BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3....
-
Upload
alexia-bond -
Category
Documents
-
view
232 -
download
1
Transcript of BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3....
![Page 1: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/1.jpg)
BPH, Inflammatory diseases of prostate
As. Prof. Lukáš Bittner M.D., FEBU
Urologická klinika 3. LF UK a FNKV
![Page 3: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/3.jpg)
BPH (Benign Prostatic Hyperplasia)
Most common „benign tumor“ in menPrevalence
20% age 41-50 50% age 51-60›90% older than 80
![Page 4: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/4.jpg)
Prevalence of BPH
![Page 5: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/5.jpg)
Etiology BPH
MultifactorialEndocrine controlled
Positive correlation between levels of fT and E and volume of BPH
Increase of E causing induction of androgen receptor, ꜛsensitivity
![Page 6: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/6.jpg)
BPH
![Page 7: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/7.jpg)
Pathology of BPH
BPH develops in transition zoneHyperplastic process, increase of cell No.Nodular grown pattern of stroma +
epitheliumStroma composed of collagen and smooth muscle • Smooth muscle target for alfa- blockers• Epithelium target for 5-alfa –reductase inhibitors• Collagen does not respond to medical Th
![Page 8: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/8.jpg)
Anatomy of the prostate
![Page 9: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/9.jpg)
Pathophysiology of BPH
Obstruction
Mechanical obstruction• Intrusion of prostate into the urethral lumen or bladder
neck= higher bladder outlet resistance
Dynamical obstruction • prostatic stroma is rich in adrenergic nerve supply, level
of autonomic stimulation sets the tone of prostatic urethra
![Page 10: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/10.jpg)
Surgical anatomy
3 lobes2 lateral1 median (impalpable)
![Page 11: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/11.jpg)
Prostate 25y.o.
![Page 12: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/12.jpg)
Prostate 50y.o.
![Page 13: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/13.jpg)
Clinical Findings
Hesitancy*Decreased force and
caliber of streamSensation of incomplete
bladder emptyingDouble voidingPost void dribbling
* Difficulty in beginning
UrgencyFrequencyNocturia
=LUTS Low Urinary Tract Syndrom
![Page 14: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/14.jpg)
![Page 15: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/15.jpg)
IPSS score
0-7 Mild8-19 Moderate20-35 Severe
![Page 16: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/16.jpg)
Examination
DRES PSAUrinalysisPost void residuum- USGUFM
![Page 17: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/17.jpg)
Uroflowmetry (UFM)
![Page 18: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/18.jpg)
UFM terminology
![Page 19: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/19.jpg)
UFM findings
![Page 20: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/20.jpg)
Differential Diagnosis
Urethral strictureBladder neck contractureBladder stoneCaPInfectionTumor of bladder
![Page 21: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/21.jpg)
Absolute surgical indication
Refractory urinal retention
Recurrent urinary tract infection from BPH
Gross hematuria from BPH
Bladder stones from BPHRenal insufficiency from
BPHLarge bladder diverticula
from BPH
![Page 22: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/22.jpg)
Medical therapyof BPH
IPSS mild symptoms- watchful waiting
Alpha-blockers5-alfa reductase inhibitorsPhytotherapy
![Page 23: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/23.jpg)
Alpha-blockers
Prostate and bladder base contains alpha-1 adrenoreceptorsShows contractile response
Fast onsetTime limited efficiencySide effects: hypotension, dizziness,
headache, retrograde ejaculationTamsulosin, Alfuzosin- alpha 1a selective,
once daily
![Page 24: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/24.jpg)
5-alfa reductase inhibitors
Block conversion of T to dihydrotestosteronAffects epithelial component
Reduction of size (6monts 20%)PSA is reducedLate onset, long actingReduced risk of acute retention and need of
surgerySide effects: erectile dysfunction, decreased
libido, gynekomastiaFinasteride, Dutasteride, once daily
![Page 25: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/25.jpg)
Phytotherapy
Saw palmeto berry (serenoa repens)Bark of Pygeum africanum
No benefit in randomised trials
![Page 26: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/26.jpg)
Surgical therapy
Conventional therapyTransurethral resection of prostate (TURP)Open simple prostatectomy
Minimal invasive therapyLaser therapyTUNATUMTStents
![Page 27: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/27.jpg)
Surgical treatment algorithm
![Page 28: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/28.jpg)
Transurethral resection of Prostate (TURP)
![Page 29: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/29.jpg)
TURP
![Page 30: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/30.jpg)
TURP
Shorter hospital stayMinimal to moderate
bleeding
Strictures of urethra5% of EDTUR sy.
![Page 31: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/31.jpg)
TUR Syndrome
The intrusion of salt-free irrigation fluid in open veins or perforation of the prostate capsule can cause a volume overload and dilutional hyponatremia (<125 mmol/l) of the patient.
SymptomsConfusionnausea and vomitingarterial hypertensionBradycardiapulmonary edema and impaired vision.
![Page 32: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/32.jpg)
TUR Syndrome
Risk factorsProstate volume over 45 mlresection time over 90 minheight of the irrigation fluid by the patient over 70
cm. Lab controla
Sodium levelTreatment
Furosemide is given (20–40 mg i.v.)hypertonic NaCl solution slowly
![Page 33: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/33.jpg)
Transvesical prostatectomy (TVPE)
![Page 34: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/34.jpg)
TVPE
![Page 35: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/35.jpg)
TVPE
Safe for urethraShorter operation time
Moderate to severe bleeding
Longer hospital stay
![Page 36: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/36.jpg)
Acute bacterial prostatitis
![Page 37: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/37.jpg)
Acute prostatitis
Associated with UTIascending urethral infectionReflux of infected urine from bladder
Most common urologic Dg. In men ≤50
![Page 38: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/38.jpg)
Presentation
Abrupt onsetFeverChillsMalaiseBack/rectal/perineal painUrinary sy
• Frequency• Urgency• Dysuria
![Page 39: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/39.jpg)
Findings
DRE- tender, warm, enlarge glandUrinalysis WBCSerum: leukocytosis, elevation PSA
Avoid prostatic massage, urethral catheterization
![Page 40: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/40.jpg)
Causative organisms
E. coliProteusKlebsiellaPseudomonas
![Page 41: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/41.jpg)
Treatment
Trimethoprim and fluoroquinolonesGood penetration4-6 weeks
If urine retention present- placement of suprapubic catheter
![Page 42: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/42.jpg)
Chronic bacterial prostatitis
Present withDysuriaUrgencyFrequencyRecurrent UTI
DREOften normal
PSA may be elevated
![Page 43: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/43.jpg)
4- Cup Test (Stamey)
Collect firs 10 mL voided urine (VB1)Discard next 100mLCollect next 10 mL (VB2)Massage prostate and collect prostate
expressate (ESP)Collect first 10 ml of voided urine after
massage (VB3)
![Page 44: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/44.jpg)
interpretation
All specimen ≤103 CFU/mL not bacterial prostatitis
VB3 of EPS › 103 CFU/mL bacterial prostatitis
Only VB1 pos.- urethritisALL positive- treat UTI and repeat
Alternative – voided specimen before and after prostatic massage
![Page 45: BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV.](https://reader031.fdocuments.net/reader031/viewer/2022033022/56649d305503460f94a08d1b/html5/thumbnails/45.jpg)
Treatment of Chronic Prostatitis
Trimethoprim and fluoroquinolonesDuration of Th 3-4 months
Alfa blocker will reduce symtom recurrences