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What is prostate? gland of the male mammalian reproductive The prostate is an exocrine
system. Function Store and secrete a clear, slightly alkaline (pH 7.29) fluid The prostate also contains some smooth muscles that help expel semen during ejaculation
What is BPH?
A nodular growth of the peri-urethral prostatic tissue May result in urethral compression, and cause a group of symptoms often referred to as "prostatism or LUTS
BPH Prostate
Cancer Prostate
BPH starts in the inner part of the gland and as it enlarges, it squashes the outer part of the gland into a fairly thin shell, called a capsule. BPH never spreads outside the gland.
These usually develop in the outer part of the gland and may not block the urethra at first. Many men with tumors coincidently have BPH in the inner part of the gland, and often these BPH symptoms leads to the cancer being discovered.
The 2 components
Static Component
Dynamic Component
Normal
Hyperplastic
OBSTRUCTIVE SYMPTOMS - CAUSED BY BPH Poor stream The urine flows with less force, traveling only a short distance, sometimes straight down. Having to wait for the urine to start flowing. The flow of urine continues after the main stream has finished, sometimes in spurts or dribbles. Occasionally a second large volume of urine is passed After finishing, there is a feeling that there is still urine in the bladder.
Incomplete emptying
IRRITATIVE SYMPTOMS DUE TO OVERACTIVITY OF THE BLADDER Frequency Nocturia Urgency An abnormally short time between passing urine. Being woken in the night by the need to pass urine. Being unable to hold on after feeling the need to pass urine. Can lead to urine leaking (incontinence).
With irritative symptoms, a sensation of incomplete bladder emptying sometimes occurs, even though the bladder is empty
AUA Symptom Score (questionnaire) Medical history Physical examination Prostate exam Urinalysis PSA blood test Transrectal ultrasound of prostate
Benign vs Malignant
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PSA Alkaline phosphatase to detect metastasis Urinary cytology to detect malignant cells Plain pelvic x-rays to detect bony metastases
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CONDITION
DRE FINDING
Prostatitis BPH
soft, boggy and tender enlarged, smooth, firm anatomical groove may be felt
Prostate Cancer
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1. Incomplete emptying
Over the past month, how often have you had a sensation of sensation of not emptying your bladder completely after you finish urinating?
2. Frequency
Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
0
0
1
1
2
2
3
3
4
4
5
5
3. Intermittency
Over the past month, how often have you found you stopped and started again several times when you urinated?
Uroflowmetry
Measures peak urinary flow rate (Qmax), voided volume and micturition time. A micturition volume of at least 150ml is required for an adequate analysis Interpretation of maximum urinary flow rate values:
Normal Equivocal Obstructed > 15 ml/s 10-15 ml/s < 10 ml/s
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Abnormal if > 50 - 100 ml on at least 2 measurements (large intra-individual variability) Related to bladder outflow obstruction but also detrusor failure, aging and sensory abnormalities
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Surgery
-blockers
5-reductase inhibitors
Medical Treatment
Symptomatic relief of BPH in patients without an absolute indication of surgery Patients in whom surgery is contraindicated Patients unwilling to go for surgery Patients awaiting sugery Prophylaxis for acute urinary retention
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They reduce the sympathetic tone of the prostate and the urethra
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By inhibiting the production of DHT, they reduce the size of the prostate
IC.ALF.04.06.03
Pg 21
p=0.02
Qmax
0 Change in IPSS -1 -2 -3 -4 -5 -6 <30ml
LUTS
3040ml 4060ml
Alfuzosin 10mg OD
Pooled analysis of 3 double-blind placebo-controlled studies
IC.ALF.04.06.03
Fast improvement of flow rate and LUTS whatever the prostate size
IC.ALF.04.06.03
Pg 25
3.9% 3.3% 0 0 0
Others Asthenia / 2.0% 2.6% 6.3% 3.8% Efficacy of fatigue Alfuzosin 10 mg OD on Qmax and LUTS was similar to tamsulosin, 1.3% 0.6% with no added Somnolence benefit of the 15 mg dosage vs the 10 mg dosage
IC.ALF.04.06.03
Standing
DBP SBP DBP
SBP
Alfu 10 mg
Alfu 15 mg
Tamsu 0.4 mg
Standing
DBP SBP DBP
SBP
Alfu 10 mg
Alfu 15 mg
Tamsu 0.4 mg
Standing
DBP SBP DBP
SBP
Alfu 10 mg
Alfu 15 mg
Tamsu 0.4 mg
Surgical treatment
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Indications of surgery
Acute urinary retention Renal failure secondary to BPH Recurrent bladder stones A large residual urine Overflow incontinence Recurrent urinary tract infections Very large prostates (generally bigger than 70 grams) are
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too large to safely perform transurethral prostatectomy, and an open retropubic prostatectomy may be required.
Complications of surgery
Hemorrhage Post operative infection Recurrence: rare, 10-15 yrs Incontinence: muscle damage Dysuria: urethral stenosis Sexual dysfunction: retrograde ejaculation
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TURP
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Gold Standard of care for BPH Uses an electrical knife (electro-cautery) to surgically cut and remove excess prostate tissue, tissue and blood vessls sealed The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels
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Advantages
Widely available Effective Long lasting
Disadvantages
Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter
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Thank you!