction of uretra

Bila terjadi kebocoran urine (ekstravasasi urin)

Inflammation of periuretra

abses

Fistel uretrokutan

Striktur uretra

A. Lipatan mukosa / mucosal fold B. Kontriksi iris / iris constriktion C. Fibrosis minimal D. Spongiofibrosis E. Inflamasi dan fibrosis sampai jaringan corpus spongiosum F. Striktur dengan komplikasi fistel. Dapat terbentuk abses,

Grade of Striktur Uretra

1) Ringan : jika oklusi yang terjadi kurang dari sepertiga diameter lumen uretra 2) Sedang : jika terdapat oklusi setengah sampai sepertiga diameter lumen uretra 3) Berat : jika terdapat oklusi lebih besar dari setengah diameter lumen uretra

Manifestasi Klinis
reduced urine flow or straining to pass urine spraying of urine or a double stream dribbling of urine for a while after going to the toilet to pass urine needing to pass urine more often than normal mild pain on passing urine.

Prostate Cancer
Reski Utami Friska nur ekasanti ade wahyu

Defenition
Prostate carcinoma is the most malignant in urogenitalia system among men. This kind of cancer attack patients that attain over 50 years, including 30% in men attain 70-80 years and 75% at the age of 80 years. This cancer is rare in men under 45 years old.

Epidemiology
Prostate-specific antigen (PSA) assay has affected incidence of prostate cancer Incidence
Prior to PSA
19,000 new cases / year in US

1993
84,000

1996
300,000

Since 1996
200,000 per year A number that more closely estimate the true annual incidence of clinically detectable disease

Etiology
Risk factors
Increasing age Family history African-American Dietary factors. Reduced fat intake Soy protein Lycopene Vitamin E Selenium

Nutritional factors have protective effect against prostate cancer

Race
Incidence doubled in African Americans compared to white Americans.

Genetics
Common among relatives with early-onset prostate cancer Susceptibility locus (early onset prostate cancer)
Chromosome 1, band Q24

An abnormality at this locus occurs in less than 10% of prostate cancer patients

Anatomy
Position
Prostate lies below the bladder Encompasses the prostatic urethra Surrounded by a capsule Layer of fascia termed the Denonvilliers aponeurosis Inferior vesical artery

Separated from the rectum

Blood supply
Derived from the internal iliac artery Supplies blood to the base of the bladder and prostate Capsular branches of the inferior vesical artery
Help identify the pelvic plexus Arising from the S2-4 and T10-12 nerve roots

Nervous supply
Neurovascular bundle
Lies on either side of the prostate on the rectum

Derived from the pelvic plexus Important for erectile function.

Theodorescu, D., Prostate Cancer: Management of Localized Disease, www.emedicine.com, 2004

Pathophysiology
Normal prostate gland PIN (Prostate intraephitelial neoplasia) prostate carcinoma

advanced prostate carcinoma

HRPC (hormone refractory prostate cancer)

prostate carcinoma metastasis

 Peripheral zone (PZ)

70% of cancers

Transitional zone (TZ)

20% Some claim
TZ prostate cancers are relatively nonaggressive PZ cancers are more aggressive
Tend to invade the periprostatic tissues.

Prostate Cancer
Clinical Manifestations
Early state (organ confined)
Asymptomatic Symptoms are not always present especially in the early stages of prostate cancer. If detected and treated in its earliest stages (when cells are only in the prostate), your chances of survival are greatly increased. Difficulty urinating Urgent need to urinate Frequent urination, especially at night Burning or pain when urinating Inability to urinate or difficulty starting or stopping urine flow Painful ejaculation Blood in the urine or semen

Locally advanced

Advanced (spread to the regional pelvic lymph nodes)

Edema of the lower extremities Pelvic and perineal discomfort

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

Prostate Cancer
Clinical Manifestations

Metastasis
Most commonly to bone (frequently asymptomatic)
Can cause severe and unremitting pain

Bone metastasis
Can result in pathologic fractures or Spinal cord compression

Visceral metastases (rare) Can develop pulmonary, hepatic, pleural, peritoneal, and central nervous system metastases late in the natural history or after hormonal therapies fail.

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

Prostate Cancer
Detection and Diagnosis

Doctors may perform the following tests

A digital rectal exam (DRE) A PSA blood test A biopsy A bone scan Computed Tomography or magnetic resonance imaging
Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

What is the DRE (digital rectal examination)?

A test in which the physician inserts a gloved finger into the patients rectum to examine the prostate by touch If the doctor determines that the prostate feels abnormal, he or she may recommend more tests

15

Digital Rectal Exam

A Central zone B Fibromuscular zone C Transitional zone D Peripheral zone E Periurethral zone

Seminal Vesicles

Prostate

What is PSA (prostate-specific antigen)?

A substance produced by prostate cells The PSA test measures the amount of PSA in the blood Very little PSA escapes from a healthy prostate Some prostate conditions can cause a large amount of PSA to leak into the blood

16

PSA Levels
PSA levels of up to 4.0 ng/mL are considered the upper limit of normal However, high PSA does not always indicate prostate cancer and normal PSA levels do not always mean that cancer is not present
Up to 25% of men with prostate cancer have PSA levels below 4.0 ng/mL Some other conditions, such as benign prostatic hyperplasia (BPH), can also lead to high PSA levels in the blood

17

What is a biopsy?
A test that may be necessary if the results of the PSA or DRE tests suggest prostate cancer A needle is used to remove a small amount of tissue from the prostate Typically, multiple samples are taken
Only a biopsy can definitely confirm prostate cancer It is still possible to have cancer even if the biopsy is negative

18

What is the Gleason grade?

If prostate cancer is found at biopsy, the tumor is graded in a medical lab The grade indicates the difference in appearance between normal cells and cancer cells when seen through a microscope

19

Gleason grades range from 1 to 5 and are based on the degree of differentiation among the cells9
A Gleason grade of 1 indicates a cluster of cancer cells that resemble the small, regular, evenly spaced prostate tissue9 A Gleason grade of 5 indicates tissue completely composed of sheets, strings, cords and nests of tumor cells9 If a prostate tumor has areas with different grades, the two grades are added together to yield a Gleason score between 2 and 109
20

What is staging?
The assessment of the size and location of the cancer (how far the cancer has already spread)
Staging is an important factor in determining the most appropriate treatment

21

A-D Staging
Stage A is early cancer the tumor is located within the prostate gland and cant be detected by a DRE8

22

A-D Staging
In Stage B, the tumor is confined to the prostate but large enough to be felt during a DRE8

23

A-D Staging
By Stage C, the tumor has spread outside the prostate to some surrounding areas and can be felt during a DRE8

24

A-D Staging
In Stage D, the cancer has spread to the nearby and distant organs, such as bones and lymph nodes8

25

Prostate Cancer
Detection and Diagnosis

A bone scan
Warranted only
PSA level greater than 10ng/mL

Computed Tomography or magnetic resonance imaging

Abdominal and pelvic CT or MRI is usually unrevealing in patients with a PSA level less than 20ng/mL. .

Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint

Complications
prostatic hypertrophy

chronic retention

Hematuria

vesico-ureteric reflux

hydroureter

hydronephrosis

renal failure

Cystitis and pyelonephritis

Management
Prostatectomy is a surgical resection of part of the prostate that cut the urethra to improve urine flow and eliminate acute urinary retention, there are several surgical alternatives include: Transsurethral resection of prostate (TURP) Suprapubic /open prostatektomi Retropubic prostatektomi Perineal prosteatektomi

Transsurethral resection of prostate (TURP) Where the obstruction of the prostate tissue surrounding the urethra medial lobes removed sistoskop / resektoskop inserted through the urethra

Suprapubic /open prostatektomi With mass indicated for more than 60 g/60 cc. inhibitor of prostate tissue removed through an incision made through the midline below the bladder, this approach is intended when bladder stones.

Retropubic prostatektomi Prostatic hypertrophy tissue mass (high location at the pelvis) removed through an incision in the lower abdomen without opening the bladder

Perineal prosteatektomi Area under the mass of the prostate through an incision between the pelvis elevated scrotum and rectum, this radical procedure done for cancer and can lead to impotence.

Prognosis
Progressive prostate cancer who are not treated have a very high mortality rate (> 90%). Testicular cancer can metastasize to the lungs, lymph nodes or central nervous system. Survival in prostate cancer depends on the stage at diagnosis. Most men who are diagnosed at stage D will die within 3-5 years.

uretrolitiasis

definition
Urethral stone usially comes from kidney stones or ureter leading down to a pot and than get in to the uretra

etiology
The protein matrix Bacteria or inflammatory Anti inhibitor Dehidration Disruption of the flow of urine

Patofisiologi
(>> Sat.urine + << Inhibitor + >> Produksi Matriks) (inhibitor) Cristalisasi

Formulasi Batu

Inhibitor: (Citrate,Pyruphospate,Magnesium,Glicosaminoglycans)/ penghalang terjadinya kristalisai

Clinical manifestation
Low back pain Difficullty miksi Pain radiating to the vulva (in women) and scrotum (in man) The stone is located in the posterior urethra,pain felt in the perineum or the rectum

Physics Diagnostic
retention of urine fever hypertension tachycardia excessive sweating

Diagnostic Exams
Lab test Hb, Leukosit, trombosit, ureum, creatinin, elektrolit (Na, K, Cl, Ca) Urinalysis

 Ultrasonography (USG) Blaas nier oversight (BNO-IVP) Intravenous Urography (IVU) Retrograd Pielography (RPG) Antegrad Pielography (APG)

DD
Vesikolithiasis Ureterlithiasis Nefrolithiasis

Treatment of Patients
Depending on the types of stone Stone size <5 mm drink that much in order to push the stone out Pain relief ESWL (extracorporeal shock wave lithotripsy) PNL (Percutaneous Nephro Litholapaxy) Open surgery : Urethrolitotomi Laparoscopic surgery

Complication
Urethral stricture Urinary tract infection Hidronefrosis Uremia Renal failure

Prognosis
Prognosis of kidney stones depends on factors of stone size, stone location, and the presence of infection and obstruction Patients with stones treated with ESWL, 60% had been free of the stone, the rest still require repeated treatments because there is still a residual stone fragments within urinary tracts Patients treated with PNL, 80% had been free of stones, but the results are also determined by the experience of the operator

PEMBAHASAN

Male, 78 years old

Anamnesis : - Retensio urine since 3 days ago

- Severe pain - Difficult to urinate since 1,5 years ago - Driblling urine, urgency, and nocturia - Failure to pair a catheter - Injury ? ( straddle injury, catheter )

Physical Examination : - Distention of Abdomen ( suprapubic regio ) - Meatal bleading ( - ) - urine dripping from the meatus externa - Digital Rectal Examination ?

Initial Diagnosis : Obstruction of urinary track

Work up

Diagnosis

Treatment

Kristal- kristal batu

Testosteron
Presipitasi Dehidrotertosteron Nukleasi

Esterogen relatif tetap

Growth factor

Agregasi

Sensitifitas sel prostat terhadap rangsangan hormon androgen , reseptor androgen , apoptosis

Menempel di epitel sal. Kemih Hiperplasi prostat

Trauma, infeksi

Jaringan sikatrik pada uretra

Obstruksi saluran kemih

Retensi Urin

Distensi vesika urinaria

Tekanan intravesikal

Hidroureter, Hidronefrosis

Renal failure

Urolitiasis Pain Dysuria Urgensi ++ to +++

Colic Flank Area

Ca. Prostate + ++ ++

BPH + ++ ++

Striktur Uretra + To ++ ++ - To +

+++ -to +
- for ureterolithiasis

Nokturia Hematuria

-to +
- for ureterolithiasis

++ +++

++ - to +

- To + ++

- To ++

Retensi Urine Other symptoms

++(Uretrolithiasis) - to + (Ureterolithiasis) Fever

+++
Painful Ejaculation, Invade the tissue around them

++
Dont invade the tissue around them

++ Systemic: Fever