evaluation of the patient with benign prostatic hyperplasia(bph)

Evaluation of the patient with BPH

Presented by :Dr. Md. Ishtiaqul Haque Mortuza (Labib)Resident Department of UrologyChittagong Medical College & Hospital

• BPH gives rise to LUTS ( lower urinary tract symptoms) and Obstruction of varying degree.

• “Symptom” is what the patients are worrying about and “Obstruction” is what the urologist should be concerned about

• Though the majority of patients with LUTS are due to BPH, but some patients may have LUTS due to other causes.

How to evaluate a patient with BPH ?

Evaluation of a patient with BPH includes the following steps to establish a correct diagnosis

History takingHistory taking

Pt. with BPH gives history of -

1. Obstructive symptoms:• Hesitancy/Intermittency • Decreased force and caliber of stream• Sensation of incomplete bladder emptying• Straining to urinate• Post void dribbling• Double voiding

2. Irritative symptoms:• Urgency • Frequency • Nocturia

• Hesitancy- during micturation urine flow stops and starts for several times

• Double voiding- second time voiding with in 2 hrs of last void

• Frequency- frequent micturation within a short interval

• Urgency- difficult to postpone urination • Nocturia- waking up from sleeping to urinate

at night

IPSS (International Prostate Symptom Score)

IPSS (International Prostate Symptom Score)

• IPSS is used to asses the severity of the symptoms. This consist a score sheet of obstructive & irritative symptoms mentioned previously.

• There are some questions that will refer both the obstructive & irritative symptoms

• The severity is scored from ‘none at all (0)’ to ‘almost always (5)’ giving rise to a maximum score of 35.IPSS score 0-7 Mild symptom

score 8-19 Moderate symptom score 20-35 Severe symptom

Quality of LifeQuality of Life

Physical examinationPhysical examination

Physical examination includes:1.DRE (Digital Rectal Examination)2.Examination of genitourinary system 3.Focused neurological examination4.Examination of hernial orifice5.Related General examination including

cardiopulmonary status of the patient

DRE (Digital Rectal Examination)

DRE (Digital Rectal Examination)

Points to be noted in DREPoints to be noted in DRE

• Size of the prostate May be enlarged• Surface Smooth• Consistency Firm, elastic• Rectal mucosa Free from prostate• Median sulcus Obliterated• Any rectal mass Absent• Anal tone Normal• Upper limit Can be reached

Examination of genitourinary systemExamination of genitourinary system

• External urethral meatus – normal• Urethra – no palpable mass or cord like feeling• Urinary bladder –

May or may not be palpable (> 200 ml)Percussion of suprapubic region(dull on percussion)

• Kidney – usually not palpable• Testis, Epididymis, Hydrocele, Varicocele

Focused Neurologic examinationFocused Neurologic examination

To exclude neurogenic bladder we have to take history & perform examinations.

History1. H/O stroke2. H/O Any spinal injury3. H/O DM4. H/O Alteration of bowel habit (e.g. constipation)

Examinations1. Perianal sensation2. Bulbocavernosus reflex3. Anal tone4. Lower extremity function (motor & sensory)

Relevant investigationsRelevant investigations

Investigation required for the evaluation of a patient with BPH includes:

1. Urnie analysis2. USG of KUB ,Prostate with PVR3. Uroflowmetry4. Serum PSA5. Plain X-ray KUB (A/P view) 6. Pressure flow study7. Filling cystometry8. Urethocystoscopy

Not recommended routinely

Urine analysisUrine analysis

• Urine analysis assist in distinguishing UTI & bladder cancer from BPH

• Components are:1. Urine R/M/E2. Urine for C/S3. Urine cytology

Findings of urine analysisFindings of urine analysis

Urine R/M/E1. Sugar for DM2. Pus cell for UTI3. RBC for UTI & other causes

Urine for C/S• To identify any significant infection & selection of

proper antibioticUrine cytology

1. Should be considered in men with H/O smoking with severe irritative symptoms

2. To exclude specially CIS

Pus Cells

Malignant Cell

RBC

E.choli

USG of KUB, Prostate with PVRUSG of KUB, Prostate with PVR

1. Size 2. Intravesical potrusion3. Echogenicity4. Capsule

1. Bladder wall (thickened or not)2. Presence of any diverticulum3. Presence of any stone4. Any growth obstructing the

bladder neck5. Determination of PVR

Prostate Prostate Bladder Bladder

Following points are to be observed in USG

Kidney Kidney

To see any bilateral pelvicalyceal dilatation, which reveals any back pressure effect of the kidney

• Size of the prostate can be classified into:1. Small prostate – < 20 gm2. Medium prostate – 20-40 gm3. Large prostate - > 40 gm

• Intravesical potrusion of prostate can be graded into:

1. Grade I – 0-5 mm2. Grade II – 6-10 mm3. Grade III - >10 mm

• Echogenicity (sonographic pattern of BPH)Mixed, heterogenous, mostly hypo echoic

parenchyma, often arranged in the form of one or more hyperplastic nodules and sometimes recognizable internal architecture

• Capsule Bright echogenic structure surrounding the

prostate (in BHP it is intact)Capsular bulging & irregularity associated with an

adjacent focal hypo echoic lesion often indicate ‘capsular invasion’ (a sign of malignancy)

USG image of a BPHUSG image of a BPH

Some important informationSome important information

• Size of the prostate correlate less well with the degree of obstruction

• A small prostate may obstruct and a large prostate may not obstruct. This is because of the distortion of the “funneling effect of the bladder neck” which is more important cause of obstruction than the compression of the urethra.

• A small nodule sitting at the strategic position at the outlet (such as median lobe) can cause a “ball-valve” effect leading to significant obstruction

• Usually large prostate are more likely to obstruct than the small prostate due to compression of the urethra

• In a study it was found that :Patients with grade I protrusion:

84% has a good flow rate > 10 ml/secPatients with grade III protrusion:

72% has a flow rate < 10 ml/sec

PVR (Post Voidal Residue)PVR (Post Voidal Residue)

• When voiding function of bladder is impaired it will be manifested as residual urine

• Normal person with no significant obstruction should have residual urine 0 ml

• Any patient with a persistent PVR > 100 ml with no obvious neurogenic cause and association with poor flow rate of 10ml/sec or less, would be suspected to have significant obstruction

Uroflowmetry Uroflowmetry • Uroflowmetry is the electronic recording of

the urinary flow rate throughout the course of micturition.

• Results of uroflowmetry are non-specific for the causes of symptoms

• For proper uroflow test, voided volume should be at least 150 ml.

Points to be noted in uroflowmetryPoints to be noted in uroflowmetry

Maximum flow rateAverage flow rateVoiding timeVoiding volumePattern of voiding

curve

• With properly performed uroflow test: Normal flow rate in male about 20-25 ml/secNormal flow rate in female about 25-30 ml/sec

• Obstruction should be suspected when maximum flow rate is < 15 ml/sec

• definitive evidence of obstruction when maximum flow rate < 10ml/sec

Plain X-ray KUBPlain X-ray KUB

• To see any stone in the urinary bladder, vesical neck or in the urethra, which might be cause of LUTS

• Any metastatic lesion in the bone

• Any calcification in Kidney, ureter, bladder, prostate

Serum PSASerum PSA

• PSA is a tumor marker used for screening of Ca prostate

• Serum PSA is considered optional, but most physician will include it in the initial evaluation.

What we should know about PSA?What we should know about PSA? PSA is a glycoprotein enzyme(serine protease)

It is secreted by the epithelial tissue of prostate

It circulates in serum in free & bound form

Its normal value is <4 ng/ml

Its level raises with increasing age & size of prostate gland

Real outcome of PSA test can be obtained by evaluating the level from time to time and observing the rate of changes

Medical opinion is divided about the usefulness of single PSA test

One test out of range could be caused by other problems

Moreover PSA is not specific for Ca prostate

Confounding factors for PSAConfounding factors for PSA

• PSA level increases in1. Ca prostate2. BPH3. Prostatitis4. Instrumentation5. DRE6. Aging7. Ejaculation

• PSA level decreases in1. LHRH agonist2. 5 alpha reductase inhibitors

Other PSA parametersOther PSA parameters

PSA velocity• It means rate of change of PSA over time• Man with Ca prostate has more rapidly rising serum

PSA than in man with BPH• Serum PSA increases by .75ng/ml/yr appear to be at

increased risk of harboring cancer.

PSA density• It is ratio of PSA to the gland volume• PSA levels are elavated approximately .12ng/ml/gm of

BPH tissueThus patients with enlarged prostate due to BPH

may have elavated PSA level

Differential diagnosis of BPHDifferential diagnosis of BPH

• BNH• Urethal stricture• Ca Prostate• Ca Bladder• Infection (Cystitis, Prostatitis)• Stones• Neurogenic Bladder

Staging of BPHStaging of BPH

Stage 1No bothersome symptom(QOL 2 or less)No significant obstruction( Qmax >10ml/sec,PVR <100 ml)

Stage 2With bothersome symptom(QOL 3 or more)No significant obstruction

Stage 3With significant obstruction irrespective of symptoms (Qmax<10ml/sec, PVR >100ml)

Stage 4 BOO with complication

Treatment of BPHTreatment of BPH

Treatment of BPH is planned after• Proper evaluation• Properly informed about the disease &

various therapeutic options of BPH

So treatment can be given on the basis of• Relative efficacy of the Rx • Side effects

Rx modalities depends on• Age of the patient• IPSS of the patient• DRE findings• USCD(Ultrasound cystodynamogram)• Uroflowmetry findings• Serum PSA level• Complication of BEP

Rx options are

•Watchful waiting•Medical therapy• Surgery

Watchful waiting

Mild symptoms (IPSS 0-7)• No bothersome symptoms • No significant obstruction

The severity & distress due to symptoms may be improved through simple measures such as:

• Decreased fluid intake specially prior to bed time• Reduced intake of alcohol & caffeine contaning

product• Follow timed voiding schedules

Patient should be observed for bothering symptoms & development of significant obstrution

Medical treatment

Aim of medical therapy

To decrease BOO, thereby-• Relieving symptoms• Improving bladder emptying• Ameliorating detrusor instability• Preventing future episodes of UTI & urinary

retention

Ideal candidate for medical Rx• Bothersome symptoms that impact negatively on quality of

life• No significant obstruction(Qmax>10ml/sec, PVR<100 ml)

Medical Rx should not be offered to individual presenting with-

1. Refractory urinary retention2. Recurrent UTI3. Renal insufficiency4. Bladder calculi/diverticula5. Recurrent gross hematuria

Medical therapy include 1) Alpha blokers• Non selective-phenoxybenzamine,• Alpha 1 (short acting)- prazosin, • Alpha 1 (long acting)- terazosin, doxazosin• Alpha 1a selective(uroselective)-tamsulosin,

alfuzosin,silodosin2) Androgen suppression (5 alpha reductase

inhibitor) Finesteride, dutasteride3) Plant extract (Phytotherapy)- popular in europe

& USA

Surgical therapyA) Endoscopic method• TURP• TUIP• TULIP- 1) HoLEP, 2)Free beam laser, 3)Contact laser,

4) Interstitial laser• TUVP• TUNA• HIFU• TUBD• TUMT• Intraurethral prostatic stent- Cobalt-Chromium stent,

Titenium nickel stentOut of all minimally invasive technique, TURP is the gold

standered

B) Open method• Retropubic prostatectomy(Millins

prostaectomy)• Perineal prostatectomy(Youngs

prostatectomy)• Transvesical prostatectomyC) Laparoscopic prostatectomy D) Robot assisted simple prostatectomy

Indications of TURP

Absolute indications1. Refractory urinary retention2. Chronic retention with renal insufficiency---- increased serum creatinine increased blood urea level, residual urine volume 200 ml or more,

hydroureteronephrosis in IVU uremic manifestation.3. BOO with complication

• Recurrent UTI• Recurrent gross heamaturia• Large bladder diverticula• Stone formation

Relative indications1.Severe symptoms(IPSS >20)2.Failed medical treatment3.Qmax <10 ml/sec4.PVR >100ml after repeated measurement

Pre operative counselling• Retrograde ejaculation • Erectile dysfunction• Success rate• Risk of re-operation• Post operative morbidity UTI & dysuria Incontinence Hematuria Dribbling Frequency, urgency etc.

Complications of TURP

A) Local complication1.Penile erection2.TUR syndrome 3.Excessive bleeding4.Perforation of capsule & extravasation of

urine5.Bladder perforation, trigonal injury6.Injury to external sphincter & urethra

Per operative complicationPer operative complication

B) General complication• Myocardial infarction• CVA• Cardiac arrest

A)Local• Bleeding• Clot retention• UTI• Sepsis• Failure to void• Epidedymoorchitis

Immidiate Post operative complicationImmidiate Post operative complication

B) General complication• MI• DVT• Pulmonary embolism• Spinal headache

• Stricture urethra• Bladder neck contracture• Urinary incontinence• Retrograde ejaculation• impotence

Local complicationLocal complication

Indications of open Prostetectomy

• Large prostate > 100 gm• Concomitant bladder condition that requires

Rx (such as symptomatic bladder diverticulumn, large hard calculus that cant be manage transurethally)

• Marked ankylosis of the hips that prevents proper placement of dorsal lithotomy position

• Co-existing unilateral/bilateral inguinal hernia

Contraindication of open prostatectomy

• Small fibrous prostate gland• Previous prostatectomy• Previous pelvic surgery• Any type of prostate cancer