Enlarged Prostate: Clinical Features \u0026 Management
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Renal Module 0309 : Class of 2016 Enlarged Prostate Clinical Features & Management Dr. Mohsin Shakil Assistant Professor Urology Azad Jammu Kashmir Medical College, Muzaffarabad, Azad Kashmir
Transcript of Enlarged Prostate: Clinical Features \u0026 Management
Renal Module 0309 : Class of 2016
Enlarged Prostate Clinical Features & Management
Dr. Mohsin Shakil Assistant Professor Urology
Azad Jammu Kashmir Medical College, Muzaffarabad, Azad Kashmir
Enlarged Prostate
What is Enlarged Prostate?
• Enlargement of the prostate is usually caused by hyperplasia (BPH), carcinoma (Ca - prostate ) and inflammation (prostatitis).
• Enlarged Prostate is commonest conditions affecting older men, which can lead to LUTS
• Advancing age and testicular androgens play a central role in enlargement.
Prostate : Revisiting Anatomy
Prostate : Revisiting Anatomy
Prostatic Smooth Muscles are provided with alpha 1 receptors predominant A1 subtype.
Prostate : Revisiting Physiology
Prostate & Testosterone
o The primary androgenic stimulator of prostate growth is Dihydrotestosterone (DHT)
o DHT is produced from testosterone via the 5-alpha-reductase (5-AR) isoenzymes type I & II
Prostate : Revisiting Physiology
Prostate : Revisiting Physiology
Functions of Prostate: o Secretory functions:
o Forms 70% of seminal fluid , alkaline for neutralizing acidic vaginal environment. o Provide carbohydrates and nutrient to sperms.
o Sphincteric Functions: o Part of internal urethral sphincter mechanism. o Close bladder outlet during ejaculation to divert semen to exterior..
o Ejaculatory Function:
o Smooth rhythmic contraction of prostatic smooth muscles in co ordination with smooth muscle of vas deference, seminal vesicle, ejaculatory duct and the Ischiocavernosus and balbocavernosusu muscles.
Anatomy of Enlarged Prostate
Ca P
Lower Urinary Tract Symptoms (LUTS)
OBSTRUCTIVE / VOIDING SYMPTOMS
IRRITATIVE / STORAGE SYMPTOMS
ASSOCIATED SYMPTOMS
POST MICTURITION SYMPTOMS
LUTS: Irritative / Storage Symptoms
o Frequency
o Urgency
o Nocturia
o incontinence
Irritative Symptoms
LUTS : Obstructive/Voiding Symptoms
o Hesitancy o Straining o Weak urinary stream o Intermittency o Prolonged voiding o Terminal dribbling o Incomplete bladder emptying o Obstruction/incontinance
Obstructive / Voiding Symptoms
LUTS : Post Micturition Symptoms
o Incomplete bladder emptying
o Post Micturition Dribbling
Post Mictrition Symptoms
LUTS : Prevalence
Lower Urinary Tract Symptoms (LUTS)
LUTS: AUA Symptoms Score (IPSS)
1-7: Mild. 8-19: Moderate. 20-35: Severe.
AJKMC Lower Urinary Tract Symptoms Score: (Under Trail)
Differential Diagnosis for LUTS
Causes of LUTS in Male
Differential Diagnosis for LUTS
Causes of LUTS in Male
Stricture
Enlarged Prostate : Clinical Examination
Abdominal: o Visible Swelling over Lower Abdomen o Palpable Bladder o Renal tenderness o Urethral discharge o Tender testis Digital Rectal Examination (DRE) o Sensations around Anus o Anal tone o Prostate size o Prostate tenderness o Prostate Consistency o Any palpable nodule
Enlarged Prostate : Investigations
INVESTIGATIONS: o Urine Routine Examination (URE) o Blood Complete Picture (Blood CP) o Renal functions Test (Blood Urea Creatinine) o Ultrasonography Kidney Ureter Bladder & Post Void Residual Urine estimation (USG KUB/PVU) o Prostate Specific Antigen (PSA)
Enlarged Prostate: Investigations
INVESTIGATIONS:
o Abdominal Ultrasonography USG Bladder / Post Void Residual Urine
o PSA
o CT Scan
o TRUS
o Biopsy
o Bone Scan
Enlarged Prostate: Investigations
INVESTIGATIONS:
o USG
Bladder
PVU
oPSA o Urodynamics
o CT Scan
o TRUS
o Biopsy
o Bone Scan
Enlarged Prostate: Investigations
Abdominal Ultrasonography Bladder
INVESTIGATIONS:
o USG KUB.PVU
o PSA
o Urodynamics
Uroflowmetry
o CT Scan
o TRUS
o Biopsy
o Bone Scan
Q Max > 15 ml/second
Enlarged Prostate : Investigations
INVESTIGATIONS:
o USG KUB PVU/PSA
o PSA
o Urodynamics
o CT Scan
o Trans Rectal Ultrasonography (TRUS)
strongly indicated
in suspected Ca
o Biopsy
o Bone Scan
Enlarged Prostate : Investigations
INVESTIGATIONS:
o USG
Bladder
PVU
o PSA
o Urodynamics
o CT Scan
strongly indicated
in suspected Ca
o TRUS
o Biopsy
o Bone Scan
Enlarged Prostate : Investigations
INVESTIGATIONS:
o USG KUB PVU/PSA
o PSA
o Urodynamics
o CT Scan
o TRUS
o TRUS Biopsy
strongly indicated
in suspected Ca
o Bone Scan
Enlarged Prostate : Investigations
INVESTIGATIONS:
o USG
Bladder/PVU
o PSA
o Urodynamics
o CT Scan
o TRUS
o Biopsy
o Bone Scan strongly indicated
in suspected Ca
DIAGNOSIS: BPH
BPH: Treatment
BPH: Treatment
BPH: Treatment
Management of BPH
BPH: Treatment
Management of BPH: watchful waiting
BPH: Treatment
Management of BPH
Enlarged Prostate
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Alpha Blockers
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Treatment
Management of BPH : Medical Therapy
BPH: Surgical Treatment
Indications for surgery
• Absolute
o Recurrent urinary retention o Recurrent urinary tract infections o Recurrent hematuria that cannot be controlled
conservatively o Bladder calculi o Dilatation of upper urinary tract/renal failure owing
to BPH-related bladder outlet obstruction
BPH: Surgical Treatment
Indications for surgery • Relative
o Relevant BPH-related bladder outlet obstruction o Bladder diverticles o No success with conservative or alternative
therapies (for example, in unchanged or increasing symptoms or obstruction)
o Allergies or contraindications for conservative therapies
o Postvoid residual urine >100 ml
BPH: Surgical Treatment
Surgical Procedures for BPH :
o Transurethral Incision of Prostate (TUIP)
o Transurethral Resection of Prostate (TURP)
o Retro Pubic Prostatectomy
o Trans Vesical Prostatectomy (TVP)
BPH: Treatment flow chart
Ca Prostate : Diagnosis
o Digital Rectal Examination o PSA o Biopsy
Enlarged Prostate : Ca Prostate
Prostate cancer: clinical presentation
o Localized prostate cancer o Asymptomatic, with screening serum PSA or
incidental DRE. o Lower urinary tract symptoms (probably coexisting
BPH) o Haematospermia o Haematuria (probably due to coexisting benign
hyperplasia) o Perineal discomfort (probably due to coexisting
prostatitis)
Enlarged Prostate : Ca Prostate
Prostate cancer: clinical presentation
o Locally advanced cancer o Asymptomatic, with screening serum PSA or incidental DRE o Lower urinary tract symptoms o Haematospermia o Haematuria o Perineal discomfort o Symptoms of renal failure/anuria due to ureteric obstruction o Malignant priapism (rare) o Rectal obstruction (rare)
Enlarged Prostate : Ca Prostate
Prostate cancer: clinical presentation
o Metastatic disease (N+, M+) o Asymptomatic, with screening serum PSA or incidental DRE o Swelling of lower limb due to lymphatic obstruction o Anorexia, weight loss o Bone pain, pathological fracture o Neurological symptoms/signs in lower limbs (spinal cord compression) o Anaemia o Dyspnoea, jaundice, bleeding tendency (coagulopathy)
Enlarged Prostate : Ca Prostate
Prostate cancer: Treatment Localized prostate cancer
o Watchful waiting o Radical Prostatectomy
o Management of biochemical relapse post-RP o Radiotherapy o Hormonal Treatment
o Radical External Beam Radiotherapy (EBRT) o Brachytherapy (BT) o Cryotherapy o High-intensity focused ultrasound (HIFU)
Enlarged Prostate : Ca Prostate
Prostate Cancer: Treatment o Management of locally advanced non-
metastatic prostate cancer (T3â4 N0M0) o EBRT o Hormone therapy o Watchful waiting o Palliative treatment of locally advanced
disease
Enlarged Prostate : Ca Prostate
Prostate Cancer : Treatment o Management of advanced prostate cancer:
o Hormone therapy o Cytotoxic chemotherapy o OTHER Developing treatment
o growth factor inhibitors, o angiogenesis inhibitors, o immunotherapy, and o gene therapy
Enlarged Prostate : Ca Prostate
Prostate Cancer : Treatment o Mechanism of Androgen Deprivation.
o Surgical castration: bilateral orchidectomy o Medical castration: luteinizing hormone-releasing
hormone (LH-RH) agonists, oestrogens; also termed androgen ablation or androgen deprivation
o Anti-androgens (steroidal or non-steroidal): androgen receptor blockade at target cell
o Maximal androgen blockade (MAB): Surgical castration plus anti-androgen
o 5 Alpha 1 Reductase inhibition (5ARI) with finasteride or dutasteride.
Ca Prostate : Algorithm
References: • Walsh P (ed). Campbell’s Urology. WB Saunders, 2002
• Kirby RS, McConnell. Benign Prostatic Hyperplasia. Health Press Ltd, 1999
• Oxford Hand Book of Urology , 1st edition
• www.slideshare.net
• www.medscape.com
Enlarged Prostate
